"People aren’t happy to see refugees coming to Switzerland. They don’t like assisted suicide for foreigners": Organizations’ perspectives regarding the right-to-die and suicide tourism

Abstract

The practice of suicide tourism refers to the traveling of individuals to other countries to seek legally permitted assisted suicide. This study employed a descriptive qualitative research approach exploring how right-to-die organizations perceive suicide tourism and its implications on the right-to-die. Five themes emerged following the analysis of 12 in-depth interviews with activists from right-to-die organizations and 13 relevant documents: (1) unequivocal attitudes toward suicide tourism; (2) relationships between the organizations and the media; (3) acting to change the legal status of the right-to-die; (4) the role of the family in interactions between the organization and the person seeking assistance; and (5) reciprocal relations between the organizations and the physicians. The findings reveal ambivalent attitudes within such organizations toward suicide tourism, inherent tension among participating physicians, and complex relationships between assisted suicide, palliative care, and the physicians’ duty to promote individual choice at end-of-life.

Introduction

The term suicide tourism refers to the practice whereby individuals travel to another state to take advantage of laws that permit assisted suicide and that do not exist in their own place of residence. These individuals are terminally ill and/or are greatly suffering (mentally or physically), and as such, have chosen to seek assisted suicide, more commonly referred to as aid-in-dying (Sperling, 2019a). The term assisted suicide can be defined as an act whereby other persons, mostly professionals, and typically physicians, provide knowledge and/or material assistance to another individual to enable them to bring about their own death. Most notably, this is conducted through the prescribing of lethal doses of drugs (provider-administered) or through the providing of instructions (self-administered) regarding these doses (Blouin, Gerson, & Cavalli, 2022).

While such a practice is prohibited by law in many Western countries – due to ethical considerations (De Andrade & Moreno, 2022; Dieterle, 2007) – it is currently allowed as a general practice in Switzerland; it is also permitted as medically assisted suicide in the Netherlands, Belgium, Luxemburg, Germany, 11 jurisdictions in the United States (California, Colorado, District of Columbia, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington), Canada, Colombia, several areas in Australia (the States of Victoria and Western Australia), and New Zealand (Downie, Gupta, Cavalli, & Blouin, 2022). Yet even in places where assisted suicide is legal, it is usually prohibited for nonresidents, and/or requires an ongoing relationship between the prescribing physician and the individual seeking such an option (Sperling, 2019a).

Suicide tourism was first reported in the 1990s, when Dignitas, the Swiss right-to-die organization, offered access to assisted suicide for nonresidents (Carrigan, 2023; Gauthier et al., 2015). Two additional Swiss organizations, Lifecircle (up until November 2022) and Pegasos, also provide this service, as do other right-to-die organizations, such as Exit (Deutsche Schweiz) and EXIT ADMD, which mainly provide their services to Swiss residents, yet may also be open to nonresidents, mostly from France, Italy, and Germany.

Despite controversies in the literature as to whether assisted suicide in general, and suicide tourism in particular, constitutes an act of suicide (Hannig, 2019; Sperling, 2024; Sumner, 2020), or should be considered a form of tourism (Christou, 2021; Yang, Mohd Isa, Ramayah, & Zheng, 2022; Yu, Wen, & Meng, 2020), these terms are widely used in both academia and the media. Contrary to suicide through violent acts (such as jumping from a height, using a gun, or taking an intentional overdose of drugs – prescribed or otherwise), suicide tourism is often regarded as a means for achieving a peaceful death – one that is based on the individual’s free choice regarding where, when, and how they wish to end their lives, usually following a period in which they have suffered substantially (Carrigan, 2023; Richards, 2017; Sperling, 2022).

While one can still find polarization regarding the acceptance and permissibility of assisted suicide (Cohen, Van Landeghem, Carpentier, & Deliens, 2014; Emanuel, Onwuteaka-Philipsen, Urwin, & Cohen, 2016), the public support for legal assisted suicide, as well as the number of countries and states that are legalizing, it are gradually increasing (Carrigan, 2023). Moreover, despite a certain degree of objections, suicide tourism is also on the rise. At the end of 2022, Dignitas, the main right-to-die organization that offers such services, reported having 11,856 members, compared to 8,319 in 2017, and 10,382 members in 2020. An increase in the number of accompanied suicides has also been reported by the organization, from about six such suicides in 1998, through 97 in 2010, to 206 accompanied suicides in 2022 (DIGNITAS, 2023).

The increasing number of people who travel for assisted suicide could be partially attributed to effective activism by right-to-die organizations, increased public and media attention to the phenomenon of suicide tourism, and the more general dominance of the values of personal freedom and autonomy (Carrigan, 2023). The growing interest in suicide tourism may also indicate that people are less concerned about choosing their place of death, as they have more pragmatic issues to consider (Pollock et al., 2024). Finally, suicide tourism could be supported by the Requested Death social movement that places an emphasis on how and when a death may occur, while objecting to the state’s control of related cultural issues and reclaiming matters of identity, privacy, and corporeality (McInerney, 2000).

Right-to-die organizations

One group of key players in the advancement of suicide tourism are the right-to-die organizations. These organizations are usually nonprofit and non-governmental social organizations that serve as support groups for end-of-life issues. Having been politically active since the 1930s (Judd & Seale, 2011; McInerney, 2000), these organizations have flourished within the context of increasing longevity and life-prolonging medical technologies. They have raised concerns regarding chronic illness, suffering, and financial cost at end-of-life, as well as fears of institutionalization and dependency, pointing also to the general increase in the number of dying people in light of the overall population growth (Incorvaia, 2022; Judd & Seale, 2011). As such, right-to-die organizations provide an accessible networking platform, where individuals can share or acquire information about the right-to-die issue in a safe and non-judgmental environment (Buttigieg & Vella, 2022).

Yet differences can be seen in their structures and regulations. Some organizations operate as local or national patients’ organizations (e.g., EXIT, that operates in the French-speaking region of Switzerland, or the UK Dignity in Dying). Others act at a regional or international level (e.g., the European Association of Palliative Care or the International Association for Hospice and Palliative Care). Some provide services to residents from other countries (e.g., Dignitas), yet others do not. Some organizations are subjected to mandatory guidelines (e.g., having to provide the authorities with official data regarding individuals who received services of accompanied suicide or aid-in-dying services from them). Others – notably the Swiss right-to-die organizations – may be exempt from reporting their activities to the authorities yet are still subject to criminal investigation following each case of death for which they are responsible (Hamarat, Pillonel, Berthod, Castelli Dransart, & Lebeer, 2022). Finally, right-to-die societies may differ in whether they offer all end-of-life options that are legally permitted in their country and as per the existing medical regulations, or whether they only provide services that are defined and permitted by the medico-legal authority, or that are in line with the goals of right-to-die movement (Dankwort, 2023).

Regardless of these differences, all right-to-die organizations strive to improve end-of-life care across jurisdictions and social and cultural settings, while enhancing the overall quality of death and dying processes. According to a typology of end-of-life interventions (Clark et al., 2017), these organizations act in a range of areas, such as promoting policies, advocating for end-of-life rights, providing ethical and legal frameworks, conducting related research, and advancing the concept of end-of-life self-determination. Since death and dying take place within a given social and cultural context (Gire, 2014; Zaman, Inbadas, Whitelaw, & Clark, 2017), right-to-die organizations that operate at the local level, for example, are mostly suitable for interacting with individuals and connecting them to resources and services that are socially and culturally fitting (Buttigieg & Vella, 2022). Regarding end-of-life care, these organizations may also facilitate patient-family communications, especially regarding the former’s wishes in life-threatening conditions – encouraging them to express their wishes through advance directives or power of attorney (Buttigieg & Vella, 2022).

The overarching aim of these organizations is to promote good death, a term that may be both vague and broad. Yet based on analyses of 54 relevant policy documents (Meier et al., 2016), this term mainly refers to the treating of individuals with dignity and respect; ensuring that they are free of pain and other undesirable symptoms; that they are familiar with their surroundings and in the company of friends and family (Borgstrom, 2020). In contemporary societies, the term good death refers to an individualized death that places planning and timing at its core (Lang, 2020). When addressed as a process (rather than merely as an outcome), good death refers to the conferral of holistic and respectful end-of-life care in an open and accepting setting, where individuals can speak openly about their desires regarding their dying and death, knowing that all involved parties will work toward complying with their explicit wishes (Borgstrom, 2020).

Right-to-die organizations and suicide tourism

Right-to-die organizations may be involved in suicide tourism in a variety of forms. For example, they may offer their services to all individuals, regardless of their place of residence, only to residents (such as EXIT), or de facto only to nonresidents (such as Dignitas)(Stewart & Nitschke, 2023). Moreover, they may provide information, support, and resources regarding the need to travel to another country to seek assisted death, including offering assistance with all necessary legal and administrative issues that are related to the death and dying process. Finally, some organizations may offer physical assistance to travel to another country for assisted dying, either by accompanying the individuals or by paying for the process (Sperling, 2019a).

Empirical data on suicide tourism

Studies have explored the difficulties and challenges encountered by individuals who sought assisted suicide services in another country, with an emphasis on these individuals’ perspectives and relationships with their families and healthcare providers – aspects that may impact their decision to embark on assisted dying in another country (Carrigan, 2023; Goh, Wen, & Yu, 2022; Richards, 2017; Sperling, 2022; Testoni & Arnau, 2023). Some studies also reveal the complex relationships between those who are considering assisted suicide and the right -to-die organizations – mainly Dignitas – who approve (or reject) and facilitate such journeys (Goh et al., 2022; Sperling, 2022). On the one hand, these organizations claim to offer an “emergency exit" or a "plan B" for critically ill individuals (Carrigan, 2023; Sperling, 2019a), yet their acceptance criteria are often complex and difficult – somewhat contradicting the perception of assisted suicide as a fully autonomous and controlled choice (Sperling, 2022; Young, Jaye, Egan, Winters, & Egan, 2021).

These complex relationships are also echoed through the international media, as seen in the high coverage of Dignitas, especially prior to 2010. On the one hand, such coverage referred to the organization as "a killing factory," reporting its involvement in scandals associated with hasty or unsafe dying. Yet on the other hand, the media also reported uplifting and dialytic stories regarding the peaceful deaths experienced by the individuals that the organization served (Carrigan, 2023). Such relationship complexity has also been observed in relation to the challenges that individuals face when seeking assisted suicide – prior to being accepted by the organization – due to communication and administrative issues (Xu et al., 2024).

Yet despite the centrality of right-to-die organizations in the literature in general, and in the phenomenon of suicide tourism in particular, research is lacking on the perspectives and roles of activists in organizations that provide services related to suicide tourism. In an attempt to close this gap, the current study addresses the following research question: What are the right-to-die organizations’ perspectives on the phenomenon of suicide tourism and their implications on the right-to-die phenomenon?

Materials and methods

Research design

The current study was conducted in line with the Interpretive Phenomenological Approach (Larkin, Flowers, & Smith, 2009; Lopez & Willis, 2004), a qualitative design that enables the understanding of participants’ tacit knowledge, shared meanings, and informal norms – in this case, regarding suicide tourism. Since end-of-life discourse differs between social arenas (Lang, 2020), it was important to analyze various sources of materials, to reveal a comprehensive picture of the suicide-tourism phenomenon and of relationships with right-to-die organizations, as perceived by key players in these organizations. The study included in-depth semi-structured interviews with 12 activists from right-to-die organizations, as well as thirteen documents written by such organizations or related to the suicide-tourism phenomenon. This combination of sources improved the validity of the findings (Dirksen, Huizing, & Smit, 2010; Potter, 2017) and can be regarded as similar to methodological triangulation (Denzin, 2012).

Sampling and data collection

Purposeful and snowball sampling were used to recruit participants for the in-depth interviews, and theoretical sampling (Charmaz, 2006) was applied to select the documents that were included in this analysis. The documents were collected through two main searches: (1) Internet and database searches, using "right-to-die organization/association," "suicide tourism," and/or "Dignitas" as the search terms; (2) A more purposeful search on specific websites and newsletters of right-to-die organizations, registered on the list of World Federation Right-to-die Societies (wfrtds.org), using the search terms "suicide tourism," "tourism," "Dignitas," and/or "travel." The analyzed documents included two legal documents, three news report, six association reports, and two press releases. All documents were published during 2021–2022.

The interviews were conducted with managers and position holders in right-to-die organizations from Switzerland (four participants), France (one participant), Germany (one participant), the UK (three participants), Italy (two participants), and Israel (one participant). The organizations and the key activists in them were chosen based on their national and international activities in the field of right to die and suicide tourism (where applicable). The participants held senior positions in these organizations (such as chairperson, director, or campaign manager). In the interviews, they were asked to reflect on and discuss their perceptions and understandings of the suicide-tourism phenomenon, the organization’s related medical and media views, and the relationship between suicide tourism and the legalization of assisted suicide (For a detailed interview guide, please see Annex 1). The researcher personally conducted the interviews as part of a larger project on suicide tourism (Sperling, 2019), during 2015–2018. The interviews lasted between 50mins–5.5 hrs. One contacted organization was unwilling to participate, claiming that it had nothing to say on the topic of suicide tourism, and that their activities do not include advocating for assisted suicide. With the participants’ informed consent, the interviews were recorded and transcribed, and translated into English if needed. Five interviews were held in person, four via Skype, and three through email correspondences.

Data analysis

The thematic analysis applied in this study is in line with the codebook approach (Braun et al., 2019), where themes are often conceptualized as domain summaries and coding is designed to prioritize “reliable” data coding – through the identifying of “accurate” codes/themes within the given data, usually based on agreement. The major themes that emerged from the interviews were developed and re-organized into a scheme of codes and central themes (Kiger & Varpio, 2020). To increase trustworthiness (Amankwaa, 2016), all interviews were analyzed discretely and independently by the author of this study and a research assistant. Intercoder reliability was used to reconcile through discussion, when disagreements between coders occurred (Campbell et al., 2013). Consensus for all themes, sub-themes, and codes were achieved through a negotiated agreement of at least 80% between the two researchers. Codes for which no agreement was reached were excluded from the analysis.

Ethical considerations

Given the sensitive context, the research data was kept anonymous and confidential. Conducting the interviews was approved by the Ethics Committee of the author’s affiliated academic institution (EMEK YVC 2018-4); the analyzed documents and reports were available to the public, and as such, required no further approval.

Results

Five major themes emerged from the analysis: (1) unequivocal attitudes toward suicide tourism; (2) relationships between the organizations and the media; (3) acting to change the legal status of the right-to-die; (4) the role of the family in interactions between the organization and the person seeking assistance; and (5) reciprocal relations between the organizations and the physicians. The following sections present each theme, with accompanying quotes from the interviews and documents.

Theme 1: Unequivocal attitudes toward suicide tourism

Both the interviews and the documents revealed a complex yet unequivocal attitude toward suicide tourism. One of the strongest arguments in support of this phenomenon, heard in many interviews, referred to the right to assisted suicide as a universal human right. As stated by F., chairperson of an organization that provides assisted suicide services for nonresidents: "Assisted suicide should be a human right for everyone around the world." E., a senior position holder in a right-to-die organization, also referred to suicide tourism as instilling a sense of security in individuals whose suffering is unbearable:

What I’m trying to say is… you know… for people who can get to Switzerland… this gives them a choice. And that’s really important. It offers them, you know, a way to end their suffering slightly earlier… Having that kind of emotional comfort and security. Knowing that you have options if your suffering becomes unbearable. There are some cases where even the best palliative care can’t alleviate a patient’s suffering.

Another finding indicated support for suicide tourism, not just in light of what it offers and represents, but also in line of what others do not, i.e., countries and states that lack basic legislation for allowing their citizens to attain their basic liberties. As suggested by T., a suicide-tourism activist and key player in one organization: “It’s a disgrace for modern democratic societies that an Australian citizen has to travel to Switzerland to execute their freedom of choice. That’s inhumane. Discriminatory.”

Moreover, suicide tourism ensures a safe way to die – a topic that was addressed by a number of respondents who spoke of the dangerous trade in lethal substances, that widely takes place via the Internet and is even utilized by some organizations. As expressed by H., a senior manager in a French association, who voiced her concerns regarding a new French organization:

It’s frightening. You know, they just order the product from China, and sell it to people, to patients, without even finding out what problems may exist. They’ve just turned it into a business… They order the Pentobarbital from China and sell it to patients, whoever they are.

Such statements highlight the importance of selecting a reliable suicide-tourism organization.

Strategically, favorable references to suicide tourism were voiced by the respondents, regarding advocation for the regulation of assisted suicide worldwide – based on the assumption that legislation is positive as it promotes the freedom of choice and the legal safety of all parties involved. Moreover, from a social perspective, legislation of assisted suicide facilitates respectful attitudes toward individuals who are considering suicide, and normalizes its related discourse, in turn reducing the number of suicide attempts. As explained by T.:

Why do people jump off a bridge, jump in front of a train, shoot themselves, drink poison…? Why do people do this? And how can we reduce this?… First, we need to do away with punishment for assisting in suicide. Anyone who is suicidal should be able to talk to their therapist, priest, teacher, parents, friends… about their suicidal thoughts, without the fear of being marginalized, ridiculed, or being admitted into a psychiatric facility. They need to be taken seriously. They need to be respected. Then you can talk about the problem that has made them suicidal and try to find solutions. And this must be embedded in the assisted-dying discourse. Because when people know that there’s a real way out, they’re less likely to attempt [unassisted] suicide.

Moreover, the findings highlight that suicide tourism is a social phenomenon that exemplifies the need for related legislation, as articulated by F.:

It seems that more and more people are coming to Switzerland [for assisted suicide]. We have to hold interviews, discussions… We have to do everything to openly show that there is a great need. It’s not just a few people … You should openly show every single case that comes to Switzerland, to show other countries that there is a need.

At times, cynical use of these circumstances can be seen among certain organizations, as described by O., a Campaign Manager of a suicide-tourism organization:

Many people who travel to Dignitas are also members of Dignity in Dying, a form of help-with-euthanasia society. We know that Dignity in Dying will say to them, “We can’t help you, but if you’re travelling to Switzerland, we can help get your story into the media.” And that’s what they do… Then these suicides are often strategically timed, to maximize their impact [via the media].

From a legal aspect, Dignitas, the most prominently active suicide-tourism organization, works hard to change the laws and the legal status of assisted suicide worldwide, as seen in the following statement (Document #1, 2022):

In most Western countries, the vast majority of populations wishes to have access to professionally supported accompanied suicide. To this date, many national laws, jurisdictions and health systems do not sufficiently take this wish into consideration. Dignitas contributes to remedying this situation by providing information and advice to political decision-makers, public officials, private institutions, and the public. From this perspective, suicide tourism serves as an alternative to existing laws. When the law changes, there will be no need for suicide tourism.

Similarly, N., an activist in a local organization and a key player in suicide tourism, stated: "My goal is to allow people to choose for themselves, to choose to remain in their homes, rather than being forced into exile in order to die without suffering."

Some respondents also spoke of the downside of suicide tourism. For example, they spoke of the high financial cost of suicide tourism, rendering it accessible to only some of the population. Additionally, suicide tourism was criticized for its exhausting and demanding procedure, such as the extensive paperwork entailed in the process and the need for the support of an enabling physician from their country of origin in which assisted dying is illegal. Some respondents also spoke of the earlier-than-desired death among terminally ill individuals who have to travel to Switzerland for assisted suicide while they are still healthy enough to do so; for these individuals, had assisted suicide been legal in their own country, they could have deferred their planned death, being able to spend more time with their friends and family, doing what makes them happy.

Indeed, the huge efforts that are entailed in suicide tourism come at great personal cost, as emphasized in document # 6: "They don’t want to travel to Switzerland, spend a lot of money, and have a lot of suffering on top by traveling." This was expanded on by G., an activist in a suicide tourism organization:

People shouldn’t have to travel. Everybody should be able to do that [assisted suicide] in their own country… So you’re looking for a solution and you come across an organization in Switzerland… You should be able to die in your own bed, the way you want to. But you need to get on an airplane… you have to travel… They shouldn’t have to travel but we can only stop suicide tourism by passing legalization in the other countries.

For critically or terminally ill patients, traveling to another country entails significant challenges – both physical and technical – as highlighted by G.:

Sometimes they have 8, 10, 12 hours of driving. From England, Ireland, Scotland, they must have the possibility of flying… It’s a two-day journey by car. So they have to fly when their health still allows this, when the airline still allows them to fly. Otherwise, they come by car… or try to drive in a campervan. People from other countries have to fly. The USA, Canada, Thailand… They usually find a way but it’s very challenging.

Because of the complexity of the process, local right-to-die organizations screen suicide-tourism requests and applications, conducting in-depth inquiry into the individual’s background and motivation. This was highlighted by H., who said:

If somebody says, “help me die immediately,” we don’t say “OK, here’s the address.” First, we take time to listen to the patient…Even if the patient has an incurable disease, they don’t always want to die right now. Sometimes, they’re just afraid of suffering. So if we can reassure them that we’ll help them when they start suffering, we could help them live longer… Also, I need to decide when they need someone to accompany them. Do they need professional help? Is this someone who’s suffered a trauma and can be helped? Or is this someone in very bad mental or medical shape who really can’t be helped? All these things have to be diagnosed. None of these decisions are taken lightly.

Some of the assisted-suicide organizations who participated in this study conveyed that they do not wish to engage in suicide tourism, due to negative media reports and social attitudes toward the phenomenon as a whole. As explained by Q., director of a local organization in Switzerland:

There are… magazines, TV, radio, that often speak about Dignitas, about Life Spirit and Ex-International, and they are polemic about death tourism. So we prefer not to be part of that. Even if, theoretically, it’s possible for us to accept foreign people. We have enough work with Swiss citizens, or foreigners who live in Geneva… So we avoid death tourism…We consider those people to be refugees. Because they have to leave their own country that doesn’t allow them to die with liberty… People aren’t happy to see refugees coming to Switzerland… They don’t like assisted suicide for foreigners, but they don’t want to forbid it either.

T. spoke along similar lines, talking about the public’s opposition to suicide tourism:

This has nothing to do with assisted dying. It has to do with… the feelings of people on the street about nationalism, about protecting your country from negative impacts, of guarding what you have and not wanting to give it to someone else, egoism. Every country in the world is anti-foreigner to some extent, and is protective of what it has to some extent.

Yet, despite these general social challenges that suicide tourism faces, the phenomenon is becoming more widely accepted, even among the Swiss public, still not receiving adequate attention from policy makers or politicians. As expressed by T.:

But you’re missing the point. Look at the figures. Look at the number of people. People coming to this country from abroad. This isn’t an issue for the entire social system. For politicians. Two hundred people per year at Dignitas out of 2.4 billion population on this planet. Sorry, this isn’t something politicians would even deal with. Why should they bother? In our society, we have much more important and problematic issues to deal with.

Theme 2: Relationships between the organizations and the media

According to the participants, the media is generally in favor of changing the law, to permit assisted suicide in additional countries, and is sympathetic toward the concept of death with dignity. As stated by O., "We call the BBC [the British Broadcasting Company] the cheerleader for assisted suicide". When a certain case is addressed in the media, it provides the organizations with an opportunity to generate related discourse. Moreover, stories that are covered in the media increase public awareness regarding end-of-life alternatives, instilling in them knowledge that they may apply in their own future. Finally, when death-with-dignity cases are in the public eye, organizations can leverage this media coverage to put pressure on politicians, as a means for achieving their agenda. In fact, these organizations may even take active steps to recruit the media for this purpose, as explained by O.:

Dignity and Dying [the organization] will say to them, “Well, we can’t help you, but if you’re going to Switzerland, we can help get your story into the media.” So that’s what they do. And then that story provides additional opportunities for changing the law.

Similar words were expressed by F., who emphasized how exposure to the organizations’ actions highlights the more complicated social and legal issues reflected in these actions:

If we lose the apartment [where the accompanied suicide is conducted], if we can perform assisted dying in a campervan, then we could get some good journalists from Basel to come and see what we’re doing, hold an interview, hold a press meeting there, where it all takes place, and tell them about our difficulties. Then they’ll write about the bigger problem.

However, concerns were also raised regarding how these cases are presented in the media. For example, media reports do not fully convey the extent of the phenomenon, as explained by O.: "The numbers appear much greater than they are because of the undue publicity given to people going [to Switzerland]." O. also spoke of the concerning normalization of the phenomenon that may occur when these stories are covered by the media:

I think there’s a degree of “suicide contagion,” where people see high-profile figures going to Dignitas and see this being publicized. In dramas or news reports or in BBC documentaries … This creates the impression that this is an acceptable solution to the problem.

An additional concern was raised regarding the complexity of the organization-media relationship, whereby media coverage also has the potential of harming the image of the practices offered by these organizations – in turn possibly jeopardizing their efforts to change the law in additional countries. As explained by T., a key player in the suicide-tourism phenomenon:

Media coverage gives the wrong picture. First, because [of the legal gap] it reduces the issue to suicide tourism, and second, because politicians see the coverage and say, “Oh, it’s that easy! Why should I bother dealing with this issue?”… What the media is spreading about us is a complete waste of time. We don’t work with the media.

Theme 3: Acting to change the legal status of the right-to-die

Another major finding of this study relates to the organizations’ efforts to legalize assisted suicide in additional countries, while regulating end-of-life decision making. Some participants were content with the existing laws, as described by O.:

Current legislation works in a way that on the one hand, very few people attempt to achieve assisted suicide, even through Dignitas. But on the other hand, there are very few prosecutions. I’d say that’s the best kind of law to have.

While O. seemed satisfied with the current legislation, including in the UK where assisted suicide is prohibited, most materials and participants in this study strongly advocate for changing existing laws to legalize assisted suicide in additional countries, as seen in the following citation (Document #3, 2021):

Conservative and religious circles never get tired of claiming that the legalization of assisted dying would lead to abuse and even to a slippery slope, although these fears have not been confirmed anywhere to date… To imply that assisted dying serves to "get rid" of the old and sick is cynical and shows a remarkably gloomy and fearful view on society.

Advocating for legislative changes refers not only to the act of assisted suicide, but also to the eligibility criteria for partaking in such a practice. For example, allowing all people over the age of 75 to die by assisted suicide, without having to justify their medical condition or their wish to die. As seen in Document #1 (2022), right-to-die organizations address the need to change the courts’ interpretation of existing provisions: "The legal work of the two Dignitas associations in Switzerland and Germany led to lifting the ban on professional assistance in suicide by the German federal constitutional Court… and in Austria… Assisted suicide is now legal in both countries."

They also advocate for eliminating legal requirements whereby assisted suicide is only legal for residents, thereby rendering suicide tourism next-to-impossible. Examples of such activities can be seen in Gideonse v. Brown and in Bluestein v. Scott (Document #8, 2022) – where the call for eliminating these requirements is supported by the demand for enhancing freedom of choice at end-of-life. This can also be seen in Document #10 (2022), as follows: "The end of the residency requirement removes part of the burden for dying patients seeking this option. It means qualified patients can now choose their doctor. It means peace of mind. It ensures a better death for so many people."

The findings reveal that the legislative residency requirement may stem from a number of reasons, including the country’s desire to refrain from providing suicide tourism to nonresidents from jurisdictions where assisted suicide is illegal, or the need to have a long-standing patient-physician relationship – a prerequisite for assisted suicide in both the Netherlands and Luxemburg, for example.

Theme 4: The role of the family in interactions between the organization and the person seeking assistance

Not only do family members provide assistance and support for their loved ones who wish to travel to Switzerland for assisted suicide, yet as explored in the interviews, they are also often required to accompany them, should a witness for these actions be required by the organization/state. Yet such a necessity may create tension among family members, especially regarding possible legal outcomes. As explained by E.:

Even though it’s unlikely that anyone who helps them would be prosecuted, it is still a possibility. So, there’s that kind of fear about whether their relatives and loved ones will be OK after they help them achieve assisted death in Switzerland, and then return to the UK [where it is prohibited].

F. offers one reason for insisting on the patient arriving with a family-member witness:

You get a passport, then you get pancreas carcinoma, and within six months you look like someone from the Holocaust. You won’t be recognizable based on your passport photo… So they’re always afraid that they’ll have the wrong person. So they want someone there for identification.

However, patients do not always want to be accompanied by a family member, or die while in their company. As explained by H.: “The sight of a corpse isn’t very nice. I’d rather no one saw me. I’d just leave letters [for my loved ones]. But in some cases, the organization will step in as a substitute for the family."

The findings of this study reveal that some organizations who provide suicide tourism services require their potential patients to inform their family members about their decision. As expressed by Q.: "Families are parted by this thing, and it would be very bad not to involve them." When objections or disputes with family members emerge, the organization may even refuse to provide their services, as seen in the example conveyed by F.:

We once had a 99-year-old lady from England. Her son was travelling around the world at the time and she wanted to die before he returned, so that he wouldn’t prevent her from doing this. She was still able to walk a bit with a Zimmer frame and was completely lucid, but she had all kinds of illnesses and was constantly in pain. Her mother had had a stroke at the age of 99 and then lived for another six years in a nursing home, and was very badly looked after. The woman said, “That won’t happen to me. That’s why I want to go at the age of 99 and I don’t want my son to prevent me from doing this.” I didn’t accept her. I sent her home. I could have had serious problems with her son… Five days after her son returned home, she came to Switzerland with her son, daughter-in-law, and two granddaughters. And it was the most beautiful assisted dying. That’s the way it should be… But it was awful for me to send this 99-year-old lady home.

Theme 5: Reciprocal relations between the organizations and the physicians

The study demonstrates that Dignitas and LifeCircle require a detailed medical report from the patient’s physician as a prerequisite for suicide tourism. Yet in countries where assisted suicide is prohibited, physicians are not permitted to issue such reports for patients who are contemplating traveling to Switzerland for this purpose. To overcome this obstacle, patients may ask their physicians for their medical records without disclosing the true reason for their request. Some physicians, who do not oppose assisted suicide, may provide these records, simply without discussing the topic or reason with their patients. As explained by E., this creates ethical tension among physicians:

I think… that kind of greyness [grey area] in the guidelines is probably very difficult for doctors, because obviously, ideally, they want to be able to talk to their patients about what they’re considering… I think that at present, some would just do it. But other doctors may be more cautious, which means that they might give the patients their medical records, thinking they’re probably going to Switzerland, but not feeling that they can talk to them about it. And I think that is a problem for the doctor-patient relationship.

Some participants also emphasized the importance of trust between the prescribing physician and the person seeking assisted death – a component that is missing in suicide tourism when the person first meets the prescribing physician in Switzerland, at the airport, hotel, or shortly prior to the action taking place. As highlighted by H., a senior manager of an association in France:

[Assisted death] isn’t a decision like, you know, having a tooth taken out. I mean, it’s a thing of trust between the doctor and the patient. And that’s why for Belgians, it’s very important to know the patient beforehand… And of course, French people who live by the border with Belgium have easier access and are accepted more willingly than someone who comes from the south of France and says “I’m dying, help me.” You see, that’s the sort of ethical dilemma for Belgian doctors, because for them, to perform euthanasia isn’t a routine thing. And they like to really know that they are doing the right thing, because it’s irreversible.

The study also revealed that even when physician-patient trust does exist, physicians usually prefer not to refer individuals to assisted suicide, but rather to support in the form of palliative and supportive care, for example. According to sone of the interviews, such a preference is more prevalent among older physicians or those with private practices. Even in Switzerland, where such practices are more widely accepted, most participating physicians will only collaborate with organizations that provide assisted suicide solely for residents (not suicide tourism). As mentioned by F.: "I think there’re about 35 doctors who practice assisted dying throughout Switzerland. That’s all. And most work for Exit. Undercover… no names… It’s much more dangerous to work for Dignitas or LifeCircle."

Moreover, as death through palliative care and assisted death entail two very different modes of dying, F. raises the importance of freedom of choice:

I don’t understand why people can’t have a choice? Why do people have to be influenced by their doctors? Because they [the doctors] think they know better and think that palliative care is the only way? That’s it’s the best way? [Do they think that] if we have good palliative care, then we don’t need assisted dying? That’s not true!

The topic of freedom of choice, regardless of medical alternatives, is also highlighted in Document #2 (2021):

Despite remarkable progress in medical science, improved end-of-life options, patients’ rights, palliative and hospice care etc., not everyone finds relief and a quality of life they personally deem acceptable. They wish for and should have a right to end their suffering and life at home, at a time of their choice, legally, in a safe way, assisted professionally, and surrounded by their loved ones.

Moreover, H. explained that palliative care may not be suitable for all medical conditions, and as such, referring patients to palliative care may not be a practical solution or a better alternative to suicide tourism:

There are lots of diseases that can be soothed with palliative care. But what are you going to do with palliative care with someone who has Lou Gehrig or Alzheimer’s? Nothing. There’s nothing we can do. So it’s a hypocritical approach. Because the palliative people think that everything is perfect in France and so we don’t need to go to Switzerland.

In general, it is the physicians’ professional obligation to promote and improve their patients’ quality of life. For some, this entails a request for assisted suicide. As seen in Document #7 (2022):

Most of the “medical establishment” occupying positions of power have not yet understood that medical science, which has brought about an enormous increase of life expectancy, should assume responsibility for the fact that a longer life does not always mean a good quality of life from the point of view of the individual.

Discussion

The aim of this study was to examine how right-to-die organizations perceive suicide tourism and its implications on the right-to-die phenomenon. The study revealed complex relationships between right-to-die organizations and the concept of assisted suicide. Yet the participants and the examined documents were found to perceive the individual’s right to make their own end-of-life choices in general, and to receive assisted suicide in particular, as a human right that should be enabled and protected around the globe. Indeed, right-to-die organizations serve as key players in constituting assisted death as a public trans-national issue (Blouin et al., 2022). Moreover, the positive interpretation of the right-to-die seen in this study, and the more general yet extensive discourse within this context, demonstrates how such organizations leverage human-rights frameworks for strategic purposes, as a means for promoting and advancing their objectives and agenda (Miller, 2010). According to the human-rights approach regarding assisted death, what matters is not where the person dies (within or outside their natural surroundings), but rather how they die – in a peaceful manner of their choosing.

The participants revealed a somewhat neutral attitude toward the individual’s chosen place of death. Dying in another country (Switzerland) may be perceived as a legitimate place to die simply because this is where suicide tourism is permitted and conducted. Their criticism of suicide tourism was mainly in light of the difficulties experienced by individuals on their journey to achieving their desired manner of death. For example, their having to travel to another country despite being desperately ill, and in the company of a family member. Yet as seen in other studies (e.g., Driessen et al., 2021), the place of death is neither neutral nor static; rather, it should be symbolically and materially in line with the individual’s values and social context – to ensure a safe and meaningful death. As such, attitudes toward the place-of-death criterion seem to be less related to the legal status of such practices in a given country, and more to the substantial and interactional approach regarding place of death (Sathiananthan et al., 2021).

One dominant notion that emerged in this study is related to freedom of choice – promoted by both assisted suicide and suicide tourism – even when medical alternatives exist, especially palliative care. Physicians, too, should benefit from such freedom, by being able to act within a legally and professionally safe environment and provide support for patients who wish to embark on suicide tourism or assisted death. Indeed, studies on both suicide tourism (Sperling, 2022) and on assisted suicide (Young et al., 2021) recognized an inherent paradox regarding the concept of personal choice: while these practices promote freedom of choice, individuals who choose to end their lives in this manner must then comply with the rigorous requirements of the facilitating organization. In some cases, this entails meeting a range of ableist, ageist and sanist criteria for eligibility (Baril, 2023), thereby fully dependent on other players (i.e., physicians and family members). While right-to-die organizations promote individual autonomy and choice, their actions are limited by social forces that impede such freedom (Gandsman, 2018). Moreover, even when patients are accepted by such organizations, and have received their medical file from their physician, they may still be limited by the organization’s requirement that their family members be involved in the process.

The findings of this study also suggest that freedom of choice is understood and interpreted from the individual’s perspective, with the assisted-dying organizations perceiving their potential clients as autonomous people who have the ability to make informed decisions. The same individualistic perspective is advanced by the media that is perceived as working "side-by-side" with them and sharing the same agenda. While the supportive role of the media in the field of assisted death and suicide tourism, as seen in this study – especially in Theme 2 – is in line with previous research (Carrigan, 2023; Young, 2017) – this study is novel as it also shows how the organizations actively leverage the media to promote their own agendas.

In addition to being based on an inadequate and rather blurry concept of autonomous decision-making at end-of-life – that may suffer from a substantial gap between its rhetoric and practice (Borgstrom, 2015; Drought & Koenig, 2002) – the findings of this study indicate that the activities promoted by the organizations and the care that they provide are of a relational nature (Borgstrom & Walter, 2015). Specifically, and as demonstrated in a previous study on declarations of right-to-die organizations (Inbadas et al., 2020), the participants did not speak of the important role of the family members, and their interactions with the individual seeking assisted suicide, in the shaping and re-constituting of the latter’s wish -to-die and other more general aspects relating to end-of-life decisions, including the desired place of death (Waghorn et al., 2011). Instead, with some organizations – as seen, for example, in the quotes of Q. and F. in Theme 4, family members are expected to simply support the individual’s already-made decisions and plans. When disagreements arise between the individual and the family members regarding end-of-life decisions, the former’s wishes are automatically muted. It appears that the organizations do not encourage fruitful discussions between these parties, let alone the reexamination of the individual’s wish-to-die within a relational and familial context. Furthermore, the contexts that have led the individuals to this point in time where they need to seek assisted dying and/or suicide tourism (i.e., their chronic illness and their great suffering) were not addressed by the participants in this study.

Through broad social movement, the topic of death and dying has been reclaimed as a social concern and responsibility (Sallnow et al., 2022). As seen in this study in general, and in Themes 1 and 2 in particular, the issue of esthetics of death has emerged as a current point of interest – following the increased public discourse on legitimate death and on the practice of suicide tourism (Blouin, 2018) and the actions of organizations that deal in end-of-life (especially regarding suicide tourism). A “good and peaceful death” is perceived as “looking death straight in the eye,” wanting it and choosing it. It challenges the death taboo and the denial of the death thesis, along with other social and historical contexts (Tradii & Robert, 2019) – thereby offering a new perspective on death and dying.

More evidently, suicide tourism may secure the safe witnessing of (the fantasy of) death from afar (through imagination, planning, and personal expectations, reflected in the notion of a touristic journey) – without actually being familiar with or having experienced it; this is akin to Michael (Jacobsen, 2016) proposed fifth phase to Philippe Ariès’s Admirable History of Death. Given the exclusivity of suicide tourism among individuals who have the knowledge and resources to participate in it, the findings of this research also help understand what Tony Walter coined as neo-modern death, i.e., the reinforcing of the prerogative to prioritize the personal choice of death-related narrative and practice (Hockey, 2007; Walter, 1994). More fundamentally, the phenomenon of suicide tourism, as explained by the participants in this study, represents Walter’s more recent conceptualization of post-materialism (or post-scarcity), referring to "the personally expressive values of people who enjoy post-industrial affluence and economic security – very different from the values of people struggling to survive" (Walter, 2017, p. 61).

Suicide tourism strives to enable an idealized death, peacefully contextualized and comprehensively established – following detailed arrangements and supported by an ideology of what Lyn Lofland (Lofland, 1978) coined the happy death movement. This is not only a description of how one dies, but also a normative call – as argued for by the participants in this study – to contemplate on how one should die (Zimmermann, 2007). Yet, as Zaman and colleagues (2017) argue, there should not necessarily be one single, global, and mandatory concept of what comprises a good death. Instead, due to the complexity and variety of components related to the concept of death – including value-system and cultural differences – we should seek a suite of solutions that promotes what is considered a good death.

The current study raises questions regarding the role and responsibility of right-to-die organizations within the context of suicide tourism. As argued by Lyn Lofland (1978), these organizations originally represented collective constructions of death and dying – mainly for those who lack resources or social support for negotiating death; yet today, those that partake in suicide tourism are acting under a neo-liberal governance and ideology, as they represent and promote the interests of individuals who have the social and material means to travel and receive aid-in-dying. Indeed, the findings of this study, especially under Theme 1, revealed the ambivalent attitudes of the organizations toward suicide tourism. Moreover, suicide tourism enhances discourse on assisted suicide and highlights the importance of the right-to-die, yet it is not free of criticism. A similar finding was observed in an earlier study on two organizations in the UK: While Dignity in Dying did not support Dignitas’ activities, which encouraged or assisted with suicide, and were critical of these activities being unregulated, FATE embraced Dignitas for promoting a lay (non-medicalized) model of assisted death (Richards, 2012). Regardless of this tension, the current findings suggest that there is no dispute regarding the role of these organizations in promoting related legislation and regulation, in order to better the individual’s choices at end-of-life. These findings reinforce the notion whereby death and dying are subject to and negotiated by body politics, thereby challenging a Foucauldian view that death is outside the power relations, constituting the end of power and biopower (Stepputat, 2016).

Additionally, the study addressed the relationships between organizations and the medical practitioners in relation to suicide tourism services. Interestingly, the findings revealed that physicians may not collaborate with individuals who require a medical opinion for being approved by an organization for assisted suicide – for fear of being prosecuted or due to their own ideology. A review of the medical files of patients who sought assisted suicide in Switzerland supports this finding: In many cases, the desire to seek assisted death was not disclosed to the physician, and even in cases where it could be assumed that the physician understood the reason behind the requested medical files, reports were written in a detached style, indicating reluctance to include such requests in the physicians’ practice (Imhof et al., 2011).

A second aspect of the relationship between right-to-die organizations and medical practitioners, as discussed in this study, refers to the perception whereby palliative care and assisted suicide are not two parallel and interchangeable alternatives. At first glance, right-to-die organizations may seem to share similar ideologies as hospices and palliative care movements – advocating for holistic and humanistic end-of-life care. Yet while some may perceive well-developed palliative care as a good alternative for people seeking assisted death or suicide tourism, the findings of this study, particularly those reflected in Theme 5, suggest tension between these options. On the one hand, these are in line with previous findings whereby proponents of assisted death question the ability of palliative care to alleviate suffering, arguing that such care could actually produce or increase suffering (Karsoho et al., 2016). On the other hand, they challenge other findings whereby voluntary assisted suicide may, in some circumstances, be offered to patients as part of palliative healthcare services (Auret et al., 2022) – providing these do not contradict one each other (Dierickx et al., 2018). Paradoxically, while the most developed palliative care provision can be found in higher-income countries (Zaman et al., 2017), it is people from these countries that tend to have the resources to travel for assisted death. This adds to other findings suggesting that individuals who become members of right-to-die organizations, and those who undertake assisted suicide, have higher social standing, education and socio-economic positions than the general population (Judd & Seale, 2011; Steck et al., 2014). This intensifies the equity problem that is inherent in suicide tourism (Sperling, 2024), which was also reflected in this study. Regardless of these problems and challenges, however, the findings of this study call for the reexamination of our understanding of death and dying in contemporary times, especially in light of the evolving phenomenon of suicide tourism and the concept of choice at end-of-life.

A number of limitations should be addressed. First, the interviews and selection of documents were conducted solely by the researcher. To overcome this limitation, the data were analyzed through a combination of sources, using a multi-layer approach to improve the validity of the findings and involving an additional researcher in the analysis process. Second, purposeful and snowball sampling were used in this study. Although these are common and accepted sampling methods in qualitative research improving the rigor of the study (Campbell et al., 2020), future research could benefit from recruiting additional respondents, possibly with different views, through additional means. Finally, additional research on the themes and issues that emerged in this study is needed, to achieve a greater understanding of the phenomenon of suicide tourism and its relationship with the right-to-die concept.

Acknowledgments

The author would like to thank Ms. Grace Qamar, RN, M.A. for her assistance with the data analysis for this research.

Disclosure statement

The author has no competing interests to declare.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Annex 1.

Interview guide

1. Please introduce yourself, your affiliation and your professional background.

2. Please tell me about your role in the organization.

3. How do you define suicide tourism?

4. How is suicide tourism perceived by your organization?

5. How is suicide tourism perceived in your country?

6. In your view, how does the medical profession in your country regard suicide tourism?

7. In your view, how do politicians in your country regard suicide tourism? Do you recall any Parliament members referring to this phenomenon recently?

8. How do you personally regard the phenomenon of suicide tourism?

9. Are there any other destinations other than Switzerland to which residents of your country travel to receive aid in dying?

10. In my other discussions, I noticed that suicide tourism did not play a significant role in liberalizing the law in the UK and perhaps also in France and Germany. Can you reflect on that? Why do you think this was the case?

11. How would you describe your experience with the current legal status of assisted suicide in your country?

12. Where do you anticipate the system would be in 10 years from today?

13. Who else would you recommend that I speak to on this subject?

14. Do you have other things issues that you would like to raise?