One-way ticket to Zürich: presentations of ‘Suicide tourism’ in European news media

ABSTRACT

In recent years, stories of individuals travelling to Switzerland for an assisted death have been the subject of a notable number of news reports, particularly in the UK, giving the impression that this is largely a British practice. Coverage of individuals undertaking this journey, colloquially known as ‘suicide tourists’, frequently features in newspaper media in other European countries however, presented as a rousing reminder of the incongruity between the modern desire for greater choice over one’s death, and the law on assisted suicide making this practice a crime in all but a few European nations. In this mixed-methods study I explore the framing of suicide tourism in the newspaper media of four Western European countries between 2002 and 2021. A quantitative analysis of trends in reporting was carried out initially, complemented by a qualitative thematic analysis of news stories using a critical discourse framework. Four themes indicative of a wider ‘European’ discourse employing common frames, language, and meaning were identified: 1/suicide tourism as an individual choice grounded on a desire for autonomy and self-determination 2/Dignitas as an ‘emergency exit’ 3/the law on assisted suicide as outdated and coercive, and 4/dying in Switzerland as a ‘good death’.

KEYWORDS:

• Suicide tourism
• news media
• assisted suicide
• right-to-die
• Europe

Introduction

By the time you read this I will be dead. On Thursday 7^th February 2019, I will have taken medication that will end my life, surrounded by my wife, Ann, my children, Alix and Dominic, and a couple of my dearest friends at the Dignitas facility in Switzerland. With their love and support I have been able to fulfil my final wish: to be in control of my end, rather than endure the immense suffering motor neuron disease had in store for me. (Dignity in Dying UK, 2019a)

These were the words of Geoffrey Whaley, a retired accountant from Buckinghamshire, written in an open letter addressed to MPs of the British Parliament before his assisted death at the Dignitas clinic, located on a verdant mountain pass just outside Zürich. The letter calls for an urgent change in the British law on assisted dying to allow those at the end of life to ‘be in control of their end’ and highlighted the ‘hypocrisy and cruelty’ of a law which punishes family members for assisting a loved one to die. Mr Whaley’s case is representative of the broader debate around assisted dying in Europe, particularly the framing of this issue as hinging on the tension between ‘an individual’s right to determine the time and manner of his or her death versus the state’s interest in prohibiting or regulating this right’ (Tierney, 2010, p. 384), and the presentation of suicide tourism as a last resort, or the only choice available to some terminally ill individuals to prevent unnecessary suffering.

The expression ‘suicide tourism’ was purportedly coined by the attorney general of Zürich in 1999 who asked Ludwig Minelli, the founder of Dignitas: ‘why do you import these strangers?’ (Minelli, Le Monde, 25 May 2008). Since then, this term has grown in popularity, particularly in the media, where it is used to refer broadly to travelling to Switzerland for an assisted death. While this term has been popularised as such, this practice has little to do with tourism in the common sense of the term however, in which questions of mobility, leisure, and mass-movements are at the fore, but is a ‘one-of-a-kind’ event which may be more appropriately characterised as a limit case of medical tourism.

In the last two decades, the desire for a change in the law to allow terminally ill persons to gain access to assisted dying has seen a growing public acceptance in many Western European countries. Opinion polls carried out in France, Spain, and the U.K have shown that 96% (Association pour le Droit de Mourir dans la Dignité [ADMD], 2019), 86% (Fita, 2018) and 84% (Dignity in Dying UK, 2019b; Ipsos, 2018) of citizens respectively are in favour of legalising assisted suicide in their own countries. In Europe, physician-assisted suicide – in which a doctor prescribes a lethal drug which must be self-administered by the patient – is at present authorised in Austria, Belgium, Luxembourg, the Netherlands, Spain, and Switzerland. Furthermore, voluntary euthanasia – in which a doctor him/herself administers lethal drugs at the request of a qualified patient – is lawful in Belgium, Luxembourg, the Netherlands, and Spain (Chapple et al., 2006). Assisting suicide is illegal in every other European country and may be punishable by up to 14 years imprisonment. By contrast, the right to refuse or withdraw medical treatment is broadly respected in Europe (Counsel of Europe, 1997). This asymmetrical legal landscape, bolstered by freedom of movement within the European Union and the galloping rise of individuals entering the fourth age, has created fertile soil for the debate over assisted dying in recent times. Within this context, discussions as to the desire for wider individual autonomy at the end of life and the moral and ethical challenges of legalising assisted suicide have become increasingly prominent, seen as a pressing issue for the future of end-of-life care in an ageing Europe.

Since the late 1990’s, following the opening of the Dignitas clinic near Zürich – the first organisation of its kind to allow non-nationals to access assisted suicide outside of their home country – Switzerland has played a central role in this debate; so much so in fact, that, at least in the UK, ‘going to Switzerland’ has become a euphemism for assisted suicide (Gauthier et al., 2014, p. 611). Unlike Belgium and the Netherlands where euthanasia has been legalised through the courts, in Switzerland assisted suicide is regulated by a ‘negative law’, in other words it is considered a crime only if the motives for assistance are ‘selfish’ (Stravianakis, 2017, p. 6). This lack of positive criteria stipulating the legality of assisted dying has led to the establishment of lay organisations offering aid in dying to foreign nationals in the last 20 years. Three such organisations are presently active in Switzerland: Dignitas near Zürich; Lifecircle near Basel; and Pegasos near Basel. Pegasos, founded in August 2019 and the latest to open its doors, has indicated the growing international demand, the need to simplify the red tape process, the reduction of waiting times, and offering a service for foreigners in English as motives for its foundation (Pegasos, 2019).

Further, in the last decade the number of Europeans travelling to Switzerland for an assisted suicide has more than doubled (Dignitas, 2020). This rise has been commonly attributed to the effective activism of right-to-die groups (Gauthier et al., 2014; Johnstone, 2013), the significant attention received by suicide tourists in the media (Chapple et al., 2006; Richards, 2017), and the entering of the baby-boomer generation – for whom values of individual freedom and self-determination have been historically significant – into the third age (Hazan, 2011; Judd & Seale, 2011; Laslett, 1996). Whereas only 14% of suicide tourists who end up travelling to Dignitas are British residents, most of the studies exploring this practice outside of Switzerland (Fischer et al., 2008; Gauthier et al., 2014) have focused exclusively on the United Kingdom (Richards, 2015, 2017). Meanwhile the large majority of these ‘tourists’ travel from Germany, France, Spain, Austria, Italy, as well as several non-European countries (Dignitas, 2020). In this preliminary mixed-methods study, I attempt to map out the presentation of this issue in the printed news media of four Western European countries (France, the Republic of Ireland, Spain, and the U.K,). In doing so, I provide an initial examination of trends in reporting in these countries, widening the scope beyond the U.K, as well as providing a first comparative discourse analysis of the themes, language, and frames used in these different territories.

Assisted dying in the media

In contemporary Europe researchers observe tendencies that experiences of dying have become predominantly individualised and private (Hanush, 2010; Walter, 1991, 1994). As Kitch and Hume (2008) have noted: ‘the mediated sharing of the stories of strangers’ deaths may be the most common death experience in modern culture’ (p. xvii). Whereas contemporary media representations of death and dying commonly feature so-called ‘exceptional deaths’ such as the death of celebrities, politicians, and victims of violence and war,¹ stories of lay individuals dying by assisted suicide and euthanasia have become increasingly prevalent as subjects of media attention (Glick & Hutchinson, 1999; Haider-Markel & Joslyn, 2004; Kalwinsky, 1998). Furthermore, news reports of a ‘notable minority’ (Chapple et al., 2006, p. 708) of individuals opting for an assisted suicide abroad and residing in countries where this is not a legal option have also become increasingly visible in media reports (Hausmann, 2004; Richards, 2017). Through the mediatised stories of the deaths of such individuals, the media thus holds an influential position on the public perception of suicide tourism as well as the institutional and policy frames used to discuss and make decisions concerning its regulation (Cottle, 2009; Sumiala, 2012).

Studies focusing on media representations of euthanasia and physician-assisted suicide have illustrated how the mainstream media tend to construct a supportive stance towards assisted dying by consistently employing notions of individual choice and personal autonomy, for instance by depicting dying persons as independent, autonomous, and self-determined, by idealised portrayals of family relations, and by the praising of judges involved in assisted suicide cases for their lenient verdicts (Birenbaum-Carmeli et al., 2006, p. 2153; Kalwinsky, 1998; Smith, 1994; Somerville, 1997). Elke Hausmann (2004), in her investigation of presentations of euthanasia in British newspapers, further identified two underlying discourses around which such stories are organised: the voluntary euthanasia discourse - in which voluntariness legitimates euthanasia by presenting it as an individual choice – and the terminal illness discourse in which terminal illness is used as the marker which legitimates euthanasia. She posits that while ‘euthanasia cases that involve terminal illness are presented as ‘tragic’, the absence of terminal illness in cases that invoke euthanasia inspires the press to present them as ‘criminal’ (Hausmann, 2004, p. 211). Furthermore, ‘euthanasia cases where both choice and terminal illness are present are doubly legitimated by the press’ (Hausmann, 2004). This is a significant observation illustrating the positive yet ambiguous double stance of the media on stories about assisted dying, particularly its construction of the subjects of this practice both as victims and as potential criminals depending on the context.

Dignitas in the media

In the last 20 years, the Dignitas clinic has been at the centre of the vast majority of stories relating to suicide tourism, particularly in the British tabloids (Richards, 2017). Depictions of Dignitas have varied considerably since its opening in 1998, ranging from gory characterisations of it as a ‘killing factory’ (The Sun, 17 April 2003) to idyllic headlines such as ‘With a smile on his face to Beethoven’s Ode to Joy, terminally ill man ended his life today at the Dignitas clinic’ (The Daily Mail, 14 August 2015). Between 2007 and 2010 Dignitas was involved in a series of highly mediatised scandals, including losing its headquarters in Zürich after ‘complaints of unsightly coffins in the elevators’ (The Daily Mail, 27 September 2007) and carrying out some of its assisted suicides in a car park, which the tabloid newspapers portrayed as ‘a suicide clinic going mobile’ (The Daily Mail, 9 November 2007). In 2010, a scandal concerning a large number of urns which had been ‘dumped in a lake’ (The Sun, 10 May 2010) by Dignitas also caused moral outrage, leading the media to speculate as to the unregulated and immoral practices of this volunteer organisation.

Perhaps due to these media-led scandals, and the subsequent drop in the number of foreigners travelling to Dignitas between 2007 and 2010 (pre-2010 numbers only returned after 2012, after which a steady rise has been observed), it is broadly accepted that suicide tourism – and Dignitas in particular – is portrayed in a negative light by the press (Hall, 2009; Richards, 2015; Weathers, 2011). Counter to this assumption, the present study provides evidence that at least since 2011, positive and hopeful news accounts of suicide tourism have come to dominate the European newspaper media.

Materials and methods

Sampling

When choosing the newspapers for each country, criteria such as readership, ranking, and national sales were considered. This was done with the intention of focusing on stories reaching the greatest number of individuals nationally, and those most likely to be leading the dominant discourse on the subject. News sources included printed newspapers and their online counterparts. Other news media such as printed magazines, radio, television, or social media were excluded from the study due partly to the constraints of the software used (NexisUni) and to a desire to remain within the same textual medium and level of semiotic ‘openness’ (Eco, 1979), facilitating comparisons between the data sets. While initially the intention was to study three nation-wide newspapers per country, the presence of a large number of local news sources in Spain and of tabloid newspapers reporting on the issue in the U.K led to the choice of two and four newspapers in these countries respectively. The inclusion of the U.K was chosen as a focal point of comparison to the three other countries due to its history of public debate on the right-to-die, the relatively large mediatic presence of British individuals travelling to Switzerland for an assisted death, and for being the only country where academic studies have been carried out. France was chosen as representative of a large continental European country, and the third most common nationality of persons travelling to Switzerland for an assisted death. Finally, Spain and the Republic of Ireland were chosen as countries actively involved in the debate over assisted dying within the last two decades . To a lesser extent their inclusion was deemed valuable for exploring whether cultural and linguistic differences and the historical involvement of the Catholic church in political decisions could be influencing the discursive frames used to characterise this controversial practice in the media.

Methods

To quantify media interest over time, news items published in major national newspapers in each country and spanning a period of 19 years from 2002 to 2021 were analysed and plotted. The NexisUni software (previously known as LexisNexis) was used to search for news items. LexisNexis has been consistently shown to give access to such a wide coverage of national and regional newspapers, including the most well-known and influential titles, and the majority of those with the highest circulation, that a sample of newspaper articles derived from LexisNexis for a 12-month period can be regarded as adequately representational of newspaper coverage for that period (Hausmann, 2004, p. 220). Search terms were designed to include diverse grammatical and linguistic variations (e.g tourisme de la mort, aide au suicide, mort choisie in French; turismo de eutanasia, muerte digna in Spanish), synonyms (euthanasia tourism, death tourism, assisted suicide abroad, suicide travel etc.) as well as articles mentioning Dignitas, Lifecircle, and Pegasos specifically.

A total of 615 news items in France,² the Republic of Ireland,³ Spain,⁴ and the U.K,⁵ were collected. All articles were pre-screened for thematic relevance, and only those where suicide tourism to Switzerland was explicitly discussed were considered for analysis. 232 articles were disqualified, including reports on related topics, duplicates, and articles shorter than 200 words. 383 relevant results were coded into SPSS (variables: newspaper, date, page, country, no. of words, incident, main theme, subtheme), which served as the basis for the subsequent analysis. Narratives which were used as ‘schemes’ or ‘templates’ (Fairclough, 2010) were identified and compared according to the number of references made to them. Text fragments referring to specific actions and explanations, as well as discursive themes, key points, metaphors, and omissions (Gitlin, 1980; Kalwinsky, 1998; Kitzinger, 2000) were then coded using a critical discourse analysis (CDA) framework in order to determine content and discourse, as well as to typify both literal and implicit meanings (Brown & Cuijpers, 2016). The codes generated were finally compared to reveal core themes. This thematic analysis was inspired by Richardson’s (2007) and Fairclough’s (1995) multifunctional framework of doing critical discourse analysis (Fairclough, 1995, p. 7) in which textual forms at all levels of organisations are regarded as relevant. In particular, Fairclough’s grounding of discourse analysis on the works of Michel Foucault (1972) in which discourse is understood as both representative and generative of socially-constructed knowledge through language, was particularly useful. Mixed-methods analyses such as the one used here have been shown to enhance the internal validity of results in several studies of representations of healthcare issues in the mainstream media (Brown & Cuijpers, 2016; Musso & Wakefield, 2009; Seale, 2002). These studies have previously combined quantification of numbers of articles and quantification of themes, drawing on insights from critical discourse analysis to elicit thematic representation of dominant voices and discourse in news media coverage.

Findings

Quantitative analyses

Between 2002 and 2021, 383 unique search results were found across the four countries. Visualizing the results over time, a broad non-linear increase in the overall reporting of suicide tourism can be observed. An alpha (α) constant was used to calculate the interval average between the data points and to allow for easier recognition of trends and cycles. Alpha (α) is a constant used to smooth out fluctuations in a series of data. It ranges from 0 to 1 and represents a moving average, or a series of numbers each of which stands for the mean of a specified interval. Trends in reporting of suicide tourism can be observed to remain relatively low and stable since 2002, with peaks in reporting resulting predominantly from personal stories of individuals making this journey, their (or their family members’) involvement in court cases, and proposals to change the law on assisted dying. Between 2014 and 2016 a peak in media interest can be identified in France, the Republic of Ireland, and the U.K (see Figure 1), with a significantly growing interest continuing in the U.K thereafter.

Figure 1. Coverage of suicide tourism in national newspapers in the U.K, France, Spain, and the Republic of Ireland. Number of articles shown per half year between 2002 and 2021, α= 0.1.

Noteworthy peaks in media interest, defined by the number of articles published on a specific event or individual over the course of a month included:

1. May 2003 (UK). Death of Jenny and Bob Stokes, neither of whom suffered from a terminal illness, at the Dignitas clinic.

2. February 2005 (Spain). Interview with Jerome Sobel – president of Exit Suisse Romande – in El País, in which he made the controversial statement: ‘God has given us life as well as freedom’

3. July 2009 (Spain). Debbie Purdy wins the right to clarify the law on assisted suicide regarding the prosecution of her husband at the House of Lords in the UK, claiming it was a violation of her human rights.

4. June 2011 (UK). Release of Terry Pratchett’s Choosing to Die documentary showing the death of Australian businessman Peter Smedley at Dignitas.

5. June 2013 (Rep. of Ireland). Marie Fleming, an Irish national, decides to travel to Switzerland to die aided by her husband.

6. January 2015 (France). Proposal of the Claeys-Leonetti law offering terminal sedation to persons at the end of life. Harry Roselmack documentary on euthanasia and end-of-life choices is released in France.

7. April 2015 (Rep. of Ireland). Acquittal of Gail O’Rourke, who helped her friend Bernadette Forde plan an assisted suicide in Switzerland.

8. August 2015 (UK). Assisted suicide campaigner Bob Cole dies at the Dignitas clinic.

9. March 2018 (UK). Parliament to vote on bill to legalise assisted suicide in Guernsey, U.K.

10. September 2019 (UK). Richard Selley, former teacher and right-to-die campaigner ends his life in Switzerland.

It should be noted that whilst some of the peaks in reporting selected above concerned stories of suicide tourists from the country in question, generally reports on this phenomenon concerned British individuals undertaking this journey, suggesting that the U.K may be acting as frame of reference for media discourse on this issue and reinforcing the belief that this is largely a British practice.

Qualitative thematic analyses

Four dominant themes reflecting prevailing attitudes to suicide tourism and indicative of a common ‘European’ discourse were identified: 1/suicide tourism as a choice grounded on a desire for autonomy and self-determination 2/Dignitas as an ‘emergency exit’ 3/the law on assisted suicide as outdated and coercive and 4/dying in Switzerland as a ‘good death’. Attempts to identify thematic or cultural differences in reporting between the countries did not yield any significant results. The frames used to characterise suicide tourism were consistent across all four countries and tended to closely mirror those used by the British media.

1/Suicide tourism as a choice grounded on a desire for autonomy and self-determination

The discourse of suicide tourism as a choice anchored on a desire for autonomy and self-determination was the most dominant theme found across all four countries. The decision to travel to Switzerland for an assisted suicide was routinely presented in press reports as stemming from an individual’s desire to do his or her will against outside interference, to control illness outcomes, and more substantively as the result of a process of reasoning in which the individual makes decisions on the basis of their personal convictions, desires, and values. Allusions to a desire to ‘have one’s way’ were also common, while the opinion of family, friends, or carers were often side-lined, and made to appear as if they would not have mattered either way.

He was in a lot of pain…we accepted his decision to die. It wouldn’t have made any difference (if we hadn’t) anyway. He had made his mind up. Mrs Cole said she could imagine her brother-in-law holding up his lethal drink in the clinic, putting two fingers up to everybody and saying, ‘I did it my way’. (Scottish Daily Mail, 15 August 2015)

In many cases, this kind of obstinate self-determination was presented as an enduring trait of character. Individuals choosing to end their lives abroad were typically characterised as ‘independent’, ‘determined’ and ‘proud’ and therefore likely to make this choice despite possible obstacles such as illegality or social stigma.

Self-determination was so important to her. Control of her own life and destiny is what she fought for throughout her life. It was no great surprise when mum told me that she wanted to be helped die. (Irish Daily Mail, 22 February 2014)

Conversely, this focus on self-determination, bolstered by allusions to a previously active and healthy life, were commonly contrasted with graphic descriptions of present loss, infirmity, and dependency. This constructed the body as a place of conflict and shame and furthermore as a vehicle for the dissolution of self-identity, which justified the desire to hasten death, as illustrated by the following passages:

She said her son was once a ‘big, fit, healthy boy’ who went training four times a week. He was reportedly paralysed in a swimming accident three years ago. ‘His life was terrible. He suffered every single day. He couldn’t do anything for himself but sit there. He was just a head and just didn’t want to be like that anymore’. (The Guardian, 15 July 2011)

Before his illness, the retired lecturer was a keen hiker and cyclist, but the disease has left him dependent on a ventilator to breathe at night and struggle to move, dress and feed himself. (The Mirror, 6 January 2017)

Birenbaum-Carmeli et al. have identified this strategy of suggesting ‘a drastic transformation rather than a gradual degeneration’ as a narrative device used by journalists to construct assisted suicide stories around a simplified binary model of mind vs. body and health vs. disease (Birenbaum-Carmeli et al., 2006, p. 2157). This, they argue, serves the purpose of highlighting mental suffering by comparing a current state of indignity with a previously youthful and healthy lifestyle, constituting suicide as a ‘release’ or a freeing of one’s ‘trapped self’ from a failing body (Birenbaum-Carmeli et al., 2006).

Although journalists placed great emphasis on the wish and determination of individuals to seek an assisted suicide as being arrived at only by themselves, family members were revealed in other instances as having been intimately involved in planning the trip. Whereas assisting in such a decision may carry serious legal repercussions for them, family members were almost always depicted as selfless and supportive, seeing the risks as worth it when it came to guaranteeing their loved ones did not suffer needlessly:

[…] you don’t relax until the aeroplane doors are closed. And not because of the consequences for Scott and I, if they arrested us, we’d cope with it, but because it would scupper the plan and Dad would go on suffering. (The Mirror, 26 May 2018)

On the other hand, the need to hide the decision due to a fear of being caught, and the feeling of being a ‘fugitive’ was presented as incurring significant emotional and physical stress for both individuals and their loved ones, who felt that they were unfairly forced to behave like criminals due to the illegality of this practice.

You are on pins and even getting to the airport was a nightmare because the law here can stop you leaving the country and you can be arrested. Because of this, we hired a car so that our car couldn’t be followed or tracked to the airport, this is the lengths that the law drives you to. (The Mirror, 25 May 2018)

A conceptual variant of the choice to travel abroad to die as a desire for self-determination was that of choice as a legal ‘right’. The ability to choose the timing and manner of one’s death was commonly presented as an inalienable human right, which the state has a moral right to uphold if it is to protect individual freedom.

A dignified death should be the greatest human right (The Sun, 18 August 2015).

Minelli says that his group lets people exercise ‘the last human right: the ability to decide how and when somebody would like to end one’s own life’. (The Guardian, 22 June 2009)

In this sense, the ‘right to die’ was presented as an extension of the right to self-determination and furthermore as a specific subclass of moral rights belonging equally and unconditionally to all human beings, ‘simply in virtue of their being human’ (Sperling, 2019, p. 93). This stance reflects the discourse of right-to-die advocacy groups, whose publications commonly allude to the illegality of assisting suicide as a violation of a human’s right to self-determination.

2/Dignitas as an ‘emergency exit’

The characterisation of Dignitas and other assisted suicide clinics as an ‘emergency exit’, a ‘plan B’ or a ‘security blanket’ was identified as a second dominant theme. The idea of having a contingency plan or an escape strategy in case suffering became unbearable was depicted as providing an important barrier to the psychological suffering, uncertainty, and anxiety which often accompanies the end of life.

People don’t understand the value of having a Plan B (the capacity to decide where, when, and how to die). I suffer a constant and extreme mental anxiety knowing that I don’t have a plan, a realistic escape route for the moment when life becomes unbearable, as will certainly happen. (El País, 30 January 2012)

The idea that the Swiss assisted suicide clinics act as an ‘escape plan’ is consistent with Minelli’s claim that out of one hundred people who receive the green light from Dignitas, only 12% end up going there, while 70% never call back (Prosinger & Thomma, 2008). ‘When they know that the emergency exit is available, individuals feel more at ease, they are less fearful’ (Ludwig Minelli, Le Monde, 25 May 2008). Richards and Rotter have recently suggested that choosing to die at a Swiss organisation offers people a means to reduce uncertainty by allowing death to be anchored in a specific time and place, in other words, that it allows ‘[individuals’] negative preoccupation with an unknown future to cede to a more concrete vision of an alternative future’ (Richards & Rotter, 2013, p. 11). Consistently with their observation, media reports were found to present this rationale as a decisive factor justifying suicide tourists’ decision to travel abroad for an assisted suicide.

3/The law on assisted suicide as outdated and coercive

The idea that the law and politicians are to blame for the unjust suffering of the terminally ill, as well as forcing people to travel abroad to die was a third shared constitutive theme. Depictions of the law as outdated and in drastic need of change, mirroring the political stance of the right-to-die movement, were common. These were the words of British author Terry Pratchett in an interview for BBC Breakfast, where he described his involvement in the 2011 documentary Choosing to Die in which he accompanied a man suffering from motor neurone disease to Dignitas:

The government here has always turned its back on it [assisted suicide] and I was ashamed that British people had to drag themselves to Switzerland, at considerable cost, in order to get the services they were hoping for. (The Guardian, 14 June 2011)

In another interview he cited Peter Smedely, the protagonist of the documentary, as follows:

He didn’t like the ‘nanny state’ keeping people alive when they are really ill and in pain. He thought every adult is entitled to make their own decision. (The Guardian, 13 March 2010)

By suggesting an untenable tension between individual autonomy and the paternalism of the state, the law on assisted suicide was frequently characterised by the news media as coercive and unfair, and as an obstacle standing in the way of a good death. In many cases, public polls were presented as a means to highlight this disparity between public attitudes and that of politicians and policymakers, and consequently the pressing need for change. In others, society at large was blamed for foregoing its responsibility to protect its citizens.

In practically all European countries, many signs indicate that the prevailing legal system no longer reflects the will of large parts of the population on this issue. (Irish Daily Mail, 30 November 2012)

The law has failed me. Society has failed me. The law must be changed. (El País, 30 January 2012)

An important component of this frame was that of the law as ‘forcing’ people to travel to Switzerland against their wishes. In this framing, the intended understanding was that suicide tourism was a ‘forced choice’ rather than a free one, justified by the fact that individuals would have preferred to die at home.

‘All he wanted was to die in the garden he cherished so much’ said Anne. Instead, he was forced to travel to a foreign place with no meaning to him. He always said he wanted to die in Blighty. (Daily Mirror, 2 October 2012)

Once more, the stark contrast drawn between the coercive nature of the law and the desire for personal freedom and self-determination was a dichotomy used by journalists to create the illusion that these are the only two possibilities available to dying persons – unbearable suffering or being forced to travel to Switzerland. Notably, other end-of-life options such as hospice and palliative care were almost entirely omitted in newspaper reports of suicide tourism. This presentation of the law on assisted suicide as coercive and forceful was furthermore shared by all news sources analysed, regardless of territory, or whether they targeted a prominently liberal centre left (The Guardian, Le Monde, The Irish Times), centre-right leaning (El Mundo) or more popular (The Daily Mail, The Irish Daily Mail, The Sun) audience.

4/Dying in Switzerland as a ‘good death’

A fourth key theme, and the logical conclusion of making the self-determined choice to travel abroad for an assisted suicide, was the characterisation of this practice as being ultimately rewarded with a good death. Since 2011, only three reports presenting Dignitas or other assisted suicide clinics in a negative light were identified. Rather, the vast majority of news stories depicted dying in Switzerland as ‘painless’, ‘peaceful’ and as a ‘good death’.

Helen Cowie, of Glasgow, told the show her son, who was paralysed from the neck down, had ‘had a very peaceful ending’ and the experience had been “wonderful, relaxed, peaceful and happy. (The Guardian, 15 July 2010)

After having absorbed the lethal drink, Fabienne Bidaux died at 12:40pm, ‘serene, relieved, and smiling, surrounded by people who loved her’. Her mother was holding her hand, I held the other, she fell asleep, and it ended just like that, as she had wished. Maybe it wasn’t a happy moment, but it was a good death. (Le Monde, 10 March 2015)

This image of dying ‘peacefully’ and ‘as one had wished’ illustrates the intended parallels between this kind of death abroad and the Western ideal of a ‘good death’ as ‘peaceful and dignified, free from pain and other distressing physical symptoms’ (Cottrell & Duggleby, 2016, p. 687). Further, the gesture of a slipping out of life ‘with a smile of one’s face’ was used to highlight the ultimate victory over all obstacles encountered in the realisation of an assisted death abroad, such as the law, the state, the fear of not being able to travel, or not getting the ‘green light’ from the clinics. The depictions of dying in Switzerland as the achievement of a good death further support the tendency of the media to present acts of assisted dying in a positive light and legitimate the place-making of Switzerland as a country for a ‘good death’ and a liberal death ‘haven’.

The question of terminal illness

Even though this was not found to be a discrete dominant theme, the question of terminal illness permeated stories of suicide tourism as a significant factor guiding the presentation of the desire for euthanasia as either rational or morally dubious. At a social level, assisting someone who was not terminally ill to die was depicted as an abandonment of that person by society, in particular the healthcare system, whilst on a moral level the absence of a life-threatening illness was thought to challenge the sanctity of life and the ethical responsibility to protect it.

I don’t want to see assisted suicide legalised for people who are disabled but not dying because morally that’s a different thing. With the right care and support someone with tetraplegia, for example, can find quality and meaning in life. (The Guardian, 22 June 2009)

This observation is consistent with Shai Lavi’s remark that ‘it is the combined occurrence of pain and hopelessness alone that can justify the practice of euthanasia’ (Lavi, 2005, p. 43), and supports Elke Hausmann’s observation regarding the terminal illness discourse as an organising principle in mediatised stories about assisted dying (Hausmann, 2004). Furthermore, the idea that terminal illness was the only factor which could morally justify helping someone to end their lives was notably defended not only by right-to-life groups such as Care not Killing, but also by several prominent right-to-die organisations such as Dignity in Dying UK.

Discussion

The results of this study characterise the multi-faceted, ambiguous, and often contradictory presentation of suicide tourism in the Western European press, and broadens our understanding of the discourse on this topic outside of the U.K. Travelling abroad for an assisted suicide was commonly portrayed in press reports as the result of two opposing rationalities: positively as an individual choice grounded on a desire for autonomy and self-determination, and negatively as a ‘forced’ choice stemming from the state of the law on assisted suicide which prohibits access in one’s own country. The mainstream news media tended to present a broadly one-sided view of the law on assisted suicide as outdated and unjust, coercing vulnerable people and their families to become criminals in order to avoid unnecessary suffering. The criminal and clandestine nature of travelling abroad for an assisted suicide was found to be a unique feature of media presentations of suicide tourism distinguishing it from other forms of assisted dying such as euthanasia. Conversely, the illegality of travelling to Switzerland for an assisted death was often played down, justified by the lack of prosecution of these cases, giving the impression that one could ‘get away’ with it even if the law prohibited it. Finally, travelling to Switzerland for an assisted death was characterised as providing individuals with a peaceful and dignified end, leading to the place-making of Switzerland as a country for a ‘good death’. This latter construal may be problematic for several reasons, including the media idealisation of secularised and medicalised discourses surrounding the ‘good death’, and the association of Switzerland as a liberal ‘haven’, in this case a ‘death haven’ where individuals can escape to bypass the laws and regulations of their own countries.

This study supports previous research on media representations of assisted dying and euthanasia, particularly the privileging of the discourse of choice, autonomy and self-determination, the positive bias presented by journalists towards this practice, and the omission of opposing voices such as those of the right-to-life, palliative care, and disability rights movements. Evidence of the terminal illness discourse and the voluntary euthanasia discourse identified by Hausmann (2004) were also found to act as organising narratives in press reports of suicide tourism, supporting the conceptual link between the presence of terminal illness as encouraging the media to present cases as ‘tragic’ as opposed to ‘criminal’, and the insistence on individual choice as the prime justifying principle for a desire to hasten death abroad.

This study contributes to the literature on suicide tourism by providing a novel characterisation of this practice in the newspaper media of four Western European countries and suggesting the existence of a wider ‘European’ discourse – broadly mirroring that presented by the British media – in the sharing of frames, themes, and narrative schemes regardless of linguistic, cultural, and historic differences. This suggests a strong transference of frames across national boundaries and, potentially, the dominant influence of the British discourse on the debate over suicide tourism and the right-to-die across Western Europe. Its originality lies furthermore in the preliminary analysis of trends in reporting of suicide tourism in several major Western European newspapers since the turn of the millennium, revealing a broad increase in media interest in three out of the four countries studied, and a case-by-case trend leading to peaks in reporting rather than an exponential progression.

An intriguing exception to these trends in reporting was observed in the Spanish press, where media reports were found to cease almost entirely since 2012. Reasons for this may be attributed to the lower number of news sources selected for analysis and undefined cultural factors. A journalist for El País described the hesitancy to publicly discuss assisted dying in Spain as having partly to do with its illegality: ‘Logically, there hasn’t been the diffusion of cases of people seeking assisted suicide or euthanasia that one would expect, as both of these are considered crimes in Spain. The absence of strong polemics in Spain does not mean, however, that these stories have not touched Spanish minds.’ (El País, 15 June 2011). Carmen Vazquez, the president of Derecho a Morir Dignamente further attributed this media silence to the widespread knowledge of a patient’s right to refuse treatment, and the availability of several ‘soft’ forms of euthanasia in Spain: ‘[Euthanasia] is a common reality. We don’t speak about it because it’s a crime in Spain and there are many religious prejudices, but it happens. I myself know three people who will undergo euthanasia in Spain in the next few months.’ (El Mundo, 5 October 2003).

This paucity of recent media interest in Spain is particularly striking given that, out of the four countries studied, it is the only one to have legalised assisted dying, doing so in March of 2021 (De Benito, 2021). These findings broadly suggest that media interest in suicide tourism may not reflect a public and political impetus for legalisation of assisted dying but may be indicative of the contrary; that is, of a felt lack of real end-of-life options and a general feeling of frustration with politicians not doing more to change the law. This tenuous correlation may also be the result of the influential presence of tabloid newspapers in the U.K and the Republic of Ireland for whom the topic of suicide tourism is an attractive one, however, and so remains a questionable hypothesis within the scope of this paper. Future studies could fruitfully explore this issue, as well as further validate some of the initial assumptions drawn here regarding a common ‘European’ framing of suicide tourism in news media reports by the inclusion of other relevant territories including Germany and Italy.

Acknowledgments

The author would like to acknowledge the kind reading of this manuscript by Patrick Brown and Stuart Blume.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Fonds de Recherche du Québec Société et Culture under Grant number [272510].

Notes on contributors

Kalima Carrigan

Kalima Carrigan is a PhD student in the Political Sociology programme group at the Amsterdam Institute of Social Sciences Research (AISSR) and the University of Amsterdam. Her research focuses on suicide tourism to Switzerland, end-of-life choice, and biographical methods.

Notes

1. An obvious exception to this has been the recent global spread of the COVID-19 pandemic.

2. N = 90; news articles, editorials, and letters to the editor published in Le Figaro, Le Monde, Le Parisien

3. N = 137; news articles, editorials, and letters to the editor published in Irish Daily Mail, Irish Independent, Irish Times

4. N = 61; news articles, editorials, and letters to the editor published in El Mundo, El País

5. N = 327; news articles, editorials, and letters to the editor published in The Daily Mail (including the Scottish Daily Mail), The Guardian, The Mirror, The Sun