An essay by Derek Humphry

The movement for choice in dying is dedicated to the view that there are at least two forms of suicide. One is 'emotional suicide', or irrational self-murder, in all of it complexities and sadness. Let me emphasize at once that my view of this tragic form of self-destruction is the same as that of the suicide intervention movement and the rest of society, which is to prevent it wherever possible. I do not encourage any form of suicide for mental health or emotional reasons. Nevertheless, life is a personal responsibility and we know some people are so tormented that they cannot bear to live. In such circumstances, understanding is called for.

I believe that there is a second form of suicide -- justifiable suicide, which is rational and planned deliverance from a painful and hopeless disease. I don't think the word 'suicide' sits too well in this context but we are stuck with it. I have struggled for twenty years to popularize the term 'self-deliverance' but it is an uphill battle with a news media which is in love with the words 'assisted suicide' and 'suicide.' They are headline grabbers. Also, we have to face the fact that the law calls all forms of self-destruction 'suicide.' Additionally, all medical journals today refer to 'assisted suicide' in their papers.*

Let me point out here for those who might not know it that suicide is no longer a crime anywhere in the English-speaking world. (It used to be in many places, punishable by giving all the dead person's money and goods to the government.) Attempted suicide, which hundreds of years ago in Europe was punishable by execution, is no longer a crime. Do not confuse this decriminalization with health laws where a suicidal person can in most states be forcibly placed in a psychiatric wing of a hospital for three days for evaluation.

But giving assistance in suicide remains a crime, except in the Netherlands in recent times under certain conditions, and it has never been a crime in Switzerland and Germany, although the taboos there are strong. The rest of the world punishes assistance in suicide even for the terminally ill; although the American State of Oregon recently (1994) passed by citizens' ballot measure a limited physician-assisted suicide law. After court battles initiated by the pro-life movement, the Oregon law took effect at the beginning of 1998, a year during which there were 16 lawful assisted suicides, while in 1999 there were 27. Not exactly the stampede our critics were predicting!

Even if a hopelessly ill person is requesting assistance in dying for the most compassionate reasons, and the helper is acting from the most noble of motives, any form of direct euthanasia remains a crime in the remainder of the Anglo-American world. You cannot ask to be killed. Punishments for this are usually 'life' and for assisted suicide, fines or up to fourteen years in prison. It is this catch-all prohibition which ERGO and other right-to-die groups wish to change. In a caring society, under the rule of law, we claim that there must be exceptions for the hopelessly ill after all other avenues have been exhausted.

Dr. Jack Kevorkian was guilty in law but morally innocent (in my view) of helping a terminal man to die by lethal injection. A Michigan jury found him guilty of second-degree murder and he was jailed for 10-25 years. In recent years two spouses in New York State have been imprisoned for assisting their sick wives to die. Exactly there is the huge law reform problem we have to surmount.

The word 'euthanasia' comes from the Greek -- Eu, "good", and Thanatos, "death". Literally, "good death". But the word 'euthanasia' has acquired a more complex meaning in modern times -- it is generally taken nowadays to mean taking action to achieve a good death.

Suicide, self-deliverance, auto-euthanasia, aid-in-dying, assisted suicide, physician-assisted suicide, physician-assisted dying -- call it what you like -- can be justified by the average supporter of the right to die movement for the following reasons:

1. Advanced terminal illness that is causing unbearable suffering - combined physical and psychic -- to the individual despite good medical care. This is the most common reason to seek an early end. (And as Oregon research has shown, being a burden to others is an additional factor).


2. Total loss of quality of life due to protracted, incurable medical conditions.


3. Grave physical handicap which is so restricting that the individual cannot, even after due consideration, counseling and re-training, tolerate such a limited existence. This is a fairly rare reason for suicide -- most impaired people cope remarkably well with their afflictions -- but there are some disabled who would, at a certain point, rather die.

• The person is a mature adult. This is essential. The exact age will depend on the individual but the person should not be a minor, who comes under quite different laws.


• The person has clearly made a considered and informed decision. An individual has the ability nowadays to indicate this with a "Living Will" (which applies only to disconnection of life supports) and can also, in today's more open and tolerant climate about such actions, discuss the option of a hastened death with health professionals, family, lawyers, etc. But they may not demand it


• The euthanasia has not been carried out at the first knowledge of a life-threatening illness, and reasonable medical help has been sought to try to cure or at least slow down the disease. The pro-choice movement does not believe in giving up on life the minute a person is informed of a terminal illness, a common misconception spread by our critics. Life is precious, you only pass this way once, and is worth a fight. It is when the fight is clearly hopeless and the agony -- physical and mental -- is unbearable that a final exit is an option.


• The treating physician has been informed, asked to be involved, and the response taken into account. What the physician's response will be depends on the circumstances, of course, but we advise people that as rational suicide is not a crime, there is nothing a doctor can do about it. But it is best to inform the doctor and listen to the response. For example, the patient might be mistaken -- perhaps the diagnosis has been misheard or misunderstood. In the last century, patients raising this subject were usually met with a discreet silence, or meaningless remarks, but in this century's more accepting climate of personal freedoms most physicians will discuss potential end of life actions, however cautiously.


• The person has made a Will disposing of worldly possessions and money. This shows evidence of a tidy mind, an orderly life, and forethought -- all something which is paramount to an acceptance of rational suicide.


• The person has made plans to exit that do not involve others in criminal liability or leave them with guilt feelings. As I have mentioned earlier, assistance in suicide is a crime in most places, although the application of the law is growing more tolerant. Few cases actually come to court. But care must still be taken and discretion is the watchword.


• The person leaves a note saying exactly why he or she is taking their life. This statement in writing obviates the chance of subsequent misunderstandings or blame. It also demonstrates that the departing person is taking full responsibility for the action. If the aim is to attempt to allow the death to be seen as 'natural' and not suicide, this note should be kept in a private, secure place and only shown later if necessary.

A great many cases of self-deliverance or family-assisted suicide, using drugs and/or a plastic bag, or inert gases, go undetected by doctors, especially now that autopsies are the exception rather than the rule (only 10 percent, and only when there is a mystery about the cause of death).

Also, if a doctor asked for a death certificate knows that the patient was in an advanced state of terminal illness then not much fuss will be made over the precise cause of death.

Police, paramedics, medical examiners, and coroners put a low priority on investigation of suicide, particularly when evidence comes before them that the person was dying anyway.

Some claim that it is sufficient to legalize physician-assisted suicide and not voluntary euthanasia as well. I have never taken that halfway view. Here's why:

1. Physician-assisted suicide (drinking prescription lethal medication) is not as efficient as voluntary euthanasia (lethal injection). Even using the best barbiturates, the oral route takes much longer - up to 11 hours in a few cases - which is a terrible strain on family present. In the Netherlands, doctors will only let such a case linger for four hours before administering a lethal injection. Injection into a vein always ends of the life of the patient within about ten minutes.


2. Some terminally ill patients are unable to drink, or keep down, the lethal fluid because of invasive surgery. If help in dying is restricted to those who can take oral fluids, then a great many patients who most need help are sidelined.


3. As the constant attacks on the Oregon law show, the pro-life movement will seek to destroy any and all laws on assisted dying, no matter how moderate and limited. So the right-to-die movement should fight to legalize what is best for the patient - both methods - and make no concessions to the religious right. But let us see what their main arguments are.

Having considered the logic in favor of euthanasia, a person should also contemplate the arguments against it:

First, should the person go instead into a hospice program and receive not only first-class pain management but also comfort care and personal attention? Hospices by and large do a great job with skill and love. The right-to-die movement supports their work. But not everyone wants a lingering death; not everyone wants that form of care. Today many terminally ill people take the marvelous benefits of home hospice programs and still accelerate the end when suffering becomes too much. Some 60 percent of those who took advantage of the Oregon physician-assisted suicide law the first two years were in hospice care.

A few hospice leaders claim that their care is so excellent that there is absolutely no need for anyone to consider euthanasia. They are wrong to claim perfection. Neither hospice nor euthanasia has the universal answer to all dying. Fortunately most, but not all, terminal pain can today be controlled with the sophisticated use of drugs, but the point these leaders miss is that personal quality of life is vital to some people. If one's body has been so destroyed by disease that it is not worth living, then that is an intensely individual decision which should not be thwarted. In some cases of the final days in hospice care, when the pain is very serious, the patient is drugged into unconsciousness ('terminal sedation'). If that way is acceptable to the patient, fine. But some people do not wish their final days to be spent in that drugged limbo.

There ought not to be conflict between hospice and euthanasia -- both are valid options in a caring society. Both are appropriate to different people with differing medical needs and ethical values. Later in the 21st century, I am confident that hospice will become a place where people go either for comfort care, terminal sedation, or for assisted suicide. It is the appropriate place for a dignified end.

Another consideration is theological: does suffering ennoble? Is suffering, and relating to Jesus Christ's suffering on the cross, a part of preparation for meeting God? Are you merely a steward of your life, which is a gift from God, and which only He may take away? My response is this: if your answer to these questions is 'Yes, God is my master in all things,' then you should not be involved in any form of euthanasia. It just does not fit.

There are millions of atheists and agnostics, as well as people of various religions, degrees of spiritual beliefs, and they all have rights to their choices in abortion and euthanasia, too. Many Christians who believe in euthanasia justify it by reasoning that the God whom they worship is loving and tolerant and would not wish to see them in agony. They do not see their God as being so vengeful as refusing them the Kingdom of Heaven if they accelerated the end of their life to avoid prolonged, unbearable suffering.

Another consideration must be that, by checking out before the Grim Reaper routinely calls, is one depriving oneself of a valuable period of quality life? Is that last period of love and companionship with family and friends worth hanging on for? Our critics heavily use the argument that this is the case.

Not necessarily so! In my twenty years in this movement, and being aware of many hundreds of self-deliverances, I can attest that even the most determined supporters of euthanasia hang on until the last minute -- sometimes too long, and lose control. The wiser ones gather with their families and friends to say good-byes; there are important reunions and often farewell parties. There is closure of wounds and familial gaps just the same as if the person was dying naturally - perhaps more so since the exact timing of the death is known.

Euthanasia supporters enjoy life and love living, and their respect for the sanctity of life is as strong as anybody's: sanctity as distinct from sacredness. They are willing, if their dying is distressing to them, to forego a few weeks or a few days at the very end and expire at a time of their choice. Moreover, they are not the types to worry what the neighbors will think.

There is another rightist argument that the acceptance of euthanasia practices will quickly destroy the traditional bond of trust between doctor and patient; that the patient will never know if the doctor is going to kill them or not; that commercialized medical practices will jump at the chance to get rid of long-term patients who are short of insurance funding.

Those arguments have been answered by the 20 years euthanasia has been practiced in the Netherlands, and by the nearly three years physician-assisted suicide has been available in Oregon. No evidence of a breakdown in relationships has emerged. Those doctors who are ethically opposed to hastening the end of life just don't do it.

The laws in the Netherlands, Oregon, and the ones which have failed to pass, all give medical professionals the right to refuse to be involved -- a conscience clause. This exemption will always be so as far as I am concerned.

In fact, many patients hold their medical advisors in higher regard if they know that he or she will go to great lengths to keep them from terminal suffering, even to the extent of providing, if necessary, a gracious final exit.

What people often do not realize is that, for many, just knowing how to kill themselves is itself of great comfort. It gives them the assurance to fight harder and therefore often extends lives just a bit longer. Many people have remarked to me that my book, 'Final Exit' is the best insurance policy they've ever taken out. Once such people know how to make a certain and dignified deliverance, with loved ones supporting them, they will often renegotiate the timing of their death.

For example, a man in his 90s called to tell me his health was so bad he was ready to terminate his life. I advised him to read 'Final Exit,' which he did and he called me back. He had managed to get hold of lethal drugs from a friendly doctor and so everything was in position.

"So what are you going to do now?" I asked him.

"Oh, I'm not ready to go yet," he replied. "I've got the means, so I can hold on a bit longer."

Now he had the knowledge, the drugs, and encouraged by the control and choice now in his grasp, he had negotiated new terms with himself concerning his fate. Surely, for those who want this way, this is commendable and is in fact an extension rather than a curtailment of life's span.

Thanks to the work in the last century of a forceful right-to-die movement, a hidden reality has emerged about terminal suffering, indicating that the time has come for change. What are needed now are laws permitting voluntary euthanasia and physician-assisted suicide surrounded with a bodyguard of rules -- but not so many that the patient in unable to jump through all the hoops.

With the inevitability of gradualness, as the idea takes hold amongst rising generations, reform will undoubtedly come. We who believe must ceaselessly work for it.

© Copyright 2000 Derek Humphry. All rights reserved.

The above essay may be reproduced for scholarly purposes without permission being sought, provided source acknowledgement is given. Reproduction in any journal or book must have the author's permission. Email: ergo@finalexit.org. Length: 2,900 words.

This essay is Chapter 4 of the book "Supplement to Final Exit" published by the Norris Lane Press and ERGO, 2000. Oregon, USA. For a complete list of books available from ERGO please consult the ERGO Online Bookstore.

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