What is “appropriate” dying?

And Who Should Forbid ThemInstead of a set of rules where “one size fits all”, or wordily-phrased “rights”, psychologists have looked at a different model: one of, “Is this an appropriate death?”

The most common scenario, where laws are proposed based on certain check-boxes being fulfilled, is deeply flawed. “Two physicians must agree” – yet if the doctors in the area all happen to be opposed on principle, then they are not likely to agree. “Where the patient has six months to live” – and quite apart from the difficulty of determining this, we know that most major headline cases were not terminal: Debbie Purdy, Tony Bland, Terri Schiavo, Ramon Sampedro. Like these cases, when you have a set of fixed rules, the future will often surprise with one that feels morally right but doesn’t fall within the strict ‘rulebook.’

Exit’s response was to commission a University study on feasibility. The researchers found that the best type of law reform, instead of ‘legalising’ certain types of assisted suicide outright, would simply be to enact powers to the Courts that would allow them to make exceptions to the rule against assisted suicide.

The confusion over law-making stems not from how and when assisted suicide should be allowed, but something more basic: the question of, what is an appropriate death? The indicators would provide clues for all possible deaths, not just assisted suicides.

Psychologist David Lester, from the Center for the Study of Suicide in New Jersey, built on the work of Avery Weisman and Thomas Hackett in considering the sort of criteria that lead us to conclude that a death is ‘appropriate.’

  1. The role of the individual. There is a temptation to just call this ‘autonomy’ whereas it may not be quite that simple. A person struck by lightning has no autonomous role in the death, whereas a suicide, whether through very understandable causes or through a lack of social support and a place to live, might or might not be judged ‘autonomous’ – depending how in control we think that person is. But if a person does play a large role in their own death, that would indeed be a factor to consider.
  2. Consistency in lifestyle. One person might always have been of the outlook, “Just leave it up to the doctors.” If they suddenly changed their mind and sought assisted suicide, it would seem less consistent than someone who had firmly believed in their ‘right to die’ for a long time.
  3. Timing. We use phrases like, “It was his time.” Someone who is very ill, without the prospect of decent recovery, or someone who is very old, may seem more convincing to us than a young healthy person.
  4. What about the kind of death? Someone who dies alone and isolated, unable to leave their house, suggests to us something inappropriate. Violent deaths such as road accidents also seem inappropriate (although Ernest Hemingway’s suicide by firearm seemed at least consistent with his lifestyle). Natural death, when a person’s body just gives up, usually seems appropriate. Psychological death, when the brain has completely ceased to function but the body goes on, can in many ways be sensed as death but does not have the finality of physical death. Assisted suicide in cases where the above conditions are recognised tend to be seen as more appropriate than when such conditions are absent.

Further reading
Robert Grimminck, 10 Heartbreaking Right-To-Die Cases
Exit website, Cases in History
Grace Murano, 8 Most Controversial Cases of EuthanasiaBBC News Assisted dying: What does the law in different countries say?
Exit website, A draft bill
Wikipedia Suicide Legislation
American Psychological Association, Psychological research can inform state policies on the controversial measure.

Further References
Weisman A, Hackett T, Predilection to Death: Death and Dying as a Psychiatric Problem
Lester D, Psychological issues in euthanasia, suicide, and assisted suicide

 

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Afraid of dying?

Sunset from the bridge, Ayr, Scotland, front cover from the first edition of Five Last Acts

Sunset from the bridge, Ayr

Earlier this year on this Blog, we added the strapline, Taking away the fear of death. Fear of dying badly is one aspect, hence Exit’s original mission; fear of everything coming to an end is also an aspect. Knowing how to take matters into your own hands, should the need ever arise, tackles the first part. But what of the taboo of even thinking about death? Is it ‘bad’ for you? Is it easier to think of someone else’s death?

A recent headline in the Living section of a popular newspaper proclaimed, “Thinking about my death is the best cure for anxiety. Trust me, it works!” It has a worryingly similarity to that dubious adage, “Trust me, I’m a doctor!” (and these days we know we cannot usually “trust the doctor” if it is a case of rational suicide assistance). Thinking deeply about death can help us to face our fears; but what about the taboo of even doing that? Just saying to one’s family that you are making an advance directive (living will) can trigger responses such as, “You shouldn’t be thinking about death!”

The next most common response is to think about it vicariously. To think about someone else’s death, to hope it will be peaceful and so on. For those in favour of assisted suicide, it sometimes fuels donations to those organisations hoping to change the law. Making a donation feels like “doing something” – after which we feel free to, “think about something else.” Most rational people realise such a change is unlikely to occur in their own lifetimes (in the U.K., people have been trying, and believing it will happen “soon” since 1935). But what about helping people now? That’s where we come in.

Scots reading this forum will remember that wonderful, crusading, independent Member of Parliament, Margo MacDonald. Margo repeatedly campaigned for an assisted suicide law (and many other issues close to the heart of the people). When I spoke to Margo, she enthused about the reasons we need a change in the law to help people die; yet when I moved the subject to self-euthanasia, to people who want answers now, she suddenly became anxious and terminated the interview.

Helping a future generation is thinking vicariously. It avoids thinking too deeply about one’s own death, about how to manage it well, peacefully, and with minimum upset to one’s nearest and dearest. Oxytocin, the ‘feel-good’ hormone, increases generosity toward philanthropic social institutions, as opposed to immediate benefits directed at individuals or groups. (Exit has run on a shoe string since its inception, even though it is our research and literature that people turn to after supporting the wealthier ‘campaign’ institutions.) Somehow the thought of helping altruistically in a generalised way is more satisfying than actually doing something that can have a more direct effect now. It takes that taboo subject (whether starving children or difficulty in dying) one step further away from direct confrontation. Until the individual thinks about his or her own last moments on earth.

Anxiety and fear can be in response both to real concerns or imaginary ones. Excessive anxiety is related to an increased risk of cardiovascular morbidity and mortality, so facing and dealing with some of the fears can actually help you live a loger life! (This mirrors letters received from some Exit members, saying how knowledge of self-euthanasia methods has given them ‘the courage to live longer.’)

In dealing with fears, a common distinction is suppression (where we avoid thinking about it) versus reappraisal (where we deliberately revisit and reformulate the meaning of a situation). In studies, reappraisal is more effective than suppression. We do this in workshops but you can also try it by following the guidance in our Blog. If the question of death anxiety is left until we are almost dying, there is little chance to for reappraisal. The suppressed anxiety may even have taken years off our life as well as the quality of your life.

If this is all a bit ‘deep’ to think about now, have a break with some of the fun links below, inspiring quotes from famous people on the subject. You can bookmark this page and come back to it at any time. If you want to help our work (see the end of this article for more about what we do and our track record) you can use the donate button in the right hand column or follow this link.

What did they say about death, dying and living? Click and see…
ALBERT EINSTEIN     ANAIS NIN     BRUCE LEE     DH LAWRENCE
EPICURUS     FRANZ KAFKA     GEORGE PATTON     HEDY LAMARR
HUNTER THOMPSON     JEAN COCTEAU     JOHN LENNON
JACK KEVORKIAN     LEWIS LAPHAM     MARCUS AURELIUS
MARK TWAIN     MAYA ANGELOU     PAULO COELHO
PSALMS OF DAVID     RIANE EISLER     SOPHOCLES
STANISLAV GROF     STEVE JOBS     TS ELIOT
you can also use the left-right arrows (next page) to scroll

 

Footnotes:
Trust me it works!” Pop star, Rita Ora, and Daisy Buchanan in The Telegraph
One cannot escape death (an ExitEuthanasia Blog on facing the fear)
Margo MacDonald and her assisted suicide bill (Evening News)
6 Positive Ways To Overcome Your Fear Of Death (Huffington Post)
Anxiety and the Fear of Dying (CalmClinic Website)
How to Overcome Fear of Death (WikiHow)
Death anxiety (psychology) (Wikipedia)
Oxytocin infusion increases charitable donations (Barraza et al, Hormones and Behaviour)
Neurocircuitry of Fear, Stress, and Anxiety Disorders (Shin & Liberzon, Neuropsychopharmacology)
Reappraisal and Suppression (Goldin et al, Biological Psychiatry)
The Choice to Face Your Choices (ExitEuthanasia Blog)
Exit: the Director’s Story (ExitEuthanasia Blog)

 

EXIT’S ACHIEVEMENTS (A history of our work)

  • 1980 First “how-to” booklet in the world on self-euthanasia, with detailed methods and materials (How to Die With Dignity).
  • 1993 First booklet in the world to be published with full peer review of its scientific data (Departing Drugs).
  • 1994 Small book on different methods that included more academic analysis, for the first time in the world. A companion to Departing Drugs. (Beyond Final Exit).
  • 2010 A more comprehensive book proposing five different methods for different circumstances and the first book of its kind in the world to detail the ‘compression method’ (Five Last Acts).
  • 2015 The ‘big brother’ edition of Five Last Acts is updated and expanded to over 800 pages, and the first book in the world to give detailed instruction on the ‘nitrogen method’ (The Exit Path).
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Can breathing inert gas rupture the lungs?

diver

A correspondent recently contacted us with an unusual concern. He had read that breathing helium could rupture the lungs: hardly a peaceful death!

Helium is an inert gas and perfectly pleasant to breathe (though dangerous as it can produce unconsciousness without warning). Death occurs through lack of oxygen to the brain rather than a rupturing of the lungs. The process, properly managed, is completely painless, as confirmed by many witnessed accounts, including those by Professor Ogden in Canada and others (a few such links are provided below). Consequently we were slightly puzzled as to the source of such information.

A quick search of the Internet soon provided the answer. The media had picked up on some foolish examples such as persons at a party, or having fun making the voice change pitch, and breathing helium directly from the canister. This is exceedingly dangerous and can cause (completely unintentioned) death. The ‘rupture’ of aveoli (the small balloon-like sacs within the lungs) was caused not by helium, but by the pressure of the gas (any gas). Helium in party balloon canisters is compressed to about 260 pounds per square inch, so suddenly opening the gas jet in an irresponsible way can cause a fairly formidable pressure of helium. The other possibility is in diving, where a diver comes to the surface and gas in his or her lungs expands suddenly.

The concern over helium and self-euthanasia is not about gas pressure, which is easily regulated by sensible adults studying the method, but over manufacturers’ announcements that many of their cylinders are now supplied with a helium-air mix, which is unsuitable for self-euthanasia.

 

http://www.cganet.com/helium%20article.php
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070864/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923352/
http://www.ncbi.nlm.nih.gov/pubmed/12198347
http://www.ncbi.nlm.nih.gov/pubmed/20216304
http://www.ncbi.nlm.nih.gov/pubmed/24501824
http://www.ncbi.nlm.nih.gov/pubmed/20211999
https://en.wikipedia.org/wiki/Suicide_bag
http://www.balloontime.com/contact-us/faqs/

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Suicide and impulsivity

suicide debateWhat can be done to help people to make rational choices? Abolitionists will say, “What about people who die who shouldn’t?” One should never advise or encourage anyone to commit suicide. In fact dissuading is part of the ‘right-to-die’ remit, for although the will to live is very strong, there is a presumption in favour if it, and it is the individual’s autonomous determination over and above the will-to-live, over and above the best efforts of palliative care, over and above the best available social support and counselling, that makes a request for assisted suicide (or the decision for rational self-suicide) compelling.

Possibly unique among ‘right-to-die’ societies, Exit is trained in suicide prevention. Both the person dying an unrelievably painful, undignified death (who actually needs information) and the high-schooler who has failed an exam and so feels suicidal (and who actually needs support) have one thing in common: they both need empowerment to make their deepest, truest objectives real (the one to die peacefully: the other one to live).

A common fallacy is that people suddenly decide to kill themselves and go out and do it. It may even appear in some cases that that is what has happened. A large proportion of us will have, or have had at some time in our life, suicidal thoughts: yet we don’t commit suicide. Somewhere, at the back of our minds, we realise the truth of the common knowledge that most pain, and even the most terrible psychological suffering, will one day go away or can be treated (even if it doesn’t feel like that). This is very different from someone who has pursued all the options, psychological, medical and palliative (and we go to great lengths in our books urging people to do just this). Very large, independent and exceptionally competent studies suggest that people do not commit suicide on sudden impulse. They will have thought about it for a long time. (In cases of irrational suicide, this is the ‘window,’ often a very difficult window, where helpful intervention tries to offer support.)

For anyone contemplating suicide, for rational or irrational reasons, there are two distinct frames of mind, often identified by two different questions: “Are you feeling suicidal?” and, “Have you made a plan?” Roughly speaking, the first is emotional, the second, intellectual. Do not be afraid to ask these questions, or to listen carefully and non-judgmentally to the answers.

There are controversial arguments on whether removing the means to suicide is effective. In some studies, it seems to work by extending the window of contemplation, whereas other studies suggest it merely diverts people to less savoury means. Information on rational suicide (books) as opposed to the means (rope, high buildings, barbiturates etc.) are two very different categories.

The methods of rational suicide investigated by Exit do not easily lend themselves to sudden, unpremeditated death. As Dr Bruce Dunn wrote in 1994 (a time when significant strides in understanding rational suicide were being made), “These materials are not inaccessible to a determined individual, but they are relatively difficult for a member of the public to acquire casually or quickly.”

A law allowing doctor-assisted suicide or euthanasia could encourage persons to voice their feelings to a doctor without fear of bias or being judged. Openness with supportive loved ones can create bonds. On the one hand, legislation would open the window of support with options to examine all available routes to make life bearable where that can be achieved or, on the other hand, provide compassionate options for euthanasia where all other routes are exhausted. Similarly, being open to the innermost feelings of loved ones, and talking to them, can extend the window – and sometimes allow a person thinking irrationally of suicide the breathing space to reconsider.

If you are maybe reading this as a ‘right-to-die’ supporter, you may be thinking, “But surely your job is to make it easy!” That is not quite the case: firstly, rational and dignified suicide is not simple in that sense (as opposed to throwing yourself of a bridge – which incidentally is not always simple either). It is one of the biggest decisions of life. Any fool can jump under a car. Rational suicide on the other hand requires very careful contemplation and planning. There are no lethal gas ovens left. Doctors don’t readily prescribe lethal pills. What we do is research and more research. Botched suicides don’t always “save lives,” they simply make death more ghastly. We look at things that can go wrong, clear the debris from the road, find the science of the most rational, painless and dignified methods. For those that wish to become empowered, we offer truth, the key that takes away fear.

If you are reading this and feeling suicidal, our first advice is to talk to someone. It might be a trusted friend or an understanding family member. Unfortunately not all irrational suicides can be prevented; and not all rational suicides will go smoothly. We can only do what we do: to help things, responsibly, legally, ethically, compassionately. We cannot solve all the world’s problems or produce perfect solutions on life and death, nor can we prevent death or bad decisions. Everyone dies: we hope that for those that have reached a point where they are committed to drawing life to a close at a time and manner of their own choosing can do so with as little pain and indignity as possible.

A few selected references and further reading:
Lester D, Psychological issues in euthanasia, suicide and assisted suicide, J Soc Issues 1996;52(2):51-62.
Anestis M, Soberay K, Gutierrez P et al, Reconsidering the link between impulsivity and suicidal behavior, Pers Soc Psychol Rev 2014;18(4):366-86.
Witte T, Merrill K, Stellrecht N et al, “Impulsive” youth suicide attempters are not necessarily all that impulsive, J Affect Disord. 2008;107(1-3):107-16.
Sisask M, Värnik A, Media Roles in Suicide Prevention: A Systematic Review, Int J Environ Res Public Health 2012; 9(1): 123–138.
Exit also includes very extensive references from all ‘sides’ in its books.
Exit, while pro-legislative reform, is primarily a research group. We are not a suicide hotline and not involved in the field of one-to-one counselling, whether for rational suicide or suicide prevention. Below are some (we believe) responsible organisations (a very short list!) that can also be consulted:
The Samaritans (Europe)
Philosophical Practice for Life Questions (Europe)
Dignitas (Europe)
Final Exit Network (USA)
Rubin Battino (therapist, USA)

 

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When this tide is not for turning

tide is turtningFalconer’s bill hits the rocks. Eighty years of no change. Public opinion consistently demands euthanasia law reform. Is the tide really turning?

In 1935, a group of eminent persons proposed a bill to allow voluntary euthanasia under carefully controlled conditions.The first attempt to pass legislation to make euthanasia legal in Britain was the Voluntary Euthanasia (Legalisation) Bill 1936 introduced to the House of Lords by Arthur Ponsonby. The debate was not split along party political grounds and the Government considered it “outside the proper range of Government intervention and to be one which should be left to the conscience of the individual members of the House.” Sound familiar?

Bills have followed with predictable regularity: none have passed. That’s 80 years of some people dying very badly without any choice in the matter: people that could have been offered a painless and dignified end.

Death is not something generally that people want to think about. Not politicians, not the population generally.  There is an anxiety, a fear of thinking seriously about one’s own death and rational decisions cannot be properly undertaken until that fear is acknowledged and dealt with. At the same time, there is a desire to “do some good.” Once a person gives some money to a charity, whether it is for starving people in Africa or campaigning for voluntary euthanasia, there is a sense that one has “done something” and that relief allows us then to stop thinking about it. (This works whether the money actually does any good or not.) Funds pour into campaign groups but very few achieve their political objective. Experts on political campaigning agree that it s a very expensive business to do properly. There is very limited evidence for instance, if any, to suggest that campaign groups connected with legalising voluntary euthanasia have any effect. Change, when it has happened, mostly comes from the support of doctors’ groups, (except in areas where the public can vote on legislation as happens in certain places in the United States). Each week someone will probably contact Exit and excitedly mention a story in a newspaper saying something like, “Look! the tide is finally changing!” (This has been happening since 1980 so please excuse me if I don’t leap out of my seat!) The tide of public opinion changed ages ago. It remains steady at around 80 per cent.

Meanwhile, those who cannot wait another 80 years for legislative change, and can’t afford the costs of going to Dignitas in Switzerland, seek out information on self-euthanasia from groups such as ourselves (other groups are Final Exit Network in the USA and the Australian Group, Exit International, both of which have a high profile and strong campaigning aegis.) As the body behind the most extensive scientific information on the subject, Exit is the focus of hate campaigns from religious groups and occasionally relatives of persons who have died as a result of getting information often from other sources, such as the Internet. We struggle on with minimal funds, and have done so since 1980 (when we published the world’s first guide on self-deliverance). We do the best that we can without getting shut down.

Many years ago, Exit funded a feasibility study by Glasgow University to find the most effective way (a legally sound way with the most chances of success) of drawing up a bill on assisted suicide. Few politicians look at it. They mostly re-invent the wheel, not very well, and then ask us afterwards for our ‘support’. The Commission on Assisted Dying (Demos), a think-tank, also published a report: full of idealistic aims and safeguards that people argue over in a sort of amour-vanité of knowledge, of terminology, of ideals, without giving the slightest technical consideration to the most important practical question of all: will it get passed?

With the time, money and expertise put into such things, something could have been done, and wasn’t. The cycle has been repeated for 80 years this year. If the law can be changed to allow assisted suicide and voluntary euthanasia in acceptable way fro those that need and desire it, Exit will hang up its hat and close. Until then, there is a job to do. Next time you feel a thrill of support for a hope to change the law to benefit people in the (probably distant) future, maybe spare a thought for Exit, that is doing something for people now.

The Voluntary Euthanasia (Legalization) Bill (1936) (Hansard)
The Voluntary Euthanasia (Legalization) Bill (1936) revisited, Tim Helm, JME
Lord Falconer: government must clean up assisted dying legal mess (Guardian)
Demos Commission on Assisted Dying

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A small site update (we’ve added a few FAQ’s)

Screen Shot 2015-08-21 at 19.36.00Just a quick post to let regular readers know we have updated the reference pages on the top menu to include an FAQ.

These Frequently Asked Questions will be updated or added to occasionally. If you have a question that you think a lot of people might ask, feel free to suggest it. We’ll answer time permitting if we feel it will be both helpful and appropriate.

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One cannot escape death

The thought of dying is one that most people push aside, at least until it seems imminent (to ourselves or someone close to us). The mission of Exit can be described as taking away the fear of death. A large part of that, and since Exit was formed in 1980, is to research the reliable means of taking things into one’s own hands if all else fails. It is an area where our research, quietly, still leads the world. It can provide the most peaceful of available exits to those that need to use it one day, or reassurance and courage for an unknown future for those with many years still to live. Stop, and think about it for a minute…

(Merely thinking about death is not harmful, in spite of superstition.) Take a calm look at the issues and how you feel about them, might handle them; then stand up, do something else, put the radio on or clap your hands: thinking about for a few minutes is not the same as dwelling on it.

Control of pain and symptoms
There are various other fears associated with death. Most can be dealt with simply with knowledge. Most (but not all) terminal pain can be relieved. This does not mean that in every (or in your case) case it will be relieved, and it is worth bearing in mind that making a loud fuss (if you pain is not being controlled) may be the best way of getting the attention you urgently require. I have a friend who explains very calmly, with a typical English stiff upper lip, that the pain he is in is “really rather considerable.” I advised him instead to let it show in his face a bit that he is in excruciating pain (it produced a more satisfactory and immediate answer).

Then there are symptoms that might occur in the time leading up to death and which people can fear. Perhaps you have seen someone struggling for breath for instance? Breathing difficulties can in most cases be lessened these days with careful medication (such as benzodiazepines) and good nursing care to ensure fresh air and a posture that makes breathing easier. If you are looking after someone at home, these things can be researched easily or advice obtained from such experts as (in the UK), Macmillan Nurses. These people are expert in the most modern methods of pain and symptom control but not sympathetic towards euthanasia or self-euthanasia, so one has to be careful to respect that. Different experts for different challenges. If you try to discuss euthanasia with a medical person in a country where it is illegal for a doctor to help you then you put him or her in a very difficult position and quite unfairly. It is probably be worse for you and for the doctor to do so (they have legal obligations, after all, and “quietly giving someone some pills” is much harder these days due to the paperwork and checks on almost every move a doctor makes).

Self-euthanasia and assisted suicide
Exit is the source of expertise for self-deliverance, or self-euthanasia. Many people think, “Oh, that’s good, I’ll just phone up if I am near to death.” As many readers of this Blog will know, it doesn’t work quite like that. Self-euthanasia is fairly straightforward but mostly when it is researched in advance so the person, while reasonably fit and mentally competent, can absorb the necessary knowledge in advance of the time, if and when that time comes, and one decides for oneself that is needed. The law does not allow an emergency ‘help line’. We provide the best knowledge available worldwide in our books, our members’ magazine, and in our very occasional workshops. Until the law is changed and you can approach your doctor for the help you need, there is no perfect solution: we simply look at this area as responsibly as humanly possible. (For those considering Dignitas, Switzerland, again, do not think that it is just a case of a phone call: get in touch with them well before such emergencies arise.) There is no ‘on demand’ service anywhere in the world at this time.

Think about tomorrow today
The key to all of this is planning. Planning for your future, planning for a good death, whether that good death will be a ‘natural’ one, aided by doctors, sudden, or by your own hand. The strange thing about this is that the grief and fears associated with death are a challenge, quite literally, for every single person on this planet. If you lose a loved one, or if your own death is approaching, it seems like the most momentous thing (and in a way, it is), and yet it is a more commonplace and universal event than anything else consciously encountered in this life. There is no “if” one is close to death. One day you and I will will be close to death. No-one has ever escaped that. So a little planning can go away.

“I have everything under control, but I am still uneasy.”
A few years ago, we realised that, even if pain and symptoms are controlled, and even if you are capable and confident of making a self-euthanasia, some people still feel worried or afraid of the final moment, that second and the seconds and minutes leading up to it where everything, consciousness, outside world, ability to do things, say things, experience through the senses, and even to have any thoughts, all will cease, finally and forever. (We are not denying or affirming any life-after-death scenarios but that is generally a slightly different matter to the ending of the here-and-now.)

Having a calm state of mind is a good start to most challenges: but how to achieve it? Fear is a neurochemical reaction that plays an important role in some circumstances but is redundant in others. When an animal or human feels threatened, fear or anxiety may stimulate appropriate and largely automatic responses such as fight or flight. It can occur whether the fear is reasonable or not (We have all probably known a child fearing the bogey-man, or a bullied child being more fearful generally.) Some fear responses are learned and can be unlearned. (An alternative psychological view is that fear at the moment of death is natural and one should just accept it.)

Some years ago I was camping solo in the desert for several days and nights. I had arranged with my guide that he would come back at a certain time, on a certain day, to fish me out. I was already very dehydrated, having slightly misjudged the water I would require, and when he didn’t arrive, my first reaction was slight panic. I decided to test some of the meditative techniques I had long researched, several of which have been used in peer-reviewed studies in hospitals and elsewhere. It was all pretty logical (once I reminded myself to be logical!) First, sitting quite still, I slow my breathing, focussing my mind on my higher aspirations (rather than the external ’emergency’ outside). I listen to the sound of my breath, enjoying the purity of the air as it enters and fills my lungs, the movement of my diaphragm, up, down, not thinking of anything else, my attention solely on the rise and fall, my breathing deeper, slower.

That first stage is very simple. Our thought patterns are closely linked to our breathing and usually agitation, excitement and so on will cause a change in breathing patterns. This simply reverses the process. Sitting very still also minimises outside distractions.

The next (but not the last) stage is to actively produce a positive state of mind. To do this, I first think of someone who loves me unconditionally (if you cannot think of someone who loves you unconditionally, then you imagine someone). I imagine I am sitting in bright room, warm and comfortable, with a chair and table. In front of me is a diary and I have been writing my life story. Then I imagine that the person that loves me unconditionally is looking in, watching me through a small window. Part of me then moves and imagines I am standing next to them, looking at me writing the diary, and I can hear them gently saying all the many wonderful things they feel and know about me. Returning to the desk, I write these things in my diary.

The purpose of the above stage is to feel good about yourself, to feel conscious of yourself as a wonderful individual, and to feel loved. It is not difficult: but is best done methodically, as just described. It should not be rushed. It has the effect of a good conversation, and releases oxytocin, making one feel good about oneself and ready to feel good about others.

The next step is to produce a feeling of being centred. So far, it has all been about oneself, not the distractions or tendencies of the mind to be swept up by that which is external to the mind, whether one’s physical state, the people around us, or the myriad cares of the world. The following stage allows us to take a pro-active stance and expand the positivity now felt to all things whatsoever.

In the desert, I chose north, east, west and south and performed the exercise four times, concentrating on one direction at a time.* Some people might prefer to think of an expanding circle. I focussed on the positive feeling of love produced from the last stage. I imagined this expanding and embracing others. (If this is difficult for you, imagine it as a warm, golden light which you radiate from the heart.) Firstly, I expand it to the people with whom I have a good emotional bond, the people I love; then to people who are simply colleagues or people I don’t have strong feelings towards one way or the other, and also then people I have never met; finally I expand it to embrace enemies, people I maybe don’t like for some reason or who maybe have some issues with me.

Conflicting emotions can reignite fear, anxiousness, feelings of ‘things left undone’ and so on; the final stage described above takes control of the process to counter all external input with a sense of non-conditional goodwill. It stops one being pulled in one particular direction while at the same time feeling expansive towards all living persons. It associates the positive emotion and neurochemicals in a continuum towards all possible sensory input.

These basic methods of controlling one’s own mind were first brought to the West by a gentleman called Allan Bennett, an analytic chemist and scientist who applied his scientific mind to the meditative practices of Buddhism; today they can be found in many palliative care programs. In essence they are neither religious nor non-religious and can be adapted to personal preference. There are versions for Christians and Atheists, Buddhists and Agnostics. In essence it is simply the application of certain psychological principles to direct one’s mind to a state of inner calm (neuroscientists describe it in fancier terms of course). It has also been used effectively for carers.

I have included a few references of related interest for those maybe inclined to investigate further how all this works. There are many more in the Epilogue to Five Last Acts – The Exit Path where the subject is treated more broadly and a variety of approaches examined. Having recognised that the fear response is redundant and inappropriate at a time when death is inevitable, we simply reprogramme our mind’s outlook, step by step, producing the neurotransmitters that enable a more productive management. Many of the sensory inputs near death may not be the most conducive to a peaceful moment (hospital wards, emotional relatives) but cannot in all situations be avoided. The process is one to allow us to take control of one’s outlook. As Viktor Frank pointed in his famous book, there is always choice, and the last choice is to choose one’s state of mind.

 

(The author got out of the desert. The calmness produced by the practice lead to a new ‘Plan B’ that would enable a successful exit from the wilderness. As he was about to execute it, his guide eventually arrived, rather late, but nevertheless very welcome.)

Five Last Acts – The Exit Path (this is the new, considerably expanded edition, just released: for reviews of the earlier edition please see here)
Viktor Frankl’s Man’s Search for Meaning (famed neurologist, psychologist and Holocaust survivor)
Dignitas (Swiss assisted suicide group)
The biology of fear- and anxiety-related behaviors (by Thierry Steimer, complete text)
Neuroanatomical and neurochemical basis of conditioned fear (M Fendt & M Fanselow)
Neurochemistry of Positive Conversations (lay article, full text)
Loving-kindness meditation: a tool to improve healthcare provider compassion, resilience, and patient care (Seppala et al.)
Loving-Kindness Meditation for Chronic Low Back Pain Results From a Pilot Trial (Carson et al.)
Mindfulness for Cancer and Terminal Illness (Carlson, L. Note: mindfulness meditation is more closely related to the first stage described above.)
When it All comes to an end (a free download from this Blog)

* The four directions can also be expanded for completeness using Einstein’s coordinates, the necessary way of defining anything: any noumena must be a) so far east-west, b) so far north-south, c) so far up-down, so far before or after a moment in time. Many meditators will at least add (c) to the four directions.
Note for members of Exit: the processes described above will be included as an optional free, additional session with the next workshop. See the next magazine for details.
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A nitrogen workshop and a special invitation!

Martin Amis’ stance on euthanasia hardened after the deaths of his stepfather, Lord Kilmarnock, and his friend and novelist Dame Iris Murdoch.

Martin Amis is famous not just for his hard-hitting novels but for his outspoken stance on euthanasia. His position, however, is a personal one, arrived at not for the sake of exercising his vast skill as a writer but as a result of a deeply held conviction, arrived at partly from witnessing the suffering of those close to him. He is clear about what he would want: yet every person’s story is different.

This year we are inviting people to contribute to our project, EXIT: The Self-Euthanasia Movie. (The film examines the immersive empowerment people experience in EXIT’s unique workshops.) What we also need is short ‘headshots’ (typically up to three minutes long) from people with their own feelings, story, reasons for wanting to be in control of their own dying moments. If you have a point to make, we do not want you to act: simply to express your own personal, genuine convictions or position with intensity.

Filming for this is expected to take place in August or September (2015), probably in Edinburgh, Scotland. If you think you could contribute, you are invited to email us at exit@euthanasia.cc within the next three weeks (if you are not a member of Exit, please include a little about yourself). You might be included in a film that is released to the public on DVD or entered at a film festival.

The other item in relation to EXIT: The Self-Euthanasia Movie is a special workshop to consider the use of nitrogen in self-euthanasia. This is a relatively new development. Exit, together with other organisations, has been presenting its research on this at an international symposium (sponsored by NuTech, in San Francisco) and in its latest work, Five Last Acts – The Exit Path (2015 edition). The workshop is for members only and is filmed (standard release forms). Exit members are invited to apply.

(Please note, participation in workshops is only open to Exit Members. Headshot contributions are open to anyone. Exit reserves the right to refuse admission to workshops or headshop auditions without giving reasons.)

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Choices are individual

jean daviesJean Davies was 86 when she died. She had devoted most of her life to the “right-to-die” movement and died both in a time and manner of her own choosing. Why, one must ask, did she starve herself to death?

Jean was surrounded by loving friends, including any number of doctors who could (and probably would) have found a way to give her some easy medications. She had been in the movement long enough, both as a leader  of the London campaign organisation and as an international speaker on voluntary euthanasia, to know how to end her own life quickly and painlessly. But she chose starvation (or more accurately, refusing food and liquids, since refusing only food makes a difficult death longer and even more intolerable).

How we make choices is a very personal thing. Choosing apples over oranges is a matter of taste, of associations of pleasure and pain, associations based on which is good for us, or associations concerned with cost if one is much more expensive than the other. Maybe one was a gift. Associations, to a certain extent, are or can be brought under our conscious control.

In a famous experiment many years ago, psychologists recruited some volunteers and monitored them while they were given unpleasant and unwanted stimuli – in the experiment, this was achieved by subjecting them to a mildly unpleasant and distracting noise. Then in a second set, the experiment was the same except participants were told they could stop the noise at any time by pressing a button. In the second group, the participants were far less bothered by the noise. Many didn’t even press the button. Something that was under their control, their choice, was less of a trouble.

Jean knew that dying by refusing food and drink was likely to be horrible, even if you had enough medications to control most symptoms pretty well. But for her, there were different associations. She was a campaigner, and intended to die as she had lived, by making a statement. The statement Jean Davies was making, roughly paraphrased, was that was in the absence of proper legislation to allow voluntary euthanasia, the average person had little recourse except to starve themself to death, refusing food and liquids. She chose that, even as a mountaineer chooses a difficult ascent involving (for a mountaineer) cold and blisters and tests of endurance. Jean Davies was a hero in her own life story.

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Nitrogen & helium: airing differences

Nitrogen cylinder headAs noted in our earlier Blog, the ‘right-to-die’ movement went into a bit of a tailspin over the news that Balloon Time, a manufacturer of helium party-balloon kits, was henceforth diluting their product. This was because helium had offered a cheap and convenient fail-safe, generally speaking, should someone decide enough was enough.

Faced with an alternative of throwing oneself under a train, hanging oneself from the rafters or blowing one’s brains out with a gun, it was little wonder that a desperate search for a peaceful alternative ensued.

It was in 1995, when I was collaborating on  a book of  New Research in Self-deliverance for the Terminally Ill,1 that one our collaborators, a remarkable biochemist from Vancouver called Bruce Dunn, came up with the idea of using inert gases (of which helium and nitrogen are two. In his chapter entitled, Nitrogen and other Inert Gases, Dr Dunn wrote: “Potentially any non-oxygen gas could be used for physician assisted suicide. However, the most suitable gases appear to be nitrogen, argon and helium. Other gases may present moderate to severe hazards to bystanders, may be disagreeable to breathe (carbon dioxide) or pose other difficulties.” After describing in detail necessary conditions regarding the application, Dr Dunn concluded, “Using inert gases requires acquisition of a compressed gas cylinder, an appropriate pressure reducing regulator, and suitable administration equipment. These materials are not inaccessible to a determined individual, but they are relatively difficult for a member of the public to acquire casually or quickly. This tends to prevent the method from being used by suicidal individuals without aid from an outside agency of individual with the requisite equipment and supplies.”

Of course, when people working in the field mulled it over with the sort of obsessiveness for which we are generally known, it soon became clear that all the materials were indeed very accessible. Thousands of people ordered balloon kits as an insurance against an unknown future, and an elderly lady in America even began making and selling a delivery system (in the form of a plastic bag with a bit of tubing attached).2 It never quite got to being like “a suicide booth on every corner,” as Martin Amis so grimly predicted and even advocated,3 but there was a big enough incidence of student deaths for several organisations to train a renewed attack on right-to-die groups such as Exit and Final Exit Network.

Amis, of course, was intending that euthanasia should be available to the exceedingly old if the person wanted it, at a time when medical science had kept them alive long enough to suffer years of debilitating disease in a slow death. Dunn had a similar market in mind – people who desperately wanted it but also had such undeniably good reasons to want it, such as living into extreme old age (at which point we might surely grant them to have lived long enough to make well-intended decisions about their own life) or else such horrific illness that any doctor in a bygone age would have “given them a little something” as a standby if they really and truly needed it.

But enough of reasoning the need! If we can educate youngsters not to drive recklessly in fast sports cars it should not be beyond human capacity to to attend to their emotional well-being and growth, so that they do not turn to the latest ‘suicide fad’ in moments of exam crisis.  A grown and competent adult, on the other hand, should really not have to prove a “need” in order to make choices about his or her life.

Helium is suddenly in disfavour. For many people, it is as if, having gone to great pains to ensure a peaceful death (one day in the not so foreseeable future), society and the market has turned round with a bitter grin, saying, “Thought it would be easy, did you? Well just you suffer like everyone else, because we say that deciding the time and manner of your own death is “bad” and not your business at all!”

So let’s dispel some panic. There are no guarantees when crossing the relatively unknown territory of life but we have some pretty good maps. Our members, by and large, managed very well before helium and will continue to do so, even if the goalposts change.  Problems with other methods mostly yielded to scientific examination (check our books if you are interested).4 Good helium supplies have not suddenly ceased and nitrogen or argon are not that difficult to obtain: they are just a bit more difficult than buying a balloon kit. This is not an entirely bad thing.

Let’s look at some differences . . .

Helium is still available. Only Balloon Time (manufactured by Worthington) have said they are selling balloon gas that they now openly describe as ‘helium mix‘.5 But for such an important item, it pays to be vigilant. Products have to be fit for purpose so the only legal constraint is that the stuff will float a balloon. Balloon Time canisters are easily recognised since they are usually bright pink in colour and the words “Balloon Time” on them. The other party balloon kits, known as Balloon Occasions are usually a dull beige colour and are manufactured by BOC. BOC’s data sheets still specify their balloon gas at the original, unmixed purity.6 (In North America, BOC trades under the Linde Group. In both continents, both manufacturers have outlets under local names, as do many of the other big gas wholesalers.)

There are some good legitimate reasons why you might want, and have a reasonable right to believe, that you are being sold pure helium (i.e. about 98 per cent pure, not 60 or 80). The two main ones are to use as a diving mix  or in welding. It is only when bought as ‘balloon gas’ that you should not assume it is necessarily helium gas and nothing else. Twenty per cent air, by the way, is probably not enough to keep you alive, as a Canadian colleague, Paul Zollman, kindly pointed out to me. (Do the maths: oxygen being 20 per cent of 20 per cent, and refer to standard tables on effects of oxygen deprivation.)7 Yet it is borderline. It could make you very ill for a day or two. Some American dealers are fond of adding “Hi-Float”, a sticky substance that adheres to the inside of a balloon and makes it float for longer with less helium. I hate to imagine what it would do to someone’s lungs! but it again stresses the need for vigilance when purchasing.

Of course, BOC could change their mind next week and say their balloon gas is also just balloon gas, like Worthington’s, and not necessarily helium: but it would be strange if they did so while claiming in print that is was indeed helium.

If you buy an industrial cylinder rather than a balloon canister, you have every reasonable expectation for it to be helium gas (and BOC, unlike Worthington, are a gas company.) The pressure inside such a cylinder can be six times that of a balloon gas canister. So a regulator, largely superfluous before, would be highly recommended. The pressure in industrial tanks is sufficient to do some serious damage!

In the U.K. a regulator, hose and small tank of nitrogen will come to about £80 in total. (No, we don’t give out addresses on the Internet or by email: that bit of work a responsible person will do themself, with or without our book.) Typical costs: We paid £18 for the gas, £25 as a one-off deposit on the cylinder itself, £20 for a regulator and £17 for a hose with the right connectors on it. There is wide variation in prices and and also a big variation from country to country. We’ve covered it in a large new Section of Five Last Acts – The Exit Path, which is selling rather well on Amazon at the moment. (Not cheap as it is over 800 pages and was costly to produce, but that alone should deter casual enquiries.)

Apart from good helium, or buying nitrogen, someone will doubtless make a custom kit available at some time, and quite probably at quite a high price to justify the work necessary to organise it (for those that can afford it). If money is not a problem, BOC also offer a very stylish tank called a Genie. The Genie is a new ‘de-luxe’ in gas tanks. Lightweight, it also has a little set of (removable) wheels to move it about easily, and an interactive digital display to say how much gas is left, as well as protective handles to prevent any regulator damage. Unlike an industrial cylinder it actually looks nice. (Note: connections for the Genie are non-standard. It requires attachments designed for the Genie. Argon and nitrogen attachments are more or less interchangeable, but helium needs a different calibration.

Here’s a few points you might need to bear in mind about nitrogen (and argon) . . .

In the U.K. you will probably need to look credible and fill in some registration details at the shop (nothing major, just name and address and so on). If you try to buy it online from one of the bigger companies like BOC or AirGas, they will probably expect you to open an account. In the U.K. generally, companies will generally not fill up an empty cylinder supplied by another company. Cylinders have to be made to certain specifications, but legal regulations make companies responsible for the ongoing condition of the cylinder and they do this by means identifying it exactly as one of their own ones.8

It is an offence to transport these gas cylinders (as opposed to balloon gas cylinders) in an unsafe manner. Small local stores do not always have all sizes in stock. If a person buys anything other than a smallest canister of nitrogen commercially available, it can pose a slight safety hazard if stored in a small room. Helium is very light indeed: nitrogen is not. Someone can pass out form inhaling nitrogen that has leaked from a cylinder before they realise what is happening.

In America, we have also had reports of small local dealers selling nitrogen that is a bit of a mixture rather than pure; much to the annoyance of the local welder, who relies on the qualities of nitrogen for the type of weld finish (like helium, it is used as a shielding gas).

Car fanatics (and some cyclists) also buy nitrogen (or pay the local garage for it) to fill their tyres (done correctly, it prevents rust). Nitrogen is also sold for the purpose of dispensing beer, including home brews. It gives that sort of head that you can see with dark stouts such as Guinness. Yet the most common nitrogen “beer gas” is only 75 per cent nitrogen, so someone wanting pure nitrogen would need to be very specific.

It might sound technically daunting at first, even before I were to explain how to choose and buy a regulator, but as Dunn said, it is, “not inaccessible to a determined individual, but … relatively difficult for a member of the public to acquire casually or quickly.” And that is perhaps the way it should be. It is something to absorb slowly. (About 300 pages of Five Last Acts – The Exit Path’s 822 pages is devoted to inert gas, with numerous illustrations, diagrams, and explanations both scientific (in the footnotes and references to scientific and medical journals) and laid out in a way that is accessible to any intelligent reader. There’s 23 pages specifically about nitrogen and the differences using industrial gas. It’s a large volume with much research. (Read and use it sensibly!)

Footnotes
1. Docker C, Smith C, Dunn B, Hofsess J, Beyond Final Exit: New research in self-deliverance for the terminally ill. 1995.
2. “The Gladd Bags” constructed and sold by Sharlotte Hydorn.
3. http://www.theguardian.com/books/2010/jan/24/martin-amis-euthanasia-booths-alzheimers
4. Five Last Acts II. This a more compact volume (at just over 400 pages) but does not contain all the detail on nitrogen that is contained in The Exit Path.
5. http://www.balloontime.com/contact-us/faqs/ Balloon Time data; and
http://www.worthingtonindustries.com/getmedia/382c642e-7458-4903-8ae7-3181c426be32/WC042-Helium-Blend.pdf Worthington.
6. http://www.boc.com.au/shop/en/au-boc-industrial-store/balloon-gas BOC data.
7. (see Table 1, below).
8. Relevant legal instruments include:
The Pressure Vessels (Verification) Regulations 1988;
The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009.

oxygen deficiency table

Addendum 28 May: Checking the data sheets for Linde Group in Canada, they are specifying the contents of balloon gas as between 60 and 100 per cent, with 10 to 23 per cent nitrogen. (Material Safety Data Sheet Version 5, printed 11/05/2014).

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The quality of mercy is not strain’d

Chiron_instructs_young_Achilles_-_Ancient_Roman_fresco

Cheiron instructs young Achilles. Fresco from Herculaneum (Museo Archeologico Nazionale) Naples

“You wouldn’t let a dog suffer like that” is a phrase that often comes to mind when witnessing the struggles of someone who, despite the best efforts of palliative care, is in a prolonged and unbearable agony: someone who in some cases is desperately seeking assisted suicide. Why do we let a human being suffer such torture and, against their competent, sustained wishes rather than give such a person their wish?

Some trite phrase is usually rolled out. “Only God gives life and only God can take it away,” or, “If we did it for one person, other people would fear being murdered.” The ancients often tackled such seemingly insoluble dilemmas in stories. Cheiron, for instance, was a centaur: half man, half-beast.He also happened to be “immortal.” One day, Cheiron sustained a terrible wound from an arrow. The pain became unbearable but, being ‘immortal” he was unable to die from it.

Around this time, you will remember that Prometheus had been chained to a rock. His only hope of freedom was if some immortal would give up his immortality. Cheiron, a wise, intelligent and benevolent healer, asked if he could give up his immortality. Hercules pleaded the case to the Zeus, which is the Ancient Greek name for God on High, or “Deus.” Zeus grants Cheiron’s wish and the centaur was thereafter remembered as a beautiful constellation in the night sky (which we now know as Centaurus, the brightest of the southern hemisphere).

There are many interpretations of the story, but you may have already seen the connection to assisted suicide. It was not something Zeus granted lightly, but eventually Zeus did the decent thing. How does it compare with our modern gods? The God of the Christians, at least according to His most vocal priests, would not allow it. Similarly, the God of the Muslims apparently feels that life belongs to God and only God can take it away. No matter how strong a case is made by a modern Hercules, it’s apparently just not on. In spite of the rhetoric, the dominant quality of these modern gods is clearly ownership, not compassion. They “own” the life of mere mortals, not just those of priests who have given their life to God but, by a dictat that seems to say that all men and women do not own their own lives.

The quality of mercy, as Shakespeare so eloquently put it, should not be under duress, and certainly not strained beyond all human endurance.

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