A special treat for readers of ExitEuthanasia Blog

20150322_221231Free! (Or at least as free as we can make them.)

The peace of mind obtained from years and years of research, peer-reviewed and supported with the best medical experts and medical journals worldwide, carefully presented in the most comprehensive manuals on the subject. You cannot put a price on that. But although the research and publication of a 750-page book costs a lot of money, we realise that there are individuals who rationally need it but are unable to afford even the cover price.

Although our organisation runs on a shoe-string and is painfully short of funds, it is a vocation enterprise to reduce suffering at the end of life, and the fear of suffering. We can’t make books with fresh air, but for a few days we are making them available at a massively subsidised rate, less than half the normal cost price, through the Amazon store.

Since most people do not check the price of a book on a daily basis, by letting our Blog Subscribers know, we are effectively making the offer to you and your colleagues and loved ones. For details of the difference between the two books please see the “Publications” tab at the top of this page (Five Last Acts II, the purple cover, is more compact; Five Last Acts – The Exit Path is nearly twice the size with much more details).

The massively reduced list prices prices are available NOW on Amazon US; they should appear on other Amazon sites in the next day or two. (For instance, Five Last Acts – The Exit  Path usually retails at just under US$50. Just now it is about $22.50. Amazon and other retailers usually sell Five Last Acts II for between $35 and $40 but the current price is about $15. This is a one-off offer to get some very solid library books on self-deliverance methods. It is only on for a few days.

Posted in assisted suicide, legislation, palliative care, research, self deliverance | Tagged | 1 Comment

To sleep perchance to dream? and dream and dream?

internet scammer warning pictureDesperate for euthanasia? Losing your money to internet scammers is not the answer.

Websites abound taking advantage of people’s desperation. One person recently lost $800 after being promised Nembutal online (Nembutal is a brand name for pentobarbitone/pentobarbital, a barbiturate sometimes used for euthanasia).

Occasionally people do obtain genuine Nembutal, usually illegally through a Mexican pet store by saying it is to put a large animal to sleep (We don’t recommend even this method: some people have been arrested travelling through customs.)

None of the genuine right-to-die organisations sell Nembutal directly. Sometimes we see sites offering early Exit books such as Departing Drugs or Beyond Final Exit as a lure. These old books are not only 20 years old, they are out of print!

The four principal books on self-euthanasia are Five Last Acts II, Five Last Acts – the Exit Path, The Peaceful Pill, and Final Exit. They are all available on Amazon (the first two are by Exit, the second two by other organisations). They all recommend the use of helium as a main choice, and various other methods as a back-up. None of them sell Nembutal.

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Assisted (costs of) suicide

Dr Preisig: "May I help you?"

Dr Preisig of LifeCircle: “May I help you?”

Most people agree that every person has the right to seek happiness in their own way, and to live life, even choosing the time and manner of death, in the way that they would wish.

In Switzerland, any citizen can make a reasonable request of any of several organisations, and any number of doctors will be willing to prescribe sufficient medicines to enable a person to die peacefully. The process is fairly open and regulated, but not officiously so. Safeguards are in place and reasonable attempts are made to dissuade a person and consider the request in light of their medical records, also considering if the person has made reasonable use of appropriate palliative care services. The costs involved are negligible.

Not so for Brits, who make up one of the largest contingents of foreigners visiting Switzerland for assisted suicide. For anyone who can fulfil the necessary requirements, the same checks are in place and if (in the very rare case) anything goes ‘wrong’ then the person can be taken to hospital to die. There is one or two extra factors to dissuade persons from the final step however, and that is that the process for foreigners is usually inordinately expensive. The standard procedure requires not only that you come up with considerable paperwork, medical records, and possibly a psychiatric assessment. Firstly you need to break the law. Not in a big way, and not in a way that doesn’t routinely go unprosecuted, but commit, or rather persuade someone else to commit, an illegal act: the simple process of having someone accompany you to Switzerland. By doing that, that person has contravened the Suicide Act as is theoretically liable to a lengthy prison term.

The pronouncements of the last Director of Public Prosecutions (DPP) made it reasonably clear that when the ‘chaperone’ was well-motivated, had not persuaded the person to commit suicide, and wasn’t doing so for selfish motives, that after all things had been considered a prosecution would be unlikely. (In practice, a person may still be liable to arrest and traumatic police interrogation before “all things have been considered” sufficiently to hand it over to the DPP, and then wait a limbo of a year or more before finding out if a prosecution will proceed.)

But there is an even bigger barrier: MONEY. It turns out that it is rather costly to process a foreigner through the stages of assisted dying. Estimates for Dignitas,(1-3) the main organisation that accepts foreign applicants, vary from £5000 to 10,000. It took this blog a little digging to discover the costs using another organisation, LifeCircle,(4-6) but it would appear that costs are about the same.(7) (Both organisations say they will waive costs in exceptional circumstances.)

Is there any reason why such a simple human act should be so prohibitively expensive? One of the arguments for legalising assisted suicide in the U.K. is that access to such facilities should not be a question of wealth. Lord Falconer’s Assisted Dying Bill is currently being examined by parliament, and yet at the latest reading we discover how enormous costs could easily creep in.

Lord Phillips of Sudbury: “On the first day in Committee your Lordships decided overwhelmingly that a person may only obtain an order subject to the consent of the High Court, Family Division. You do not need to be a lawyer … to know that applications to the High Court of any sort are apt to be expensive. … A city lawyer charging £500 or £700 an hour is rather different from a country lawyer charging £100 or £200. It will also depend, as I said, on the complexity, but one is talking of thousands, not hundreds, of pounds.”(9-10)

One could, of course, always try to get legal aid (11) . . .

Notes
1. Dignitas (homepage)
2. Dignitas (brochure)
3. Exit’s quick guide to Dignitas
4. LifeCircle (homepage)
5. LifeCircle (introduction)
6. LifeCircle (brochure)
7. Two elderly Scots die with help from LifeCircle (cost £15,000)
8. Canadian review of LifeCircle
9. Read the full discussion of: House of Lords 16 January 2015
10 Exit considers the Falconer bill
11. MoJ refuses to release information on legal aid cuts (Politics.co.uk)

(further links: please scroll down using the right-hand column)

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Living wills again

livingwillExit’s main work is associated with research into self-deliverance (“self-euthanasia” or “rational suicide” as it is also referred to). Yet along the way, living wills have also been a major area of research. We published the first volume of Collected Living Wills (no longer in print) and took research to the Law Commission and the Ethics Department of the BMA, successfully encouraging the inclusion of “values” clauses in the legislation which ensued. Our work arose over concern whether living wills were used enough and, even if they were, whether they were effective.

We were fortunate in being able to use the resources of Glasgow University’s library for our research, for independent researchers are not always so lucky. Academic publishing is largely controlled by major corporations around the world, who effectively harvest enormous sums for access to cutting edge material. Individual authors see very little, or even nothing, in recompense for an article that may have taken months or years to produce and for which the public are charged on average about £30 just to view. Academic books strain the finances even of the students that need them for their studies.

The real problem with this is that it holds back knowledge. Although we now have legislation to increase compliance with living wills, the theory and practice of making them as effective as possible is often poorly understood. Exit’s work was published in an academic book currently listed at retail for almost £240. Although the work is widely quoted by academics it is virtually unobtainable at a reasonable price by the public unless you come across a second-hand copy.

The research is quite old now, but still valid in understanding the nature of living wills, pitfalls to avoid and useful features to keep. Bear in mind that it was written in 1996 in a format that is difficult to transcribe for the web, but we are doing our best to bring it to you free of charge on Scribd (follow the link below). This version was taken from a draft and is imperfectly formatted (English law cases, for instance, have round instead of square brackets) but the essence should be useful for anyone seeking a more technical understanding of the living will process.

Living Wills / Advance Directives on Scribd (free).
Contemporary Issues in Law, Medicine & Ethics (the book from which it is a chapter, on Amazon).
Contemporary Issues in Law, Medicine and Ethics (search inside the book using Google)

Posted in legislation, living will, research | Leave a comment

The choice to face your choices

five-questionsWhat does choice mean when you visit a website such as this?

Often we talk about choice as if it is something that is a right, something we believe in, or something we want to have. It rather implies that we have already decided about what. “It is my choice to die with dignity, at a time of my choosing.”

These things are easy to say, but I wonder, are they sometimes a bit like believing in world peace. You can “choose” to go on a world cruise but, if your ticket is just to cross the river, then your “choice” not only doesn’t mean much, it isn’t a choice at all.

Choosing is about choosing from available options. In most situations, we can increase the range of those options through effort. Our choices, of course, relate to the life in question, our own: not some abstract world where if, like a child, we holler loud enough it will be done.

Many people put off expanding the range of options until it is too late to do very much at all. “I’m going to diet one day soon,” or “I really ought to join the gym and exercise,” or “I believe in death with dignity and one day I am probably going to find out how to do it.” Just like that.

In other words, we put off choosing anything because we think there will always be another day. Somehow our riverboat ticket can be upgraded to a cruise in the Mediterranean. We’ll undo years of strain on our heart by suddenly eating salads and buying a running machine. Or when death comes knocking well, I guess I could buy a book or jump on a flight to Switzerland. Then, when we realise that it doesn’t work like that, we realise that our choices are actually rather limited.

Our goal at Exit is not to get you to vote for a politician that supports our aims. It’s not to ask you for a subscription or to sell thousands of books. Our aim, quite simply, is to take away the fear of death. We want to do that by inspiring you to think about it. Gently, sensibly, but to face life (death included!!) in real terms, not as a “one day I will…” .

It is not the duty of this blog even to tell you whether you should support dignity in dying or whether you are part of a minority with the opposite belief. But you’ve read this far: stop for a minute! Try these questions*:

  1. What is your understanding of your current health or condition?

  2. If your current condition worsens, what are your goals?

  3. What are your fears?

  4. Are there any trade-offs that you are willing to make? Or not?

  5. What would a good day be like?

By thinking deeply about these questions you can begin to approach real choices by addressing your real situation. Whether you are for or against euthanasia, think for a moment if you will about your health, what your death might be like, what you would like it to be like, what you would, or might, need to do in order to have the sort of choices you desire. If you wish, there is a video to help you here.

The original author of those questions, Dr Atul Gawande, rather sits on the fence on the question of euthanasia; but the questions are equally valid whatever your answers might be. You can consider what life might be like in the period before the inevitable. Learn about it if need be (if you need information, there’s an excellent book on the most common ways that death occurs by Dr Sherwin Nuland called How We Die: Reflections of Life’s Final Chapter). If you are opposed to euthanasia, you might wish to investigate the realities of palliative care realistically, to understand best and worst case scenarios. If assisted suicide in Switzerland comes to your mind, it could be worth checking the Dignitas website (or the relevant articles on this Blog) to see what is involved. If self-euthanasia is maybe a back-up plan at the back of your mind, then perhaps check out our publications page or go to Amazon to have a quick look inside some of our books. Or of course there is one other choice: do nothing.

You may or may not have the “right”: but do you choose to have choices?

A notice to our print subscribers (Members of Exit):
You may have wondered why you have not heard from us in the past couple of months. You may recall from the last Newsletter magazine that we were facing a very serious financial crisis. We had to take a hard look at our existence and prepare for some difficult choices. Fortunately we are still running (or ‘unfortunately’ for the abolitionists and those resorting to morally dubious tactics to shut us down). We have reorganised things and the future is looking secure even if (as has been the case for 35 years) we keep going by sheer good luck, grit and determination, and the knowledge that people rely on us worldwide in the work of leading research. Thank you for any help you can give.

*Taken from: Being Mortal: Medicine and What Matters in the End by Atul Gawande.
These types of questions also relate to work Exit did previously in the area of advance medical directives (living wills) by helping to persuade the government to include a section about values in the legislation.

Posted in living will | Tagged | 5 Comments

EXIT: The Self-Euthanasia Movie

EXIT: THE SELF-EUTHANASIA MOVIEDeep emotions. Self-examination. Joy and seriousness. A roomful of people gathered together last week to spend the day familiarizing themselves not just with ‘methods of self-euthanasia’ (helium and other techniques), but facing the fears, breaking taboos, finding a new community of openness for a sensible discussion but also much laughter and shared good feelings.

It was one of Exit’s long-running full-day interactive workshops. There was a look at the law and the moral dilemmas, then fast forward to imagine a situation when time runs out. Could you remain so calm? Take decisions sensibly and in full control?

Exit workshops are carefully paced to allow people time and opportunity to examine their feelings as well as the physical and intellectual dexterity that they might need one day. Different ‘methods’ are compared and questions asked. What about if you were paralysed? What if an illness was not so serious after all? How do you make sure you get the best pain relief available? For the practicals, people work in small groups, finding out for themselves, what helium is really like, how to make their own ‘hood’ should they need one one day, the pitfalls and care points of five or more methods: not just to think, “I am going to do this one day,” but to know that one is capable should all else fail.

But “A Good Death” is not just about knowing how to swallow pills or use inert gas or any of the other most safe, reliable methods of drawing one’s life to a close when the time comes: it is about peace of mind. A sense of life completed. A sense of one’s own time. The tried and tested techniques for achieving mental composure are introduced. Being at ease with oneself, one’s loved ones and the rest of the world is just as much a part of a “good death” as is lack of pain and indignity in the final moments.

Workshop facilitator Chris Docker has spent not only more than 20 years researching methods of self-deliverance (rational suicide), but has also trained in suicide prevention, palliative care, and advanced meditation techniques. He holds a Masters Degree in Law & Ethics in Medicine and has been a leading advisor on the legalities of end-of-life issues to the professions.

EXIT: THE SELF-EUTHANASIA MOVIE See the trailer HERE

Posted in self deliverance | 6 Comments

The things that become important

audience at a TED talk

audience at a TED talk

Some of the questions in life can be downright scary. Take death, for instance! We know it’s going to happen yet we do so little about it. When the time comes, sometimes everything happens in a rush.

For this Blog post, I have taken three uplifting but intensely practical inputs. Firstly is a TED talk by an emergency medical technician called Matthew O’Reilly. He identifies three common scenarios he sees when attending someone in the last moments of life. Secondly is a re-blog from my friend Derek Humphry’s mailing list where he recalls the transformative attitude of a dying woman as recounted by philosopher John Hardwig. Finally is a story from our recent Exit workshop that maybe pulls these together.

First, here’s the TED talk, called, “Am I dying?” The honest answer.

(apologies to our readers who found a large blank space here! … we weren’t aware that video embedding isn’t allowed on wordpress blogs without a $99 subscription, so they were deleted after a day or so — do please just follow the link above — it’s only five minutes but has great emotional and practical impact)

Matthew looks at common crises that persons face inside and how he answers the question, “Am I going to die?” But he goes deeper.  He finds out what people are really looking for. He tells them the truth, and listens to what is important when someone knows that they are dying. They found inner peace and acceptance. But the reactions vary. 1) It’s about forgiveness, knowing that their life was good. Or (2) a need for remembrance, and in this a sense of eternity. Or (3) “The dying need to know that their life had meaning,” he says, and how that one always moves him the most.

Next, here is an example of someone with more than a few minutes, someone who knows they are dying and wants to act on the sort of realisations that Matthew mentions: she wants to do good for others and make her life count in that way.

Looking outside oneself in dealing with death by John Hardwig
(originally published in The Daily Republic and reprinted on the Ergo NewsList)

Brittany Maynard’s ordeal is now over. On Nov. 1, the 29-year old with terminal brain cancer, who became the face of a movement to allow dying patients to choose when to end their lives, used the pills provided by her Oregon physician and died. Compassion and Choices, the nonprofit Maynard worked with, reported that “she died as she intended -peacefully in her bedroom, in the arms of her loved ones.”

I would trade quite a few more days (especially days spent with searing pain or doped into semi-consciousness in an effort to manage symptoms) for the ability to say my goodbyes and die like that. We all know by now that the best death is not the one that can be postponed the longest.

The most striking thing about Maynard was the way she transformed herself so quickly, with an essay, from just another person into a warrior with a mission. But this is in keeping with the way many terminally ill people behave. They often spend their remaining days trying to improve the lot of those who will suffer similar illnesses in the future. Some, like Maynard, campaign for policy changes. Some offer themselves as subjects for medical experimentation, knowing full well that any findings will not help them. Some participate in support groups for those with similar medical prognoses.

“I didn’t launch this campaign because I wanted attention; in fact, it’s hard for me to process it all. I did this because I want to see a world where everyone has access to death with dignity, as I have had. My journey is easier because of this choice,” Maynard wrote on Oct. 9. In that way, she gave meaning to her final days in a way that a series of purely self-centered decisions never could have.

Discussions about physician-assisted suicide – and Maynard’s death – almost inevitably focus on what’s good for the terminally ill patient. But not every patient takes such a self-centered approach. A self-centered life, focused on personal gratification, aggrandizement and comfort, may or may not be good for the one living it. But a self-centered death is not. If all we care about is ourselves, everything we care about will perish in our death. That is unbearable.

Those who see themselves as connected to something bigger and more enduring than themselves, however, can die in a context of meaning and purpose. For some, religion provides this connection. But religion doesn’t always work. Many cannot summon the necessary theological convictions, especially on demand. And some kinds of religion fail at the end of life. A Christian oncologist told me that she deals with many patients who die filled with rage against God.

For others, a sense of connection comes from family, a deeply felt affinity with the natural world, or commitment to some ongoing endeavor such as art, science or efforts on behalf of disadvantaged kids. This approach clearly spoke to Maynard, who wrote that she worried she’d soon be unable to recognize her husband; her family moved with her to Oregon so she could die there.

For those who live a life of connection, when illness threatens to sever the connections, it is time to go. But the survivors go on, burdened or blessed with the memory of the death of their loved one. For them, the death is never the end of the story. And a death in the family – especially a long, drawn-out dying process – can be much worse for the survivors than it was for the deceased. This is part of the reason Maynard gave for opting against hospice care: “I probably would have suffered in hospice care for weeks or even months. And my family would have had to watch that. I did not want this nightmare scenario for my family.” She was looking outside herself.

The evaluation of Maynard’s death and of physician-assisted suicide more generally, must not be exclusively focused on the dying person. That would be to revert to the self-centered, unconnected perspective. Those of us with deep attachments to family and loved ones are all charged with carefully weighing what each of our alternatives probably would mean for our loved ones, with helping them to understand whatever choice we make, and with preparing them, as best we can, to go on to live happy, fulfilled lives without us.


How do these things all relate to each other in a practical way?

Some while ago, we looked at peer-reviewed research on the way we can choose to influence our state of mind when facing death. Matthew has described the needs, but not all of us will have Matthew to talk us through or be in Maynard’s position. For the first time in a face-to-face situation, confronted with a fairly hard-nosed audience unwilling to swallow any psychobabble, we introduced one of the several techniques. Called LKM, it is used by persons of any religion or none and, like mindfulness meditation, involves meta-cognition (the psychological ability we have to ‘think about our thinking’). There are two stages, one is to feel good (and forgiving) about oneself and the second is to feel good about everyone else.

The first of these, feeling good about oneself, one’s life, can be particular hard at a moment when it is all about to go away. I sometimes go through this stage with people by asking them to think of someone who loves or has loved them unconditionally. Imagine that person is glancing at you from the other side of a screen as they write about you. Imagine you can look over their shoulder. Look at all of the wonderful things they are writing about you. Make peace in this way and value the goodness of your life; and then, only now, turn to your feelings towards others.

This second part involves holding that feeling now built up inside oneself, a feeling and knowledge gained from a sense of unconditional love, and extending the feeling to others. Starting with those close to you, feeling love for them and extending forgiveness for anything that has happened in the past. Then extend it to carers, associates or people you barely know. Lastly, to anyone who wished you harm or that was your enemy.

While this sounds a wonderful exercise, I have not introduced it merely to suggest we should all love each other! – even if you think that should be the case (and of course, maybe it is). But the issue we are tackling here is our own inner state of mind at the time of death. If you want a good death, whether by your own hand at a time of your choosing, whether by going to Dignitas, whether by letting ‘nature’ take its course, or it could even include a road accident (going back to the first story in this blog) then you might want to spend a moment deciding how you will handle it.

A close and very elderly friend recently said to me the other day that, with severely declining health, continuing to live a little longer became acceptable on realising contributions to the needy she can make. She probably has her ‘Exit’ kit to hand, but she is practicing her mental attitude in a wholly fulfilling way.

Sometimes learning how we want to die can inspire us to enjoy the way we really want to live our lives (first!) EXit wishes all its readers a good life, and (quite literally) a good death, and a good dying.

n.b. This is a more upbeat approach than our previous, rather graphic blog, but there is maybe a common theme running through them which we have touched on in a practical way in our ‘last moments’ essay (find it at the very foot of the ExitEuthanasia Blog). 

Posted in assisted suicide, palliative care, self deliverance | Leave a comment

Realising oneself in life and in death

Meryl Streep in The Hours © Paramount Pictures

You have a “right” to choose when and how you die and, unless you have been incarcerated, it is not that easy to take the right away from you. Whether you use it wisely is another matter. Whether you manage to do it with grace and dignity may be a matter of skill, style, breeding and knowledge. But is it selfish?

Much well-documented work has been done on the immense opportunities for bonding with loved ones in the days before death occurs. There are moments of deep sincerity in which love is somehow communicated, pathways to the heart opened, and a deep meaningfulness achieved. Critics of self-euthanasia and assisted suicide argue that these moments are not to be tossed away lightly. Exit agrees, and has published much work on this theme, yet does it negate the idea of choosing the moment of one’s death? The importance and value of our loved ones, and meaningful moments shared, are things that can be rightly treasured. The self-willed person, planning euthanasia, may even value them more, and plan or discover them to an even greater degree. Studies suggest that rational suicide, such as at the end of a terminal illness, often brings healing and a sense of closure to those bereaved (but this is reversed in cases of irrational suicide.)

So how far should we live for others, stay alive for others? Is the purpose of your life to exist for others?

I’d like to share if I may two clips from an award-winning film, The Hours. Richard is a Pulitzer-Prize winning poet. His best friend, Clarissa (Meryl Streep), is throwing a party in his honour to celebrate. Richard is dying, slowly, of AIDS.

(apologies to our readers who found a large blank space here! … we weren’t aware that video embedding wasn’t allowed on wordpress blogs without a $99 subscription, so they were deleted after a day or so — do please just follow the links below, where they are shown legitimately – warning, these movie clips are quite graphic and some viewers may find them upsetting.)

1. http://youtu.be/CWAAUSNLZXQ   2. http://youtu.be/vWZapP8b11s

In the first clip, he raises the question of his death with her and she responds as expected. He also takes her back to a moment they had shared many years ago, a moment of beauty that encapsulated (for them) the joy and meaning of being alive.

In the second clip, just before he ends his life, he takes her back to the moment again and lets her realise the depth of love he feels for her as his friend, a love she has always felt for him but never realised in totality. He brings her to an awareness that she has been living her life for him, just as much as he has been staying alive for her. He calls her “Mrs Dalloway,” a character from Virginia Woolf’s eponymous novel.

“Would you be angry if I died?”, he asks. She responds as you might expect.

” I think I’m only staying alive to satisfy you,” he continues.

She replies: “That is what we do, that is what people do, they stay alive for each other.”

On Richard’s death, she discovers that she also is now also released, she rediscovers her own life (not shown in the clip) and her love for her partner.

This is a fictitious drama with an intertextual play on the character of “Mrs Dalloway,” who, at the start of the novel, decides to “Buy the flowers herself” (presumably, rather than send one of the servants.) Flowers are here a symbol of love, and it is an action that Clarissa also decides on for the party. Yet she is living a character, trying to be someone for someone else. Richard uses his dying moment to free her from the illusion of living in character – in other words, for someone else.

The film makes no judgement on the rightness of wrongness of self-euthanasia (rational suicide); yet the rich emotion that it is possible to present in great fictitious works such as this enables us to access a depth that is hard to achieve in dry analysis alone.

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Exit welcomes CPP clarifications

Screen Shot 2014-10-19 at 22.28.40A statement issued last week by the new Director of Public Prosecutions, Alison Saunders, clarifies the Guidance of the Crown Prosecution Service (England & Wales), and eases some of the fears of doctors and others in the medical profession over cases of encouraging or assisting suicide.

The medical professions have seemed particularly vulnerable until now, given that they have a special relationship with patients known as the “Duty of Care.” This is a legal obligation requiring a doctor, nurse or other professional, to conform to a standard of reasonable care when saying or doing anything that could foreseeably harm the patient. Failure to do so, could see that medical professional taken to court for negligence or barred from further practice. What is more, the test for negligence is based on what a doctor (for instance) of similar training and experience would have done (this, in law, is known as the ‘Bolam’ test). Under current UK law, a doctor or nurse is not reasonably expected to explain to you how to kill yourself, or travel to Dignitas for assistance in dying, and could be negligent if doing so. But what if that doctor is not the doctor treating you but just happens to be your friend or acquaintance?

Until last week, this was a slightly murky gray area. The CPS Guidelines provide two long lists of factors that are formally considered in the balance when deciding whether to prosecute an individual case. (You can find links to the Guidelines, together with the new update, in the sidebar of this Blog: if you are reading this on a mobile device, you may need to switch to desktop view to access them.) One of the factors tending in favour of prosecution, reads:

the suspect was acting in his or her capacity as a medical doctor,
 nurse, other healthcare professional, a professional carer
 [whether for payment or not], or as a person in authority, such as
 a prison officer, and the victim was in his or her care;

This might seem fairly straightforward, but as a doctor, do you want to take the risk? As a patient, do you want to risk putting that doctor in an impossible position?

Fears had led to some fairly draconian advice (doctors might feel supportive but that is not the same as being willing to risk 14 years in prison). The British Medical Association was quick to advise:

The BMA advises doctors to avoid all actions that might be
interpreted as assisting, facilitating or encouraging a suicide
attempt. This means that doctors should not:
 • advise patients on what constitutes a fatal dose;
 • advise patients on anti-emetics in relation to a planned overdose;
 • suggest the option of suicide abroad;
 • write medical reports specifically to facilitate assisted suicide
abroad; nor 
 • facilitate any other aspects of planning a suicide.
 • Patients have rights of access to their own medical records under
the Data Protection Act, and where a patient makes a subject access
request, doctors are obliged to provide the requested information,
subject to certain exemptions.

While the General Medical Council (which can revoke a doctor’s licence) wrote:

...any advice or information doctors give about suicide to patients
should be limited to an explanation that it is a criminal offence
for them to encourage it.

In June of this year, the (United Kingdom’s) Supreme Court urged the DPP to clarify her guidance after they had tussled with its clauses in relation to the Tony Nicklinson case. The new amendment to the CPS guidelines, issued last Thursday, clarifies the phrase “and the victim was in his or her care” with the following footnote:

For the avoidance of doubt the words and the victim was in his or
her care qualify all of the preceding parts of this paragraph.
This factor does not apply merely because someone was acting in a
capacity described within it: it applies only where there was, in
addition, a relationship of care between the suspect and the
victims such that it will be necessary to consider whether the
suspect may have exerted some influence on the victim.

The most pertinent application we might deduce from this is the difference when you consult your doctor, a situation where there is an accepted degree of influence, as opposed to when you speak to someone who just ‘happens to be a doctor. ‘ There are exceptions, and it is up to a court to decide if a duty of care exists in a particular case, but it generally means a situation where a doctor (or even a carer) is demonstrably caring for that person. Your registered doctor has a duty of care, as does the doctor in charge of your case if you go into hospital: but when there is no formal relationship then a person who happens to be a doctor may not have any more legal duty of care towards you than any other person. For instance, while his professional ethics may insist that he or she acts to help a drowning child, or a passenger on an airplane, there is no such legally required duty in UK law (this is not the case in a number of other countries).

Although Exit would, of course, like the present law to go further in protecting doctors or others that help someone out of compassion, it would seem that the DPP is doing the best job that can be done under existing legislation to be completely fair-handed. Indeed, her amendment reflects the fairness of her verbal submissions to the courts.

Our readers can discover more about how the law on assisted suicide is applied in some of the links below. Remember, it is a two-part test that the CPS always uses: these weighing up of factors to decide if it is in the public interest to prosecute only apply if the CPS considers there to be sufficient evidence to obtain a reasonable chance of conviction.

Further information

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The ethics of euthanasia, our books, this website, right or wrong?

motor way aheadIn almost every religion and philosophical system, the right to life and the right to live the way we want to as long as it does not interfere with the same rights of others, is something universally respected. I don’t much like the phrase “the right to die” because each of us is going to die anyway. Each of us is going to experience that both in our life one day, and as an ‘observer’ long before that. You could ask every family on this planet today and not one of them could say they have not experienced the loss of someone through death. Death, undoubtedly, is a fact of life. You have no right to die but you have a right to choose when and how. However, for ease of everyday expression we can talk about a right to die.

Rights can be a natural, civil or political privilege. They are a claim to an entitlement of some sort, and it follows that to mean anything your entitlement has to be recognised by others, hence our laws – and the philosophical idea that all rights entail duties (FindLaw UK). In the example I gave above, the duty is to observe the same rights in others.

Liberties and rights are not always the same. You have a liberty to be promoted in your job, but not a right (as it would affect the rights of others). But as a woman, you have a reasonable right not to be discriminated against on account of your gender! This is not something we will always feel instinctively. Your boss may feel privately and even passionately that he can discriminate on account of your gender: but the moral law, now enshrined in the laws of the country, says he may not do so. As he considers the moral position, how you are entitled to the same freedoms as man, as any person, he may come to understand. A person’s freedom, every person’s individual freedom, is the reason we have moral law at all; correspondingly, it is the moral law that provides us with the opportunity to understand our freedoms and the freedoms of others. In a way it is, and has long been, the basis of our society for many years (Kant 1788). For without freedom, what is your life worth?

At a recent conference, I started by listing some of the freedoms we often take for granted. You have for instance the freedom to live the way you want, to speak however you want, to write what you want, to love others the way that you want to. The only moral argument is that you do so without infringing the same rights in others, and unless there is a law set in stone then you also often have to be the judge of the morality of your action. You can’t walk into the National Gallery and write your name on a Picasso just because you have an innate right to write what you want to. You may decide, in certain circumstances that you have a moral right to help someone else, including helping them to die. The law however may disagree (in some circumstances and not others); and sometimes when you exercise what you believe to be your right the consequences might be so severe that your own right to freedom would be infringed, so you would have to weigh up the options carefully (DPP 2010). A person also has the right, let us not forget, to try dissuade someone else whom he feels is misguided in wanting to die.

Having dissected the “right to die” to find what it really consists of, it would feel natural to look at a similar “right” and ask the same questions. What is the “right to life”? Thomas Jefferson wrote in the Declaration of Independence that it was self-evident that all men are endowed with certain inalienable rights, among which are the rights to life, liberty and pursuit of happiness. It was not, however, self-evident to everyone – since a war for independence quickly ensued (Hood).

The “right to life” does not mean quite the same as the “sanctity of life,” but both ideas are deeply embedded in our society and way of thinking, without being absolute (Lord Keith 1993). War is a commonly quoted exception, which could be defined as the defence of one’s right to live the way one justifiably wishes to, without interference from others. Many books have, and still could be written on this subject. A difference between “right to die” and “right to life” organisations might be caricatured as “I have the right to live and die the way I want to, and I wouldn’t want to stay alive as a ‘vegetable’,” vs “I have the right to live and die the way I want to, and I want to stay alive as long as possible, even if I’m in a vegetative state.” The difference between the two sides is either a) a desire to extend one’s personal interpretation of these rights to others, or b) a fear that others will infringe on one’s rights.

What we are talking about is the rights of the living, to make choices, to do. Not so much of existence, but of the right to exercise and enjoy that life, that existence, in the way that one sees fit, without fear or favour. The idea of a debate between “right to die” and “right to life” can throw light on the issues but, alone, not progress them. Most people are somewhere in the middle. It is philosophically disingenuous not to see things from all sides and for this reason it is mostly not in my nature to engage in debate. Yet however all-embracing any one of us might wish to be, as individual, as persons, individual organisations, we still have specific lives to fulfil, specific tasks to achieve, and particular people we are drawn towards helping. Suicide prevention is as important an issue as rational assisted suicide (I’ve studied and worked in both.) I’m trained as an ethicist to examine all sides equally. Who can not feel the pain of someone bereaved at a moment that seemed wrong? Also, who could not feel the pain of someone forced to exist against their wishes, their lives fulfilled, but tortured to a slow death in direst agony? Suicide prevention is still, relatively, a new science. If society intervened with everyone displaying ‘at risk’ signs, ten times as many people would have their lives disrupted than helped (Smith 2008). Only when someone is clearly a danger to themselves can we, as society, intervene; but if there is any doubt then the principle of autonomy, of self-determination, takes precedence (Lord Keith).

The roots of Exit go back to 1935 (when the first voluntary euthanasia society was formed, in London) and to 1980 when it broke away from its parent group to publish a manual detailing ways of painless, dignified death. It was imperfect (and still is, as are all such manuals) but the work continues, and it is to address the rights of those people who want to be able to determine their own time and manner of dying. The purpose of this Blog, our books, our workshops, is to look at the practical options for that group of people. Years ago, such people would have thrown themselves off Beachy Head, put their head in a gas oven, hung themself from a light fitting or driven their car into a tree. If you have lost someone to an untimely suicide that was at least relatively painless, would you really have preferred their bodily remains to be scattered over the rocks below a cliff-top? Doing everything we can to prevent untimely suicide and empowering people with knowledge, even knowledge of the methods of suicide, are not mutually exclusive. Almost 280 pages of our current manual are devoted to examining the moral issues, to dissuade the unprepared and encourage them to explore all other possible solutions rather than death, and, if no other solution is acceptable to them, how to communicate with their loved ones and those dear to them and minimize their pain as well.

Among groups concerned euthanasia and with self-euthanasia, Exit is among the most conservative. Our legal proposals are for exceptions to the rule; our books are quite voluminous to read and absorb the information; there are no “how-to” instructions on our Blog or Homepage and we do not offer one-to-one advice even to members. We work (and encourage others to work or act) completely within the law. We run on a tiny budget (data-led research is costly) and are frequently harassed and blamed: yet it is a fact that anyone with internet access can simply skip our websites and find “instructions” on how to die from underground chatrooms and discussion groups (many of those are so irresponsible that we really can understand attempts to have them shut down for good, but please, leave us in peace!) If you are among the small proportion of people in this thankfully democratic country that opposes euthanasia, this is not the place for you (unless you are genuinely trying to understand a different view). We are sorry for your pain but please don’t send us your haranguing emails or death threats: really, we did not cause the problems in the world. We built the motorway for people who need to get somewhere quickly and safely; we put up a sign saying No Learner Drivers or Persons Unfit to Drive. We can point you to responsible sources for suicide prevention, bereavement, mental illness and so on, but that is not the job that Exit was set up for, the work that people desperately trust us to do to give them that insurance, that key to the door marked Exit if things get so bad they cannot take it any more. (And many have said how simply knowing how they could take matters into their own hands gives them courage to live on, to live longer.)

There is a small book in our office compiled in 1989 by one of the founders of Exit, Sheila Little, a tireless, charismatic, elderly grey-haired lady who devoted her life to our mission. That mission is expressed in the letters printed, with permission, in its pages: heartbreaking tales of people who just needed to know there would be a way out for them. They trust us to do that work.

And Who Should Forbid Them

 

Professional bodies working in law, medicine, psychiatry or other areas specific to our work are invited to contact us at any time. We cannot as a matter of course enter into general correspondence with the general public however, and if you are a member of the public wishing to discuss the issues raised on this website, please follow the appropriate links. (This is not a discussion forum.)

References. These are a small selection. Our book The Exit Path contains a deeper look at the ethics of publishing data on self-deliverance for both professionals and the public. It includes over 1000 references. Exit is committed to empowerment: that means data-led knowledge of methods of rational suicide as well as suicide prevention wherever that is a realistic option.

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“I will take my life today around noon. It is time,” she began.

Gillian Bennett, Jonathan BennettWhat sort of emotions does the statement evoke in you as you look at the picture on the left of this elderly woman and her husband? What assumptions do you make? 

The woman probably appears older. We maybe look at the title of the post, searching for clues. Readers might then divide between those that “Support the option of euthanasia with proper safeguards” and those that “Feel euthanasia is immoral under any circumstance” (plus a few in-between). Every picture perhaps tells a story, but the “story” may be quite different according to our perceptions and prior beliefs.

In real life, we all have particular principles, ideas, skills and knowledge. They are part of who we are. But when we interact with another person, a different sort of thinking also comes into play. Life is not a monologue. Our understanding of another person, of their situation, is modified as we talk with them. What might have been described quite clinically as “the situation” a few moments ago, has maybe developed into what we see as “their situation” and “our reaction.” The ancients called this type of knowledge ‘phronesis’ (φρόνησις), a practical wisdom that was acquired by thinking within a particular situation rather than applying prior knowledge alone.

The lady in the photograph is Dr Gillian Bennett, an eminent psychotherapist who was 83 years old at the time that she took her own life, after careful consideration of the ravages of dementia that she was starting to face.

“There comes a time,” she wrote in the four-page letter that was posted online by her son after her death — as per her request, “in the progress of dementia, when one is no longer competent to guide one’s own affairs. I want out before the day when I can no longer assess my situation, or take action to bring my life to an end.”

Bennett told her family of her plans, but did not allow them to take part: it would be a criminal offence in Canada (where she was living) to assist in a suicide, as it would be in the United Kingdom. She would not even allow her husband to take a mattress to the spot she had chosen to die, worried in case it could cause him trouble. “That pretty much broke his heart, that he couldn’t help her with that,” said her daughter, Sarah Fox.

In some ways physicians, they say, have it easier, since they have fairly ready access to drugs: but no-one can measure the extent of another’s suffering. The strident anti-euthanasia campaigners stay in an ivory tower of technical principles. Perhaps they would not be so judgmental if they sat down and actually listened to patients like Dr Bennett. It would seem that no matter how expert, how competent, how knowledgeable a person is, no matter how unrelievable and unbearable (to them) their situation is, an anti-euthanasia campaigner always thinks they “know best.” They feel doctors cannot be trusted. They feel that the law cannot be crafted to provide sufficient safeguards. Yet common sense says the opposite.

No matter what the prohibitions on voluntary euthanasia or assisted suicide, there will still be people who take their own life for very good reasons, some going to Switzerland to make the process where at least some others, their loved ones, can be present. “Certainly, assisted suicide doesn’t lead to more deaths. We’re all going to die anyway,” says Sarah Fox. “It doesn’t lead to more deaths, but it could lead to less suffering.”

Goodbye and Good Luck! Gillian Bennett’s memorial page (written by herself)
Newspaper report (Canadian Press)
Her letter to the Vancouver Sun
British newspaper report, and a video explaining dementia
Empathy and the application of the ‘unbearable suffering’ criterion in Dutch euthanasia practice
Empathy Versus Analytical Reasoning Not So Simple (PsychCentral News Story)

 

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