Hemlock was not the only right-to-die society to publish instructions on how to take one’s own life. The first such manual had been promised in 1979 by the Voluntary Euthanasia Society. After decades of quiet respectability, the British group had been invigorated by a recent influx of younger members, including general secretary Nicholas Reed, a brilliant, energetic Oxford graduate. One of the steps taken under his leadership was to change the society’s name to Exit, a name more in tune with its upbeat new image. With increased visibility, Exit received a growing number of letters and calls from desperate people seeking information on pain-free suicide methods. Under the Suicide Act of 1961, Exit could not advise those people without risk of prosecution for aiding and abetting a suicide. Although many right-to-die advocates were aware that information on lethal dosages had long been available in certain medical textbooks, no one had ever written a book on how to commit suicide. In October of 1979, Exit announced plans for a ten-thousand-word Guide to Self-Deliverance. To avoid possible abuse, Exit said that the booklet would be available only to members of three months’ standing. Within several months of this news, membership—a matter of three pounds’ dues annually, ten for foreigners—jumped from two thousand to nine thousand. But these anxious new members were forced to wait longer than the required three months. Fearing prosecution, Exit postponed release of the booklet. Meanwhile, in Scotland, where laws against assisted suicide were more lenient, a branch of Exit seceded and published its own guide, How to Die with Dignity, in September 1980, not long before Hemlock released Let Me Die Before I Wake. Since then, manuals have been published in France, Belgium, Switzerland, Germany, and the Netherlands.
The guides constitute an intriguing cross-cultural study. Exit’s A Guide to Self-Deliverance, a thirty-one-page booklet to which Koestler, a vice president of the society, wrote the introduction, was finally published in 1981. Like Let Me Die and Final Exit, it is intended for the terminally ill and not for the merely depressed. “Before considering Self-Deliverance,” the book’s inside cover cautions, “HAVE YOU RUNG THE SAMARITANS?” Like Let Me Die and Final Exit, it urges the reader to consider alternatives (hospice care, second opinions, pain clinics, other methods of treatment), to make sure the distress is not temporary, and to consider the effect of the death on family and friends. Suicide, it stresses, is not a decision to be taken lightly but a matter to be pondered over a period of months, time permitting. This said, the manual recommends how not to commit suicide. It advises against shooting, jumping, wrist-cutting, and hanging, methods that are especially traumatic for friends and relatives and may leave the victim alive and brain-damaged rather than dead. The manual advocates peaceful, nonviolent methods, suggesting that “the body when found should look simply dead and not disgusting.”
To achieve this end the guide outlines five bloodless techniques, most of which combine drugs with a supplementary method—car exhaust, alcohol, drowning in a bathtub, plastic bags—to ensure lethality. “A combination of sedative drugs and a plastic bag should both shorten the process of dying and minimise unpleasant sensations,” advises the manual. Written by a committee of Exit members, including several doctors, the guide is disarmingly matter-of-fact, as when it counsels the reader, “You need two plastic bags approximately three feet (one metre) in length and 18 inches (50 cm) in width. Bags smaller or very much larger than this should not be used. Kitchen bin liners are an obvious possibility.” A “postscript” written by psychiatrist Eliot Slater strikes a lone lyrical note: “It is the sovereign right of the individual, absolute and inalienable, to say, ‘I have thought well what my duties are to all those who love me, and to all others. I have thought also of the rights I owe to myself. Fate has called to me, and I say to you, Farewell.’”
Dedicated “To the memory of those many millions who lived for a while in agony and eventually died in torment because of cruel laws and the prejudices of bigots,” the forty-four-page Scottish manual, How to Die with Dignity, is even more pragmatic. “I think that already-distressed people can do without long-winded paragraphs,” George Mair, a retired surgeon, chairman of Scottish Exit, and author of the manual, told a reporter. “My book is more like a recipe for scones—you add a pinch of this and half a pinch of that.” Mair’s “recipe” stresses dignity and courtesy. In the section “Methods of Self-Deliverance Which Should Not Be Used,” the author advises that jumping off a ship is “highly inconvenient for the ship’s crew and passengers,” while jumping onto a live train rail is “not in any way dignified and is a great offence to witnesses.” Those intending to die by dropping an electric cable in their bathtubs are advised to leave behind “a large notice instructing no one to touch ‘anything’ without first switching off the mains current.” Dr. Mair adds, “It is a matter of personal choice as to whether or not some form of bathing suit is worn.” The plastic bag is dismissed with the comment “This is not dignified.” Mair outlines the recommended procedure—a lethal dose of barbiturates—in a seventeen-step list of instructions that concludes, “Take soda and spirits and drugs to bedside. Swallow the drugs as rapidly as may be convenient and sip both soda and spirits while doing so.” Mair adds that if the place of “deliverance” is a hotel, it is advisable to ask the front desk to hold all calls, to hang the DO NOT DISTURB sign outside the door, and to leave a short letter “to thank the manager and apologise for abusing hospitality.” Available only to members, the booklet sold some five thousand copies over fifteen years.
In April 1982, another how-to guide appeared that made the manuals of the right-to-die societies seem relatively innocuous. Suicide, Mode d’Emploi (“Suicide: Operating Instructions”), the work of two young Parisian journalists, proposes suicide as a revolutionary act—not merely for the terminally ill but for anyone and everyone. The book contains a section listing fifty recipes for “cocktails” that will ensure a “gentle” death, giving precise lethal dosages and advice on how to forge prescriptions. “I feel no remorse,” said the book’s publisher, responding to news that Suicide had been used by several physically healthy young people to end their lives. “This is a book that pleads for life. But it also recognizes that the right to suicide is an inalienable right, like the right to work, the right to like certain things, the right to publish. What use is a right without the means to execute it?” Others were less appreciative. Suicide provoked the outrage of French psychiatrists, clergy, politicians, suicide prevention agencies, and the Association pour le Droit de Mourir dans la Dignité (a French right-to-die society). Although a number of bookstores declined to stock it, and several newspapers, magazines, and radio stations refused to carry advertisements, the French parliament, despite repeated attempts, could not put a stop to the book until 1987, when it passed a law banning all how-to suicide manuals. By then, Suicide had sold almost two hundred thousand copies in France, been translated into seven languages, been the subject of eighty criminal complaints and four court cases, and served as a blueprint for the suicides of at least fifteen people, none of them terminally ill, most of them young and unemployed. In one case a depressed young woman from Nice killed her eight-year-old son, then killed herself. An annotated copy of Suicide was found on her bedroom table.
Though right-to-die societies around the world denounced the book, pointing out that Suicide had been aimed not at terminally ill people but at everyone, even some of the more responsible manuals encountered difficulties. Among the more than twenty suicides linked to England’s Guide to Self-Deliverance was a physically healthy twenty-two-year-old music student with a history of psychological problems who was found dead in a London hotel with the booklet at his bedside. Although it was ostensibly available only to members over the age of twenty-five, the boy had simply lied about his birth date. In 1983, Guide was withdrawn.
By that time Exit had run into even more serious trouble. In 1980, following the suicide of an elderly Exit member, police raided Exit’s cramped basement offices in Kensington and arrested general secretary Nicholas Reed. Soon there
after, sixty-eight-year-old Exit volunteer Mark Lyons was also arrested; both were charged with various counts of aiding and abetting suicide. Over the following months an extraordinary and unsettling story emerged in court. Moved by heartrending calls from dying people who begged for help, Reed, without the knowledge of anyone else at Exit, had dispatched Lyons to their homes. Carrying a bag containing brandy, barbiturates, and plastic bags, and pretending to be a doctor, Lyons, a bearded, shabbily dressed retired taxi driver, supplied his “patients” with the means for suicide, then sat with them until they died.
Most of the victims were tragic cases: a woman suffering from terminal cancer who had only a short time to live; a victim of spinal osteoarthritis; a man who had been an invalid for three years and who for the last six months had worn an oxygen mask twenty-four hours a day. In each case the victim had repeatedly begged to die. But Reed and Lyons had intervened in less extreme situations. In one, Lyons helped a physically healthy, middle-aged agoraphobe to die. In another, a twenty-five-year-old army veteran told the court that he suffered from depression, drank heavily, and had attempted suicide several times. He had called Exit, met with Reed, and described his miseries. Reed notified Lyons. When Lyons telephoned and demanded thirty pounds for traveling expenses, the man grew suspicious and dropped the matter. And a bedridden woman suffering from severe spinal injuries testified that Lyons was “furious” when she changed her mind about wanting to die. She said that Lyons told her, “You are the only person to disobey me.”
After a two-week trial, Lyons was found guilty of five charges of aiding and abetting suicide, and one of conspiring to aid and abet suicide. Taking into consideration the 325 days Lyons had spent in jail awaiting trial, the judge gave him a two-year suspended sentence and the admonition, “No more meddling with pills and plastic bags.” Reed, found guilty of two charges of aiding and abetting suicide and one of conspiring to aid and abet, was sentenced to two and a half years (later reduced on appeal to eighteen months). As he was led from the dock of London’s Old Bailey Criminal Court to begin his sentence, Reed shouted, “That shows the idiocy of the present law!”
The image of the erudite Reed and the eccentric Lyons with his “suicide kit” taking matters into their own hands was chilling. Although a few radical right-to-die advocates maintained that the ends justified such means, the majority of euthanasia groups were appalled. Exit, which knew nothing of Reed’s and Lyons’s extracurricular activities until their arrest, was dubbed a “suicide club” by the tabloids, and its credibility was tarnished. Exit subsequently expelled Reed, changed its name back to the Voluntary Euthanasia Society, and assumed a decidedly lower profile for the next several years.
Final Exit would be Derek Humphry’s swan song at Hemlock. He was weary of managing the rapidly expanding organization, which was spending most of its resources trying to change legislation to permit physician-assisted suicide and euthanasia. His personal life, too, had entered what he would later refer to as “that black time.” In 1986, Humphry and Wickett had assisted Wickett’s parents in a double suicide, using prescription drugs obtained by Humphry. Humphry had been in one room attending to Wickett’s ninety-two-year-old father, who was suffering from congestive heart failure, while Wickett was in another room with her seventy-eight-year-old mother, who was recovering from a stroke. When her mother’s breathing had grown agitated after swallowing the pills, Wickett had panicked and covered her mother’s mouth with a laundry bag. The experience would haunt Wickett and eventually lead her to question her belief in Hemlock’s mission. In 1989, Wickett was diagnosed with breast cancer. Three weeks after her mastectomy, one day after she had started chemotherapy, Humphry left her. Wickett claimed Humphry was so unnerved by having to deal with a second wife with breast cancer that he was unable to act rationally. Humphry said the marriage had been troubled for several years and accused his wife of mental instability. They divorced. Wickett, a cofounder of Hemlock, was forced out of her position as deputy director; Humphry ordered the office locks changed. Humphry remarried in early 1991. In October of that year, while Final Exit was topping the best-seller lists, Wickett, depressed, lonely, and emotionally exhausted, rode her horse into the hills near her home and took a fatal overdose of barbiturates. In her suicide note, she accused Humphry of doing “everything conceivable to precipitate my death.” In 1992, saying he was “temporarily burned-out,” Humphry left Hemlock.
Although Hemlock would live on, its position of influence in the right-to-die movement would be eclipsed by two other developments, both of which were, in some way, godfathered by Hemlock. Final Exit had sold so well that Hemlock was able to donate nearly a million dollars to support ballot initiatives in California, Washington, and Oregon. (Indeed, without Hemlock’s financial resources, the Oregon Death with Dignity Act would likely not have passed—or would, at least, not have passed so soon.) And in 1993, eleven AIDS activists and caregivers, including a physician, a hospice nurse, and several members of the clergy—many of them ex-Hemlockers who had worked on the unsuccessful 1991 Washington initiative—formed Compassion in Dying, the first organization in this country devoted to providing information, consultation, and emotional support for mentally competent, terminally ill adults who wished to end their life. Although Compassion in Dying’s support would not extend to providing lethal medications, its volunteers, if requested, would be present at the very end so that clients would not have to die alone. In Compassion in Dying’s first thirteen months, three hundred people requested the organization’s help; forty-six qualified for their services, of whom twenty-four were helped to their death.
Over the years, the group refined its protocol, which, with some alterations, provided the blueprint for Oregon’s Death with Dignity Act. In 1997, shortly after the act went into effect, Compassion in Dying formed a chapter in Oregon. Since then, while continuing to work with clients across the country, the organization has served as a clearinghouse for the vast majority of Oregon’s assisted-suicide cases. In recent years, Compassion, which does not charge for its services and is supported by grants and contributions, has responded to inquiries from some four thousand people annually. In most cases, that might mean something as simple as sending them a copy of the Compassion pamphlet “A Gentle Death,” which describes end-of-life options; putting them in touch with various social service agencies; or referring them to the Compassion in Dying Web site, from which they can download a letter to give to their physician that will help “start a conversation between patient, family and doctor that can lead to better care and better dying.”
But for some five hundred people each year, Compassion in Dying provides “full-scale counseling services.” For those who live in Oregon, Compassion in Dying will help them fill out the paperwork required by the Death with Dignity Act, guide them through the legal and medical system, and recommend physicians sympathetic to assisted suicide. The group’s medical adviser, a retired oncologist, will shepherd physicians through their legal responsibilities. For clients who live out of state, where physician-assisted suicide is illegal, Compassion in Dying might send a protocol outlining strategies for accumulating and self-administrating a lethal dose of medication. Wherever the clients may live, Compassion in Dying, which is staffed by doctors, hospice workers, social workers, ministers, and twenty-two trained “client support” volunteers, will help them to sort through their options, to deal with conflicting feelings, and to explore their views on dying.
Volunteers might help clients prepare advance directives or, by speaking to their doctors or visiting their nursing homes, help them get those directives enforced. They might drive clients to doctors’ appointments, sit with them in the hospital while awaiting a surgical procedure, or, like the volunteer whose client had advanced breast cancer and no one to care for her, take them on a tour of the local hospice. They might get a Compassion in Dying physician to advise a client’s doctor about alternative pain medication strategies. When a woman from a small town in the Midwest, for instanc
e, began to experience the gasping breathlessness known as air hunger and her hospice staff appeared to be unaware that small doses of morphine could relieve it, her volunteer coordinated a phone consultation between the hospice staff and a palliative-care expert in that state. They might counsel a client’s family, as in the case of a man who asked for help explaining to his teenage son and daughter that their mother, who had terminal brain cancer, was planning to end her life. They might share information on lethal dosages. When a thirty-two-year-old man dying of AIDS asked his physicians for medication to end his life, the doctors were willing to prescribe but weren’t sure which medication and what dosage might be reliable. Compassion in Dying managed, through a friend of the patient’s, to share that information with his physicians, and the patient took the lethal dose with family, friends, and physicians in attendance. Finally, they might help in such simple but important ways as bringing high-quality bathroom tissue to a client in a medical foster home who, when asked what might make her more comfortable, said what she really wanted was softer toilet paper.
Compassion in Dying takes pains to point out that its work does not inevitably end in assisted death. “Compassion is not an advocacy organization for physician-assisted death, it is an advocacy organization for choice,” writes Michaele Houston, a “client support” volunteer for more than forty people since joining the group in 2000. “If that choice is a hastened death, we do not flinch or turn away.” Four out of five clients who get full-scale counseling do not end up killing themselves. Some never even get the pills. A sixty-seven-year-old man dying of cancer called Compassion in Dying and insisted that he had to have the lethal medication right away. A volunteer talked to him, visited him regularly, and supported him through several surgeries. Because he had no friends or family to help him get to his doctor’s appointments, Compassion volunteers shuttled him to his radiation sessions five mornings a week for two months. Shortly after he finished treatment, the man developed pneumonia. His volunteer sat with him in the hospital for three days until he died—nine months after he had contacted Compassion in Dying.
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