17 Oct, 08 | by BMJ Group
Dr Philip Nitschke, director of the Australian pro-euthanasia group EXIT International, has come to the UK to promote the launch of his ebook ‘The Peaceful Pill Handbook’ – a controversial guide to methods of suicide. The paper version has been banned in Australia and published in New Zealand with some pages blacked out.
At the presentation on 13 October we counted five organisers, seven members of the press, three researchers (ourselves) and twelve other people (mostly elderly), some of whom appeared cachexic and at least one of whom was wearing a syringe driver.
Throughout the public meeting and subsequent workshop, Dr Nitschke and his colleagues criticised the current legal situation in most developed countries where is it not illegal to commit or attempt suicide, but it is illegal to assist someone to do this. They strongly advocated for the free choice of the individual about the timing and circumstances of death, and felt that legislation in this area was inappropriate.
The use of high dose morphine for severe pain in advanced cancer was caricatured: Each day the doctor sees the patient and increases her morphine for the pain. It does not help her pain, but makes her so drowsy that soon she is unable to express the fact she is still in pain and soon afterwards dies. Killed by morphine, but drowsy and still in pain.
Dr Nitschke spoke of his desire for reliable, peaceful and available methods of suicide to be known to everyone, and that everyone should be prepared. He told a cautionary tale about a man with dementia. He killed himself with the help of his wife and a family friend who was an EXIT campaigner. Both women were convicted of manslaughter, but before the sentencing the EXIT campaigner killed herself. The patient’s wife is likely to face several years in prison. He expressed regret, not that the suicide had gone ahead, but that the man was insufficiently prepared: Had he not needed help there could have been no prosecution.
The favoured method of suicide is drinking an entire bottle of a veterinary anaesthetic available in Mexico for $20-$50. Each year about 300 Australians make the trip across the American border to towns such as Tijuana where the drug is readily available over the counter. Travellers were advised against flying directly into Mexico to avoid getting a stamp on their passport (the authorities have begun asking questions of elderly people travelling to Mexico). To solve problems of the drug expiring before it is needed, EXIT International runs an assay service by which the potency of out of date drugs can be checked, so unsuccessful attempts or needless trips abroad can be avoided.
Two more case histories were outlined: One was of a retired academic who was not unwell, but was 80 years old and felt that she couldn’t tolerate becoming frail and sick. The other was of a healthy elderly couple who had met in old age after both being widowed. They felt they could not tolerate being bereaved again, so carried out a suicide pact.
Other methods of suicide discussed included the use of helium and a plastic bag. A large party balloon cylinder continuously fills a plastic bag with helium. This bag is placed over the head. The continuous flushing of new gas prevents rebreathing of exhaled carbon dioxide, and unconsciousness and death follow quickly and peacefully. Good points of this are that the equipment can be easily bought and then hidden by family members afterwards. Dr Nitschke had assembled most of the components of the apparatus on a shopping trip that morning, including a helium canister bought from a well known card shop to demonstrate the technique. The audience was given a detailed step by step guide by ‘Betty’ who cheerfully demonstrated the process in a series of video clips.
The last part of the workshop was advice on how to negotiate three potential (Australian) legal complications: First, the advice was to leave a note only if you are ok with your death being considered a suicide. The second was that a note may well protect your family from accusations of assisting you if you specifically exonerate them. The third was that life insurance usually does cover suicide, but only thirteen months or more after the policy is taken out.
This talk was missing some of the key messages we would have expected: Suicidality fluctuates quickly, and fluctuates with symptoms of physical illness. Rates of suicide are affected to a great extent by the availability and lethality of means. There were misleading representations of palliative care activity and of the effects of opioids. The most striking omission though was any acknowledgement of different ways of understanding suicide and suicidality: Is it a simple expression of individual choice or is it a symptom of a mental health problem which may be treatable? Mental capacity was added as an aside (and in inverted commas in the powerpoint presentation) and advice was given to get a friend to do an MMSE test before your suicide to demonstrate possession of capacity.
We had questions to ask, but to our surprise we were so uncomfortable with a lot of what we had seen and heard that we left as soon as we could.
William Lee, Annabel Price, and Lauren Rayner.
Competing interests: William Lee and Annabel Price have experience of working in a palliative care setting. Annabel Price’s post is part funded by St Christopher’s Hospice. They do not have any religious affiliation.