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The many ways to hasten death

Thursday, August 20, 1970

The sixth meeting of NuTech was held in Seattle in January to continue the quest to develop new technologies for self-deliverance. It was attended by 20 people from six countries including several member organizations of the World Federation.

Background
Many right-to-die organizations have attempted to change the law so that patients could have legal assistance from their doctors to die a peaceful death under careful safeguards. In the Netherlands and Belgium voluntary euthanasia is available, albeit under restricted conditions, and in Switzerland and Oregon physician-assisted suicide can be obtained. The Northern Territory of Australia was the first place to provide both as legal options in 1995 though the right was rescinded by an act of the federal parliament in 1997. In all of these models a physician must supply or administer the means to die which is usually by injection or providing a prescription for fast-acting barbiturates. To date, most people in World Federation countries do not have access to help from a physician.

Final Exit
The success of Derek Humphry’s Final Exit in 1990 was evidence that people want to control their own death. Though the earlier editions relied heavily on obtaining medication for self-deliverance, the physician was only the means to an end and usually was not asked directly to assist in the death. In the second edition the means to death using a plastic bag and over-the-counter medication is described in detail. It is a method that is successful if the directions are followed precisely; the risk is that in breathing into a plastic bag the person breathes carbon dioxide which creates air ­hunger. Unless there is heavy sedation, the person may rip the bag off and thus thwart their intention.

Helium
Though the plastic bag is a low-tech method and one that many find repulsive, it does use means that are generally ­available. The third edition of Final Exit (2003) describes a methodology that evolved from the NuTech group—the inhalation of helium in a plastic bag. This method meets the ­criteria of accessibility (in those countries where small helium kits are available for inflating balloons), relative ease of use, and resulting in a gentle, quick and –certain death.

Birth of NuTech
The helium method emerged from the work of engineers, physicians, divers and others in the Nu Tech group—a small number of people first assembled in 1998 under the leadership of John Hofsess, Philip Nitschke, and Derek Humphry. All had fought to change the law but realized that for most people legal help would not be a reality; something had to be available that people could use to facilitate their own dying.

The 2004 NuTech group met in the shadow of prosecutions currently occurring in New Zealand, Canada, and, at that time, the Isle of Man which have affected the way research can be done and findings made public. The objective is to find new technologies for self-deliverance that can empower people to make the decision for themselves about hastening their dying in a dignified, painless and certain way—preferably using methods that do not require the active assistance of another person, thus keeping it within the law.

Beyond helium
Although reports of the helium method over the years indicate that it is always successful and that death occurs reliably, quickly, and peacefully there are concerns that other methods must be developed. There are places where the small helium tank is unavailable, other place where breathing a gas is not an acceptable option, and still other ­situations where the dying person would prefer not to have a bag on her head. Worse yet is the prospect that law ­enforcement will cause this method to become unavailable.

Political considerationsThere is not a consensus in this loosely-knit group about how these methods are to be used, or within the right-to-die community generally, about the ­wisdom of developing this information. Some insist that assisting a death should be done by the medical profession under strict guidelines and only for imminently dying persons. On the other hand is the realistic assessment that such an option is not available for most people and that methods need to be available until the law changes. It is understood that general dissemination of methods, such as in Final Exit, may be the end result so that guidelines and safeguards would not exist. This position assumes that people can be trusted to use the information appropriately; also, that people determined to end their lives will at least have a gentle and certain method to do it.

Some organizations support both a legal, carefully safeguarded model and access to information about self-deliverance by their members until that time comes. Others, having tried to put their resources into a legal-change model, are working primarily in the area of new technology. Organi­zations working solely on a carefully-safeguarded medical model often oppose these efforts and have frequently denounced NuTech’s efforts.

Another area where consensus has not been reached is about assistance: some feel that it is humane to offer at least the presence of a person with expertise, others feel that assistance is unnecessary as long as the technology is dependable. Those organizations which proffer assistance have varying criteria for when they accept a case. These policy differences aside, there is unanimity among the NuTech participants that the technology must be developed.

Criteria for methods
There is agreement that the method must be easily obtained, that it should be able to be used easily by a sick person, that the death should be dignified, humane, painless, quick, and absolutely certain. It is agreed by most that loved ones should be present and should remember the person as dying peacefully. The method should also be invulnerable to political machinations so should be composed of commonly-found ingredients. (It is unlikely that Attorney General Ashcroft could ban plastic bags, for example.)

The pursuit of such a goal, were it legal, would not be difficult since many pharmaceutical compounds, for example, are considered too lethal to be acceptable in therapeutic doses but could be used as euthanatics were the information available. Also, if help were legally available to use the method then a larger variety of instrumentalities could be developed rather than those which rely on the patient’s ability to use them without assistance.

Current explorations
Methods can be classified by the mechanism of action, the way they are used, and/or the type of method.

Mechanical
One category is methods that use mechanical means to stop oxygen from reaching the brain. That would include the low-tech plastic bag. Individuals are working on ways to absorb the carbon dioxide build-up so that air hunger is not a problem. At the World Conference in 2000 there was a demon­stration of a method to ­provide fresh air in the bag until the sedative medications go into effect and produce a deep sleep. The availability of high quality bags has been an issue. For some years excellent quality Exit Bags have been produced in Canada and elsewhere that are large, translucent, made of heavy ­plastic, and equipped with Velcro fasteners around the neck to make them comfortable and effective. Video tapes have been made showing the use of these bags to dispel the fear and revulsion people have when they think of tight-fitting thin plastic around their nose and mouth. Methods of production and distribution of these bags have been a consideration in NuTech since the legalities of their importation and distribution have arisen

A Debreather was invented which would cause a peaceful death but the drawback is that it cannot be self-administered.

Inhalants
Various gases can be inhaled and death can occur painlessly and quickly. Helium is now widely used because of its availability and ease of use. It displaces ­oxygen in the brain and results in quick unconsciousness and a peaceful death in a few minutes. It is undetectable at autopsy and, unlike breathing carbon dioxide, produces no air hunger or adverse sensation. Many other inert gases, like nitrogen or Freon, would serve the same purpose but the delivery systems are more difficult in that large tanks would have to be rented or purchased. The shelf life of these gases, particularly in small containers, is uncertain. Pressure gauges are ­recommended as are additional tanks.

Carbon monoxide (CO) has long been used and is a ­popular method in Australia. Though the catalytic converter slows this method down it does no make it impossible. The danger of being discovered prior to death and being left brain-damaged, as well as the possibility of leakage which may kill innocent people has dampened enthusiasm for this method. It is possible to fill a space with inflatable pillows, etc. so that less gas is necessary. Those who believe that people should not die alone in their cars also do not recommend it. CO has been used by Dr. Kevorkian in a more clinical setting where the gas is not contaminated by elements found in car exhaust which make it smelly and unpleasant. The CoGenie, being developed now in Australia, uses two CO-generating chemicals and a tube going to a nasal prong. CO binds to hemoglobin which provides certain advantages over helium and leaves a red color in the deceased. There are workshops where people pay to manufacture their own mechanisms and write the ­workbooks for succeeding “students.” In Asia people use ­charcoal braziers to generate CO in an enclosed space.

Oral medications
The gold standard around the world for oral administration is 9­–10 grams of a fast-acting barbiturate—Secobarbital or Pentobarbital. These are lethal, though the time to death varies from minutes to hours when ingested. For two years secobarbital was unavailable in the U.S. but is now being manufactured. Pentobarital is no longer available in capsules but is obtainable as a liquid. It is also used for ­veterinary purposes but it is not legal to purchase it for human use. Though no failures have been reported in Oregon where it has been prescribed legally since 1997, problems with the medication have been reported in the Netherlands. It must be preceded by antiemetic medication or it will be vomited and must be ingested quickly before sleep comes. Of course, the person must still be able to swallow; the medications are extremely bitter and must be mixed with syrup and sweeteners.

There is a fertile field for research on drug combinations. Recent studies have shown that certain antidepressant ­medications are lethal if combined with benzodiazepines, for instance. Chloroquine is also of more certain lethality in this combination. This type of research will be extremely helpful since it will enable patients to obtain medications that are not as difficult to get as barbiturates.

Other oral medications are being developed that are compounds of existing available drugs with some molecules rearranged to promote their lethality. Toxins, such as those found in the blowfish, Fugu, or in poisonous plants such as hemlock, are being examined, assayed, and explored for their practicality.

Other methods
Terminal (palliative or total) sedation is a widely used method that is legal since the intent is to relieve pain and suffering and not to cause death. Patient refusal of food and hydration, with good palliative care, is being recommended to people who find this more acceptable than self-administration of lethal methods.

Funding
Monies needed to fund the research and meetings of NuTech, which had been supplied primarily by one organization, are no longer available. Currently

ERGO

is seeking funds to continue the work of NuTech and to disseminate its findings.
Faye Girsh, Ed.D.
Senior Vice President
END-OF-LIFE CHOICES
(formerly The Hemlock Society USA)

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