The Most Difficult Decision

Final Exit : The Practicalities of Self-Deliverance and Assisted Suicide for the Dying
by Derek Humphry

As the legal controversy continues — this newly revised and updated third edition of the landmark bestseller contains new, critically important information for patients, loved ones, and medical personnel.

The original publication of Final Exit stunned the nation by offering people with terminal illness a choice on how — and when — to end their suffering. It helped thousands by giving clear instructions to doctors, nurses, and families on how to handle a patient's request for euthanasia.

In the wake of court cases and legislative mandates, this revised and updated third edition goes far beyond the original to provide new information about the legality of euthanasia and assisted suicide, and a thoughtful examination of the personal issues involved. It has become the essential source to help loved ones and supportive doctors remain within existing laws and keep a person's dying intimate, private, and dignified.

With deep compassion and sensitivity, it spells out why a living will may not be sufficient to have a person's wishes carried out — and what document is a better alternative. It updates where to get proper drugs and exactly how to carry out the quickest, most peaceful way to make a final exit. Finally, it gently talks to a person considering self-deliverance about alternatives, planning, and the means to make every death a "good death" at our time of greatest need.

This is the scenario: You are terminally ill, all medical treatments acceptable to you have been exhausted, and the suffering in its different forms is unbearable. Because the illness is serious, you recognize that your life is drawing to a close. Euthanasia comes to mind as a way of release.

The dilemma is awesome. But it has to be faced. Should you battle on, take the pain, endure the indignity, and await the inevitable end, which may be days, weeks, or months away? Or should you take control of the situation and resort to some form of euthanasia, which in its modern-language definition has come to mean "help with a good death"?

Today the euthanasia option — or the right to choose to die — comes in four ways:

Passive euthanasia. Popularly known as "pulling the plug," it is the disconnection of medical life-support equipment without which you cannot live. It could be a respirator to aid breathing, a feeding tube to provide liquids and nutrition, or even the sophisticated use of certain drugs to stave off death. There is not likely to be much ethical or legal trouble here provided that you have signed a Living Will and also a Durable Power of Attorney for Health Care — they are also known as Advance Declarations — that express your wishes. (More on these later.)

Self-deliverance. Taking your own life to escape the suffering. This method does not involve any other person directly, although a loved one or friend should ideally be present. It is legal in all respects, and widely accepted ethically.

Assisted suicide. You get lethal drugs from somebody else, usually a physician, and swallow them to cause your death. It is legal for you to do so, but at present it is a felony for the person who supplied the drugs or took any action physically to help you. Despite the present criminality of assistance, this procedure is gaining increasing ethical acceptance. In 1996 two U.S. appeals courts ruled in favor of physician-assisted suicide, making it likely that this is the modified form of assisted death which will be adopted. But the U.S. Supreme Court quickly squashed that and the appeals court were overruled.

Active euthanasia. Death brought about by a physician's injection of lethal drugs. This procedure is illegal and, despite the necessity for it in certain cases, has limited ethical acceptance in the medical profession. It is already available in the Netherlands but is probably more distant in America.

Often, persons who have not properly thought these situations through claim they are not worried about a bad death because they have a Living Will and the plug can be pulled at their behest. Probably so, but roughly half the people who die in Western society are not connected to life-support equipment in their final days, so relief by that way is not an option.

Before we go any farther, let me say this: If you consider the God whom you worship to be the absolute master of your fate, then read no more. Seek the best pain management available and arrange for hospice care.

If you want personal control and choice over your final exit, it will require forethought, planning, documentation, good friends, and decisive, courageous action by you. This book will help in many ways, but in the last analysis, whether you bring your life to a quick end, and how you achieve this, is entirely your responsibility, ethically and legally.

The task of finding the right drugs, getting someone to help or at least be with you, and carrying out your exit in a place and in a manner that is not upsetting to other people is yours. Suicide, even the most rational and justified version, the sort we are talking about in this book, is not something other people are anxious to be involved in. It is best to seek the help of family or the closest of friends.

If you have not already done so, sign a Living Will and have it witnessed, but not by anybody who is going to gain from your other will dealing with your estate. A Living Will, which has nothing to do with property or money, is an advance declaration of your wish not to be connected to life-support equipment if it is judged that you are hopelessly and terminally ill.

Or, if you are already on the equipment because of an attempt to save you that has failed, a Living Will gives permission for its disconnection. By signing, you are agreeing to accept the fatal consequences.

Make sure you get the particular Living Will form that is relevant to your state. They all differ in small details. Strictly speaking, the Living Will of one state or nation does not apply in another place. But carry it when you are away from home, because any sensible physician would recognize it as a valid statement of your wishes. A valid Living Will is likely to survive a court challenge because all American states recognize them and the U.S. Supreme Court has given them its blessing.

But remember this: A Living Will is only a request to a doctor that you not be kept needlessly alive on support equipment. It is not an order. It may not be legally enforceable. But as your signed "release" of his or her responsibility, it can be a valuable factor in the doctor's thinking about how to handle your last hours. The Living Will gives the doctor a measure of protection from lawsuits by relatives after your death. And it gives you a measure of control and choice.

A more powerful document is the Durable Power of Attorney for Health Care, which, in different forms, is available in all American states. Here you assign to someone else the power to make health care decisions if and when you cannot.

For example, if your doctor is unable to make you understand the consequences of what treatment or care is planned, then he or she will turn to the next of kin; you are considered incompetent. Now, if the family member is confused, or has different ethical values than you, that may not work well. You may end up getting medical attention of the sort you did not want when you were rational.

With the medical Power of Attorney given to someone in whom you have already confided your general or specific wishes, someone who has accepted the responsibility, then it is most likely that you will get the kind of treatment — or dignified death — that you desire. A doctor must get the approval of the person (also known as surrogate or attorney-in-fact) that you have named. This is especially important if there is disagreement in the family about what to do. The surrogate person has the absolute right to make the final decision, although only if you are too ill to make it yourself.

The medical Power of Attorney is legally enforceable, whereas the Living Will is not. It may seem like a man using both a belt and braces to keep his trousers up, but experience shows that if you care about a good death you cannot be too careful.

The Durable Power of Attorney for Health Care could be the most significant document you ever sign. As of today, however, it works only for passive euthanasia — the cessation of treatment. It does not empower anybody to assist in your suicide or provide euthanasia. Since 1991 the Patient Self-Determination Act, passed by Congress, requires all federally funded hospitals in the United States to advise patients of their right to make out any Advance Declarations their state has. Some hospitals supply this information efficiently; others do not. So it is absolutely necessary for you to sign these documents when you are healthy and get copies into your medical files, your private files, with your attorney if you have one, and with the person who is to be your surrogate decision-maker. Also, hand copies to some or all of your adult children.

Copyright © 2002 by Derek Humphry. Excerpted by permission of Delta, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

About the Author

Derek Humphry is the founder of the Hemlock Society USA in l980 and was its executive director until l992, when he resigned to write and lecture. Before that he was a journalist on the Los Angeles Times, the London Sunday Times, and the London Daily Mail.