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Final Exit: the end of argument.

The November defeat of Initiative 119 in Washington state promises only a pause in the public efforts to legalize physician-assisted suicide and active euthanasia. The news reports, while analyzing the eight-point margin by which voters rejected the measure, noted that a hefty 46 percent did approve, and that efforts are already underway to try again in California and Oregon. [1] Meanwhile, measures have been introduced in Canada and a number of European countries. [2] Assisted suicide and euthanasia are "hot"--high on the agenda of a public seemingly poised for action.

Derek Humphry's publication of Final Exit, [3] billed as a suicide manual for the terminally ill, has played no small part in fueling the current swirl of activity. Concern about whether physicians should assist suicide or deliberately kill their patients is ancient. But the recent reawakening of public attention has been marked by the Journal of the American Medical Association's "It's Over, Debbie," Dr. Timothy Quill's piece in the New England Journal of Medicine, Dr. Jack Kevorkian's dispatch of Janet Adkins and more recently two others in Michigan, and now Final Exit. [4]

This last holds a special place in the roster. The others are individual cases (though some have claimed "Debbie" to be fictional)--traditional catalysts to analysis and discussion. However, outrageous one might find the actions of these physicians, each seems to have intended to spur debate.

Final Exit is something else altogether, though few have noticed the discontinuity. Commentators have been content to accept the book's self-description on its jacket--that it provides guidance for the "mature adult who is suffering from a terminal illness and is considering . . . rational suicide." The book's persistence at the top of the New York Times best-sellers list for nonfiction has thus been seen as further proof of widespread fear of suffering, anxiety about loss of control near death, and discontent with the way physicians handle terminal illness. And so it is. Those are the obvious lessons of Final Exit.

But there are other lessons, less obvious and equally important. For Final Exit inaugurates a new stage in the debate--the end. At least that is evidently how Humphry would have it. The book rejects the very idea of considered argument. Instead, it urges doctors and nurses to begin assisting suicide and performing euthanasia now, without engaging in discussion, seeking consensus, or awaiting changes in law. The book meanwhile encourage patients to commit suicide, with misstatements making the alternatives seem exceedingly difficult.

Wherever you stand in the debate, this book is thus profoundly disturbing. It is nearly certain to close minds, to lead caregivers to irresponsible acts, and to contribute to unwarranted deaths. It is hard to imagine a question more significant than whether certain citizens, particularly physicians, should be permitted at their discretion to kill others. Yet this ultimate question is here reduced to propaganda and diatribe. There are profound lessons in Final Exit, especially for those in bioethics.

Against Argument, for Suicide

Final Exit barely discusses the weighty question of whether physician-assisted suicide and active euthanasia should be legalized in America. Instead, it basically assumes the current state of affairs, with physician-assisted suicide and active euthanasia condemned by law and by the ethical pronouncements of the organized medical profession. Final Exit offers no real argument to change that. The New York Times Book Review is simply wrong in its squib--this is not "the case for suicide." [5] There is no "case" offered here at all.

Final Exit is in fact profoundly dismissive of argument. Its message, to quote a popular advertisement, is in effect, "Just do it." To that end, it discusses method in considerable detail: how to rig the hose to your car exhaust, how to tie the plastic bag around your neck, the pros and cons of swallowing household cleansers. But there is more--how to lie to your physician to get fatal drugs, exactly which drugs to seek and how to hoard them, how to avoid detection and police scrutiny.

In lieu of argument, Humphry's book offers exhortation and propaganda. He claims he is not urging suicide, and that readers contemplating the act should first consider the alternatives. Yet read closely, it is hard to see this book as anything other than an encouragement to suicide. He lauds suicide as "decisive, courageous action" (p. 21). He describes support groups available (pp. 86-87). He recommends you rehearse putting a plastic bag over your head (p. 98). Methods he disapproves of are labelled "messy" (p. 54), "painful" (p. 46), and "violent" (p. 110). He assures the reader that his recommendations attend to aesthetics (p. 95), ease (p. 63), and peacefulness (p. 46). He refers to "The Magic Pills" (p. 91).

Even more disturbing is the book's misstatement of the law, which makes less drastic alternatives seem exceedingly difficult. This begins on the second page of text, in the foreword by Betty Rollin. The book there characterizes the termination of life-sustaining treatment as illegal: "technology can now prolong life past its natural span. And once those 'miracle machines' are turned on, it is also illegal, most of the time, to turn them off" (p. 13). This is flatly wrong. Since the Quinlan decision fifteen years ago, hundreds of court cases have proclaimed that turning off life-sustaining treatment is most certainly legal. Indeed, the U.S. Supreme Court indicated in the Cruzan decision--noted elsewhere in the book but never fully explained--that there is a constitutional right to refuse life-sustaining treatment.

After the foreword, the book continues to understate the amount of control people can assert over the dying process without killing themselves. Humphry cautions that "a Living Will is only a request . . . It is not an order. It may not be legally enforceceable" (p. 21). Yet the great majority of states have statutes or judicial decisions formally recognizing living wills. [6] Such documents are more than an optional request. They are a written record of the patient's refusal to consent to invasive treatments under certain clinical circumstances. They derive their legal force from state statutes (which may actually provide penalties for health care professionals who fail to obey the documents), from the federal and state constitutions, and from the commonlaw right to be free of unwanted bodily invasion. To treat a patient over her written refusal thus may violate her statutory, constitutional, and commonlaw rights. Though there is certainly work to be done to ensure greater clinical compliance with living wills, [7] Humphry understates their legal effect.

Humphry's jumbled presentation of the law, understating the alternative means people have for controlling their dying process without suicide, may well provoke a false panic. Moreover, physicians may take their cue from Humphry and counsel patients inaccurately about advance directives and the legally protected right to refuse life-sustaining treatment. The misinformation may effectively encourage suicide.

Who is at risk? Here again we encounter more caveats. Humphry insists he speaks only to the terminally ill: "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" (p. 20).

Yet this limitation too is belied by even a cursory reading of the text. Chapter headings blare the true reach of his intended audience: Chapter 8, "The Dilemma of Quadriplegics"; Chapter 20, "Going Together?"--a guide to suicide for couples when only one is dying, indeed when neither is terminally ill but both are merely in "physically degenerating conditions" (p. 102). In fact, Humphry goes even further. Chapter 18 advises how to obtain lethal drugs when you are perfectly healthy.

Thus Final Exit addresses not simply the terminally ill, but nearly all patients. In any case, no matter whom the book purports to address, the distributor is making sure this book is readily available to everyone. No longer need a suicidal individual write away for information, or take other deliberate steps over time. That deliberateness and time at least provided a minimal safeguard; the resolve to commit suicide was thus tested to some extent and subject to reconsideration. Now one need only get to the store and shell out $16.95. An adolescent's paper route will easily cover the sum.

Urging Euthanasia

The press has persistently characterized this book as a "suicide manual." Yet only the first part of the book can properly be labelled that. What follows is "Part 2: Euthanasia Involving Doctors and Nurses," in five chapters. Humphry does not take the trouble to distinguish between physician-assisted suicide and euthanasia. But lest there be any ambiguity about how far he is urging clinicians to go, page 142 shows it is all the way:

Increasingly physicians are being asked to perform active euthanasia for dying patients. The following chapters are intended to help doctors and nurses carry out this sensitive and responsible procedure with confidence and skill.

Page 152 to 170 offer a detailed guide to methods, complete with drug names, dosages, and different means of administration. After all, Humphry laments, "Most physicians have remarkably little knowledge of how to end a life" (p. 144).

Thus Final Exit urges physicians to start practicing assisted suicide and active euthanasia without delay. Indeed, Humphry suggets that doctors who resist have simply not "taken the trouble to think this through" (p. 25). Thus he denigrates the weighty public debate under way about whether we should dramatically alter the law and ethics of medicine by permitting these practices. He encourages health care professionals simply to ignore that debate. Rather than be governed by social constraints and morality, clinicians should fly solo and do as they please, violating the operative rules instead of working to change them.

Nor need the doctor report cases in which she performs active euthanasia. Humphry enumerates six "criteria" to guide the practice, comparing the situation to that in the Netherlands (p. 142-43). Yet he does not embrace the Dutch requirement that the physician report the practice to the authorities. Dutch cases do appear to be significantly underreported, [8] but at least there is a procedural requirement to report. Humphry does not suggest even that. That means we would never know for sure who was doing it and in what numbers. We would never be able to hold the health care professionals accountable or to discover what sort of mistakes or abuse were occurring.

Indeed, Humphry urges clinicians to perform active euthanasia without any meaningful procedural safeguards to protect the patient. The "criteria" he recommends--even with confirmation by a second doctor that the patient is likely to die "in the next few months," and a witness to the patient's final request for death (pp. 142-43)--fail to guarantee genuinely independent review of the patient's medical circumstance, competence, and knowledge of the alternatives. Thus Humphry is attempting to spread among physicians a secret practice of taking patients' lives through active euthanasia with essentially no safeguards or accountability.

It is hard to imagine any other sphere in which the public would readily accept, much less laud, a manual instructing and urging people to take human life without substantial procedural safeguards. In every other domain in which taking another's life is accepted, safeguards are extensive and public. Complex and lengthy judicial process precedes capital punishment. A declaration of war or other governmental process is meant to precede fatal combat. Even spontaneous killing in self-defense is subject to rigorous testing in court in the retrospective adjudication of the act's criminality. Yet Humphry here takes steps to create a realm of organized killing that is uniquely without protections.

The Lessons for Bioethics

It is no accident that Humphry has defended Final Exit by attacking bioethics. [9] Humphry denigrates ethicists as "junior philosophers," mincing cowards who "pontificat[e] from TV studios," offering "warnings and theories--never answers." Never mind the long history of considered philosophical and legal debate on physician-assisted suicide and active euthanasia. Never mind the advocacy by ethicists on both sides. Mr. Humphry has had enough: "the public is taking the law into its own hands."

The historical vigor of the exchange on this complex problem among those in bioethics would make Humphry's name-calling and dismissal a joke if they were not echoed by a journal as prestigious as Nature. An August editorial bemoaned "the abstract debates of ethicists," [10] as if there were nothing at all abstract to worry about in condoning physician-assisted suicide or euthanasia. Evidently, we can simply abandon the Hippocratic injunction to dispense no deadly drug, as well as the commandment "Thou shalt not kill," with no further delay or abstraction to trouble our fevered brains. Nature announced that "it is . . . disappointing that Final Exit has come under attack by ethicists and others who piously fear that its prescriptions for suicide . . . will be abused."

The defense of Final Exit has thus turned into a broadside against not only reasoned argument, but specifically bioethics. The ethical arguments--on both sides--are declared irrelevant. Ethicists are described as cowardly apologists and "self-styled" experts with no feel for the reality of terminal illness. [11]

There are important lessions to be learned from all of this. Those in bioethics cannot simply laugh off Final Exit with jokes about how-to manuals. For Final Exit is an attempt to fire the bioethicists. And Humphry has struck a chord. After decades of articles and learned treatises on physician-assisted suicide and euthanasia, people are evidently sick of what they see as palaver. Convinced that ehticists are ivory-tower pedants who have yet to face the realities of pain and suffering, the audience is apparently leaving the theater. We are in danger of speaking to ourselves.

The sad truth is that those of us in the field of bioethics may indeed have done the public a disservice, in several regards. First, by categorizing the problem and our arguments as "bioethical," we may have invited others to see an opposition between the insights of the lay public and the concerns of bioethics. In fact there should be no question of greater individual concern than whether to participate in taking another person's life. There should similarly be no question of greater public concern than whether to allow the taking of life and, if so, under what safeguards. Labelling this a "bioethics debate" characterizes it too narrowly. It is a momentous public debate with profound ethical, legal, religious, psychological, and medical implications. Those in bioethics participate along with necessary others.

Yet broader labelling and greater modesty in bioethics will not alone resolve the deeper suspicions that fuel the attack on bioethics. I suspect we will also have to intensify our efforts not only to offer cogent arguments, but also to speak deliberately and clearly to those beyond the borders of our discipline, including real patients and families. The policy question of whether euthanasia and assisted suicide should be legalized, or if not legalized then tolerated under certain circumstances, has long since gone to the public. If bioethicists speak merely to each other, or indeed only to health care personnel, they ignore the full reach of the relevant audience. This means that instead of esteeming merely the analysis written for each other and looking askance at public and media presentations, bioethicists must strive to reach a popular audience and convey argument effectively. A recent conference of bioethicists usefully discussed how to respond to journalists' inquiries in a way that produces not isolated sound bites but meatier argument. Suggestions included routinely recommending others with differing views to whom the journalist should speak, and taking the time to talk through the issues in some depth with the caller in an effort to more fully inform the resultant piece.

Beyond these matters of audience, Final Exit suggests that we bioethicists will have to fix our method. The demand to offer more than abstract argument, to address the felt reality, has become compelling. Confessing the difficulty of this issue, the emotional rigors of caring for the suffering and dying, and the anguish of fallibility at the bedside is in order. There is a growing critique of a bioethics overly driven by abstract principles from which we seem to deduce the answers to human dilemmans in a way that is sterile and empty of human experience. It seems particularly inadequat the inhuman to ignore the felt experience of those who suffer extremely, when that experience is at the core of the call for assisted suicide and euthanasia. An argument that pays inadequate attention to those human realities cannot and should not prevail.

Finally, those of us in bioethics must take seriously the indictment that we speak only from the head and not the gut. While others take the risk and gain the credibility of speaking as situated selves with revealed personal experience of the problem, we may too often rest our claims on merely academic expertise. We speak as if no one in our family had faced death, as if no suffering friend had begged for assistance. This type of argument, lacking life's context, offering a stand with no stander, a view with no "I," has come under increasing attack. The critique has special force in the debate over assisted suicide and euthanasia. It would be strange indeed if our personal experiences did not affect our views on the human costs of suffering, the dynamics at the bedside, the role of the physician, and the likely effects of permitting deliberate taking of life. The audience understandably wishes to draw aside the curtain and find the human Wizard of Oz who operates the argument's public face. The challenge we confront is to find a way to show and integrate both -- the speaker and the speech.

Some will find these recommendations far too drastic, certainly in response to such a little book. Yet the lessons of Final Exit are no less. That slim volume and its popularity angrily scream messages only calmly murmured before. It is time to take heed. If doing so threatens to turn much of bioethics'usual method on its head, then that simply shows how long we have neglected a fundamental challenge.

Meeting the challenge by attending to the lived experience of real people and revealing our situated selves need not rob the debate of its intellectual complexity or lower it to the level of a public-releations contest. Rather, the bitter dismissal of bioethics may point to a genuine lack of complexity in much of our discussion. The debate about how to respond to suffering patients begging to be put to death may simply require more than intellectual rigor. It may require manifest humanity.

The matter is, finally, that important. It tests what we are made of. With his irresponsible publication of a dangerous and misleading book, Humphry has weighed in. So will we are.


[1] Jane Gross, "Voters Turn Down Legal Euthanasia," New York Times, 7 November 1991.

[2] Suzanne Morrison, "Death-with-Dignity Debate Omits the Dying, Doctor Says," Vancouver Sun, 20 November 1991; "Reluctant' Clerics Urged to Oppose Legalized Euthanasia," Ottowa Citizen, 23 November 1991.

[3] Derek Humphry, Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying (Eugene, Ore.: The Hemlock Society, 1991). Page citations to this book are given in the text.

[4] "It's Over, Debbie," JAMA 259 (8 January 1988): 272; Timothy E. Quill, "Death and Dignity: A Case of Individualized Decision Making," NEJM 324 (7 March 1991): 691-94: Lisa Belkin, "Doctor Tells of First Death Using His Suicide Device," New York Times, 6 June 1990; Janice Bullard and Steve Marshall, "Doctor Assists 2 Other Suicides," USA Today, 24 October 1991.

[5] See the best-sellers list for nonfiction, New York Times Book Review, 1 September 1991.

[6] Society for the right to Die, Refusal of Treatment Legislation (New York: Society for the Right to Die, 1991).

[7] Susan M. Wolf, Philip Boyle, Daniel Callahan et al., "Sources of Concern About the Patient Self-Determination Act," NEJM 325 (5 December 1991): 1666-71.

[8] Andrew Ferguson, Robert George, Peggy Norris et al., "Ethanasia," Lancet 338 (1991); 1010-11.

[9] Derek Humphry, "Perspective on the Right to Die: For Whom Do Ethicists Speak?" Los Angeles Times, 16 August 1991.

[10] "Final Exit: Euthanasia Guide Sells Out," Nature 352 (1991): 553.

[11] Final Exit, p. 18.

Susan M. Wolf is associate for law at The Hastings Center.
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Title Annotation:Derek Humphry's physician-assisted suicide
Author:Wolf, Susan M.
Publication:The Hastings Center Report
Date:Jan 1, 1992
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