How to die

John Sutherland

  • Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying by Derek Humphry
    Hemlock Society, 192 pp, $16.95, April 1991, ISBN 0 9606030 3 4

Goethe’s novel The Sorrows of Young Werther is reported to have inspired an epidemic of imitative suicides. It is likely that many of the victims also imitated the incompetence of Werther’s self-slaughter – an act worthier of the Three Stooges than of a latter-day Hamlet. The clock strikes twelve and with the forlorn cry ‘Lotte! Lotte! Farewell! Farewell!’ Goethe’s romantic hero shoots himself in the head. Six hours later a servant comes in to find his master in a pool of blood, but still breathing. It is not until noon that Werther dies. His mistake was to shoot himself with a low-velocity pistol ‘above the right eye’. The ball’s impact was absorbed by the boniest part of the skull, an area which human evolution has specifically fortified against missile attack. Had Werther devoted his last hours to reading anatomy rather than Lessing’s Emilia Galotti, he would have known to shoot himself through the right eye, or up through his open mouth. Literature might have been poorer by an operatic gesture but a lot of young men would have been spared needless agony. An equally famous suicide in literature is similarly botched. Emma Bovary steals arsenic from the pharmacist’s locked cupboard with the vague sense that as a rat poison it must be fast and certain. The result is a day-long agony during which she vomits blood and screams curses at the poison she has injudiciously taken. Emma would have done better with a pint of laudanum – as easily come by in a 19th-century chemist shop as milk.

One of the best-known ‘assisted suicides’ in literature – of Mrs Morel in Sons and Lovers – is rather more efficiently handled but is still far from expert. Paul overdoses his mother’s milk with her whole prescription of morphia tablets, which he and his sister have pulverised. Mrs Morel evidently guesses why her night-time drink is so bitter, but drinks nevertheless. This is in line with the drill laid down in Final Exit, although Humphry recommends sweetening the lethal potion with extra sugar, or honey. But Paul then has to stand a painful watch for 13 hours, while his mother loudly snores and grunts her way into oblivion. Consultation of Final Exit would have enlightened him on two points. First, that invalids build up tolerance to their medicines; he should either have weaned her from the drug for a few days or have found some way of enhancing its effect. Secondly, he should have taken steps to shorten his mother’s death-throes. Humphry suggests the plastic bag over the head to suffocate the unconscious ‘loved one’.

One can, of course, find wholly efficacious recipes for suicide in fiction. There is a very practical description of how to exit with razor and warm bath in Huxley’s ‘Sir Hercules’. Greene’s The Heart of the Matter is instructive on how to simulate death by angina and cheat the insurance companies into the bargain. The first chapter of A.N. Wilson’s The Healing Art outlines a very useful-looking technique which only requires a motor-car, a length of rubber hose, a quiet country lane and a bottle of scotch. But in general, Derek Humphry’s warning is a sound one: ‘Beware of taking ideas about death and dying from novels and films.’ But where else are they to be found? ‘Ideas’ about suicide are strongly discouraged by the British authorities. They decree a protective ignorance on the subject – even to the extent of threatening prosecution against high-minded publications like Exit’s 1981 guide to self-deliverance. It will be a brave (one might say suicidal) British bookseller who stocks Final Exit, although it has not yet, as far as I know, been formally banned.

Britain’s policy of rigorously suppressing public information about the practicalities of suicide is designed to persuade the population that easy ways to die are as hard to come by as asps. All suicide, we are to believe, is painful, messy, undignified and inconvenient. Or as Dorothy Parker (an inveterate botcher of suicide) put it:

Razors pain you;
Rivers are damp;
Acids stain you;
And drugs cause cramp.
Guns aren’t lawful;
Nooses give;
Gas smells awful;
You might as well live.

Britain’s policy of benign censorship keeps the annual rate of (officially recorded) suicides down to 500 – infinitely fewer than are killed by smoking, many fewer than are killed in road accidents, and, in 1990, fewer than are killed by murder. Most people, it seems, decide they might as well live. Against this, those Britons who decide to die by their own hand often suffer hideously and, Humphry argues, unnecessarily. There are easy ways to die. What is difficult is finding out about them.

Final Exit, like Spycatcher, is a best-seller in America. Like Peter Wright, Derek Humphry is a renegade Briton. He admits to having ‘assisted’ three of his loved ones exit: under British law he is a serial killer. Humphry confessed to his part in the suicide of his first wife Jean in his biography of her, published in 1978. He was investigated by the police and shortly afterwards gave up his job on the Sunday Times. Since 1978 he has lived and worked on the West Coast of America. Much of the work has been in aid of euthanasia. In 1980 Humphry launched the Hemlock Society, for which he claims a current membership of 38,000. The 1981 guide to self-deliverance, Let Me Die Before I Wake, sold 130,000 copies and, as the author claims, ‘countless hundreds of people have used it as an informational aid to end their lives.’ Humphry has lobbied to get a euthanasia proposition passed by the California electorate, so far unsuccessfully. From 1988 to 1990 he was President of the World Federation of Right to Die Societies, which may be a less grand assembly than it sounds. Final Exit is his ‘book for the Nineties’.

Humphry targets his readership carefully. He distinguishes between what he calls ‘emotional’ and ‘rational’ suicide. His book has a covering note reminiscent of a nervous pornographer: ‘Final Exit is intended to be read by a mature adult.’ More particularly, it is intended to be read by a mature adult who ‘is suffering from a terminal illness and is considering the option of rational suicide’. No young Werthers need apply. In fact, American booksellers observe that Final Exit is being bought as a ‘before need’ item by large numbers of perfectly healthy middle-aged citizens who apparently want the book handy when the time comes. It’s presumably not the kind of item you can order from the library trolley in the intensive-care ward; nor, I suspect, will the managers of hospices want to have it around.

One of the more entertaining sections of Final Exit is its review of the menu of options available to the would-be suicide. Humphry devotes a whole chapter to what he calls ‘the Cyanide Enigma’. Cyanide is the poison of choice among chemists, 40 per cent of whom apparently use it in their suicide attempts. It is also beloved of thriller writers and high-level Nazis. It is part of cyanide’s mythology that it kills instantly, before the body hits the ground, leaving behind it the tell-tale odour of almonds. There have been elegant variations on the cyanide theme – like that of Alan Turing who dipped a red apple in the poison and then did a Snow White. But the evidence of the Jonestown massacre in which 800 luckless fanatics drank Koolaid laced with cyanide suggests a death which is painful and anything but swift. On the whole, Humphry does not recommend the enigmatic poison, although chemists will probably continue to use it.

Humphry devotes another chapter (‘Death – Hollywood-Style’) to a mode of suicide initially popularised by Dorothy Sayers – the intravenous injection of air by syringe. The film Coming Home gave a more recent boost to this technique. Most life-loving patients undergoing an injection experience a pang of anxiety about some errant bubble getting into a vein and circulating fatally into the chambers of the heart. Humphry, having taken medical advice, is sceptical about air injection, as either efficient or productive of the ‘gentle death’ he favours. Much more is required than the bubble of suicide folklore. In fact, so much air is needed to stop the heart that it would make more sense to use a bicycle pump. The method is not recommended.

In shorter order Humphry covers an array of what he calls ‘bizarre ways to die’. In car-owning democracies drivers who deliberately crash their vehicles apparently make up a large but statistically invisible group of suicides. Humphry regards freeway suicide as irresponsible, since it can lead to injuries to others and public expense. It is, however, one of the easier ways of circumventing insurance restrictions. Electrocution (the heater in the bath, for instance) is likewise inconsiderate: ‘the person who finds you might also be electrocuted.’ Skilled electricians might be eligible for this mode of exit, he concedes. Hanging is ‘unacceptably selfish’ and ‘almost always an act of protest, a desire to shock and hurt someone’. In my experience, hanging is also – like the ingestion of rodenticide – the expression of an intensely punitive self-hatred. Drowning is hard on survivors when the body can’t be immediately recovered, and often expensive for the authorities who have to fish for it. And people who drown themselves are strangely reluctant to leave suicide notes. Shooting is ‘definitely not the exit of choice for euthanists’, although in the US over half of suicides use guns. Shooters that leave aesthetically neat wounds often don’t work. Bigger weapons – especially shotguns – are horribly messy for whoever has to clean up afterwards. He also objects that suicide by shooting ‘has to be a lonely act, the opposite of the right-to-die credo, which aims to share the dying experience’.

Self-gassing by car exhaust ‘is a chosen way of death for some, particularly elderly couples who want to go together’. The sharing quotient is high, and consequently this exit receives a tepid endorsement. But it has the disadvantage of being slow, dirty and easily interrupted. Ovens are out since the innovation of non-toxic natural gas. And anyway the risk of explosion was unacceptably anti-social. Humphry delivers his strongest warning against household cleaning, drain and insecticide chemicals: ‘the manner of death is painful in the extreme ... I have heard of people throwing themselves through plate-glass windows in their death agonies after drinking lye.’ He ‘always’ advises against asphyxiation by barbecue pits in enclosed places; it’s painless but highly unreliable. Poisonous plants are unreliable, and often painful: ‘no matter how desperate you are, don’t even think about it.’

Freezing to death on the hillside is one of the few bizarre methods that Humphry approves of. It is, apparently, much favoured by the Japanese. Ritual disembowelling, however, like suttee, is passed over in silence. Non-prescription drugs (especially aspirin) are branded ‘a prescription for disaster’ – by which Humphry means failed, not achieved, self-destruction. Oddly, Humphry does not mention suicide by razor, which was a favourite method in the 19th and early 20th centuries. ‘No man,’ according to Byron, ‘ever took a razor in hand who did not at some time think how easily he might sever the silver cord of life.’ The advent of the safety razor inhibited such morbidity. It is unlikely that anyone has ever held a Bic disposable in his hand and contemplated severing the silver cord.

The method that finally gets Humphry’s seal of approval is unromantic and would seem rather hard work. Intending suicides should wheedle and hoard lethal quantities of sedatives from their physician, if necessary years before the drugs are actually needed (but remember to keep them in a safe, cool, dark place, and to renew them every five years). The technique he recommends is to fake insomnia and ask for progressively stronger pills on the grounds that Halcion, Equanil or whatever don’t do the trick. Eventually, in sheer irritation, the doctor will prescribe the ‘magic pills’, barbiturates. The exact amounts needed and variant brand names (English and American) are laid out in tabular form. For maximum effect on the day, the intending suicide should stop taking drugs altogether for a period. Humphry instructs on how to enhance the lethalness of drugs with alcohol (‘vodka is extremely effective’). He also advises on how to avoid the two great pitfalls of drug overdose – spewing the pills back up while unconscious and falling asleep before enough have been gulped down. And to ensure a speedy exit a plastic bag should be used. It is not exactly complex, but there is a knack to putting the bag over the head which is explained with the pedantic thoroughness of cabin staff going through the oxygen mask demonstration. Humphry offers a set of useful tips on how to exit without cheesing survivors off (such as leaving a useful tip for the staff if you do it in a hotel). Don’t take your phone off the hook – it makes callers suspicious. And leave a will.

An admirable feature of Final Exit is its stress on companionship during the last act. ‘Rational’ suicide should not be a lonely experience. ‘It is imperative,’ according to Humphry, ‘that your loved ones know what you are contemplating.’ (Rather cunningly, he suggests that taking out membership of the Hemlock Society might he a good way of dropping the necessary hint.) If possible, loved ones should assist, if only in the sense of being present and holding hands. Clearly suicide undertaken in these consensual circumstances is unlikely to be impulsive or ‘emotional’, in Humphry’s rather impoverished use of the term. The most disagreeable feature in Final Exit’s prescription is its sheer drabness and lack of climactic glamour. Death with dignity is one of Humphry’s refrains, but there is something inherently undignified about entering eternity with a black plastic garbage sack wrapped round your bonce.

Final Exit oozed into print in America in April 1991. No established house would touch it and it was taken on by a Hemlock Society member, Steven Schragis, who owns a small publishing group (now a lot less small than it used to be). Initial sales were very slow. Only a thousand copies had been sold by July. But strong word-of-mouth promotion got the book talked about and it was featured in the Wall Street Journal, and on the breakfast show Good morning, America. By August it had shot to the top of ‘How-to and Advice Books’ best-seller list where it has remained ever since, apart from a hiccup when the publisher could not supply copies fast enough. The book will probably sell half a million copies in its first year. This is a figure to rival Dr Spock.

Final Exit was generally rubbished by doctors and bio-ethicists. Editorial commentators were kinder, or at least more thoughtful. Anna Quindlen wrote a particularly influential piece in the New York Times in which she suggested that ‘instead of worrying about the content of this book we should be considering its popularity ... We should all wonder how it has happened that the terror of our waning years sends a book for the terminally ill with chapters like “Self-Deliverance via the Plastic Bag” to the top of the sales charts.’ She concluded that the sales of Final Exit were an inarticulate protest against the massively mechanised American medical industry. For anyone over the age of 50, the words ‘life-support system’ inspire the terror of a viewing of the Inquisition’s torture instruments. Once you are hooked into the system’s tubes and monitors all agency and choice are gone. The terminal patient can no more exit voluntarily than a jellyfish can jump through hoops. In the well-publicised case of Nancy Cruzan, a patient was kept ‘alive’ for seven years after all worthwhile brain function was gone. Most rational adults of a certain age are much more frightened of these triumphs of ‘intensive care’ than they are of dying – even painful dying. Humphry asserts that ‘roughly half of the people who die in Western society currently are connected to life-support systems.’ The Journal of the American Medical Association has called this estimate preposterous’. Since 40 million Americans have no health insurance and it is not the AMA’s policy to give state-of-the-art treatment for nothing, Humphry probably does exaggerate. But anyone with a good health plan and a degenerative terminal illness will more than likely be life-supported to death.

America’s desire for physicians who will deliver death on the cheap rather than unwanted life at $1000 a day has been demonstrated by the strange case of Jack Kevorkian – alias ‘Dr Death’ and ‘Jack the Dripper’. Kevorkian is a retired Michigan pathologist who has had a lifelong love affair with the human corpse. His current business card reads: ‘Jack Kevorkian MD, Bioethics and Obiatry. Special death counselling’. ‘Obiatry’ is a term invented by Kevorkian for doctor-assisted death. It has not caught on in the profession. In 1958 Kevorkian attracted notoriety by his campaign to get death-row prisoners to donate their bodies to science – a facility which luckier pioneers like Dr Mengele had enjoyed. He retired in 1988 and kept himself busy inventing a suicide machine out of $45 dollars’ worth of aluminium scrap. It was a parodic life-support system whose main feature was a red button. By pressing this button the patient would release an anaesthetic drip into his or her blood-stream, followed, after unconsciousness, by a lethal drip of potassium chloride. With gruesome chutzpah Kevorkian tried to advertise his contraption in leading medical journals. He did not succeed, but the publicity got him onto the networked Donahue talk show. There he was seen by an Oregon housewife, Janet Adkins, who at 54 had been diagnosed as having Alzheimer’s disease. She could still play tennis well enough to beat her 32-year-old son, but she had lost her capacity to enjoy music and her memory was blanking out. Alzheimer’s is irreversible, incurable and progressive. The terminal conditions in which sufferers often linger for years are horribly humiliating and burdensome for their families.

With her family’s consent, Mrs Adkins asked Kevorkian to help her kill herself. He agreed, but only on condition that she come to Michigan, a State where the laws on euthanasia are vaguer than anywhere else in America. Kevorkian was not prepared to risk being thrown out of his apartment by using it for business. Mrs Adkins was consequently hooked up to his suicide machine in his rusting 1968 van, parked in a local camp site. At his wife’s request, Mr Adkins waited in a nearby hotel. Kevorkian had been careful to videotape an interview with his patient in which she made clear the voluntary nature of her act and the balance of her mind. He was equally careful that it was her finger which pressed the fateful button. As subsequent trials confirmed, Kevorkian’s precautions put him beyond the reach of the law, at least in Michigan. No one liked Kevorkian’s act, or Dr Death himself. Even the Hemlock Society was sniffy: ‘it is hardly death with dignity to have to travel two thousand miles and die in the back of a van in a campside lot.’ Nonetheless, Kevorkian was swamped by applications from candidates for his machine, wherever he chose to park it. So far he has assisted three applicants kill themselves. His long-term aim is the provision of euthanasia stations on every US street corner.

Humphry and Kevorkian between them have put ‘rational suicide’ on the political agenda. Over the next decade it is likely to be as urgent an issue as abortion was in the Eighties. But it is hard to like either of these advocates. Kevorkian is a ghoul, the kind of doctor who gives killing a bad name. Nor does Humphry seem a nice man. According to newspaper reports he left his second wife two years ago, shortly after she was diagnosed as having breast cancer. When the unfortunate woman killed herself, Humphry took an advertisement in the New York Times disassociating himself and the Hemlock Society from her act, which he labelled irrational. Furthermore, Humphry’s book is profoundly dishonest. Final Exit claims to address only one large (but by no means overwhelmingly large) segment of the suicidal population – the old and terminally ill. The text is set in oversize type and is written in elaborately simple English, as if to be easy on ancient eyes and failing minds. But Derek Humphry must know that his manual will be consulted and used by many suicides who are young, physically healthy, and whose motives are wholly irrational. A main test for the authorities will come when a lovelorn teenager is found dead with a plastic bag on his head and a copy of Final Exit in his hand.

Nonetheless, Derek Humphry has effectively drawn attention to a glaring anomaly in the laws relating to suicide which surely cannot last. In Britain killing oneself has been decriminalised since 1961. But the penalties for assisting suicide – even by the provision of printed advice – have been kept ferociously high. As a result, many suicides are mismanaged, painful and lonely. There are good arguments both for freedom of information and the control of dangerous knowledge. But the chances are that in a couple of years the paper-back Final Exit will be freely available from W.H. Smith, and that in ten years Britain will have a euthanasia law similar to that of Holland, where doctors (with less relish than Jack Kevorkian, one hopes) can legally shorten the final suffering of their patients.