A non-medical model for a self-controlled death?

In a newly-produced short film, Philip Nitschke argues for a non-medical model to replace the medical model for a self-controlled death.  His argument is compelling.  If we have a right to a self-controlled death, we should not have to ask permission from doctors to honor that right.  As he has said, “You don’t have to be a doctor to understand dying.”

Nitschke is an Australian humanist, author, retired physician, and founder and director of the pro-euthanasia group Exit International. His involvement as a right-to-die (RTD) activist began around 1995 when the Northern Territory of Australia passed a euthanasia law that was subsequently overturned by the Australian Parliament. Nitschke has invented many devices and processes useful for achieving a peaceful death.  (See Wikipedia).  Some of them are creations in which he was a contributor, along with others, such as Derek Humphry and John Hofsess, working together through NuTech and the Euthanasia Research and Guidance Organization (ERGO), research organizations dedicated to finding peaceful methods for dying accessible to those who are suffering from serious health problems.

In the new film, Nitschke explains his position about RTD laws (my transcription):  

There is a debate that is gathering momentum around the world by populations which are aging about access to rational suicide.  This should be your right.  Not something you have to argue about.  Not something you have to ask for.  Not something you have to qualify for, but your right–the debate over rational suicide.  So, I myself believe that the medical model is dead. 

It’s where privilege is granted to patients of doctors who are sick enough to qualify.    And, of course, the laws mean you have to qualify.  You have to be given access.  You have to be eligible, and that process requires being taken around to doctor after doctor after doctor to have yourself tested to see whether you are eligible to die.  The approach has been to make it tougher and tougher and tougher to qualify.  And you’re going to have to spend a lot of your time trying to prove that you are eligible.  So, you’ll be there cap in hand begging for this right.  The argument seems to be if we make it really hard for someone to qualify, there won’t be any mistakes.  

And so the problem with that is that they come up with laws which I describe as “beg and grovel” laws.  You trying to get access to this right to end your own life means you’ve got to go in there and convince this whatever set of criteria that you are an eligible person and that means you’ve got to beg and grovel.  No one is going to subject themselves to this vigorous, difficult assessment unless they have to, and that’s what the law, the medical model insists on.  When push comes to shove, the patient is not the one who decides on their euthanasia.  It is the doctor who decides and no one else.  So, don’t be under any illusion that if you pass medical model legislation, you will not be in control.  The doctors are in control.  You can ask, but that by no means is going to guarantee that you will get what you wanted.  That is not a right.  A right is something that you have because of who you are.

Much of what Nitschke says could apply to the process followed by the Final Exit Network (FEN), as well as the nine laws that we have in US jurisdictions.  He uses three examples to explain his view.  The first concerns a woman who decided at age 76 to die when she reached the age of 80.  In another case was a couple who had been married for sixty years and wanted to die together because the husband had terminal cancer.  In a third case, a man who was 104 decided that he wanted to die because of his diminishing independence, not because he was dying of disease.  He went to Switzerland where, according to Nitschke, they have a non-medical model.  Here, Nitschke began to confuse me.

Currently, as far as I can tell, there are three RTD organizations in Switzerland.  Both DIGNITAS and lifecircle (the Eternal Spirit Foundation) will assist people from outside the country who travel to Switzerland, and EXIT confines itself only to Swiss citizens or permanent residents.  However, the websites for both DIGNITAS and lifecircle explain that doctors are intimately involved with the process, which includes medical consultations and approvals similar to those in US jurisdictions, and appears to follow a medical model (physicians are involved both as gatekeepers and dispensers of fatal drugs).  Hence my confusion about what Nitschke says about Switzerland.

Richard N. Côté explains in his book In Search of Gentle Death the basis for the RTD in Switzerland:

On November 3, 2006, the Swiss Federal (Supreme) Court at Lausanne ruled that a person’s decision as to when, where, and how to end his or her life is part of the right to self-determination protected by Article 8(1) of the European Convention on Human Rights (ECHR), as long as the person is capable of free will and can act upon it. The same court ruled that this right belongs also to mentally ill persons, on the condition that in those cases, a physician may write a prescription for a lethal medicine only if a psychiatrist has conducted an in-depth review of the patient’s condition to determine whether or not he or she has the capacity of free will. Patients whose suicidal impulses are simply the product of depression and not the result of a carefully made rational decision are excluded.

This process involves physicians in two potential ways:  writing a lethal prescription and examining a person for mental competency.  

The meaning of a right to die

Nitschke, nevertheless, raises an interesting point:  How can it be a right if someone else must give approval before it can be exercised?

The right, however, is the right to accomplish one’s own death, not to have someone provide a lethal substance or administer it.  When someone else becomes involved by providing a lethal prescription (or administering it, as is permitted in Canada and a few other jurisdictions), regulation of the process seems inevitable, even if the involvement is only supplying information, as is the case with FEN, which has its own criteria for whom it will educate and train in the use of inert gas.

Whenever one asks for something that could be lethal–a substance or information about a process–there will be criteria to be satisfied before the person or organization asked will accede to the request.  With respect to a self-controlled death, no doctor or organization wants to do anything that will enable that death if the person is mentally ill and/or not competent to make informed decisions about life and death.

Further, Nitschke’s own manual–The Peaceful Pill eHandbook– includes this disclaimer:

The Peaceful Pill eHandbook is published for people aged 50 years and over (or who are seriously ill or who have other valid reasons for wanting this sensitive information) and their friends and family.  

(I would note that there are several terminal diseases that often occur before the age of 50, which raises the question about why that age is used.)

And both the print edition and the electronic addition of the book include this qualifier: 

The print Peaceful Pill Handbook and online Peaceful Pill eHandbook are aimed at providing research and information on euthanasia and assisted suicide for the elderly, those who are seriously ill (for example with cancer, ALS), their family/ friends as well as for folk who wish to be organised and in control of their futures.

The Peaceful Pill website even provides the following information in an effort to protect against the use of its information by those who have mental health problems: 

If you feel that you do not fit the specified audience for our books, or feel that you need emotional/ psychological help, please use the phone numbers listed below: 

Nth [North] America: National Suicide Prevention Hotline USA on 1 800 273 8255/ Crisis Services Canada on 1 833 456  4566.

UK/ Ireland: The Samaritans on 116 123 & NOSP Ireland on 016352139.

Australia/  NZ: Lifeline on 13 11 14 & Suicide Prevention NZ on 0508 828 865.

Exercising some discretion about who receives the information about controlling one’s death is seen by Nitschke and his collaborators as important–presumably a matter of ethics or morality.  While I have disagreements with all of the existing RTD laws, it is not because they want to make sure that people with treatable mental illness or lack of mental capacity do not end their lives precipitously or impulsively.  My main problem with the laws is that they are drawn too narrowly and prevent many people who are suffering or will reasonably expect to suffer in the normal course of their disease (such as with incurable neurological disease) from having access to the means to achieve a peaceful self-controlled death.

I don’t criticize establishing ethical controls about who will be helped under these laws, or who will be educated by FEN, or who will receive the Peaceful Pill Handbook.  Such ethical controls are responsible, though imperfect.  But I don’t understand Nitschke’s claim that the medical model is dead.  It is dead only in the sense that lethal prescriptions no longer have to be obtained to peacefully end one’s life.  But Nitschke tries to screen those who want to receive the information he provides.  Likewise, the laws that allow willing physicians to provide a prescription for lethal drugs observe ethical controls for the same reasons Nitschke does.  

Mental illness–the main reason for the controls–continues to be a barrier for the RTD movement.  The problem is how to determine that those with mental illness have an irremediable condition from which they suffer and are competent to make a decision to end their own lives, i.e., they have the capacity to judge the significance of ending their own life.  If this conundrum can be resolved (perhaps by requiring a competency exam by a trusted psychiatrist), even the mentally ill may be candidates for assistance under RTD laws and through FEN.  

But there will always need to be a process when someone asks for assistance or information.  In spite of Nitschke’s claims that the medical model is dead, someone (whether a doctor or someone else) will always be a gatekeeper for those who want help to end their lives to end their suffering.

The alternative is to produce a comprehensive instruction manual, perhaps with video, that elaborately explains one or more peaceful and effective non-medical processes for ending one’s suffering, and make it available to anyone who wants it, no questions asked.  The main benefit of such an action would be to discourage violent deaths by means of guns, hanging, suffocation, drowning, poisoning, jumping from great heights, or other violent or painful methods.  A detailed instruction manual would eliminate any medical model that stands between the right to die and carrying out that right.  The main question to ask about such an action is, “Would that be responsible?”

Whatever direction we go, we should always be guided by what Derek Humphry has called “a more compassionate understanding of the feelings and rights of the dying.”

If Nitschke means by “the medical model” that a person must have a medical reason to want to die, then a “non-medical model” would be when a person is ready to die and does not have a medical disease that motivates them.  If the person needs no assistance, advice, or information to carry out their own death, that could be described as a “non-medical model.”  Increasingly, though, it is difficult to get the needed lethal drugs to carry out one’s death, which means that such people will need to rely on other easily obtained substances that can achieve the peaceful death they seek.  

My perspective on this issue is that even extensive research leaves most people with some concerns about whether they understand the process sufficiently to assure that they are successful.  When people seek advice or information from a knowledgable person, physician, or organization, they will likely face the kind of screening that Nitschke seems to believe should not be necessary if we have a right to die on our own terms.  If there is a gatekeeper for that advice or information, it will be difficult to escape something like “a medical model.”