Deciding when suicide is a rational choice

While there is disagreement about whether suicide can be a rational choice, in this post I put those disagreements aside in order to address the ways that the Final Exit Network (FEN) protects the right of individuals to make informed and rational choices about the end of their lives.  From my perspective as a Coordinator (and trained Associate Guide), FEN reduces the chance that a person with a mental disorder or lacking mental capacity will be able to learn from FEN how to take their own life.  Usually, when a person who is mentally ill or incompetent does so, it is considered an irrational act.  Put another way, I want to discuss how I believe FEN works to make hastening one’s own death a rational endeavor.

FEN’s guiding principle sets the stage for its education and training program on hastening death:

We hold that mentally competent adults who suffer from a terminal illness, from intractable physical pain, or from a constellation of chronic or progressive physical  disabilities, or who face an impending loss of autonomy and selfhood through dementia, have a basic human right to choose to end their lives when they judge their quality of life to be unacceptable.

FEN provides speakers to many groups to discuss the services we offer.  In addition, the FEN Newsletter, which contains articles touching on many aspects of the right to die (RTD), is published quarterly.  This blog publishes posts usually once a week, with breaks for holiday periods and vacation.  Beyond those public presentations about the services FEN offers and the issues we address, are direct contacts by individuals and/or their families to ask for FEN’s education and training services aimed at helping qualified individuals peacefully achieve their wishes for a hastened death in the face of inevitable or actual suffering that they do not want to endure.

Most of these contacts come through calls to FEN’s toll-free phone number (866- 654-9156) and taken by an answering service, or made via a web-based contact form at <finalexitnetworkcontact@gmail.com>.  All such inquiries are funneled to the volunteer Coordinator responsible for responding to requests for assistance or information.  Each Coordinator is responsible for one or more states.  We try to respond to all contacts within 24 hours.

From the first time a Coordinator talks with an individual, we listen for signs of depression or irrational thinking.  It may be the sound of the person’s voice or what they say that gives clues about their mental state.  Most Coordinators are not psychologists or clinical social workers with training in suicide prevention, but all are compassionate people, who listen carefully to what the person says and make an initial determination about whether this person makes sense about what they are saying and whether they sound depressed beyond anything that may be seen as normal for someone dying or preparing to do so.

These initial clues about depression may be less significant for determining mental health than the medical records that are provided to FEN as part of the application process.  Often, these documents record concerns about mental status from clinicians that the person has seen, sometimes over many years before contact with FEN.  Medical records are usually from primary care doctors and specialists.  In addition, the applicant writes a letter to FEN, explaining in their own words why they seek to be educated and trained in FEN’s preferred method for hastening death–the use of inert gas.  It is preferred because it is peaceful, effective, and readily available.

The next step in the process is for another FEN volunteer to conduct a lengthy, structured telephone interview with the applicant.  The range and depth of questions discussed often suggest whether the person may be suicidal, rather than rationally preparing for dying.

The final step in the application process is presentation of all of the gathered information to FEN’s Medical Evaluation Committee, which is made up of three physicians, who volunteer their time and expertise to FEN.  The three-person committees rotate among several physicians.  They determine whether the applicant meets several “General Criteria,” as well as four “Specific Criteria.”

The General Criteria alone make it unlikely that someone who is suicidal will make it through FEN’s screening process.  Those criteria, paraphrased, include–

•  existing or reasonably anticipated unbearable suffering or an unacceptable, intolerable quality of life with no reasonable hope of improvement

•  receiving appropriate medical and/or psychological advice and being aware of treatment options (though applicants may refuse treatment unacceptable to them)

•  being mentally competent

•  willingness to inform close family members and intimate associates of intention to hasten death

•  submission of a signed and dated personal statement that describes how the applicant’s medical condition meaningfully reduces or will reduce the applicant’s quality of life, with examples of current mental or physical decline; the applicant’s values as they pertain to end-of-life choices; and what the applicant wants from FEN.

The above information, when combined with one or more other specific conditions–serious physical disease; chronic, severe, somatic pain; dementia; or a constellation of irreversible medical conditions–usually means that the applicant satisfies FEN’s criteria to be accepted for education and training about the use of inert gas to hasten death.

That education and training is provided by a volunteer Senior Exit Guide and a volunteer Associate Guide on a schedule agreed to by the applicant and the guides.  The guides meet the approved applicants in their residence and continue to assess the mental status of the accepted applicant during the education and training process.  It is important to understand that guides never physically assist or encourage a person to hasten their death.

Sometimes, an applicant wants education about voluntarily stopping eating and drinking (VSED).  This information can be provided by FEN volunteers or by referral to other appropriate resources.

No one with FEN explains the inert gas process in full detail to someone not approved as an applicant.  Often callers ask for detailed information about the process–information that we refuse to supply.  Some of these people have researched using inert gas to hasten death and are trying to get additional information from FEN so that they can end their own lives without being screened by FEN.  

By assuring that a person satisfies the criteria to be accepted as an applicant, FEN guards against providing information on hastening death to someone who is mentally incompetent or mentally ill.  It is FEN’s position that such people cannot make fully-informed, rational decisions about self-deliverance.  In addition, FEN believes that it is ethical to provide its education and training only to people who have been thoroughly evaluated.

While this process usually takes three to four weeks, FEN sees the time it takes to go through its process as necessary to operate as a responsible organization. 

Comments about this process are welcome, including communications from other volunteers to provide additional or clarifying information or opinions.