**3. Why seek an end of life?**

Many presume that patients with terminal illness endure great suffering without access to relief. This sad, desperate, and incomplete picture is commonly presented in lobbying campaigns that seek to legalize physician-assisted suicide. Actual reports from existing programs create a different picture. Oregon's 2020 report [2] on its PAS program, which presents the statistics for 2020, shows that 27% of patients were either in pain or worried that they would be in the future. Far more common reasons for seeking assisted suicide were loss of autonomy (93%), decreasing ability to participate in the activities that make life enjoyable (92%), and loss of dignity (68%). Ironically, even patients concerned about autonomy are required to sacrifice some of

#### *Leaving Early: The Reality of Assisted Suicide and Euthanasia in 2022 DOI: http://dx.doi.org/10.5772/intechopen.105989*

it to participate in a state's assisted suicide program. Participation usually requires pleading one's case to two separate doctors who will make the final judgment about whether to write a lethal prescription. The doctor—not the patient—decides whether a request for PAS will be honored. Use of the prescription itself remains autonomous; however, as no USA state exerts significant control over the prescribed lethal dose once it has been dispensed. Many patients inquire about assisted suicide but make other choices; many do not use the lethal prescription even when they have it in hand. In 2021, 383 people in Oregon received prescriptions for lethal medication, but only 219 are known to have died from ingesting the medication. One patient awoke after taking medication, 58 died without taking medication, and information on 106 patients is unclear, with 69 lost to follow-up [3].

## **4. Asking the doctor: it seems like a natural response**

Facing the question of whether and how to seek an early end of life, some will fall back on their own resources, and others will seek help from the doctor. Why seek help from a doctor? Though ending one's life requires no collaboration with anyone at all, much less with a physician, the reality for most cancer patients is that they have been deeply involved in the medical care system for some time, from initial symptoms and diagnosis through rounds of chemotherapy, surgery, and radiation, or through rejection of those therapies as no longer valuable. Most cancer patients, therefore, have a close relationship with a physician, perhaps several, and are familiar with the medical care system. Thus, it follows that an initial search for relief might begin in that very system.

#### **4.1 The limits of the doctor's power**

Can a doctor simply prescribe a pill to end it all? No, not actually. A doctor is a surprisingly limited source of help in ending life early. Not only is there not a single pill that will instantly and painlessly end life, but also a doctor who assists with an intended suicide faces potential charges of homicide unless laws protect that participation. Though ending one's own life is not illegal, it is illegal to assist another person's suicide. The law views assistance in dying as helping kill the person. Only in the relatively few states or countries that have passed laws protecting doctors, pharmacists, and other professionals will doctors be able to help end life on request. At the present, doctors can help in 11 of the 50 states or districts in the USA, states with about one-sixth of the country's population. Nowhere in the USA can physicians perform euthanasia, legally administering lethal medication to end life. However, in those states with laws permitting PAS doctors can prescribe lethal medication for patients who can take it themselves. Elsewhere in the world, the Netherlands and Belgium have considerable experience in permitting physicians to produce death for patients by euthanasia or assisted suicide. Twelve countries around the world have passed laws protecting doctors who participate in assisted suicide or euthanasia; those countries are discussed extensively at the end of this chapter.

#### **4.2 Doctors dealing death: a new phenomenon**

Turning to a doctor as an agent of death is a relatively new phenomenon. In fact, doctors from the time of Hippocrates have given allegiance to an oath [4] in which they promise not to give poison to anybody when asked to do so, nor to suggest such a course. Doctors have portrayed themselves as healers, not dealers in death, and two thousand years of Hippocratic humility have consistently rejected the immense power inherent in allowing one human to cause the death of another [5]. Until relatively recently, physicians and society have agreed on the importance of keeping the power of death separate from the powers and privileges granted to physicians. In the past century, however, society has been willing in various locations to experiment with granting physicians the power to cause death. We are still early in a societal experiment, still recording the effects of unleashing that power.

#### **4.3 The search for understanding**

Killing any person, whether oneself or another person, has profound ethical implications, even when such an act is legal. This survey chapter is too short for complete ethical discussion. We have chosen to look at the situation in existence rather than questioning whether it should exist, reserving that discussion for another time. We acknowledge ending one's life is entirely possible in these times, with or without physician assistance. We have simply compiled in one place the information needed to begin a search for one's own answers to the question of what to do. How might one choose to end one's own life, and what consequences might follow? What choices deserve mention? We hope that some who have entered these discussions to choose a method for ending their lives will find that there are other choices, not obvious when the search began.

For readers making a serious attempt to understand options as fully as possible, and to choose whether to use any of those options, we strongly recommend additional reading and contemplation. Patients who want to end their own lives have access to a variety of means other than prescribed lethal overdoses of medication from physicians. Some of the means are messy, distressing, and uncertain (firearms, hanging, jumping from high places, poisoning) and some are little known and poorly publicized (inert gas inhalation, voluntary stopping of eating and drinking—VSED).

For serious seekers after truth, we recommend two books and a website. We do not agree with all the points of view in these sites, but we do believe that by and large the information is accurate. We believe that all three of these resources try to present detailed "how-to" discussions of techniques for ending life, coupled with careful and insightful discussions of not-so-appealing consequences of choosing any method, and thoughtful discussion of alternative choices.

#### **4.4 Resources**

#### *4.4.1 Final Exit*

Derek Humphrys' Final Exit is the classical "how-to" book, with detailed instructions on such non-doctor approaches as inert gas inhalation, and a careful rundown of preparations that must be made so paperwork and finances are in order. The book is full of caveats, legally sensitive, and a good book to have read at least twice for those who are increasingly serious. Many will find their curiosity satisfied and go no further [6].

#### *4.4.2 The Peaceful Pill*

Nitschke and Stewart's The Peaceful Pill is a meticulously detailed online book that's kept up to date (also available as hard copy that can become out of date).

*Leaving Early: The Reality of Assisted Suicide and Euthanasia in 2022 DOI: http://dx.doi.org/10.5772/intechopen.105989*

Written by an Australian physician who has been a pioneer in this field, it discusses medications and methods in excruciating detail. It provides copious detail on how to find Nembutal (pentobarbital)—still considered the holy grail of the "peaceful pill" search (reliable, peaceful, and available). Finding the holy grail in 2022 requires veterinary connections, foreign sources, and a willingness to abandon being completely legal. Authors rate each method of suicide they discuss on Reliability, Peacefulness, and Availability. This book does not assume that a doctor will be involved in every death. The book provides considerable detail on suicide tourism in Switzerland [7].

#### *4.4.3 Lostallhope.com*

Lostallhope.com is a website constructed and maintained by a man who survived his own suicide attempt(s) years ago. It has an excellent and detailed review of approaches to suicide, as well as ranking by lethality, time to die, and agony. The author unblinkingly contrasts methods of suicide by country (USA 50% firearms, 25% hanging, 16% poisoning; versus United Kingdom [UK] 51% hanging, 20% drug poisoning), includes his own story and the stories of other survivors, discusses helpful reading, has a "help me" section, and lists several pages of people to call in crisis.

## **5. Permitting assisted suicide and euthanasia: laws that protect the doctor**

Many people do not realize that suicide is legal almost everywhere in the world. Patients face no legal obstacles and need no legal protection to end their own lives or ask for assistance in doing so. A physician asked to assist, however, does need legal protection, as assisting may lead to a homicide charge. Legislation that "permits" PAS or euthanasia provides that legal protection, allowing a physician to provide lethal medication or even to administer it without being prosecuted for homicide. These laws generally protect physicians and other professionals, not patients. True, most laws have specific criteria for eligibility and a number of procedural steps, but those criteria seem primarily intended to demonstrate that physicians have conducted their due diligence and deserve protection.
