The debreather: a report on euthanasia and suicide assistance using adapted scuba technology

Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying

A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.

Trajectories to seeking demedicalised assistance in suicide: a qualitative in-depth interview study

BACKGROUND

In the Netherlands, people can receive (limited) demedicalised assistance in suicide (DAS)-an option less well known than physician-assisted dying (PAD).

AIM

This study explores which trajectories people take to seek DAS, through open-coding and inductive analysis of in-depth interviews with 17 people who receive(d) DAS from counsellors facilitated by foundation De Einder.

RESULTS

People sought DAS as a result of current suffering or as a result of anticipating possible prospective suffering. People with current suffering were unable or assumed they would be unable to obtain PAD. For people anticipating possible prospective suffering, we distinguished two trajectories. In one trajectory, people preferred PAD but were not reassured of help by the physician in due time and sought DAS as a backup plan. In the other trajectory, people expressed a preference for DAS mainly as a result of emphasising self-determination, independence, taking their own responsibility and preparing suicide carefully. In all trajectories, dissatisfaction with physician-patient communication-for instance about (a denied request for) PAD or fearing to discuss this-influenced the decision to seek DAS.

CONCLUSIONS

While PAD is the preferred option of people in two trajectories, obtaining PAD is uncertain and not always possible. Dissatisfaction with physician-patient communication can result in the physician not being involved in DAS, being unable to diagnose diseases and offer treatment nor offer reassurance that people seem to seek. We plea for more mutual understanding, respect and empathy for the limitations and possibilities of the position of the physician and the patient in discussing assistance in dying.

Euthanasia tactics: patterns of injustice and outrage

Struggles over euthanasia can be examined in terms of tactics used by players on each side of the issue to reduce outrage from actions potentially perceived as unjust. From one perspective, the key injustice is euthanasia itself, especially when the person or relatives oppose death. From a different perspective, the key injustice is denial of euthanasia, seen as a person's right to die. Five types of methods are commonly used to reduce outrage from something potentially seen as unjust: covering up the action; devaluing the target; reinterpreting the action, including using lying, minimising consequences, blaming others and benign framing; using official channels to give an appearance of justice; and using intimidation. Case studies considered include the Nazi T4 programme, euthanasia in contemporary jurisdictions in which it is legal, and censorship of Exit International by the Australian government. By examining euthanasia struggles for evidence of the five types of tactics, it is possible to judge whether one or both sides use tactics characteristic of perpetrators of injustice. This analysis provides a framework for examining tactics used in controversial health issues.

The debreather and NuTech: a reply to Kleespies

This article responds to Phillip Kleespies's (2010/this issue) commentary on NuTech fieldworkers and their use of the debreather. Non-medical assistance with suicide raises legitimate concerns about accountability, public safety, and care for those who are suffering. Given that suicide is not a crime, an outcome of the NuTech movement may be that suicide techniques will become refined to a point where covert assistance is unnecessary. Assuming that the internal social controls of NuTech fieldworkers will permit greater transparency, it is foreseeable that fieldworkers will eventually report suicides to the authorities, similar to the Swiss model for assisted suicide.

Psychological and ethical considerations concerning the debreather and assisted suicide: a commentary on Ogden

This article offers a commentary on the report by Russel Ogden (2010/this issue) on the use of the "debreather" for suicide assistance by the NuTech (or New Technologies for Self-Deliverance) program. The emergence of NuTech is set within its historical and political context. Nu Tech is criticized for its anarchic and extreme advocacy of self-determination to the neglect of other psychological and ethical considerations (e.g., the individual's emotional state, the mutability of his or her quality of life, and his or her decision-making capacity). Some of the risks of covert, unregulated, assisted death are noted as is a potential shift in healthcare that might diminish interest in the undignified NuTech methods of dying.