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Assisted suicide by oxygen deprivation with helium at a Swiss right-to-die organisation

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Abstract and Figures

In Switzerland, right-to-die organisations assist their members with suicide by lethal drugs, usually barbiturates. One organisation, Dignitas, has experimented with oxygen deprivation as an alternative to sodium pentobarbital. To analyse the process of assisted suicide by oxygen deprivation with helium and a common face mask and reservoir bag. This study examined four cases of assisted suicide by oxygen deprivation using helium delivered via a face mask. Videos of the deaths were provided by the Zurich police. Dignitas provided protocol and consent information. One man and three women were assisted to death by oxygen deprivation. There was wide variation in the time to unconsciousness and the time to death, probably due to the poor mask fit. Swiss law prevented attendants from effectively managing the face mask apparatus. Purposeless movements of the extremities were disconcerting for Dignitas attendants, who are accustomed to assisting suicide with barbiturates. None of the dying individuals attempted self-rescue. The dying process of oxygen deprivation with helium is potentially quick and appears painless. It also bypasses the prescribing role of physicians, effectively demedicalising assisted suicide. Oxygen deprivation with a face mask is not acceptable because leaks are difficult to control and it may not eliminate rebreathing. These factors will extend time to unconsciousness and time to death. A hood method could reduce the problem of mask fit. With a hood, a flow rate of helium sufficient to provide continuous washout of expired gases would remedy problems observed with the mask.
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1
Assisted Suicide by Oxygen Deprivation with Helium at
a Swiss Right-to-Die Organisation
Corresponding Author:
Russel D. Ogden
207 Osborne Avenue
New Westminster, BC
CANADA V3L 1Y7
Tel (604) 540-4342
Email rdogden@telus.net
Affiliation: Groningen University, PhD candidate
William K. Hamilton, M.D.
Santa Rosa, CA, USA
Affiliation: Emeritus Professor of Anesthesia,
University of California, San Francisco, CA
Charles Whitcher, M.D.
Stanford, CA, USA
Affiliation: Emeritus Professor of Clinical Anesthesia,
Stanford University, Stanford, CA
Competing Interest: None declared
The Corresponding Author has the right to grant on behalf of all authors and does grant
on behalf of all authors, an exclusive licence (or non-exclusive for government
employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to
permit this article (if accepted) to be published in Journal of Medical Ethics and any other
BMJPGL products to exploit all subsidiary rights, as set out in our licence
(http://jme.bmj.com/ifora/licence.pdf).
Key Words: right-to-die; assisted suicide; oxygen deprivation; helium; Dignitas
Word count: (3908) - excluding title page, abstract, references, figures and tables.
2
ABSTRACT
Background:
In Switzerland, right-to-die organisations assist their members with suicide by lethal
drugs, usually barbiturates. One organisation, Dignitas, has experimented with oxygen
deprivation as an alternative to sodium pentobarbital.
Objective:
To analyse the process of assisted suicide by oxygen deprivation with helium and a
common face mask and reservoir bag.
Method:
This study examined four cases of assisted suicide by oxygen deprivation using helium
delivered via a face mask. Videos of the deaths were provided by the Zurich police.
Dignitas provided protocol and consent information.
Results:
One male and three females were assisted to death by oxygen deprivation. There was
wide variation in the time to unconsciousness and the time to death, probably due to the
poor mask fit. Swiss law prevented attendants from effectively managing the face mask
apparatus. Purposeless movements of the extremities were disconcerting for Dignitas
attendants, who are accustomed to assisting suicide with barbiturates. None of the dying
individuals attempted self-rescue.
Conclusions:
The dying process of oxygen deprivation with helium is potentially quick and appears
painless. It also bypasses the prescribing role of physicians, effectively demedicalising
assisted suicide. Oxygen deprivation with a face mask is not acceptable because leaks
are difficult to control and it may not eliminate rebreathing. These factors will extend
time to unconsciousness and time to death. A hood method could reduce the problem of
mask fit. With a hood, a flow rate of helium sufficient to provide continuous washout of
expired gases would remedy problems observed with the mask.
3
Assisted Suicide by Oxygen Deprivation with Helium
at a Swiss Right-to-Die Organisation
In Switzerland, Article 115 of the Penal Code makes assisted suicide punishable only if it
is performed with self-interest.[1-3] While this legal situation makes it possible for
anyone to assist in suicide, as long as there is no self-interest, right-to-die organisations
have led the development of an open practice that ensures routine reporting of assisted
suicides to the authorities for criminal investigation.[2-3] Every year there are several
hundred such deaths and prosecutions are very rare.[1]
The two largest Swiss right-to-die organisations were established in 1982. In Zurich, Exit
Deutsche Schweiz was founded for German speaking members. In Geneva, Exit ADMD
(Association pour le droit de mourir) was founded for French speaking members.[1] In
1998, Ludwig A. Minelli, a human rights lawyer, founded Dignitas—To live with dignity
- To die with dignity. Foreigners make up the majority of suicides assisted by Zurich-
based Dignitas, thus the organisation is frequently characterized as a destination for
“suicide tourism” (table 1).[3] This suicide tourism was the subject of an acclaimed 2007
documentary, The Suicide Tourist, which aired on television networks in several
countries. The documentary showed the assisted suicide of a terminally ill man who
drank sodium pentobarbital.[4]
4
Table 1 Number of Assisted Suicides by Country and Year (May 1998 – April 2008)
1998
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total Total %
Switzerland 1 4 3 11 17 9 14 12 15 6 8 100 11.63
Germany 1 4 31 50 45 66 78 120 75 14 484 56.28
Great Britain 1 15 10 15 26 17 7 91 10.58
France 2 4 12 3 12 16 18 10 77 8.95
Austria 1 2 2 2 3 2 3 2 17 1.98
Italy 1 2 4 2 1 10 1.16
Australia 1 1 1 1 4 8 0.93
Belgium 1 1 0.12
Denmark 1 1 0.12
Greece 1 1 0.12
Hong Kong 1 1 0.12
Ireland 1 1 3 5 0.58
Israel 1 4 1 2 2 10 1.16
Canada 1 1 1 3 0.12
Lebanon 1 1 0.12
Morocco 1 1 0.12
Mexico 1 1 0.12
Netherlands 1 1 1 2 2 1 8 0.93
Peru 1 1 0.12
Sweden 2 2 3 2 9 1.05
Spain 1 1 1 2 3 3 1 12 1.40
Thailand 1 1 0.12
Czech
Republic 1 1 2 0.23
Hungary 1 1 0.12
Uruguay 1 1 0.12
USA 1 4 3 3 2 13 1.51
860
100
%
5
There is a fundamental difference between Switzerland and other jurisdictions that permit
assisted suicide. In Belgium, the Netherlands, Oregon, and Washington, patients must request
assistance from a physician, who then evaluates the patient’s eligibility with regard to terminal
illness or unbearable suffering.[5-7] In Switzerland, it is right-to-die groups that evaluate
requests for suicide assistance in accordance with the person’s prognosis, suffering, and
disability.[1-3] Under the Swiss model, the role of physicians in suicide assistance is generally
limited to prescribing a lethal dose of sodium pentobarbital. The drug is usually stored by the
right-to-die organisation. Someone from the organisation, who is normally not a doctor or nurse,
assists by preparing the drug and handing it to the patient/member to drink.[3]
In some cases, patients who have difficulty swallowing have self-administered the drug through
a stomach tube or a percutaneous endoscopic gastrostomy (PEG) catheter.[8] Swiss law allows
an assistant to engage in preparatory activities such as setting up an intravenous drip, but it is
legally critical that the individual member who wishes to die must carry out the final act
independently.[1,8] Right-to-die organisations ensure that there is a witness to the final act, and
in the case of Dignitas, it is routine to provide video evidence to the police, which helps to speed
the criminal investigation.
On January 31, 2008 the medical director of the Canton of Zurich took the position that
physicians must consult with patients more than once before prescribing sodium pentobarbital.
Dignitas interpreted this as a signal that the Cantonal medical director intended to restrict suicide
assistance. It was also viewed as an obstacle to Dignitas’s foreign members, particularly those
who would delay their travel to Switzerland to a point where return trips for further medical
consultations were out of the question.[9]
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Dignitas believed that the Cantonal medical director’s position infringed on a person’s right to
self-determination and the freedom of its resident physician to prescribe sodium pentobarbital.
Therefore, Dignitas explored oxygen deprivation with helium as an alternative to an active
pharmaceutical, such as sodium pentobarbital. The application of a non-drug method would help
Dignitas establish that medical control over assisted suicide is not necessary.[9]
Physiology of suicide and oxygen deficiency
Humans require sufficient oxygen to live. Without it, the body’s oxygen cycle will break down
and death will occur.[10] The effects of hypoxia (oxygen deficiency) are well known (table 2);
sudden exposure to severe oxygen deficiency will result in loss of consciousness within 5 to 10
seconds and within 2 minutes permanent brain injury is probable.[11]
Table 2 Progressive Human Response to Oxygen Deficient Atmosphere
Oxygen
Concentration (%) Symptoms
12 – 16 Increase breathing/heart rate; slightly disturbed
muscular coordination
10 – 14 Emotional upset; fatigue on exertion; breathing is
disturbed; consciousness is not lost
6 - 10 Nausea; loss of free movement; possible collapse; may
be aware but unable to move or speak; may lose
consciousness
> 6 Convulsive movement; gasping breaths; cessation of
respiration and heart rate
Adapted from Clayton & Clayton.[11]
Dignitas intended to achieve oxygen deprivation by introducing near 100% of the inert gas
helium into a mask, to replace the atmospheric air that participants are normally breathing. The
composition of air is approximately 21% oxygen and 78% nitrogen, and thus the gas expired in
7
the first few breaths may add sufficient oxygen to the inspired mixture to delay the effects of
oxygen deficiency. To obtain the maximum advantage, the replacement of atmospheric air with
helium must occur very rapidly. Humans can “live” for several minutes while breathing very
low concentrations of oxygen, so the system must almost immediately exclude expired breath,
which normally contains about 14% oxygen.
This may be accomplished by one of two methods. One is to have a reservoir bag and mask
apparatus similar to that used in clinical anesthesia. To totally exclude expired breath, a system
of two unidirectional valves directs expired gas to the atmosphere and allows helium to fill the
reservoir bag, from which inspiration occurs. The other method is to continuously introduce into
the reservoir a steady volume of 100% helium equal to or greater than two and one half times the
subject’s normal minute volume (approximately 10 litres per minute in an average adult).[12]
This requires a flow meter in the system. Normal minute volumes for humans can be found in
physiology texts. This continuous flow of helium acts to “air condition” the reservoir bag by
totally washing out expired gas. A critical necessity of these methods is a perfect fit of the mask
to the face so that room air will not enter the system. This is an important matter—maintaining
such a good fit often requires considerable expertise. Straps and harness are helpful, but they
add a dangerous possibility of facilitating respiratory obstruction.
The use of inert gas, such as helium, for suicide and assisted suicide is a relatively recent
trend.[13-20] Helium is non-flammable and non-toxic, and it is often chosen for suicide because
it low odor and low viscosity make it very easy to breath.[21] This gas is also widely available,
given its applications in industry and for party balloons.
8
In brief, helium is used to replace oxygen. Human exposure to a 100% helium environment will
result in the sudden loss of consciousness, without warning.[11,20] Continued exposure will
result in death from anoxia within very few minutes.[11,20]
The suicide guidebook, Final Exit, did not discuss inert gas methods when it was first published
in 1991.[22] The 2002 edition, however, offers illustrated instructions on suicide with a plastic
bag “hood” filled with helium.[23]
METHODS
Material
This study is based on videos of 4 assisted suicides by oxygen deprivation with helium, which
occurred at Dignitas in the first quarter of 2008. Dignitas routinely provides video evidence of
assisted suicides to the the Kantonspolizei Zurich (Cantonal police), and the police return the
videos after their investigation. In this instance, the copies returned by the police contained a
technical malfunction that interfered with the playback. In April, 2008, Dignitas’s Ludwig
Minelli arranged an appointment with the police so that the principal researcher could view the
videos at the police station. At that time, the police corrected the technical error and provided
copies of the videos to Minelli and the researcher. Dignitas also provided a German language
copy of its client information sheet, the protocol for helium, and a blank copy of the client
consent.
It is important to bear in mind that the videos are used to establish that the assisted suicides are
lawful. As such, the videos are Dignitas property shared for the purpose of researching the
technical aspects of oxygen deprivation with helium. The Dignitas informed consent included
the following clause, to which its members agreed:
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I hereby declare that I am prepared to assist Dignitas in assembling its own data on the
helium method, in my own interests as well as the interests of other members of Dignitas,
and am therefore prepared to take these risks to myself into account (translated from
German).
Prior to data collection, the principal researcher submitted an ethics application to the Research
Ethics Board (REB) at Kwantlen Polytechnic University, British Columbia, Canada. The REB
responded with a series of questions about privacy, anonymity, terminal illness, Swiss right-to-
die groups, and secondary use of data. The researcher appeared before the REB to explain that
the identities of persons receiving assisted suicide was not known and anonymity would be
protected. In private, the REB deliberated and decided that secondary video analysis did “not
deal with human participants and so is not appropriate for review by the REB.” Therefore, the
research was exempted from REB review.
The process of suicide by oxygen deprivation with helium
Dignitas members choosing to die from this method received training in two stages. First, they
received a document titled, “Instructions and Terms and Conditions for Informed Consent.” This
consent process explained why helium was being used instead of sodium pentobarbital, the
known effects of helium, and a caution that Dignitas had little experience with this method for
assisted suicide.
The second stage required that Dignitas members choosing to die by oxygen deprivation practice
the correct placement of a mask which covered their nose, mouth and chin, in what was called
the “working position.” With the tubing disconnected from the helium tank, the mask would
next be placed in a “preparatory position” with the elastic band positioned over the ears and
around the back of the head, and with the mask resting on the member’s forehead. The member
10
would practice moving the mask from the preparatory position to the working position (fig 1).
Once the mask was in the working position, the member was instructed to place his or her hands
at the sides of the body. The above process would be repeated until the Dignitas assistant was
confident that the member could carry out the steps competently.
An additional instruction was that the member should exhale deeply immediately before placing
the mask in the working position. According to Dignitas’s protocol, this would have the effect
of “clearing the lungs of all used air so that the breathing with helium functions properly.” We
believe that this forced expiration, although it may result in a deeper inhalation, would have little
or no significant effect on the process of oxygen deprivation.
The protocol required that the member confirm that she or he was confident with the process. If
not, then Dignitas would inform the member that the suicide could proceed at a later date with
sodium pentobarbital, after another physician consultation.
If the member was both confident with the process and capable of positioning the mask correctly,
the Dignitas protocol required that the assistant explain the following:
[T]he assistant must explain to the member that, when the member places the mask in the
prescribed and practiced manner over his or her own nose, mouth, and chin, and begins to
breathe helium, he or she will, after few breaths, lose consciousness. Because breathing
will continue without difficulty, the resulting oxygen deprivation will cause a breakdown
of brain function. Should this breakdown persist for longer than three minutes, the
consequence is virtually certain severe, permanent brain damage. Oxygen deprivation to
the brain results finally in death, which will occur without the conscious realization of the
member, as he or she will have long before passed out, and his or her consciousness
terminated. . . .
11
The informed consent process for assisted suicide by oxygen deprivation noted that
despite what had been published about the use of helium, Dignitas was inexperienced
with the method and there could be “unexpected consequences.” Members agreed that
they were willing to assume these risks and that they were “prepared to assist Dignitas in
assembling its own data on the helium method,” for the benefit of themselves and others
(translated from German).
Variables
The main attributes for observation are time to unconsciousness, breathing patterns, movements
of the extremities, eye and eyelid movements, and time to reach death.
RESULTS
We present 4 cases of assisted suicide using helium as an alternative to sodium pentobarbital.
Specific health information was not provided, but the decedents were 1 male and 3 females (aged
61, 73, 73, and 89). Each death took place in bed with the members resting on their backs as
shown in Figure 1. Data are summarized in table 3.
In each case, helium flow was initiated before the mask was put in the working position. Time is
recorded with 0 seconds marking the moment when the member finished placing the mask in the
working position.
Case 1 (Male)
In accordance with the Dignitas protocol, the member exhaled deeply before placing the mask in
the working position. Subsequent breathing appeared normal for about 35 seconds, and then the
breathing rate accelerated. At this point (36 seconds), the eyelids opened, the eyeballs rolled,
12
and the head tilted back. It is estimated that consciousness was lost approximately 36 seconds
after the face mask was in place.
At approximately 60 seconds, there were purposeless movements in the arms. The left arm
extended upward and reached about involuntarily. The right hand was held by an attendant, for
support. The attendant appeared surprised at the arm movements. Without struggle, the
attendant continued to hold the member’s right hand. Gross arm movements and fine tremors
lasted for approximately 1 minute. Eventually, both arms relaxed and the left arm rested with the
hand under the lower back.
Approximately 3 minutes after the start of the procedure, breathing appeared to stop, except for 6
gasps between 3:05 and 6:30. There were two faint breaths at 7:16 and 7:55. The helium flow
was shut off at 8:25. After the gas was stopped, there were 4 gurgled snorts at 8:38, 9:07, 9:17
and 10:15.
Case 2 (Female)
After exhaling deeply and placing the mask in the working position, the member appeared to
breathe normally for about 50 seconds, after which the breathing rate accelerated and the eyelids
blinked rapidly. It is estimated that consciousness was lost approximately 47 seconds after the
face mask was in place. At about 58 seconds the eyelids fixed open. At 1:05 there were tremors
in the arms, arching of the back, and the head tilted back. At 1:18 the neck relaxed and 1:36 the
back-arch relaxed. At 1:37 the left arm contracted at the elbow, relaxing 15 seconds later, and
then contracting/relaxing 2 more times over the next 45 seconds. There were two more slight
movements in the left arm at 6:33 and 6:46.
13
At 2:14 the member exhaled deeply and this was accompanied with a moaning sound that lasted
for 12 seconds. From 2:45 through to 8:35 there were 21 short gasps, spaced apart by as few as 6
seconds and as long as 47 seconds. At 11:47 gas flow was stopped, more than 3 minutes after
the final gasp.
Case 3 (Female)
This member exhaled prior to applying the mask to her face, but she then spoke a few words,
which suggests that she may have inhaled room air before the mask was in the working position.
She spent 11 seconds adjusting the mask in the working position and approximately 3 seconds
after releasing her hand from the mask she uttered a few indistinct words. After the mask had
been in the working position for at least 26 seconds, the Dignitas attendant spoke to the member.
The member nodded affirmatively, indicating that she was conscious. At 52 seconds, the
member’s breathing rate began to accelerate and her eyelids fluttered and blinked. Loss of
consciousness is estimated to be approximately 52 seconds after the face mask was in place. At
1:06 her eyelids fixed open; her head tilted back; and her quickened breathing continued. At
1:21 the left hand clenched into a fist and at 2:33 the left arm slowly extended for 10 seconds.
During this same period the member’s lips vibrated with her exhaled breaths, implying relaxation
of facial muscles.
At 2:23 there was a contraction of the left arm; a deep exhalation at 2:30; a contraction of the left
arm at 2:50; and at 3:17 there was a big snort and extension of the left arm. At 4:03 breathing
paused and then at 4:17 there were 7 quick short breaths lasting to 4:33. At 4:48, 4:43, and 4:56
there were 3 final breaths.
Case 4 (Female)
14
The member exhaled prior to placing the mask in the working position and after 30 seconds she
appeared conscious. At 33 seconds she nodded “yes” to an attendant’s query whether she was
breathing. Immediately afterwards the member’s eyelids blinked rapidly. It is estimated that
consciousness was lost 55 seconds after the mask was put in place. At 1:11 her eyeballs rolled,
and there were tremors in both hands. The tremors continued to 2:06 and then the body appeared
relaxed. At 2:09 the breathing rate quickened for about 6 seconds. At 3:03 there was a slow
extension and contraction of both arms, which then relaxed at the member’s sides at 3:26.
At 3:58 breathing began to accelerate, pausing occasionally, and then accelerating again. From
5:36 to 10:12 there was intermittent moaning. During this same period the eyelids were open
and the eyeballs were moving, but without appearance of control. Between 10:13 to 38:16,
intermittent patterns of accelerated breathing, relaxed breathing, and moaning continued. During
this period a number of movements occurred: at 26:03 the head tilted back; at 30:41 the
shoulders shrugged and left arm contracted; at 34:55 the left shoulder shrugged; at 37:06 both
arms contracted for 10 seconds after which the member appeared quite inert.
At 38:16 the camera was turned off, to replace the video tape. The time elapsed for this is not
known. The duration of the second tape is 26:57. At 0:49 of part 2 the member let out a deep
gasp and the head tilted back to 0:57. At 1:31 the tongue extended slightly and withdrew. This
tongue movement continued at 15 – 20 second intervals until 3:45, after which no further signs
of life were apparent. The camera continued to run from 3:45 to 26:57, but the member appeared
dead.
The recorded time from the start of the procedure to cessation of all signs of life was
approximate 42 minutes. The actual time from start to finish is not known due to the change of
15
video tape. The changes in breathing patterns, moaning, and longer dying time appeared to
concern and confuse the Dignitas attendants.
Table 3 Summary of Findings
Case
Estimated time to
loss of consciousness Intermittent, gross
extremity movements
(start/finish)
Time to cessation
of breathing Terminal gasps/breaths
(time/number)
1 36 sec.
1 min; 2 min 3 min 3:05 – 6:30; 8
2 47 sec.
1:05; 2:37 2:45 min 2:45 – 8:35; 21
3 52 sec.
1:21; 3:17 4:03 min 4:03 – 4:56; 10
4 55 sec.
1:11; 37:16 37:16 post 38 min*; 1
* Note: a change of video tape prevents exact recording of time. Only 1 gasp is noted, but
others may have occurred in the interim of tape change
CONCLUSION
The estimated time to unconsciousness ranges from 36 to 55 seconds, which varies greatly from
the 5 to 10 seconds noted by Clayton and Clayton.[11] Precise determination of
unconsciousness onset is not possible, but it appeared to coincide with blinking eyelids, rolling
eyeballs, and increased breathing rate. In general, arm movements were limited to uncoordinated
contractions or extensions at the elbow. Neither attendants nor members touched the mask once
it was placed in the working position. There were no attempts at self-rescue, which implies that
each member was unconscious.
While the camera was focused on the dying member, the attendants could occasionally be
observed, and they appeared anxious about the process. One attendant later stated that the
sudden change in skin colour (cyanosis), and wide open eyelids were unexpected, because, with
sodium pentobarbital the loss of consciousness is slower and the eyelids tend to remain closed.
16
The time to death in Cases 1 - 3 was approximately 5 to 10 minutes, and in Case 4 it was over 40
minutes. In Case 4, it is probable that sufficient oxygen was leaking into the breathing system to
sustain breathing and heart function.
Though each member followed the same breathing protocol, variances in breathing patterns and
total time to death can be attributed to health differences, variable rebreathing, inspiratory leaks,
and dilution of the inhaled mixture with room air (which would include 21% oxygen). While
health information and flow rate data are unavailable, the video image reveals variances in the fit
of the mask. Gaps noted between face and mask would have allowed room air to enter into the
breathing environment, thereby extending the time to unconsciousness and the time to death.
Even if the Dignitas attendants were trained to recognize a poor mask fit, they probably could
not make adjustments without running afoul of the law. This is because Swiss law requires the
dying individual to perform the final act, and a third party intervention to adjust the mask would
probably constitute an offense.
We conclude that much of the variability in time to unconsciousness and death can be attributed
to differences in the mask fit. A hood method could reduce the problems of fit. The fit at the
collar must be loose enough to serve as an exhaust port, but tight enough to ensure that the flow
of gas will maintain inflation of the hood.
DISCUSSION
In these 4 cases, oxygen deprivation by breathing helium through a mask proved lethal.
Nevertheless, we believe a mask breathing apparatus is problematic because it is very difficult to
achieve and maintain a gas tight seal between the face and the mask. Even if the initial mask fit
is gas tight, subsequent involuntary movements of the head, neck, and facial muscles are likely to
spoil the fit. In anesthesia, it is well known that achieving a continual airtight fit is technically
17
difficult. Even tiny leaks may substantially allow ingress of oxygen into the breathing
environment.[12] By enhancing the video images, gaps are visible around the nose bridge and
under the chin, thus room air could easily prevent an oxygen free environment. Gaps of some
degree may well have been present in all four cases.
The inspired concentration of air, and therefore oxygen, will be determined by the relative
amounts of added helium and expired gas. To completely replace expired air, and thus insure the
highest possible concentration of helium, the flow rate of added gas (helium), has been
determined to be a volume of at least two and one half times the subject’s minute volume.[12]
This would be true with either the bag and mask as used by Dignitas, or with the use of a large
hood. This flow rate would require tubing of an adequate internal diameter to deliver helium
from the tank to the inhalation system.
Final Exit offers detailed information about using a plastic bag hood and helium for suicide.[23]
For aesthetic reasons, Dignitas chose a mask instead of a hood. A hood, however, may be easier
to manage than any mask that we know. The elastic collar on a hood provides an exhaust port.
Sudden exposure to a completely oxygen deficient environment should result in loss of
consciousness within 5 to 10 seconds.[11] Given the visibly poor mask fit, and that the
estimated time to unconsciousness ranged between 36 and 55 seconds, it is probable that the
breathing environment was not completely oxygen deficient. In two case reports of sudden
exposure to a helium environment inside a hood, Ogden reported loss of consciousness within
10-12 seconds.[20]
Assistance with suicide is not necessarily a medical procedure and these cases of oxygen
deprivation show that the prescribing role of physicians and the use of drugs can be bypassed.
Ziegler recently noted that Swiss model of assisted suicide has significant potential to inform the
18
debate over the right-to-die, and that it “could also help demedicalize the way that we die.”[2]
The transparency of the Swiss model and the boldness of organisations like Dignitas provide
unique opportunities to shed light upon otherwise hidden behaviours. Switzerland is probably
unique in that its right-to-die organisations can account for nearly 5% of all suicides.[24] Given
the nature of Swiss law and the good faith transparency and accountability of right-to-die groups
in that country, the Swiss model offers unique opportunities for observation and measurement of
a phenomenon that cries out for empirical inquiry and understanding.
19
Figure 1
Mask in “working position.” Mask is similar to type used by Dignitas for breathing helium
(photo R. D. Ogden).
20
Figure 2
“Exit-bag” hood. Apparatus is similar to that described in Final Exit (photo R. D. Ogden)
21
Acknowledgement:
The authors thank Cecilia Martell for assistance with translation.
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... The most popular Swiss organizations dealing with assisted dying are Exit Deutsche Schweiz (website: www.exit.ch), which advises German-speaking individuals, and Exit Association pour le Droit de Mourir dans la Dignité (Exit A.D.M.D., website: www.exit-genev e.ch), which serves French-speaking individuals, both founded in 1982 [26][27][28]. The services provided by Exit A.D.M.D. are available only to Swiss citizens [29]. ...
... Dignitas, a Zurichbased organization established in 1998, seems to be particularly popular among foreigners, including Germans and British [29]. These practices, involving performance of euthanasia abroad in countries where it is allowed, have been dubbed "suicide tourism" [28]. In the USA, the largest nongovernmental right-to-die organization is Compassion and Choices (www.compa ...
... Helium is a colorless, odorless, and non-flammable gas commonly used for filling balloons [38]. It is also used in industry and medicine, among others to treat decompression sickness [28,39,40]. Unlike xenon, it shows no anesthetic properties [39]. ...
Article
Full-text available
Purpose The authors reviewed the literature paying attention to helium suicide rates, autopsy findings in people exposed to helium, methods of collecting biological material for toxicological tests, and analytical methods used for detection and quantification of helium in the collected specimens. Methods All reviewed information was gathered through a detailed search of Scopus, PubMed and the World-Wide Web using relevant keywords, e.g., helium, asphyxia, and suicide. Results The use of helium for suicidal purposes is becoming an increasingly common phenomenon around the world. This is undoubtedly influenced by the Internet, which explains in detail the technical aspects of the suicidal use of helium and describes the dying process. Exposure to helium does not lead to poisoning; instead, death is caused by asphyxia. Conclusions Deaths due to helium asphyxiation are still a problem for modern forensic toxicology. Most current methods for collecting biological specimens and identifying the gas seem to be insufficient to give definite opinions in cases of helium asphyxiation. More attempts should be made to modify these methods in order to improve and facilitate detection and quantitative determination of helium and other inert gases.
... For example, in one study, forensic experts studied a case of self-immolation [25]. In another, researchers studied the death of an individual at a Swiss right-to-die organization by oxygen deprivation [26]. The organization typically used barbiturates, and the researchers were assessing the feasibility of using oxygen deprivation, noting ways to improve the process. ...
... However, the authors noted that due to the presence of CCTV, they were able to conclude that the individual had died by suicide [25]. In another study, an individual was found to have died due to impact by a motor vehicle [26]. While the individual presented with self-harm scars and prior substance use, the CCTV of a neighboring business was able to definitively conclude that this was in fact a suicide. ...
Article
Full-text available
Background Suicide is a recognized public health issue, with approximately 800,000 people dying by suicide each year. Among the different technologies used in suicide research, closed-circuit television (CCTV) and video have been used for a wide array of applications, including assessing crisis behaviors at metro stations, and using computer vision to identify a suicide attempt in progress. However, there has been no review of suicide research and interventions using CCTV and video. Objective The objective of this study was to review the literature to understand how CCTV and video data have been used in understanding and preventing suicide. Furthermore, to more fully capture progress in the field, we report on an ongoing study to respond to an identified gap in the narrative review, by using a computer vision–based system to identify behaviors prior to a suicide attempt. Methods We conducted a search using the keywords “suicide,” “cctv,” and “video” on PubMed, Inspec, and Web of Science. We included any studies which used CCTV or video footage to understand or prevent suicide. If a study fell into our area of interest, we included it regardless of the quality as our goal was to understand the scope of how CCTV and video had been used rather than quantify any specific effect size, but we noted the shortcomings in their design and analyses when discussing the studies. Results The review found that CCTV and video have primarily been used in 3 ways: (1) to identify risk factors for suicide (eg, inferring depression from facial expressions), (2) understanding suicide after an attempt (eg, forensic applications), and (3) as part of an intervention (eg, using computer vision and automated systems to identify if a suicide attempt is in progress). Furthermore, work in progress demonstrates how we can identify behaviors prior to an attempt at a hotspot, an important gap identified by papers in the literature. Conclusions Thus far, CCTV and video have been used in a wide array of applications, most notably in designing automated detection systems, with the field heading toward an automated detection system for early intervention. Despite many challenges, we show promising progress in developing an automated detection system for preattempt behaviors, which may allow for early intervention.
... Otherwise, there is a risk that vulnerable citizens may be killed by suboptimal, or even cruel, means. In some countries, individuals have resorted to hypoxic methods ('debreather' hoods, involving helium rebreathing) [56,57] where death is accompanied by noisy, obstructed breathing and which have considerable shortcomings (see also online Supporting Information, Data S2) [57]. These considerations also apply to other non-injection methods of capital punishment (see also online Supporting Information, Data S1) [58]. ...
... Otherwise, there is a risk that vulnerable citizens may be killed by suboptimal, or even cruel, means. In some countries, individuals have resorted to hypoxic methods ('debreather' hoods, involving helium rebreathing) [56,57] where death is accompanied by noisy, obstructed breathing and which have considerable shortcomings (see also online Supporting Information, Data S2) [57]. These considerations also apply to other non-injection methods of capital punishment (see also online Supporting Information, Data S1) [58]. ...
Article
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.
... They often examine the assistance in dying regime adopted by their own country but also look at other regimes that they sometimes contrast with the one prevailing in their jurisdiction. For example, American researchers studied decisions made by Dutch regional euthanasia review committees (Miller & Kim, 2017), Canadian and American researchers studied assisted suicide by oxygen deprivation in Switzerland (Ogden et al., 2010), American and Dutch researchers studied evidence concerning the impact of physician-assisted dying on patients in "vulnerable" groups in Oregon and the Netherlands (Battin et al., 2007), and other researchers from different countries compared national models of assistance in dying (Steck et al., 2013, this issue). Experts also have international networks. ...
Article
Assistance in dying has become a transnational issue debated and lawfully practiced in several jurisdictions around the world. This article focuses on persons, terms and themes that circulate from one context authorizing assistance in dying to another. Building on Joseph Gusfield’s concepts of judgment, ownership and responsibility, we explore how national debates on assistance in dying draw on transnational circulations which are instrumental in the construction of this issue as a public problem. Adopting a transnational lens shows that local public problems of assistance in dying should not be apprehended in isolation nor compared as independent contexts.
... In most cases using the helium method after the publication of the book and DVD, suicide publications were found at the scene of death. Several studies have been published about the rise of suicides by helium asphyxiation in other countries [10][11][12]. Equally, the influence of a rise in the availability of information about assisted suicides or euthanasia, has been discussed widely both online and in publications [4][5][6][13][14][15]. ...
Article
Introduction In 2012 and 2013 a movie and a book about a ‘dignified end of life’ were published in the Netherlands. These items described suicide using an ‘exit bag’ to establish asphyxiation using helium (the helium method). ‘Right-to-die-organisations’ inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. Material and methods We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. Results The study showed a stable trend in the use of the helium method in the period 2012–2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at ‘helium method’ cases than with the ‘other, related, methods’ cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. Discussion The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst ‘right-to-die-organisations’ strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.
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The author wrote this book in an attempt to address a wide audience, ranging from experts in the area of tourism, to students and tourism/hospitality practitioners. The author merges findings from empirical studies with instances from the tourism/hospitality sector, covering different types of hotels, restaurants, airlines, museums, national parks and theme parks. The author uses contemporary cases drawn from the international scene. A more philosophical approach to tourism can help all of us understand that there is more to life than taking advantage of the natural environment, customers, employees, or hosts, for the sake of profiteering or self-indulgence. Therefore, the acquisition and channelling of certain rudiments and notions such as philanthropy are deemed crucial at a personal, organisational and societal level. The cultivation and circulation of virtues such as love, kindness, patience and charity in tourism are of the utmost importance if organisations are to be associated by their guests with terms such as 'anthropocentric', 'extraordinary', 'unexpected', 'quality' and 'satisfaction'. The author hopes to cast light on the rather perplexing and multifaceted nature of tourism in order to help practitioners, students of tourism/hospitality, and general tourism bibliophiles truly to become 'friends of (tourism) wisdom' ('philosophy' literally meaning love of wisdom).
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Asphyxia due to inhalation of nitrogen, as accidental or suicidal event, has been seldom reported in the forensic field. Death usually occurs because of a displacement and decrease of environmental and alveolar oxygen concentrations, but taking into account that nitrogen is a normal component of atmosphere, autopsy findings, which may be in certain cases unremarkable, must be corroborated with a careful scene investigation in order to determine the cause of death. We present a case of a 37-year old male found unresponsive inside his car with five liquid nitrogen tanks placed in the trunk, three of them with clear losses because of incomplete lock. Resuscitation efforts were unsuccessful. Autopsy findings and histological analyses were unremarkable, but toxicological analyses were crucial. Percentages of nitrogen were high in blood collected from the inferior vena cava (85.2%), left ventricle (81.01%) and the right lung (80.73%). Concentrations of nitrogen were higher than those detected in control samples: 14 autopsy cases, room air and water. The cause of death was identified as an inert gas asphyxiation, which was classified as accidental in accordance with the police report.
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Reviewed by Jim Gleason, heart recipient 1. Surgeons view of death from personal, physical and emotional views 2. Even if you don't read all of the various death descriptions, be sure to read the final two chapters, The Lessons Learned and Epilogue to see what he summarizes from all the details provided in the earlier chapters 3. Lot said about extending life beyond what is reasonable, due to drs wanting to solve the Riddle 4. Interesting seeing his views and contrasting them with his actions when it came to his own brother dying of cancer – admits a mistake, very human 5. eloquent writing, well read and quoted 6. 1994 National Book Award nonfiction winner, Yale physician Nuland's study of the clinical, biological and emotional details of dying was a 14-week PW bestseller. In the same year as my own heart transplant, an amazing book was published titled: How We Die. I only coincidently "discovered " this book twelve years later and was fascinated in its reading, especially from the perspective of one who was still alive due to the gift of a donated heart and at 62 years of age, am now again looking to the future where my own mortality gets more interesting with each passing year of living this very fulfilled life post transplant. Let me say up front that nowhere in this book is the organ transplant subject or words mentioned. By the time you finish reading this amazing book, you will change the way you view your own mortality and how you expect to die and face that final moment.
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In recent years information about suicide with helium has spread rapidly on the Internet, in print, and even on video. Increased awareness of this suicide method means that instead of turning to a physician for aid in dying, some people will terminate their lives with this nonpharmaceutical method. Although there are many case reports of hypoxic suicide by helium inhalation, little is known about the pathophysiology of this type of death. Pathologists should know what hypoxic suicide looks like. Carefully planned, autonomous suicides present possibilities for passive, naturalistic observation of the phenomenon. This article describes a method for direct observation of suicide and reports on 2 hypoxic suicides from inhalation of helium inside a prefilled environment.
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Death, like many social problems, has become medicalized. In response to this medicalization, physician-assisted suicide (PAS) has emerged as one alternative among many at the end of life. And although the practice is currently legal in the states of Oregon and Washington, opponents still argue that PAS is unethical, is inconsistent with a physician's role, and cannot be effectively regulated. In comparison, Switzerland, like Oregon, permits PAS, but unlike Oregon, non-physicians and private organizations play a significant role in assisted death. Could the Swiss model be the answer? The following essay explores the Swiss model of assisted suicide for its potential to enhance the regulation of PAS, reduce physician involvement, and perhaps demedicalize the way we die.
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Suicide by helium inhalation inside a plastic bag has recently been publicized by right-to-die proponents in "how to" print and videotape materials. This article reports a suicide performed according to this new and highly lethal technique, which is also a potentially undetectable cause of death. Toxicology information could not determine helium inhalation, and drug screening did not reveal data of significance. The cause of death could be determined only by the physical evidence at the scene of death. Helium inhalation can easily be concealed when interested parties remove or alter evidence. To ensure that their deaths are not documented as suicide, some individuals considering assisted suicide may choose helium methods and assistance from helpers. Recent challenges to Oregon's physician-assisted suicide law may increase interest in helium instead of barbiturates for assisted suicide.
Article
A 44-year-old woman was almost completely paralysed after a severe brainstem haemorrhage. Even after several years of efforts at rehabilitation, she remained completely dependent on the help of others. However, a special device enabled her to administer (after careful preparation) liquids through the PEG catheter despite her poorly coordinated movements. Four years after the stroke, the woman joined a right-to-die society with the wish to bring her life to an end. A doctor working with this organisation prescribed her a lethal dose of pentobarbital. In the presence of her husband and her companion from the organisation, the woman administered herself the lethal substance by means of the device. On the basis of the fact that she herself had switched the device on this death was classed as (assisted) suicide.
Article
In Switzerland, nonmedical right-to-die organisations offer instruction and personal guidance in committing suicide to members suffering from incurable diseases. Suicide is usually committed with a lethal dose of barbiturates prescribed by a physician. This study is a retrospective analysis of all case files of assisted suicide kept during the period 1990-2000 by "Exit Deutsche Schweiz", the largest Swiss right-to-die organisation. Between 1990 and 2000 Exit assisted in 748 suicides among Swiss residents (0.1% of total deaths, 4.8% of total suicides). 54.4% of the deceased were women. Mean age at death was 73 years in males and 72 years in females (range 18-101 years). Assisted suicide was over-proportionately represented in the German-speaking (p <0.0001), more urbanised (p <0.0001), predominantly Protestant (p <0.0001) cantons. Over the study period the annual number of Exit deaths more than tripled (p <0.0001). Of the 331 who died in Canton Zurich, 47.4% had cancer, 11.8% cardiovascular/respiratory disease, 12.4% neurological disease and 7.3% HIV/AIDS. The remaining 21.1% suffered from other, usually non-fatal conditions; 76% of these were women. There were no significant changes in sex, age and distribution of diagnoses during the study period. At first all the lethal substances were taken orally, but by the end of the study period 14% were administered via infusion or PEG catheter. All assisted suicides in the City of Zurich were duly notified to the authorities. The number of suicides assisted by "Exit Deutsche Schweiz" and the practices followed markedly expanded over this time. There was no apparent relaxation of the indications for assisted suicide. Notification of the authorities appeared to be total.