Who Should Be Able To Seek Assisted Suicide? Members of Final Exit, a group that provides counsel to people who want to take their own lives, were arrested in February. State laws governing assisted suicide vary greatly. 36 states outlaw it, but two states allow physician-assisted suicide, with many stipulations.


Who Should Be Able To Seek Assisted Suicide?

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This is TALK OF THE NATION. I'm Neal Conan in Washington.

Last Thursday, Washington became the second state to legalize a procedure for physician-assisted suicide. Like an earlier law in Oregon, two doctors must agree that a patient is terminally ill with in all likelihood, less than six months to live. The patient must be mentally competent, must request a dosage of lethal drugs three times.

First orally, then in writing, then again, 15 days later. Finally, the patient must be able to administer the drugs him or herself. By their nature, these guidelines are arbitrary. Why not nine months or a year? Why is the process not available to end intolerable suffering that might not be terminal?

Last month, four members of a group called the Final Exit Network were arrested in Georgia and Maryland in a sting operation. Investigators charge they went beyond council and advice to participate in a suicide, and they believe the group may be involved in the deaths of as many as 300 people.

Who should be able to seek out assisted suicide: a clinically depressed 25-year-old, someone with advanced multiple sclerosis, a person diagnosed with Alzheimer's? If you've had experience making or considering this decision as a spouse, a child, doctor, caretaker, where do you draw the line? Tell us your story, 800-989-8255 is the phone number. The email address is talk@npr.org and there's a conversation at our Web site. Go to npr.org, click on TALK OF THE NATION.

Later in the program, the difference between naked and nude from a woman who makes a living with her clothes off, "Live Nude Girl." But first, assisted suicide. NPR correspondent Kathy Lohr has reported on the Final Exit Network. She joins us from our bureau in Atlanta, where she's based. Kathy, nice to have you back on the program.

KATHY LOHR: Good afternoon, Neal.

CONAN: And this case centers around the death of a man named John Celmer. Tell us about him.

LOHR: John Celmer was a 58-year-old Georgia man, and he had cancer of the jaw. He had had several surgeries to remove part of his jaw and was reportedly very unhappy with his appearance.

CONAN: And his appearance, but was he terminally ill?

LOHR: He was not terminally ill, according to his family. They say he was improving, he was free of cancer when he died. He was, however, again, unhappy about the way he looked. The group said he was - the group, meaning the Final Exit Network - said he was unhappy about his quality of life.

CONAN: And that is one of the issues about which they are concerned. They say human - that suicide in the 21st century should be a basic human right. It should not be defined by the narrow distinctions, even that we have in places like Oregon and Washington State - the only two places in the country where it is legal to do this through a physician-assisted suicide.

LOHR: That's correct. They say, it's my body, it should be my decision. They contend that the right to kill yourself should be left up to the individual to decide if they would like to do it or not. Whether - depending on what kind of illness they might have - whether or not it's terminal.

CONAN: And following the death of Mr. Celmer, the police have found literature from this group in his possessions, and the Georgia Bureau of Investigations started an undercover operation to try to see how far the group would go in assisting suicide. And that's where an undercover agent, a sting, gets involved in this story, Kathy.

LOHR: That's right. Actually, there was an eight-month-long investigation by the Georgia Bureau of Investigation. And an undercover agent went to the group. They - he said he had pancreatic cancer. He went through a long process of talking to members of this group, sending in his medical records, and eventually meeting with two people in the Atlanta area.

Now, Ted Goodwin, who was the group's former president, went to this agent's home and did a kind of walk-through. This is what will happen the day of the assisted suicide. And according to an affidavit, Goodwin got on top of the agent, actually held him down on a bed, held his hands down so the agent couldn't move, and that's when the Georgia Bureau of Investigation moved in, arrested Goodwin, and ultimately a second person in Georgia and also, two others in Baltimore, including the group's medical director.

CONAN: And held his hands down, his arms down because the technology they use is a so-called exit bag, a plastic bag you place over your head, fill it with helium gas. Apparently very quick but apparently, also, people have a natural inclination to try to take it off.

LOHR: That's what they say. That is their reaction, and you have to go out ahead of time, buy two tanks of helium and this exit bag, which is like a shower cap that's pulled over a person's head. And that's supposed to be done approximately a month before the suicide is scheduled. Then, according to the group, the person has to actually turn on the tanks themselves and be able to put on this so-called exit bag. Then on the day of the event, a couple of members of the group visit the person's home and stay with them during the procedure.

CONAN: And according to the allegations, also there to remove the equipment so there's no question - the gas itself leaves no evidence, and this would look like a natural death.

LOHR: Exactly. And they even say that they might place a person so he looks like he died of natural causes, according to the wishes of the person who's deceased.

CONAN: Now, you've talked with the president of the Final Exit Network, what do they say? I mean, is it - it's just beyond human right? Is that what they…

LOHR: Well, it is a human right to them. They also, you know, they deny that they actually assist in suicide. They say, I mean, you've heard the tape earlier on the show, they say they hold a person's hands and direct them to literature. That they're not actively involved in committing the suicide. They also deny - there are charges of racketeering, in this case.

The three charges are assisting in a suicide, tampering with evidence and racketeering. And the tampering with evidence, obviously, goes to moving the equipment out once it's over. And the racketeering goes to, basically, that they're a group involved in this activity. And they say this is a ridiculous charge that the state of Georgia is bringing against them.

These are regular people. They're not a bunch of gangsters. But as a result of these racketeering charges, the group's assets have actually been frozen. And they say it might be difficult to hire attorneys without those funds.

CONAN: Another thing the Georgia Bureau of Investigation allege is that this group may have been involved in the deaths of as many as 300 people, and they're publicizing this case in hopes that other police agencies, not just in Georgia, but around the country, will look into suspicious deaths.

LOHR: That's correct. And I think even the former president, one of the folks arrested admitted to being involved in up to 200. And they believe there's maybe another 100 more that we don't know about. They've also, the Georgia Bureau of Investigation has conducted search warrants in eight states, in connection with this investigation.

They're still going over all of this evidence. So, you know, there's some thought that perhaps there might be some more arrests or some more charges coming in this.

CONAN: Let's bring another voice into the conversation, Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, the author of "Finding Common Ground: Ethics and Assisted Suicide." He's with us by phone from his office in Philadelphia. Nice to have you back on the program.

Dr. ARTHUR CAPLAN (Author, "Finding Common Ground: Ethics and Assisted Suicide"): Hey. Hi, Neal, thanks for having me.

CONAN: And this is less about this one particular group, the Final Exit Network, and more about the broader question of assisted suicide. I guess we have to make an important distinction between assisted suicide and physician-assisted suicide in the two states where it's legal.

Dr. CAPLAN: That's right. So in Oregon and Washington, there's a highly regulated system that's been created. Doctors provide the means; if you will, they write the prescription. They make the determination whether someone is terminally ill. It has to be confirmed by another doctor.

There is a waiting period. You have to report it to the authorities. The law basically exempts things, if you follow all this, from any penalty to your life insurance. So it's something that doctors play an active role in.

In just assisted suicide, it's community groups, organizations, going online, sort of sharing their experiences, but without any necessary medical experience to either diagnose somebody's problem, determine whether they're competent, or really present them with options and alternatives, if there are any, to kind of coping with their problems.

CONAN: Believing that it might be their decision.

Dr. CAPLAN: Yes. But, you know, one of the problems with - people face, let's say, with a person who's got terrible cancer of the jaw, or someone who's finding themselves unable to be mobile because of a paralyzing injury or a disfiguring burn leaving someone that way, there's a ton of obvious depression, despair that comes with that.

And whether or not you can trust what people say under those circumstances becomes a major problem when you're outside the medical sphere.

CONAN: And does it, I assume, comes as no surprise to you that there are these networks, obviously, outside the structure of the laws in those two states that are working to help people if they wish to go this way?

Dr. CAPLAN: No surprise at all. We've certainly seen relatives help loved ones die and taking the decision that Alzheimer's has done too much to take away their dignity, and maybe using a weapon or poisons to help a person die. We've seen situations, also, where people have signed pacts and said, you know, if I get sick this way, you help me. I'll help you otherwise. Many of those arrangements are out there.

And I have to say, Neal, in general, people, while they do get prosecuted, and I think appropriately so because they have to check to see what's going on, when it's truly a quote, unquote mercy killing, you don't really see people getting very much in the way of jail time.

CONAN: Though they do get convicted.

Dr. CAPLAN: They do. And they often get sentenced to community service. They might get a tokenistic jail sentence, but juries and judges are very reluctant to bring down the full, you know, weight of the law on situations like this.

CONAN: Yet, all that being said, these distinctions, they are arbitrary. They are subjective.

Dr. CAPLAN: They are somewhat subjective. If you look at the Oregon and Washington laws, they say when you're terminally ill. Well, subjectively, that's been defined as six months. It could be 12 months, it could be five minutes. We kind of drew a line and said six months to live by the best doctors can prognosticate. That allows you to avail yourself of assisted suicide.

Some physicians will tell you, well, we're not always that good at predicting, you know, who's got six months to live. In the community-based, layman's assisted suicide, you get people sort of listening to someone complain and saying well, you know, I think he means it, and I think he's competent enough.

And I think that despair is not the function of some psychological problem, but a real assessment of the quality of their lives. Okay, I'm going to give them instruction how to end that life. Very subjective.

CONAN: And yet, people watching their loved ones in terrible pain or terrible suffering, it's an awful situation.

Dr. CAPLAN: Terrible situation. And part of the problem, both with legalization of assisted suicide and with lay groups in other parts of the United States sort of taking on this role when it isn't legal, is that we have a health care system that makes it pretty miserable to die in America.

A lot of people die with technologies they don't want. They can't seem to leave instructions to get them taken away. It's very expensive. A lot of people wind up losing their home and going into terrible debt because of end-of-life-care situations. They don't really have enough hospice out there, and worst of all, perhaps, Neal, a lot of doctors are afraid. Afraid to prescribe narcotics and pain-relieving drugs for fear that they're going to be prosecuted for turning somebody into an addict.

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CONAN: Art Caplan, stay with us. We're going to continue this conversation. We also want to hear from listeners. Kathy Lohr is going to stay with us, as well. No, Kathy, actually, in fact, we're going to let you go. Kathy, appreciate your time today.

LOHR: Thank you very much.

CONAN: Kathy Lohr, NPR's Atlanta correspondent, with us from her home office there at NPR's bureau in Atlanta. We want to hear from you if you've been involved in making this decision or considering this decision. Stay with us. It's the TALK OF THE NATION from NPR News.

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CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. Oregon and Washington draw one line on assisted suicide with physician-assisted suicide laws. The Final Exit Network drew a very different one and now faces criminal charges.

Today we're talking about where states should draw the line on assisted suicide. Should it be available only for those with a terminal illness, for the very depressed? Should it be available to anyone?

If you had experience making or considering this decision as a spouse or a child, a doctor, caretaker, where do you draw the line? Tell us your story, 800-989-8255. Email talk@npr.org. And you can join the conversation at our Web site, npr.org. Just click on TALK OF THE NATION.

Art Caplan is with us. He directs the Center for Bioethics at the University of Pennsylvania and wrote the book "Finding Common Ground: Ethics and Assisted Suicide." And let's see if we can get a caller on the line. Let's start with Jeff(ph), Jeff with us from Rockford, Illinois.

JEFF (Caller): Yes, good afternoon.

CONAN: Good afternoon.

JEFF: Regrettably, I have been involved in this more times than I care to think about. My mother's entire side of the family dies of cancer. Twenty-five years ago, when she was sick - I'm a health-care provider, and I'm in the position to get what I need - and my mother was a wonderful woman and not a great patient.

And when she got to the end of her life, and she was in a great deal of pain, I told her that this is not an offering, it's simply an option. If at some point you can't take this anymore and you want to go to sleep and stay asleep, I will help you.

CONAN: So you thought it was your decision to make and hers?

JEFF: Absolutely not. I told her that if the pain reaches a point where she can no longer tolerate it, I would be willing to help her.

CONAN: So it was her decision.

JEFF: Absolutely. We both cried a great deal. My brother cried. My father cried. They thanked me. She chose to go on with her life and die slow and hard. That's her option.

I lost my wife 15 years ago, same story. I said to both of them, I will never repeat this and this is not a recommendation, but if you reach a point where you can no longer tolerate this, I will help you go to sleep and stay asleep. She cried, I cried and for reasons I don't understand, she chose to die very hard and very slowly. I never brought it up again.

When I was diagnosed with cancer 10 years ago and given six to 18 months to live, by the way, I got myself what I needed from the sources that I have available, and my decision, and I discussed this with my present wife, if it reaches a point where this is intractable - and I know how to read charts, and I know how to read radiographs - much to everybody's total astonishment - my brother's a doctor - we did wild alternative stuff.

And, in fact, it's been 10 years. My oncologist told me two months ago he doesn't want to see me anymore. He thinks I'm cured. That's terrific.

CONAN: Well, we're glad you're a hypochondriac now, Jeff, but would you have - had it come up and the decision had been made, obviously, this is not legal in the state of Illinois.

JEFF: Absolutely not. Not at all. It's humane.

CONAN: I understand. But would you have been willing to go to jail for helping?

JEFF: Yes.

CONAN: All right. Jeff, thanks very much for the call.

JEFF: Good day.

CONAN: Thank you very much. Those, Art Caplan, are decisions that people have to think about as they go through this process.

Dr. CAPLAN: They do. And one thing that is very important, Neal, is that we take some time to think about this before we're in the middle of it. It is really hard to take on issues about dying and who's going to make decisions and who you communicate with and who you want to speak for you if you can't, for some reason, communicate your wishes. But it's something we really have to do.

That's probably the biggest obstacle to getting the death that you want. It's that people don't know what you want. Families begin to fight about it. It's not clear who has the authority at the bedside.

So if you can say to somebody, look, I want my brother to make the decisions, or I'm going to be in a position where this is what I want. I don't want you to extend my life if I get into situation A, B and C - have everybody around understand that, that - those are the crucial steps to minimize the need for assisted suicide.

CONAN: Let's talk with Roger in San Francisco.

ROGER (Caller): Yes. Thank you for this opportunity.

CONAN: Go ahead, please.

ROGER: For years, I have tried to keep people from committing suicide off our bridge here, the Golden Gate Bridge.


ROGER: And right now, the full board has voted for a suicide fence. We're going to put one up, hopefully, if we can get the money for it.

CONAN: And hundreds of people have leapt off that bridge to their death, and a suicide fence would be too high and curled inside and very difficult to climb.

ROGER: About 2,000 people have jumped off. I would like to know from your guest whether there are no narcotics, no way of putting people in a sleep state that -where they will not suffer. Well, why can't we use this drug that we've demonized for years - I've never used any drugs like this - but what about heroin? Would that alleviate or make the going easier? I just don't see why it's so necessary for the state to grant the killing of those people.

Dr. CAPLAN: You can control just about any and all pain if doctors are trained to do it, if the services are out there, if they're not afraid to do it. They don't want to be accused of hastening someone's death, for pushing the morphine too hard. But the short answer to that question is, it is a scandal, an unacceptable moral scandal in the United States for anybody to die in pain.

Now, some people say they don't want to live because they're disfigured. Some people say they don't want to live because their dignity is being taken away from them because they're in an Alzheimer's state. You're not suffering. You're not in pain in an Alzheimer's state. You're just not the person you once were.

So those are tougher problems but literally speaking, pain control should be something that we don't - we're intolerant if it isn't achieved, and to me, taking the risk of killing someone inadvertently because you're pushing the pain meds very hard is a risk that everyone should be taking. The primary objective is no pain.

ROGER: You know, to me, it seems like it's a state problem. We have to loosen up on doctors, allowing them to prescribe narcotics to people who are suffering. Now…

CONAN: It's just that Art Caplan said that…

ROGER: I know for a fact that many people commit suicide because they're simply in a depressive state. I mean, we see it all the time here in San Francisco. Young, healthy people jumping off a bridge because they broke up with their girlfriend or they have acne. I mean, this is ridiculous. And something has to be done to stop this, whether it's a fence or whether it's drugs.

CONAN: And in those kinds of circumstances, Art Caplan, you can see that intervention, like a suicide fence, is - well, it's simply, you know, wise.

Dr. CAPLAN: Absolutely. And some of the difficulty here, Neal, is you have situations where people, you know, have been disfigured, again, by a burn or find themselves paralyzed in a wheelchair and say, I don't want to go on. What we know is that if you talk with them, if you try to give them support, if you show them what other people can do, most of those people are going to come around from their despairing state.

But in other situations, if you make suicide too attractive, if you put the instructions up online, if you give the suggestion that someone who's just miserable ought to take their life, not terminally ill, not even necessarily with a serious illness, just awfully unhappy, then we're in a position where the state, I think, is encouraging the kind of behavior that the caller is so deeply concerned about it.

So when we make legalization of assisted suicide the goal - that's why the two states, Oregon and Washington, have drawn the line at terminal illness. They don't want to make it too attractive just to the despairing and the despondent.

CONAN: Roger, thanks very much for the call.

ROGER: Thank you, Neal.

CONAN: And Art Caplan, I did want to ask, there are people who - among those, the people who worked so hard to get this law approved in the state of Washington, to say wait a minute. These people like the Final Exit Network, they're undermining everything we're trying to accomplish.

Dr. CAPLAN: They do. And they fear that the Final Exit people or those, sort of, fostering self-help assisted suicide aren't really in a position to know the people they deal with very well. They're not their loved ones, they're not their family, they're not their friends. They're strangers coming to render advice, kind of cold to a situation. And it's not clear that a lot of these people have been given all their options, gotten a lot of aggressive help, so that they don't feel imprisoned or trapped, or that they're going to have to suffer from whatever is bothering them.

So, yeah I think there still is a significant moral chasm - if you will, Neal -between the - what's going on in Oregon and Washington, what goes on in the Netherlands and Switzerland, and what goes on with some of these groups.

CONAN: And similarly, those who opposed these laws in Oregon and Washington would say look, there is the slippery slope that we're taking about. Once you legalize it in any sense, well, people are going to try to legalize it in every sense.

Dr. CAPLAN: Well, you know, I have tried - I've been concerned myself about that slope. I do have to say in Oregon, which has had the law in the books a long time now, very few people actually end their lives. They like knowing they have the option. And there hasn't been much in the way of a demonstration of abuse of this - a slippery slope to anywhere. So, I haven't seen it. On the other hand, you got a country with a third of the citizens underinsured and having a hard time getting into the health-care system. I hate to be flip about it, but it might be useful to say you have a right to health care before we legalize the right to be killed by the doctor.

CONAN: Let's get Doris(ph) on the line. Doris with us from Sacramento.

DORIS (Caller): Hi, Dr. Caplan. It's nice to speak with you. I've long admired your work.

Dr. CAPLAN: Oh, thank you.

DORIS: My comment is - well, I have a lot of comments but I'll try and narrow it down here. Earlier, you said that people who were outside the hospital and not getting medical advice as they were contemplating assisted suicide needed to be connected with health-care professionals. And I agree with that with the caveat that when I worked in the hospital, there were plenty of situations where we weren't even talking about assisted suicide, just getting a do not resuscitate order from the doctor, where the patient was - the doctor thought the patient was depressed and therefore, would not take that patient's word that this is what they wanted to do.

And so I - I hesitate to say it has to be - I think you should work with professionals of some kind. I'm not sure if it's a medical professional because I know that not all doctors will go along with the patient's wish, even to just have a do not resuscitate order.

Dr. CAPLAN: Yeah, very fair point. And I have to say that's why I think this planning in advance is crucial before these terrible situations arise so that you can at least talk with your family members, get them unified. You may even then be able to communicate those wishes to your doctor, who's just seeing you in the course of ordinary practice, so they can add their voice in. And then you're ready, also, when you get to the hospital, to say this is - if things go this way, this is what I want. And I do know people who've said - well, if that's how the hospital policy is, then I don't want to be in this hospital. I'm going to go somewhere else, where they're going to respect my wishes.

CONAN: Is there one way that's better, to make those choices clear, than others? Is writing better?

Dr. CAPLAN: Writing is the best, but a few tips on writing. One thing you don't do is, do advance directives or things in writing just with your lawyer. I can assure you in American medicine, the last place they call up, if you get very sick, is your lawyer. So you want to make sure that your family knows that you have written these instructions out, and they're on board.

So doing it literally in front of the family, having them witness it. That is a crucial thing. The other thing is when you're writing these things out, update it. It's very difficult for doctors to know what to do if presented with a document that was filled out 20, 25 years ago. Every three to four years, you should just initial it and say, I still mean this and I attest that these are still my wishes. Remember too, you can ask in a written document for as much care as is possible. It doesn't have to be something that is just written to say, don't treat me. It can be written to say, do treat me.

DORIS: Absolutely. And I think that assigning an agent, at least in California, the durable power of health care - durable power of attorney for health care requires you to name - I don't suppose it requires but encourages - the naming of an agent to carry those wishes out for you if you are not able to.

Dr. CAPLAN: By the way, I'm jumping in because I'm so glad you said that. I forgot to mention it. It is the single most important thing you can do if you're not comfortable writing up these recipes or instructions. If you pick one person, don't designate your family, but pick that agent to speak for you. That really is a - the most useful thing you can do.

CONAN: Doris, thanks so much.

DORIS: That's super critical if you're not wanting your legal spouse to do that - for instance, in gay couples and things like that. You must have the documents.

CONAN: Thanks very much, Doris. Appreciate it.

DORIS: You're welcome, bye.

CONAN: We're talking with Art Caplan of the - professor of bioethics at the University of Pennsylvania, about assisted suicide. You are listening to TALK OF THE NATION from NPR News. And on the air with us now is Michele(ph) from Healdsburg in California.

MICHELE (Caller): Hi. My mother starved herself to death at age 82, and it was a quality-of-life issue. She wasn't terminal. Because she was so healthy, it took 11 weeks, and it was just dreadful. It was horrible for everybody concerned. So, I think that there should be a system whereby somebody screens people who want to commit suicide and…

CONAN: Oh yes. Setting up a God squad.

MICHELE: Well, I wouldn't call it that. She made - none of us were in agreement with her decision but - by us, I mean her family and her doctor. But she made a very good case for herself. She was 82, her quality of life was declining and she just was tired of it. So…

Dr. CAPLAN: Can I ask you a question? I don't mean…


Dr. CAPLAN: …draw on a very sad, tough experience but I would like to know: Do you think it was harder for you or for her?

MICHELE: I think it was harder for us, but towards the end it got very bad for her, too.

Dr. CAPLAN: Because in those circumstances, again, you want to - if you stop eating, you stop drinking, that is your right. If it's artificially provided to you, as we saw in the Terri Schiavo case, you want to make sure that you're getting all the pain medication as well. You shouldn't be suffering.

MICHELE: Well, yes.

CONAN: But Art Caplan, what about her proposal for some sort of screening system?

Dr. CAPLAN: Yeah. Well, again, ideally I think where this country needs to go is this: Let's get everybody into the health-care system. Make sure that people who are dying have options, like hospice or going home. Let's teach doctors to manage dying better. Let's take personal responsibility to give instruction about what we do want, what we don't want. Everyone one of us should have designated an agent to make those decisions.

Then at the end of that road, there may be some who say, you know what, I want to go through a committee, I want to go to a doctor or two doctors or a panel and have the right to end my life. I guess I would say at that point okay, but we don't want to get to that, jumping over the other five steps.

CONAN: Michele, what criteria do you think the panel should consider?

MICHELE: Well, first I'd like to say that that suggestion that your guest just made makes tremendous sense to me. The panel should consider the quality of life. In my mother's case, because she was so healthy, she probably would've lived another 20 years. But she just couldn't bear the idea of living the way she was living and as I said, it wasn't something that we agreed with. We, you know…

CONAN: Should this committee, if they decide, well no, should they be able to force-feed her?

MICHELE: Oh, no.


MICHELE: No, we went - I don't know about my brother and sister, but I went through that thought process, and I felt it would be a terrible violation of her person and herself to force-feed her. And also, it would've ruined the time that I had remaining with her…

Dr. CAPLAN: Hmm.

CONAN: Hmm. An important point. An important point.

MICHELE: …which is - it really is.

CONAN: Michele, thank you so much for the call.

MICHELE: Thank you, bye.

CONAN: And Art Caplan, thank you again for your time today. We appreciate it.

Dr. CAPLAN: Thank you very much.

CONAN: Arthur Caplan joined us from Philadelphia where he is director of the Center for Bioethics at the University of Pennsylvania, the author of "Finding Common Ground: Ethics and Assisted Suicide".

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