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Derek Humphry, Final Exit: The Practicalities of

Self-Deliverance and Assisted Suicide for the
Dying

Article in Journal of Health Politics Policy and Law · February 1992

DOI: 10.1215/03616878-17-1-186 · Source: PubMed

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 Journal of Health Politics, Policy and Law

186 Journal of Health Politics, Policy and Law

carefully reviews the flaws in most behavioral genetic studies, serving

as both a roadmap and a warning about the pitfalls of such studies. But
pitfalls or not, we can expect to see a resurgence of such claims in the
coming decade.
While Duster is not sounding an alarm of the coming of eugenics in
the misdirected and often malevolent forms seen earlier in this century, he
suggests this eugenics will come in more subtly by the backdoor through
screens, treatments, and therapies. “Some will be health-giving , and that
will be the wedge. But sooner or later we will face the question of when
to shut the backdoor to eugenics” (p. x).
The book has stops, starts, and hesitations, raising some points without
developing them and occasionally taking the argument in different direc-
tions at once. Yet it ranges widely and raises numerous important issues in
a brief space (the book actually contains only 128 pages of text plus several
appendices). In the context of burgeoning prenatal, postnatal, and carrier
screenings for genetic disorders, this book will serve as an important re-
source for those interested in the social and public policy implications of
the “new genetics.”
Peter Conrad, Brandeis University

Derek Humphry. Final Exit: The Practicalities of Self-Deliverance

and Assisted Suicide for the Dying. Eugene, OR: The Hemlock Soci-
ety, 1991. 192 pp. $16.95 cloth.
Why has a suicide manual hit the New York Times best seller list of hard-
cover advice books? Directed primarily to mature adults who are termi-
nally ill and in severe pain ,Final Exir became number one just two months
after its publication. Now in its fourth printing, many booksellers are
having a difficult time keeping up with the demand for the book. Final Exit
explicitly instructs readers on using barbiturates, benzodiazepine deriva-
tives, ketamine, insulin, and other agents to end life, and points out the
drawbacks of electrocution, hanging, drowning, shooting, car exhausts,
ovens, and over-the-counter drugs. Americans extol the value of self-
reliance, and self-help books have been popular on topics ranging from
how to lose weight, look younger, find a mate, and cook the perfect cake.
But why has such a weighty tome now been added to this collection? The
Hemlock Society, an organization formed in 1980 to campaign for the
right of terminally ill persons to choose euthanasia, published and pro-

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Reviews 187

moted the book, and its ranks have grown steadily since its inception to a
membership of 38,000.
Some see the popularity of the book as an indictment of the medical
profession. By laying out the option of “self-deliverance,” Humphry as-
suages the fears of a public that no longer trusts doctors to handle medical
care at the end of life humanely. At the same time, however, Humphry
presents plenty of reasons why physicians should assist a suffering ter-
minally ill patient to die. Physicians know better when death will occur.
They have lawful access to lethal drugs, know the techniques for their ad-
ministration, and undertake, as physicians, the professional responsibility
to relieve suffering, as well as to cure disease. This is hardly a book that
encourages the terminally ill to go it alone. It preaches self-reliance only
as a last resort. And it expresses hope that the medical profession will rise
to the occasion and come to the aid of patients who request assistance
in dying. “In the last decade physicians’ attitudes have changed,” notes
Humphry. “A good many, particularly if they are under forty-five, will
discreetly prescribe lethal drugs in appropriate cases.” Yet, if the medical
profession remains “our best ally in self-deliverance,” why does Humphry
gives precise suicide instructions to the lay public? And what explains the
commercial success of Final Exit?
To address these questions requires placing Final Exit in broader per-
spective. A number of other incidents have sparked discussions about
death and dying in recent years and predate the popularity of Humphry’s
book. Prior to the publication of Final Exit, as early as 1988, the Hemlock
group brought the issue of legalizing active euthanasia before the people
of California. In California, as in other western states, citizens can circu-
late a petition and, if they gain enough signatures, place their proposition
on the ballot at a general election. The Hemlock organization sought, but
failed, to gather sufficient signatures to place an initiative on the ballot
in California, and a similar attempt in Oregon failed to qualify for signa-
ture gathering. Washington State was the society’s most recent target. On
November 5, 1991,citizens of Washington State voted down, by a margin
of 7.2 percent, an initiative that would have amended the state’s Natural
Death Act to permit physicians to provide aid in dying to competent, ter-
minally ill patients who request it. Had the initiative passed, Washington
would have become the first jurisdiction ever to authorize euthanasia by
formal legal enactment.
At about the time that Washington State citizens were circulating a peti-
tion to legalize aid in dying, national attention was focused on the killing

Published by Duke University Press

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of a patient, Janet Adkins, by a physician’s suicide machine. In Prescrip-

tion Medicine: The Goodness of Planned Death, physician Jack Kevorkian
(1991) recounts how he devised a machine (which he names “Mercitron”)
to assist suffering or doomed persons to kill themselves. Dr. Kevorkian
made the device available to Ms. Adkins, a newly diagnosed Alzheimer’s
patient, in 1990, and in his book extols its virtues for other uses, such
as capital punishment. According to Kevorkian, the machine’s cardinal
virtue is to render the participation of doctors or other health professionals
“strictly optional.” It is a machine, he claims, that can ameliorate the
moral responsibility of third parties by placing death in the patient’s
own hands. In Final Exit, Humphry recalls the Kevorkian case and notes
that the Hemlock Society, of which he is a member, approved of Dr.
Kevorkian’s actions because Ms. Adkins had contemplated suicide for at
least six months and was refused help by other doctors; in addition, her
family was receiving psychological support and counseling.
Also predating the popularity of Humphry’s book was the Supreme
Court’s first right-to-die case, Cruzan v. Missouri. In its decision, the
Court recognized the right of an individual to refuse life-sustaining medi-
cal care at the end of life, but said states could prevent surrogate decision
makers from withholding medical treatment from patients who fail to leave
“clear and convincing” evidence of their wishes. The case embodied some
of the public’s worst fears. The patient, Nancy Cruzan, was a young and
active woman when an automobile accident left her in a persistent vege-
tative state. Her rigid body lay for almost eight years tethered to a feeding
tube, with occasional seizures and vomiting, eyes moving aimlessly.
Most recently, and coinciding with the publication of Humphry’s sui-
cide manual, a moving account appeared in the New England Journul of
Medicine of a physician, Timothy Quill (1991), who helped to end the
life of a patient whom he had known for many years. The patient was
a young woman diagnosed with acute leukemia. Quill’s narrative cast in
vivid relief the degree of suffering that people often undergo in the pro-
cess of dying. And it helped to legitimize, to physicians as well as the
lay public, the idea of humanely helping someone one knows well to face
tragedy squarely. The author of Final Exit himself presses the point that
“people (doctors included) should only help each other to die if there is
a bonding of love or friendship, and mutual respect. If the association is
anything less, stand aside. This is too serious a matter to be relegated to a
poor, a casual or a brief relationship.” Humphry adds: “There is no point
in asking Hemlock for the name of sympathetic doctors [who will provide
aid in dying] because those who help only do it for patients whom they

Published by Duke University Press

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Reviews 189

know and trust. With the exception of Dr. Kevorkian, we never hear of
physicians who help strangers to die.”
Perhaps, then, Final Exit is the out prescribed for those who do not
stand in a close relationship with a willing physician. Perhaps its popu-
larity reflects the fear of having no physician to whom one can turn. If
so, it bodes ill for the most vulnerable members of society. It is the un-
insured and persons who depend on Medicaid that are the least likely to
have a continuing relationship with a doctor and the most likely to receive
medical care in a hospital emergency room or clinic. These groups are at
a distinct disadvantage if the moral authority of physicians to participate
in active euthanasia requires that they stand in a special relationship with
their patients. (See Pear 1991; Jecker 1991.)
These broader concerns are never broached in Final Exit, and Humphry
gives no pretence of addressing them. This, in and of itself, is difficult to
criticize. But the devising of simple formulas and checklists encourages
the perception that choosing death is easy. “If you are now comfortable
with your decision to die,” writes Humphry, “be sure that you are in the
hopeless condition.” Do not forget to “leave a note of explanation” and
“tell those around you the complimentary things which have been left
unsaid .” The sixteen-item checklist Humphry proceeds to enumerate im-
plies a glib response to a wrenching and complex issue. Like Kevorkian’s
suicide machine, Humphry’s book depersonalizes the dying process. The
generic formula it offers for “self-deliverance” has the effect of reducing
the situation of those who choose death by failing to recognize the indi-
viduality of their predicament. Initiatives, such as Washington State’s
119, pose similar concerns. Even if active euthanasia or assisted suicide
represents an ethically honorable course in individual cases, the difficulty
of crafting a general policy that is humane and dignified remains. We
still do not know how routinizing medical killing might change our very
humanity.
In the Netherlands, an informal agreement has existed since the early
1970s not to prosecute physicians who participate in active euthanasia.
Yet the practice of aid in dying is not widespread. One recent study (Van
der Maas et al. 1991) estimates that only 1.8 percent of deaths in the
Netherlands are the result of euthanasia with some form of physician in-
volvement and that assisted suicide occurs in only 0.3 percent of patient
deaths. Moreover, many physicians who had practiced euthanasia said that
they would be reluctant to do so again. Apparently, supporting patients’
requests to die is not yet routine in the Netherlands. Should it be rou-
tine anywhere? Are we in the United States prepared to embark on such

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a course? What alternatives exist? The pressure now is on the medical

profession to give these questions a more careful hearing. The appearance
and overwhelming popularity of Final Exit will only increase the heat.
Nancy S. Jecker, University of Washington

References

Jecker, N. S. 1991. Giving Death a Hand: When the Dying and the Doctor Stand in a
Special Relationship. Journal ofthe American Geriatric Society 39: 831-35.
Kevorkian, J. 1991. Prescription Medicine: The Goodness of Planned Death. New
York: Prometheus.
Pear, R. 1991. Low Medicaid Fees Seen as Depriving the Poor of Care. New York
Times, 12 March, p. B6.
Quill, T. 1991. Death and Dignity: A Case of Individualized Decision Making. New
England Journal of Medicine 324: 691-94.
Van der Maas, P. J . , J. J. M. van Delden, L. Pijnenborg, and C. W. N. Looman. 1991.
Euthanasia and Other Medical Decisions Concerning the End of Life. Lancet 338:
669-74.

Books Received

AIDS

AIDS and AlcohollDrug Abuse: Psychological Research. Edited by Dennis G. Fisher.

Binghamton, NY: Haworth, 1991.97 pp. $19.95 cloth, $9.95 paper.
Blacks and AIDS: Causes and Origins. Samuel V. Duh. Newbury Park, CA: Sage,
1991. 153 pp. $19.95 paper.

Disability

Americans with Disabilities Act: From Policj to Practice. Edited by Jane West. New
York: Milbank Memorial Fund, 1991. 360 pp. $8.95 paper.
Disability in America: Toward a National Agendafor Prevention. Institute of Medicine.
Washington, DC: National Academy Press, 1991. 362 pp. $29.95 cloth.
Muscular Dystrophy and Other Neuromuscular Diseases: Psychosocial Issues. Edited
by Leon I. Charash, Robert E. Lovelace, Claire F. Leach, Austin H. Kutscher, Rabbi
Jacob Goldberg, and David Price Roye, Jr. Binghamton. NY: Haworth, 1991. 250 pp.
$34.95 cloth.

Published by Duke University Press

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