'Exit Guides' Straddle the Line Between Freedom of Speech and Murder
An interview with Dr. Faye Girsh about her work helping people die well.
"There are lots of ways to die," Dr. Faye Girsh began. We had just sat down in the cafeteria of her retirement home. "I had a young woman friend who jumped off the Coronado Bridge. Somebody here had early Alzheimer's, and went to the shopping center and shot himself in his car. Robin Williams used his belt, for heaven's sake. And, somebody else here recently died by refusing food and hydration in his room." The psychologist paused a moment to glance at the menu. "Do you know what you want to eat?"
The animated 81-year-old's charming informality around death is the product of over three decades as an advocate for the right-to-die movement. Girsh is currently president of the World Federation of Right to Die Societies, an alliance of 37 organizations from 23 countries. "We believe that quality of life is more important than quantity," she said. "We believe that people should die in ways that are consistent with their own values and beliefs. If they don't want to suffer, they should have a peaceful way out. They should not have to die violently."
As expressed in its manifesto, the WFRtDS views euthanasia as an intrinsic human right: "We strongly believe that the manner and time of dying should be left to the decision of the individual." It is a right that countries like Switzerland, Holland, and Belgium have ratified. More recently, in the United States, Oregon, Washington, Montana, and Vermont have followed suit with their own physician-assisted dying laws. WFRtDS's objective is to expand the legality and availability of assisted-dying for "all competent adults... suffering unbearably from incurable illnesses" throughout the world.
I spoke with Dr. Girsh about her mission, as well as her experience as an "exit guide" with the Final Exit Network—a nonprofit that supports individuals wishing to end their lives. It is support that, across much of the country, occupies a legal gray area between freedom of speech and murder.
VICE: You mentioned starvation as a method. Do you advocate that?
Dr. Girsh: There are advantages to it—like it's legal. You don't have to do anything. You just lie there.
They won't force-feed you?
Not anymore. That was actually the case that brought me into the [right-to-die] movement. In 1983, a young woman wanted to die that way. She was a quadriplegic. When she stopped eating, they force-fed her, and she got the ACLU to take her case. I examined her as a forensic psychologist. She eventually won her case in the appellate court, and now everybody has the right to refuse food and hydration.
That can't be pleasant.
The data show that about 25 percent of people don't have a good death that way. The other 75 percent sort of lapse in and out of a coma. If they have good caregiving, and enough medication to handle pain or anxiety, it can go okay. But if you're at a hospital or nursing home that doesn't approve of it, they can make your life pretty miserable.
Is starvation the only legal way?
Well, it's perfectly legal to shoot yourself. Suicide has always been legal here.
They won't prosecute you for it if you fail?
That would be a civil case. If you're a danger to yourself or others, they can have you involuntarily committed. I have a situation like that now. There's a local psychiatrist who deliberately overdosed on methadone, but he survived, and they want to put him away for observation.
Do you primarily advocate death by helium?
We don't advocate it. It's the only thing left to us. We would certainly like to figure out some other way to do it. It's just so awkward. The person needs to get all this equipment and put a bag over his head. It's not wonderful, but it is very effective. Our criteria is, that [suicide] should be quick, certain, painless, and relatively dignified. Helium is all that. When people watch their friends or their loved ones die that way, it's not so terrible.
There are no chemoreceptors for helium so you wouldn't get a feeling of suffocation, right?
The way that I explain it is: it just supplants the oxygen in the blood. Carbon dioxide can give you the feeling of suffocation. Carbon monoxide is good. [Dr. Jack] Kevorkian used carbon monoxide. We just don't have a good way to produce it.
How do you administer the helium?
There are different ways. A 91-year-old woman here in San Diego named Charlotte used to make these "exit bags" that you would put over your head. They were really good bags, thick plastic, and you could see through them. They had really nice Velcro around the neck, and the tubing was all in place with these little clips. She was selling those until this 29-year-old guy in Oregon used one to kill himself. His mother put the FBI on the trail of Charlotte, who was not very hard to locate. Ten FBI agents came in with guns pointed. They busted her whole operation—not that there was anything illegal about it. They charged her with tax avoidance, because she hadn't paid last year's taxes. That was it. They also took her computer so they knew who she distributed to.
What happened to her customers?
Well, [the authorities] did wellness checks all over the world. "Knock, knock. I understand you bought one of these bags. Are you OK? Are you suicidal?" People just laughed and said, "Are you kidding? I bought this bag just in case things get bad."
Just to feel empowered?
Right. Just to take control.
How are people getting exit bags now that Charlotte is out of business?
Well, there's plenty of information around. Derek Humphry has a new DVD about using the helium method. It's not hard to get a turkey bag and hem it up with scotch tape. You can use a headband or something elastic to keep it around the neck. And then you have to get the right diameter tubing, but that's really all there is to it. People are happy to know there's a way.
And I'm sure they're happy to know they're not alone.
I think that's a big deal. Nobody should die alone. We're there to provide our expertise, and also in many cases to provide companionship and a compassionate presence. Many people don't want to tell their loved ones or friends about their plans. Although, often there are many people there when it happens.
What is that final day like?
Surprisingly casual. One of the first cases I worked, the woman wanted us to recite a poem while she was dying. She made scrupulous arrangements. Her husband was to be out walking the dog while she died, because he should have an alibi. I was present at another euthanasia [performed by] one of Kevorkian's colleagues, a Belgian psychiatrist. [The patient] was a relatively young man with multiple myeloma. His wife got into bed with him. They hugged and kissed, and said goodbye, and she held him while he got the shot in his arm. He died very peacefully in her arms.
How does that compare with the helium method?
Helium is not always a pretty sight, because there's some gasping, and these little animal noises people make when they're dying. We helped this one woman recently and she lapsed into unconsciousness after just ten or 15 seconds. A couple deep breaths, and you're not conscious anymore. You die after about 20 minutes. That woman was probably in her early 60s. She was in hospice, but they couldn't help her pain because she was allergic to opiates. She was very religious. When I visited her, she had crucifixes all over the house. I asked her about that. She said, "It's fine with my God." She died with a well-worn Bible in her lap.
What do you do after someone dies?
We usually take the equipment away. The person has a choice if they want us to take the equipment away and make it look like a natural death or not. The good thing about helium is that it's practically undetectable. The coroner rarely tests for it. My friend just worked with a man here in San Diego, who did want it to look like a suicide. He wrote a note: I have this disease, and nobody helped me end my life, and I'm of sound mind. He had his do-not-resuscitate orders with him, and the police recorded it as a Final Exit suicide.
The police here usually go along with it?
Yes, as long as there isn't some reason why the person couldn't have done it himself.
What do you do if you're contacted by someone who's physically incapable of killing themselves?
We can't help them. But the window of opportunity comes and goes if it's Alzheimer's or ALS. Thomas Hyde, who was Kevorkian's last patient, was long past the point where we could help. He couldn't swallow, and even if he could have, he couldn't even lift a spoon up to his mouth. An injection was absolutely the right course for him.
It seems that one of the ironies of the law is that it induces people to exit earlier than they might want to, just because they have to be healthy enough to kill themselves.
That's especially true with Alzheimer's. I've been lecturing on what you can do when you're past the point of being able to kill yourself. You can do things like make sure that your infections are not treated, or even something like a broken hip is not treated. Just make sure you have good comfort care.
Alzheimer's is an interesting case, too, because a lot of times, the dementia destroys so much of the person that they become happy.
It happens. In Holland, they allow an advance directive: "If get to this point—if I can't recognize my loved ones, or if I need 24-hour care, and so forth—then I want to be euthanized."
I believe they use phenobarbital injections in Holland, right? Are you aware of people buying that on that black market?
It's hard to get that, but you could look online presumably.
Or take a trip to Mexico?
Presumably. [Phenobarbital] is the way animals are allowed to die. It used to be fairly easy to get it from a veterinary supply store. Philip Nitschke in Australia published a map of where the veterinary supply stores were, and what to say when you got there. I can't remember if Philip was arrested, or if he just had his medical license revoked. Even in Europe [where euthanasia is legal], they have to resort to these Chinese Internet connections.
Why do you think society allows suffering animals to be euthanized, but not suffering people?
As one of our esteemed senators said, "Dogs don't have souls." So, there's the answer to your question.
It's a religious objection?
Yes. And, that reflects the amazing statistics I've read. They asked Americans if they supported doctors helping people with a terminal illness to end their lives, and 70 percent of them agreed. But when the word "suicide" was used, support went down to 50-50. We [at WFRtDS] don't refer to it as "suicide" anymore. Most of us call it "assisted-dying" or "self-deliverance."
It sounds like semantics. Is there any difference?
Well, as a psychologist, I could say that "suicide" is usually an impulsive act that's done alone. It's usually a permanent solution to a temporary problem that could be remediated. "Assisted dying" is for people who are suffering unbearably from a terminal or chronic disease. But there's a lot of middle ground in there.
Do you advocate only for people in pain, or do you believe that everyone should have the right to take their own life?
At the Final Exit Network, we get a lot of calls from elderly people who don't have a chronic or terminal illness—they're just tired of life. They have a lot of aches and pains. We just had a 97-year-old man who fit that category. He wanted to be finished with life, and his children agreed. He wound up shooting himself in the garage, because the kids were afraid they might get in trouble, and that we might get in trouble. That's the way he chose to end it. There are many old people warehoused in nursing homes who have completed their lives and are ready to go, but there's no simple, dignified, and nonviolent way for them to go.
Is self-deliverance something you've ever personally considered?
Well, I'm 81 and I feel great! But, if we're talking 30 years from now, you never know. I don't have a good plan, and that's a concern. I have one of Charlotte's original bags and I have some very old barbiturates, but they might be too old by now. My fear is that I won't be able to get my Final Exit Network people in here. You have to sign in at the front desk.
I've been collecting dreams from around the world recently for a project. Your work must be so emotionally intense. I wonder, do you ever dream about it?
Well, I remember a dream from when I first got into this movement. It was more of a nightmare. There was this VA newspaper with a man's picture on the front of it. The headline was "Patient of the Year." It read, "Joe Jones is patient of the year, because he decided to end his life. We awarded his family $5,000." I thought, "Is that what it can come to?" You know, I'm just as big an ACLU supporter as I am a Death with Dignity member. If we were ever incentivized to end our lives, that would be just awful.
That's one of the arguments that critics bring up. What else do your critics say?
They say, it's a slippery slope that will lead to all disabled people going into gas chambers. Oh, and I just about died recently when [a right-to-die opponent] said that doctors should never kill their patients, but then went on to say, that if a patient is really suffering terribly, it's OK for a doctor to use terminal sedation. Terminal sedation is, of course, legal under the principle of double effect. A doctor can administer something that will end the patient's life, but the intent is not to end the life, but to end suffering. Well, that's fine, but it's not up to the patient. The doctor decides. Well, I think that the patient should decide, and that's almost where the line is drawn.
So, in order to qualify as double effect, we're basically talking about an opiate or barbiturate overdose, right?
It's often some combination of painkillers and sedatives which could be barbiturates. Do you have a background in medicine?
Well, I've worked as an EMT.
You must have seen a lot of suicides then.
One thing that stands out is how violent most suicides are. A lot of people jump off buildings in New York. A lot of people use guns.
When I hear that someone shot themselves, the first thing I ask is, "Did it work?" I don't know the percentages, but I wouldn't be surprised if the failure rate was high.
It depends on where they shoot themselves. I don't know why people shoot themselves in the temple. If they aim wrong, they just blow off their face. The brainstem is still intact, and the airway's still viable.
I want to know how you can shoot your heart, because I think women would prefer not to be disfigured. But it's not for us to distribute that information, because we don't believe in violent, lonely means. You wouldn't gather your family around to shoot yourself in the head. On the other hand, it's better than jumping in front of a train, or jumping off a hotel balcony.
Well, guns are so accessible in America. People are going to use whatever they can get their hands on.
We would love to find a better, more gentle method. At our upcoming conference, someone is presenting [a device] that we started out calling "the killer potato." It's a contraption with two potatoes that you place on your carotid arteries. Then you have this thing that tightens them automatically. I've had people suggest that [the device] could be marketed for autoerotic asphyxiation. There is some question about whether it would really work. The problem is, how do you try these things out?
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