Correspondence

Suicide by Asphyxiation after the Publication of Final Exit

N Engl J Med 1994; 330:1017April 7, 1994

Article

To the Editor:

The article by Marzuk et al. (Nov. 11 issue)1 on the increase in suicide by asphyxiation in New York City after the publication of Final Exit confirms what many of us who keep statistics already knew. My book has not increased the number of suicides in the United States, but it has changed the method by which some people end their lives. The plastic bag is a bloodless, nonviolent method, whereas guns, knives, and jumps from high places are not.

Marzuk et al. raise the alarm that the plastic-bag method does not give a person time to reconsider suicide. But it does. It takes 30 minutes for the sealed bag to deprive the person of oxygen. If he or she has also ingested drugs, they require at least 15 minutes to work. There is no similar moratorium once the trigger has been pulled, or the jump made.

The study also raises the alarm that the plastic-bag method is being used by an undue number of depressed people, as compared with those who are terminally ill. What no survey will ever uncover is that a terminally ill person who wishes to accelerate the end of his or her life usually does so in the company of family or friends. (It is a credo of the Hemlock movement that one does not act alone if it can be avoided.) Once breathing stops, family or friends pull off the bag. Therefore, the medical examiner is unaware of the method, and the death certificate records the underlying illness as the cause of death.

A depressed person who commits suicide acts alone, of course, with no one present to destroy the evidence. If the plastic-bag method has been used, it is recorded as the cause of death.

The plastic bag is getting the same sort of public-relations reputation as the wire coat hanger did in the abortion debate, except that the bag is 100 percent effective. When are we going to get down to rethinking the laws and guidelines on the right to choose to die with the assistance of willing physicians, so that Final Exit can be trashed and Dr. Jack Kevorkian can go into retirement?

Derek Humphry
Euthanasia Research Guidance Organization, Junction City, OR 97448-9559

1 References

1. 1

   Marzuk PM, Tardiff K, Hirsch CS, et al. Increase in suicide by asphyxiation in New York City after the publication of Final Exit. N Engl J Med 1993;329:1508-1510
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Mr. Humphry contends that the method of suicide he recommends is superior to other means because it allows people time to reconsider their actions. However, plastic bags, if small and tightly sealed, lead to suffocation in less than 30 minutes. Moreover, people who ingest the sedating drugs he recommends before applying the bag are unlikely to be in a lucid state of mind to reflect on the relative merits and disadvantages of suicide.

As Humphry suggests, the true suicide rate, an unknowable number, may be higher. Our study could not identify those people who might have had serious medical illnesses and killed themselves by asphyxiation, whose relatives then removed the plastic bag, and who were presumably certified as having died naturally. This should provide little comfort. As serious medical illnesses become more chronic, the concept of “terminal” illness is defined more broadly. Almost anyone with a chronic illness that is not imminently life-threatening will, at times, be gripped by pain, disability, or hopelessness. As compared with its lengthy advice on suicide, Final Exit offers little advice on how to seek relief from pain or physical discomfort or how to recognize the signs of depression.

Humphry takes pride in the fact that his recommended method of suicide is bloodless and nonviolent. But dead is dead. No amount of salesmanship about the aesthetics of this method will change either the biologic reality or the ethics of what he advocates.

Peter M. Marzuk, M.D.
Kenneth Tardiff, M.D., M.P.H.
Cornell University Medical College, New York, NY 10021

Charles S. Hirsch, M.D.
Office of Chief Medical Examiner, New York, NY 10016