More of Us Will Need Assistance to Die Well

(Faye Girsh is a retired clinical and forensic psychologist. She founded the Hemlock Society of San Diego 38 years ago when it was a chapter of Hemlock Society USA, started by Derek Humphry in 1980, which since 2005 is a fully autonomous 501(c)(3) organization. She received her doctorate in Human Development from Harvard University. She was associate professor and chair of the Psychology Department at Morehouse College, a research associate at the University of Chicago, and on the faculty at Roosevelt, Northwestern, and United States International universities. She served as president, board member, and newsletter editor for the World Federation of Right to Die Societies, was president of Hemlock USA, and co-founder of Final Exit Network.)

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Several recent events seem to point to the fact that many Americans would prefer greater access to aid in dying. For example, renowned psychologist Daniel Kahneman – an expert on decision-making – chose to go to Switzerland at age 90 to have a legal, peaceful, medically assisted death. He reasoned that the burdens of continuing his life would outweigh the benefits of ending it. It is a decision model he advocated and ultimately used. 

How much less anxiety would older people experience if they knew that after a certain age, like 85 — and/or with difficult, painful chronic conditions — they could choose to end their lives peacefully, with assistance if required? To prevent coercion, it would be appropriate to have an Advance Request, which could be completed before the person loses capacity — a measure adopted by the Canadian province of Québec (which is, by the way, 61 percent Catholic). This could prevent prolonged, expensive stays in nursing homes where “life” often exists without cognition, but with pain and over-medication. 

It is cruel to require that kind of ending of a life that was productive, loving, and interactive if the owner of that life prefers it to be finished before independence is irretrievably lost.

In a July 2025 article in Medscape, doctors say they would decline aggressive treatment including CPR, ventilation, or tube feeding and would choose assisted dying for advanced cancer or Alzheimer’s disease. This from doctors who see patients suffer with incurable, often crippling illnesses that bring an intolerable loss of personhood and well-being or require loved ones to often sacrifice employment and relationships in order to assume the responsibility of their care.

Even in the states that do permit assisted dying, dementia does not meet the criteria for help since, though it is a terminal illness, it will not cause death in six months – and the patient, in their final stages, loses capacity to make the decision. 

Presumably, a physician facing the reality of wanting to die would be able to find a way that regular people would not have access to. With dementing diseases on the increase and causing anxiety in older individuals and couples, it would be a service to include dementia as an eligible condition. Physicians who care for these patients, and may even cooperate with the family’s plea to extend their lives, see the futility of doing so and would not want it to happen to them.

An article in the NY Times discussed the Canadian Medical Assistance in Dying law and how it continues to expand. Now, one out of 20 of our northern neighbors uses the law and dies by choice. This includes the much-preferred choice of an IV injection over self-administration, the latter being the only U.S. option. Our laws require that the patient must “ingest” the lethal medication themselves — either by mouth, rectally, or through a PEG feed directly into the stomach.

Another article presents data showing how underutilized our law is, comparing California, where the End of Life Option Act (EOLA) has been law since 2016, with Canada, with the same population of 40 million, and their law is also nine years old. Since 2019, approximately 2,900 Californians have died using the state’s EOLA. During the same period, over 51,000 Canadians have died using the Medical Assistance in Dying (MAiD) law. Canada’s MAiD program has a much higher rate of utilization relative to its population compared to California’s EOLA. 

Four factors could explain the difference: 

1) The U.S. law requires that a person be judged by two doctors as having no more than six months to live and to retain capacity at the time of death. Canada does not require imminent death, and capacity can be lost at the time of the lethal injection by signing a waiver. 

2) Requests are only honored by Canadian residents who are members of the Health Service, which covers the cost of the physician’s visits and the medication. In the U.S., with the exception of the Kaiser Hospital system, doctors may charge between $3,000 and $5,000 for their services, and often more for the medication, which is made by special compounding pharmacies. 

3) The law is universal in every Canadian province; in the U.S. it is permissible in only 13 states and the District of Columbia. In 11 of those states, including California, residency is a requirement although it is not in Vermont and Oregon, which do open it up to those financially and physically able to travel. 

4) The U.S. eligibility requirement of six months to live eliminates most categories of chronic illness such as ALS, dementia, cancer, and heart disease, until the terminal phase. If a person wants to call it quits before frailty, pain, and suffering take over, they cannot be helped by the law.

But there are ways some of those people have found to end their lives, though they are not easily available or known to most people. Following are some of the existing paths desperate people and families have discovered. 

For example, Voluntarily Stopping Eating and Drinking (VSED) is legal and has no eligibility requirements. Death usually comes 9-14 days after the last fluid intake and is often described as peaceful. This is especially helpful for people who have lost their appetite and are very frail. People lapse into a coma after three or four days and will need nursing care for hygienic purposes and to administer medications for anxiety, pain, or sleep. 

Some hospices will help as will “death doulas,” who sit with patients. Doulas are unlicensed; it is not clear if they, or family members or other caregivers, can legally administer the prescribed medications. They serve as surrogate family members to be with the dying person while agreeing not to provide food or water, even when asked. 

It is important for a person choosing VSED to write out their wishes. This should cover any caregivers who, at the patient’s request, will not feed or hydrate them. Loved ones or others who do this without such a document could be in legal difficulty.

Also, going to Switzerland for help in dying has been a solution for many years. There are at least three organizations known to Americans like Professor Kahneman: Dignitas, Pegasos, and Athanasios. All follow Swiss law and have informative websites. They require detailed documentation before a request is granted. There is a charge of around $11,000 plus the expense of such a trip; they will send back cremated remains. (Editor’s note: Phönix Care (Phoenix Care) is a fourth alternative.)

An option closer to home, Final Exit Network (FEN) provides a model of guided self-deliverance. Following an interview with a coordinator and perusal of medical records, FEN will determine if their criteria are met — which go beyond terminal illness. Once accepted, they will assign an exit guide and instructions for the use of an inert gas, which has to be purchased by the person and used themselves without help. A guide — and others — can be present, but cannot help. There is no charge for this service. 

Another resource is books that help with self-deliverance (“suicide” is often the wrong term in these situations): Final Exit by Derek Humphry, the 3rd edition, or Final Exit 2020 (online only), and the Peaceful Pill Handbook by Philip Nitschke, inventor of the Sarco. That device is designed for people not eligible under existing laws, or don’t want to use the above methods but do not want a violent, uncertain, lonely death. (It is not illegal to be with someone who is taking their own life.)

As a clinical psychologist, I worked with suicidal people and am grateful they changed their minds. But I had two “normal” friends who died violently — one by shooting himself, and one by jumping from a high bridge. The way they died traumatized friends and families as much as the suicides themselves. That Robin Williams died by strangling himself when faced with the horrors of Lewy body dementia surely speaks to the need for a better way.

I am now old myself and worry about how I could die if I chose to. Why couldn’t there be a service for these people – i.e., truly suicidal and depressed people, demented people, old people, people who feel they’ve had a completed life — where they can get MAiD-type help or have guidance on using a peaceful, lethal method?

The constraints of current US laws push a lot of people into violent, unsuccessful, and tragic attempts, or endless nursing home care. It is difficult now in this country for even the most restrictive aid-in-dying law to be adopted. Expanding the law to include people who are not even sick — but are ready to be finished with the burdens of living — will be a difficult task.

But help must be available, as it is in Belgium for instance, so people can choose a peaceful, dignified send-off. Good life, good death seems like a small favor to ask.

 

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Final Exit Network (FEN) is a network of dedicated professionals and caring, trained volunteers who support mentally competent adults as they navigate their end-of-life journey. Established in 2004, FEN seeks to educate qualified individuals in practical, peaceful ways to end their lives, offer a compassionate bedside presence and defend a person’s right to choose. For more information, go to www.finalexitnetwork.org.

Payments and donations are tax deductible to the full extent allowed by law. Final Exit Network is a 501(c)3 nonprofit organization.

 

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