Suicide bag

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Diagram of a suicide bag; details sourced from the books Final Exit and The Peaceful Pill Handbook

A suicide bag, also known as an exit bag or hood,^[1][2] is an euthanasia device consisting of a large plastic bag with a drawcord used to commit suicide through inert gas asphyxiation. It is usually used in conjunction with an inert gas like helium or nitrogen, which prevents the panic, sense of suffocation and struggling during unconsciousness (the hypercapnic alarm response) usually caused by the deprivation of oxygen in the presence of carbon dioxide. This method also makes the direct cause of death difficult to trace if the bag and gas canister are removed before the death is reported.^[3][4][5]

Suicide bags were first used during the 1990s. The method was mainly developed in North America.

History

Self-administered and assisted suicides by asphyxiation using a plastic bag with helium were first recorded in the 1990s. Since the 2000s, guides have spread on the internet, in print and on video and the frequency of suicides by this method has increased.^[6][7]

The suicide bag with inert gas method was originally developed by John Hofsess and the NuTech group, which consisted of Hofsess, Derek Humphry, engineers and physicians.^[8]

In the book Final Exit by Derek Humphry, a suicide bag was described as a large plastic bag with an adjustable velcro strip around the neck.^[9][10] Its use with inert gases was mentioned in the Supplement to Final Exit in 2000.^[11]

The pro-euthanasia group Exit Australia distributed a manufactured version of the bag in Australia in 2002, alarming government officials and pro-life groups.^[12][13] The Australian chapter of Right to Life expressed concern that they would be used by vulnerable people.^[12][13]

In 2007, The Vancouver Sun cited Russel Ogden, Canadian criminologist and right-to-die advocate,^[14] who said that the combination of a suicide bag and helium was "a method of choice" within the right-to-die movement for people who are terminally ill and that its promotion does not appear to cause an increase in the number of suicides. However, he said that he has no way of knowing if the method was being used by people with terminal illness or by people who are mentally ill.^[15]

In 2008, Ludwig Minelli, founder of Dignitas, filmed four people committing suicide by helium inhalation.^[16] Subsequent to this, the method "has been winning supporters both in the USA and in Europe as a reliable, rapid and painless way to die".^[16]

In 2009, Philip Nitschke, founder of voluntary euthanasia organisation Exit International, wrote in a member newsletter that nitrogen has a lower risk of an adverse reaction by the body than helium and is also more available than helium in Australia and New Zealand.^[17] Nitschke's organisation sells suicide kits that contain nitrogen tanks and regulators for A$690.^[18] He promotes the use of nitrogen and suicide bags with lectures and films, such as Doing it with Betty – in which an elderly woman describes how to make a plastic 'exit' bag,^[19][20] and with published materials such as workshop handbooks.^[21] Nitschke calls the suicide bag death a "hypoxic death", and likens it to pneumonia, the "old person's friend", where hypoxia occurs because pneumonic inflammation stops the lungs extracting sufficient oxygen from the air, and "a peaceful death often results".^[22]

In 2015 author and right-to-die advocate Derek Humphry reported that Worthington Industries, the world's largest manufacturer of disposable helium cylinders, had announced that their helium cylinders will guarantee only 80% helium, with up to 20% air, making them inappropriate for use with a suicide bag.^[23][24]

Dutch psychiatrist Boudewijn Chabot, in his 2015 book Dignified Dying, calls the suicide bag with inert gas method "rapid, painless and safe".^[25]

Legal issues

It is not illegal to own a suicide bag in any jurisdiction.

Selling suicide bags is prohibited in some places. In 2011, the FBI raided a small mail-order business in California, which shut down afterwards.^[26][27] In July 2011, this raid caused Oregon to be the first US state to pass legislation prohibiting the sale of kits containing suicide bags or hoods.^[28]

Canadian right-to-die advocates stopped shipping suicide bags to Australia in 2001, when the Australian government announced that it would review their importation.^[13] In 2002, the Queensland Police in Australia said that suicide bags did not violate any laws at that time, and the Australian federal government said it would look into banning them.^[12] Exit Australia gave them away to members upon request; they put warning labels on them, called them "exit bags", and included no instructions for use to circumvent Australian laws against assisting suicide.^[12][13]

Medical and scientific research

Suicides using bags or masks and gases are well documented in the literature.^[29][30]

Suicide bags have been used with gases other than inert gases, with varying outcomes. Examples of other gases are propane-butane^[31] and natural gas.^[32]

Suicides using a suicide bag and an inert gas produce no characteristic post-mortem macroscopic or microscopic findings.^[4][16] Forensic death investigations of cause and manner of death may be very difficult when people commit suicide in this manner, especially if the apparatus (such as the bag, tank, or tube) is removed by someone after the death.^[3][16] Petechiae, which are often considered a marker of asphyxia, are present in only a small minority of cases (3%).^[33] Frost reported that of the two cases he studied that featured death from inert gas asphyxiation using a suicide bag, one had "bilateral eyelid petechiae and large amounts of gastric content in the airways and that these findings challenge the assumption that death by this method is painless and without air hunger, as asserted in Final Exit."^[34] A review study by Ely and Hirsch (2000) concludes that conjunctival and facial petechiae are the product of purely mechanical vascular phenomena, unrelated to asphyxia or hypoxia, and do not occur unless ligatures were also found around the neck. The authors wrote,^[35]

Unless the bag is fastened around the neck by a ligature with sufficient tension to obstruct venous return from the face, in our experience, such persons never have facial or conjunctival petechiae. Persons with tight fastenings around the neck are recognizable instantly by their facial plethora and numerous petechiae. We are aware that some observers may have seen an occasional petechia in rare instances of plastic bag suicide. However, we have not seen detailed descriptions of such observations that permit another person to evaluate the variables that might have produced an isolated petechia in a rare victim. Conversely, in New York City, an average of approximately 15 persons per year accomplish suicide by plastic bag, and we never have observed petechiae in a person who did not tightly fasten the bag around his/her neck

— Ely SF, Hirsch CS, "Asphyxial deaths and petechiae: a review". J. Forensic Sci, (2000)

There are also documented cases of suicide attempts using the suicide bag that failed.^[32] A case report study in 2015 discussed the risks associated with failed attempts using this method. The authors wrote, "If the process is interrupted by someone, there is no gas or the tube slips out of the bag, there is a high risk of severe hypoxia of the central nervous system."^[16]

Bioethics

Russel Ogden (2002) said that the existence of "how-to" literature involving the suicide bag has been "shown to influence the choice of suicide method but not the overall suicide rate, and that an emerging counterculture of death providers, operating outside of the traditional medicolegal framework of health care, was placing assisted death outside the normative gaze of medicine".^[5] In 2010, Ogden and colleagues observed four cases of assisted suicide with helium delivered by face mask. The authors stated that a hood method might be able to play a role in "demedicalising assisted suicide".^[36] Ogden views a bag and inert gas as "the quickest way to go; used properly, you're unconscious after the second breath and dead in about 10 minutes".^[37]

Clinical psychologist Phillip Kleespies said that Ogden's work calls attention to some of the risks associated with covert assisted suicide using unregulated methods like the suicide bag with inert gas. Disagreeing with Ogden and other right-to-die proponents, who call the method "swift, highly lethal and painless",^[15] Kleespies feels it is an undignified, impersonal and "hurried" manner of death.^[38]

A study poses the dilemma for medical ethicists and the general public who "may also want to carefully weigh the unintended adverse consequences of widely disseminated suicide methods likely to appeal to some depressed persons (irrespective of their physical health status or age) against the putative benefits associated with making these methods more widely known and available".^[39]

Characteristics of users

Promoters of this suicide method recommend it to terminally ill patients.^[34] However, across the world, most people who use suicide bags are physically healthy.^[34][39] Instead of having incurable cancer or other life-threatening physical diseases, most of the users have psychiatric disorders or substance abuse problems that might possibly be addressed through medical and psychological treatment.^[34][39] The demographics of its users varies; in one survey, the method had been used mostly by middle-aged adults in failing health, who were attracted to the relative nonviolence of the method.^[33]

This suicide method is also typically used by younger or middle-aged adults, rather than by older adults.^[34][39] In the US, it is more commonly chosen by non-Hispanic white males than by women or people of other races.^[34][39]

See also

• Advocacy of suicide
• Euthanasia machine
• Hemlock Society
• Charcoal-burning suicide

References

Further reading

• Ogden RD (2001). "Non-physician assisted suicide: the technological imperative of the deathing counterculture". Death Stud. 25 (5): 387–401. doi:10.1080/07481180126092. PMID 11806409.