Professional Documents
Culture Documents
The Peaceful Pill EHandbook (August 2012)
The Peaceful Pill EHandbook (August 2012)
Preface
C h a p te r 1 - E n d o f L ite C o nsideratio ns
C h a p te r 2 - S uicid e an d the L aw
C h a p te r 3 - T h e P eaceful Pill
C h a p te r 4 - T h e E xit R P Test
C h a p te r 5 - H y p o x ic Death & th e Exit Bag
C h a p te r 6 - C arb o n M o n o x id e
C h a p te r 7 - C y an id e
C h a p te r 8 - D etergent Death
C h a p te r 9 -
Introduction to Drugs
C h a p te r 10 - D ru g O p tio n s - M o rp h in e
C h a p te r 11 - D ru g O ptio ns - P ro p ox yp hen e
C h a p te r 12 - O th e r D ru g s & C o m m o n M yth s
C h a p te r 13 - D ru g O p tio n s - N em butal
C h a p te r 14 - O b tain in g N em b u tal
C h a p te r 15 - U s in g N em b u tal for a P eaceful Death
C h a p te r 16 - S y n th esis o f a Peaceful Pill
C h a p te r 17 - T h e S w iss O ption
C h a p te r 18 - A fter i t s O v er
Exit R P Table
R eferences
S u p p o rt E xit International
A bo ut Exit International
Founded in 1996 by D r Philip Nitschke, Exit International (non-profit)
is a global leader in the provision o f end o f life information to Seniors,
people suffering serious illness and their families.
At the heart o f Exit International's activities is the Safe Exit informa
tion Workshop and Meeting Program. Safe Exit Workshops are held
regularly in Nth America, the UK, Ireland, New Zealand and Australia.
Exit International has offices in Bellingham (WA) and Darwin, Aus
tralia. Exit operates chapters in towns and cities around the world.
For more information about Exit International, please visit:
http://www.exitinternational.net
http://www.peacefulpill.com
or email: contact@ exitinternational.net
Phone: + 1 248-809-4435 (USA)
+44 (0)20 7193 1557 (UK)
1300 10 3948 (EXI T) (within Australia)
+61 407-189-339 (outside Australia)
C o n ten t R evised :
1 A u g u st 2 0 12
For
D e re k H u m p h r
fo r h is c o u r a g e a n d c o m p a ssio n in sh o w in g th e w a y
In m e m o ry o f
Caren J e n n in g
The
Peaceful Pill
eHandbook
Dr Philip Nitschke
with
Dr Fiona Stewart
E X IT IN T E R N A T IO N A L US
contact@exitinternational.net
P h ( + 1 ) 248-809-4435
T H E P E A C E F U L P IL L H A N D B O O K . N o v e m b e r 2011
C o p y r ig h t D r P h ilip N its c h k e a n d D r F io n a S te w a rt 2011
T h e m o ral rig h t o f th e a u th o rs h a s b e e n asserted .
A ll rig h ts re se rv e d . W ith o u t lim itin g th e rig h ts u n d e r c o p y rig h t re se rv e d
a b o v e , n o p a rt o f th is p u b lic a tio n m a y b e re p r o d u c e d , s to r e d in o r in tro
d u c e d t o a r e t r i e v a l s y s t e m , o r t r a n s m i t t e d , in a n y f o r m o r b y a n y m e a n s
(ele ctro n ic , m e c h a n ic a l, p h o to c o p y in g , re c o rd in g o r o th e rw ise ), w ith o u t
th e p r io r w ritte n p e r m i s s io n o f th e c o p y r ig h t o w n e r a n d p u b l i s h e r o f th is
book.
IS B N 978 -0 -9 7 8 8 7 8 8 -4 -9
w w w .p e a c e fu lp ill.co m
w w w . e x i t i n t e r n a t io n a l .n e t
W h a t th e C ritics sa id a b ou t
Killing M e Softly:
Voluntary Euthanasia & the Road to the Peaceful Pill
D r P h ilip N itsch k e & D r F io n a S tew art
P en g u in - 2005
The Mercury
Nitschke has never been shy about speaking out against the
establishment and w as already no friend o f the medical one.
The B ig Issue
D isclaim er
Preface
T h e P e a c e fu l P ill e H a n d b o o k h a s b e e n c r e a te d a t a tim e
w h en there are v e ry f e w p la c es w h e r e S en iors an d those w h o
are serio u s ly ill can g et in fo rm a tio n a b o u t th eir en d -o f-life
choices.
In 1996, A ustralia p assed the w o r l d s first right to d ie law; the
R ig h ts o f th e Term inally Ill A c t (R O T I). U n der R O T I, four o f my
serio u sly ill p atien ts self-ad m in istered a legal, lethal o verdo se
o f d ru g s; a P eaceful Pill i f y o u like. All d ied peacefully in their
sleep, s u rro u n d e d b y p eo p le they loved.
I k n o w this, b ecau se b ack then I w a s their tre atin g physician. I
w a s the o n e w h o p u t th e n eed le into th eir veins. A n d I w a s the
o n e w h o built th e D eliv eran ce M a c h in e that th ey u sed to die.
T h e D eliv eran ce M a c h in e w a s a laptop c o m p u te r an d p ro g ram
that g ave these individuals the ultim ate control ov er their deaths.
T h e ir d eath s tau g h t m e m u c h , b u t m o stly h o w im portant it is
f o r people to be a llo w e d to h a v e control at th e end.
O n each s e p a ra te o c c a s io n , th e c o m p u te r p re s e n te d a short
series o f questions:
1. A re y o u a w a re that i f y o u g o a h e a d to the last screen and
p ress th e y e s b u tto n y o u w ill be g iv e n a lethal d ose o f
m e d ic a tio n s a n d die?
2. A re y o u certain y o u understand that i f y o u proceed an d press
th e y e s button on the n ex t screen y o u w ill die?
3. In 15 se c o n d s y o u w ill be given a lethal injection . .. press
y e s to proceed.
P reface
The Deliverance machine built by the author. Used by four people in the
Northern Territory between 1996 - 1997.
Now on display at the British Science Museum
Preface
Acknowledgements
The P e a c e fu l P ill e H a n d b o o k c o u ld n o t h a v e b een w ritte n
w itho ut th e sup po rt o f m a n y people. First to thank are the m any
E xit m e m b e rs w h o h ave c o n trib u ted th eir expertise, ideas and
travel stories. T h is is truly a j o i n t effort.
Secondly, o u r s ta f f a t E xit International w e thank very sincerely
for all they d o d ay in, d ay out. O u tsid e o f Exit, special thanks
to S teve H op es o f iK andy F ilm s in Sydney, B ran d en B arber
in San F ra n c isco an d th e tech n ical s ta f f a t Y udu in th e UK.
Finally, w e ' d like to thank o u r publisher, R ich ard West, for his
c o n tin u ed su p p o rt an d w ith ou t w h o m n o n e o f this w o u ld have
b een possible.
D r Philip N its c h k e & D r F iona Stew art
B ellingham , W ashington
A W ord o f C a u tio n
T his b o o k is intended for Seniors and people w h o are seriously ill
( a n d th eir fam ilies). T h is bo o k is n o t in tend ed for y o u n g people
o r a n y o n e su fferin g from p sy ch ia tric illness o r depression. As
a u th o rs w e a c k n o w le d g e that there is a small risk th a t th is book
m a y b e m isu s e d b y p eo p le f o r w h o m this inform ation is clearly
n o t appropriate.
T h e risk that info rm ation o f this n atu re m a y be m isu s e d w a s
a fact a c k n o w le d g e d by th e g o d f a t h e r o f th e rig h t-to -d ie
m o v e m e n t, fo rm e r British jo u rn a list, D erek H u m p hry . W h e n
Derek first p u b lish ed F in a l E x it in 1991 he w a s c riticised for
e n d a n g e rin g suicidal teen s the w o r ld over. H ow ever, a s he
w o u ld later p o in t out, th e suicide statistics h ave failed to sh o w
th e m u ch talk ed a b o u t b lip . T h e re has b een n o rise in the
su icide rate. P ro v id in g p eo p le w ith inform atio n d o e s n o t incite
o r e n co u rag e p eo p le to die. A n d this is a critical point.
R ath er, re lia b le , a c c u ra te in fo rm a tio n e m p o w e r s p e o p le to
m ak e m a k e in fo rm e d d e c is io n s a b o u t th eir o w n e n d -o f-life
c irc u m s ta n c e s . G o o d in fo rm a tio n s h o u ld n o t o n ly preven t
grim , horrible d eath s o f g u n sh ot an d hanging (the m o st com m on
causes o f suicide in the U S , U K an d A ustralia respectively) b u t it
sh o u ld allay fears. It is paradox, perhaps. B y e q u ip p in g Seniors
an d those w h o are serio u sly ill w ith k n o w led g e that em p o w ers
an d retu rns con trol, th e se s a m e people arc m o re likely to stop
w o rry in g a n d g et on w ith living. A n ecd o tal e v id en ce to this
effect can be seen a t each an d e v e ry E xit m eeting. F ears are
a d d re ss e d a n d participants feel b ack in control.
Preface
H o w to G et th e M o st from y o u r eB ook
T h e P e a cefu l P ill e H a n d b o o k b reak s n e w g ro u n d in th e socalled ' v o o k ' p u b lish in g p h en o m en o n . P art-book, part-video,
th e Y udu te c h n o lo g y platform o f the P e a cefu l P ill eH a n d b o o k
allo w s users to T urn th e P a g e in m u ch th e s a m e w a y they
have a lw a y s done. T h e re is also a N o te p a d . B y clicking on
this icon in th e to p m en u bar, a u s e r can m ak e notes a s th e y go.
T h e n o tes are sto red a s y e llo w p age ico n s at vario us p laces in
th e text. A n o th e r featu re is th e B o o k m a r k so p a g e s can be
m ark ed for fu tu re reference.
T h e traditional In d ex o f a H a n d b o o k h as been ab an d o n ed , and
rep laced b y th e search function. F o r th is reason, an d because
th e con ten t a n d size o f the e H a n d b o o k c h a n g e s as n e w m aterial
b e c o m e s available, p ag e n u m b e rs are being gradually rem oved.
W h e n quoted, p a g e n u m b ers refer to th e p a g e co u n te r a t the
c e n te r to p o f th e digital display.
Best o f all, how ever, an e B o o k by its n a tu re allo w s a u s e r to
m o v e s id ew ay s a s w ell as forw ards o n th e p age. M an y o f the
k e y co n cep ts in this bo o k are hyp e r lin k e d to external w e b
pages. O th ers co ntain v id e o s that y o u can w a tc h as y o u read
o r return to at y o u r leisure. Finally, i f y o u are h ard o f sight,
y o u can click on the e H a n d b o o k 's built-in m ag n ify in g g lass that
allo w s th e u s e r to zo o m an d rep osition text on th e screen with
am a z in g customizability.
Preface
N o te : P u rc h a se rs o f th e P rin t ed itio n
1
End o f Life Considerations
D e v elo p in g an E nd o f L ife Plan
People m ak e en d o f life plans for all sorts o f reasons. S om e
p eo p le a re c o n cern ed that o n e d ay th ey w ill b e c o m e so sick and
frail an d th eir qu ality o f life w ill b e c o m e so im p aired that death
will b e c o m e the p referred option. O th ers w o rry th a t because
c u rre n t g e n eratio n s are living lo n g e r th an th eir p a re n ts an d
g ra n d p a re n ts g en eratio ns, th ey w ill have to face that n e w set o f
w o rries that c o m e from lo n g ev ity itself. S o m e eld e rly people
are sim p ly ' tired o f l i f e '.
T h e re a so n s that lead an eld e rly p erso n o r so m e o n e w h o is
serio u sly ill to seek inform ation about th eir end-of-life choices
are m a n y an d varied. All are in ten sely perso nal. R ew ritin g the
w a y s in w hich s o c ie ty can plan for an d ex p e rien c e death and
d y in g is th e ch allen g e o f o u r time.
T h e d e v e lo p m e n t o f an e n d o f life plan is o n e sm all step that
all o f us can take to pro tect those w e love fro m the rav ag es o f
th e law. W h ile m o s t o f u s w ill n e v e r u se o u r p lan, w e can all
d ra w c o m fo rt in k n o w in g that i f th ing s e v e r b e c o m e to o painful
o r und ig nified (esp ecially in the con text o f seriou s illness and
age), w e will h ave a plan in p lace that w ill a llo w us to m aintain
o u r dign ity an d o u r independence.
E nd o f L ife C onsiderations
O u r A g ein g P o p u la tio n
A century ag o w h en life expectancy w a s ap pro xim ately 25 years
less than it is today, f e w p eo p le h ad the o p p o rtu n ity to reflect
on h o w th ey m ig h t die. T h e n p eo p le w ere m u ch m o re likely
to d ie q uick ly w ith little w arn in g . F o r ex am p le, o n e hundred
y ears ag o infectious disease w a s co m m o n . P eople co n sid ered
th e m se lv e s lucky i f th ey w ere still aliv e in th eir m id 50s. The
w id e s p re a d in tro d u c tio n o f p u b lic h ealth m e a s u re s such as
sew erage, w a te r reticu latio n, g o o d housing, a n d o f co u rse the
introduction o f m o d e rn an tib io tics h av e all p la y e d a p a rt in
g re a tly redu cin g th e toll o f infectiou s disease.
E nd o f L ife C onsiderations
T he Q u e stio n o f S u icid e
A n y o n e w h o m a k e s p lan s for th eir o w n d e a th can be said to be
p lan n in g th eir o w n suicid e. W h ile for so m e people su icide is a
ta in te d concept, for a g ro w in g n u m b e r o f o ld er p eo p le it is an
issu e o f g reat interest an d discu ssion . In this con tex t, suicide
is a w a y o u t o f a life th a t an individual m ight c o n s id e r is not
w orth living.
P eo p le w h o c o m e to E xit w o r k s h o p s are w e ll a w a re o f the
im p o rtan ce o f m ak in g that ultim ate o f d ecisio n s, th e decision
to die. T h e y are all a c u te ly a w a re o f the n e e d to get it right.
In this C hapter, w e e x a m in e th e p h en o m en o n o f suicid e in the
context o f the m o d e m life co u rse, an d w h y a c c e s s to the best
in en d o f life inform ation is s o im portant.
A B r ie f H isto ry o f S u icid e
O v er the years, th e w a y in w h ic h so ciety v ie w s the tak in g o f
o n e 's o w n life h as v aried enorm ously. S u icide has n o t alw ays
b een seen a s th e act o f a sick an d d e p re ss e d person. In ancient
Greece, A thenian m agistrates kept a supply o f poison for anyone
w h o w a n te d to die. You ju s t needed official perm ission. F o r the
S toics o f ancien t tim es, su icide w a s c o n sid e re d an ap pro priate
resp o n se, i f th e p ro b le m s o f p ain , g ra v e illn ess o r p hysical
ab no rm alities b e c a m e to o great.
W ith th e rise o f C h ristia n ity , h o w e v e r, s u ic id e c a m e to be
v ie w e d as a sin (a violation o f th e sixth c o m m a n d m e n t). As
L isa L ieb erm an w rites in h er b o o k L e a v in g You, all o f a sudden
' the R o m an ideal o f h ero ic in d iv id u a lism ' w a s re p la c e d ' w ith a
p latonic co n cep t o f su b m issio n to d iv in e au th o rity '.
E nd o f L ife C onsiderations
S ev ere d ep ressiv e
T h e re is a s ig n ific a n t d iff e r e n c e b e tw e e n a p e rs o n h a v in g
m o m en ts o f feeling d o w n o r h av in g a transitory feelin g that
th eir life h as lost p u rp o se an d the person w h o h as severe clinical
d epression , w h e re ev en the m o st basic d aily d e c is io n s o f life
b e c o m e problem atic.
T h is is quite different from an eld erly o r serio u sly ill p e rso n 's
d esire to form ulate an en d o f life plan; a p lan w h o s e sole aim
is to m ain tain control o v e r their final days. P eople w h o like to
b e p rep ared an d w h o are n o t d ep ressed sh o u ld n o t b e v iew ed
in p sychiatric term s.
E nd o f L ife C onsiderations
E n d o f L ife Considerations
S o m e o f th e se p e o p le a r e so w e a k that they c a n n o t m o v e
u n a s sis te d . O th e rs h a v e s h o rtn e s s o f b reath w h ic h m a k e s
in dep en dent livin g im possible. F o r a significant n u m b e r o f
p eo p le, it is n o n-m ed ical issues that h ave m o s t im p act upon
the q u a lity o f th eir life.
O n e recent m em o rab le case con cern ed a m iddle ag ed m a n called
B ob. B o b w a s suffering fro m lu ng cancer. H e w a s in cred ibly
sad that his favourite p a s t tim e - a ro u n d o f g o ld with his m ates
- w a s no lo n g er possible. T h is p erso n w a s clear. It w a s his
frustration a t b e in g h o u s e -b o u n d an d d e p en d en t on visits from
frien ds an d family, rather th an the p hysical sy m p to m s o f the
cancer, th a t m ad e h im c h o o se an elective death.
P alliative care is no u n iv ersal p an acea. W h ile this branch o f
m edicine d oes h ave a v alu ab le contribution to m ak e, especially
in th e field o f pain co ntro l, it is u n h elp fu l to u se sy m p to m
m a n a g e m e n t as the b en ch m ark again st w h ich a p e rs o n s quality
o f life is m easured.
Rather, p eo p le rate their q uality o f life in different w a y s with
no tw o in d iv id u als a sse ssm e n t th e sam e. W h ile a life w ith ou t
p ain is clearly b e tte r than a life w ith pain , this is n o t alw ays
th e m o s t im p o rta n t issu e. I n s te a d it is that p e r s o n s o w n
com plex a sse ssm e n t o f their life s w o rth that is th e key. The
physical sy m p to m s o f an illness are often on ly o n e o f m any
considerations. Just ask A ngelique.
E n d o f L ife Considerations
T h e T ired o f L ife P h en o m en on
In recen t y ears, a n e w tre n d h as beg un to em erge; o n e that
has cau sed E xit to rethink o u r ap p ro a c h to d e a th an d dying.
Increasingly at o u r w o rk sh o p s , w e m e e t eld erly people w h o are
lit an d health y (fo r th eir ag e), b u t fo r w h o m life h as becom e
in c re a sin g ly b u rd e n s o m e .
S u ch p e o p le a r e n o t dep ressed .
E nd o f L ife C onsiderations
Lisette N ig o t insisted that
s h e h a d led a g o o d a n d full
life. S h e s a id she h a d always
k n o w n that she w o u l d not want
to b e c o m e ' too old.' ' I d o not
take to old ag e v e r y w e ll' she
told film-maker Janine Hosking
w hose feature docum entary
M a d e m o ise lle a n d th e D o cto r
tra c e d the last m o n t h s o f he r
life.
In late 20 02, sh ort ly bef ore her
E nd o f L ife C onsiderations
34
E nd o f L ife C onsiderations
E xit W o rk sh o p s
In recen t y ears, E x its w o rk sh o p s have g ro w n in p op ularity
spreading o v e r A u stralia, N Z , UK, U S A an d C an ad a. From
th eir c o m m e n c e m e n t in 1997, this flagship Exit p ro g ram now
p ro v id e s factual, accu rate in fo rm atio n to o v e r 4 0 0 0 p eo p le
every year.
T h e w o rk sh o p idea w a s first c o in ed in 1997 after th e w o rld 's
first e n d o f life law - the R ig h ts o f th e T erm inally Il l A c t - w a s
o v e rtu rn e d by th e A u stralian p arlia m e n t. A t th a t tim e, the
V oluntary E u th an asia R esearch F o u n d atio n - a s Exit w a s then
k n o w n - w a s ap p ro ach ed b y increasing n u m b ers o f o ld er people
w h o w a n te d to k n o w th eir en d o f life op tio ns. T h e se people
w ere not ill. Rather, th e y w a n te d to k n o w w h a t th e ir options
w ere, s h o u ld th ey ever b e c o m e ill.
U nable to v isit these rational, eld erly adu lts on a o n e-o n -o n e
basis, Exit D irector Philip N itsch k e b egan w o rk sh o p s, initially
w ith a ro u n d 2 0 p eo p le at a tim e. H eld in local co m m u n ity
ce ntre s, the w o rk sh o p s p ro v id e d a perfect o p p o rtu n ity to correct
m isin fo rm atio n a n d a n s w e r questions.
S in c e th a t ti m e w o r k s h o p s h a v e o n l y g o tte n b ig g e r, n o w
attracting o v e r 100 particip ants at each m eeting. B ecause Exit
can still n o t k eep u p w i t h p e o p le 's d esire to o b tain en d o f life
inform ation, th is b o o k h as b een c re a te d . W elco m e to E xit's
n e w global w orkshop.
C o n clu sio n
I f o n e is to su g g e st that th e eld erly an d serio u sly ill h av e the
right - for g o o d an d so u n d reason s - to en d th eir lives earlier
th an n atu re w o u ld h ave it, th en the p ro v isio n o f accurate, upto-date in fo rm atio n is an im p o rtan t first step.
I n f o r m a t i o n is t h e m a i n r e a s o n w h y p e o p l e j o i n E x i t
International. Inform ation is certainly th e m ain reaso n w h y
o u r w o rk sh o p s are b o o k e d o u t m o n th s ahead. P eople w a n t to
k n o w h o w to end th eir lives peacefully, reliably an d w ith dignity.
M o st p eo p le k n o w that they m a y n e v e r u se this inform ation.
All are com forted , how ever, in k n o w in g that i f things ' turn b a d '
a s th e y p u t it, they h av e a p lan in p la c e .
R em em ber, su icide is legal, y et assisting a suicid e is illegal.
T h is is w h y ev e ry o n e s h o u ld d e v e lo p an e n d o f life plan. An
e n d o f life plan will k eep o n e s fam ily a n d loved o n es safe from
th e law. A n en d o f life plan is the respo nsib le th in g to do.
In
Suicide a n d th e Law
I f t h e y q u a lifie d , th e y o b ta in e d th e r ig h t to r e q u e s t lawful
assistan ce fro m a d o c to r to die. O th e r law s (O reg o n , H olland
etc) h ave also set o u t to define e x a c tly w hich g ro u p o f people
can h av e help to die. In all cases, eligibility is tightly controlled.
Yet ev en w h e re V E law s w o rk w ell, there is o n e significant
d ra w b a c k . T h e v e r y strict set o f co n d itio n s m e a n s th a t the
p ro c e ss o f e sta b lis h in g elig ib ility is d e m a n d in g a n d can be
h u m iliatin g to th o se involved.
B esides, there are so m e p eo p le (th o se w h o fit th e ' tired o f life'
d escrip tion ) w h o will sim p ly n e v e r qualify. In the N orth ern
Territory, a te rm in a lly ill p erso n h ad to o b tain tw o m edical
op in ion s, a palliative care rev iew an d a psychiatric consultation
b efo re th ey c o u ld qualify to u se th e law to die. In practice,
this m e a n t th a t s o m e very sick p eo p le h ad to b eg the m edical
p rofessio n in o rd er to qu alify to die.
In the course o f m y involvem ent with this law, it q uick ly b ecam e
ap p aren t that no n e o f m y four patients w h o u sed th e R O T I A c t
w o u ld h ave both ered w ith th e ex h au stiv e a sse ssm e n t p ro c e ss if
they h ad access to a P eaceful Pill a t h o m e in the cupboard. W h y
w o u ld a p erso n su b je c t th e m se lv e s to a co m p u lso ry p sychiatric
e x a m in a tio n , i f th e y a lr e a d y h a d th e m e a n s to a p e a c e fu l,
dignified death?
T h e y w o u ld sim p ly h av e w a ite d till th e tim e w a s rig h t a n d then
taken th e Pill. T h e v ery law s th a t w e re s u p p o se d to e m p o w e r
these sick an d frail people s eem ed to d o the exact opposite.
T h e law d en ied th e se in d iv id u als' control. Instead, control w a s
p laced in th e h ands o f those d o c to rs task e d w ith establishing
eligibility.
Suicide a n d th e Law
W h il e s o m e p e o p le m a y w i s h to in v o lv e d o c to r s in th e ir
deaths, o th ers do not. O u r point at Exit is that death n eed not
be a m ed ical event. It is also arg u ab le w h e th e r th e m edical
profession s h o u ld b e given th e role o f arbiter, o f w h o gets the
rig h t to d ie w ith dignity, an d w h o d o e s not.
(A n e x te n s iv e d iscussio n o f E x it's p h ilo so p h y o f d e a th and
d ying can be found in K illin g M e S o ftly: V E a n d th e R o a d to
th e P e a c efu l P ill, P en g u in , 2 0 0 5 - republished in 2011 b y Exit
U S an d av ailab le fro m Exit). T h is m e d ic a l m odel o f death an d
d ying h a n g s o v e r u s an d n e e d s to be challenged. T h is is, in part,
w h y this bo o k h as b een p rod uced. T h e Internet A g e h as proven
p erfect fo r the de m o cratisatio n o f inform ation.
C o n clu sio n
T here are m a n y u n d e rsta n d a b le re a so n s w h y a serio u s ly ill
person ( o r an eld erly p erson ) s h o u ld be en c o u ra g e d to m ake
an en d o f life p lan. E xit do es n o t accep t the p ro p o sitio n that
serio u sly ill p eo p le w h o p lan f o r the en d o f th eir life are either
d ep ressed o r m en tally ill.
R ather, a p e r s o n 's right to en d -o f-life in fo rm atio n is better
u nd ersto o d a s critical to e m p o w e rin g that p erso n to m ak e their
ow n c o n sid e re d d ecisio n s a n d choices, j u s t a s th ey h ave done
all th eir life.
B y im p le m e n tin g la w s th a t re s tric t a n d w ith h o ld th is
inform ation, the State is b eh avin g in a w a y that is n o t only cruel,
b u t inequitable an d unjust. T h o s e w ith m o n e y an d co nn ectio ns
w ill alw ay s be better resourced, better able to g et th e necessary
info rm ation an d better a b le to access th e restricted drugs, than
those w h o are less w ell off.
th e balance.
W h a t is a " P e a c e fu l P ill"
In
2 0 0 4,
Exit
International undertook
a m ajor study o f our
supporters' attitudes
to v a r i o u s m e t h o d s
of dignified dying
( n = 1163).
Fig 3.2; Survey of Exit Members
Methods of Self Deliverance
C o n clu sio n
E x it's s u rv e y h as e sta b lish ed a stro n g p referen ce f o r a reliable
an d effective P eaceful Pill a s the best m e a n s o f p ro v id in g the
option o f a peacefu l death a t th e tim e o f o n e 's cho osing . M uch
o f th e re m a in d e r o f this b o o k fo c u se s on the v a rio u s fo rm s a
P eaceful Pill m ig h t take.
In p ro v id in g this inform ation w e are fo llo w in g the ag en d a set
by lo n g-stand ing m e m b e rs o f Exit International.
4
The E xit RP Test
P r im a ry C riteria
T h e ' E xit R P T est' p ro v id e s a b en ch m ark again st w h ich all end
o f life optio ns can be co n sid ered . T h e v a lu e s ad d ressed b y the
test cam e to E xit's attention thro u g h specific research on the
n o tio n o f a P eaceful Pill an d also th ro u g h person al accou nts
a n d an ecd o tes o v e r the past d e c a d e . T h is feed back co n tin u es to
identify tw o principal factors in p e o p le 's p referen ces for en d o f
life m eth o d s. T h e se factors are R eliability an d P eacefulness.
In th e R P Test, R eliability a n d P eacefu ln ess are each given
a sc o re o f 1 to 10. T h e h ig h er the num b er, th e m o re reliable
an d peaceful the m eth o d in qu estion . F o r e x a m p le , N em b u tal
ach iev es a high overall score, h an g in g a v e ry lo w score.
T h e E x it R P Test
A v a ila b ility (A - 5)
To be o f an y u se th e m e th o d m u s t b e a v a ila b le . T h e m o s t
p eacefu l an d reliable d ru g is o f n o u se i f it is unavailable.
P r ep a ra tio n a n d A d m in istr a tio n (P r - 5)
S im plicity o f preparation an d adm inistratio n is an im portant
factor. N o o n e w a n ts to use co m p licated eq u ip m en t that is
difficult to asse m b le o r d ru g s that a re hard to use.
U n d ete cta b ility (U - 5)
M eth o d s that leave n o o b v io u s tra ce are strongly preferred. In
reality, this m ig h t m ean that an atten d in g physician will be m ore
likely to assu m e that th e death h as been cau sed b y a know n
u n d e rly in g disease. In this situ ation , the question o f suicide
d oes n o t arise.
S p eed o f E ffec t (Sp - 5)
S p e e d o f d e a th is a fu rth e r sig n ifican t factor. S p e e d lim its
th e lik e lih o o d o f d i s c o v e r y a n d a n y p o s s ib le in te rf e r e n c e
(resuscitation).
S a fety to O th ers (S a - 5)
M o st serio u sly ill p eo p le d o n o t w a n t to die alone. M ethods
that present a d an g er to o thers are u n p o p u la r for this reason.
S to ra g e - S h e lf life (S t - 5)
T h e re is a stro n g p reference for m eth o d s that u se su b sta n c e s,
drugs o r item s that do n o t d eteriorate with tim e. T h is m e a n s the
p erso n sh o u ld be able to asse m b le the required item s o r obtain
Score
Reliability:
T h is is g o o d , b u t tech n iq u e is im portant
R =8/10
Peacefulness:
T h e re is s o m e sh o rt term a w aren ess an d alarm
P=7/10
Availability:
N e c e s sa ry item s are readily available
A = 5 /5
Preparation:
Item s req uire a sse m b ly an d coo rdination
Pr=l/5
U ndetectability:
I f item s rem oved, totally undetectable,
U=5/5
e v en in th e e v e n t o f an au to p sy
Speed:
U n co n scio u sn ess an d death o c c u r qu ickly
S p = 5 /5
Safety:
T h e m e th o d p resen ts n o risk to o th ers present
Sa=5/5
Storage:
E q u ip m en t do es n o t d eteriorate an d testing
readily available
T otal fo r H eliu m a n d a n E xit B ag
S t= 5 /5
41 (82% )
Score
R =10/10
P=5/10
A=2/5
Pr=5/5
U=3/5
Sp=5/5
Sa=3/5
St=5/5
T otal for S o d iu m C y a n id e
3 8 (76% )
A N o te o f C a u tio n
T h e R P T e s t s c o r e s e r v e s o n l y a s a g u i d e . I n d iv i d u a l
c ircu m stan ces an d p referen ces will alw ay s influence a p e rso n 's
d ecision. T h e re are p e o p le for w h o m a plastic E xit b ag o ver
th eir h ead will n e v e r be a v iab le o p tio n , n o m a tte r h o w peaceful
an d reliable th e m etho d.
T h is m a y b e b ecau se o f an in d iv id u a ls p artic u la r aesthetic
c o n c e r n a n d h a v e n o t h i n g to d o w it h th e m e t h o d 's high
reliability physiologically. N evertheless, if this is a real concern,
th e m eth o d w ill n o t be co n sid ered , irrespective o f th e high RP
Test s c o re .
Similarly, the availability o f a p artic u la r m eth o d can differ
fro m individual to individual. T h e co m p ariso n a b o v e suggests
that h eliu m w o u ld b e preferred ab ov e cyanide.
H o w e v e r, i f an individual h as recen tly b e c o m e s o d isabled
th r o u g h i lln e s s t h a t th e u s e o f an E x it B a g is p h y s ic a lly
im possible, an d y e t that sam e person h as access to cy an id e
pow d er, th e final ch o ice w ill clearly n o t b e d e te rm in e d b y the
high est R P Test score.
See Table 1 w h ic h p ro v id e s th e o verall R P Test s c o re s for the
six a p p ro a c h e s d e s c rib e d in this book.
In tro d u c tio n
T h e plastic Exit B ag p ro v id e s p eo p le w ith th e m eans to obtain
a sim p le, effective a n d p eaceful death. W h ile E xit research has
fo u n d that relatively f e w p eo p le w o u ld p r e fe r to u se a Plastic
B ag o v e r th e sim p le ingestion o f a P eacefu l Pill, it rem ain s one
o f the m o s t accessible m e th o d s available.
T h e re is m u ch m isin form ation , h o w ev er, a b o u t h o w a plastic
E xit B a g w o r k s a n d w h y it is s o effe c tiv e . T h e c o m m o n
assu m p tio n is that th e b ag cau ses death by ' su ffo catio n '.
Suffo catio n o ccu rs w h en a person c an n o t easily take a breath.
E x a m p le s o f th is in c lu d e ty in g a rop e a r o u n d th e n eck , or
p u s h in g a p illo w into o n e 's face. T h e act o f m e c h a n ic a lly
b lo ck in g o n e s b reath in g is te rrify in g , an d p eo p le will struggle
w ith th e last o f th eir strength to clear th e obstruction.
W h e n used properly, th e plastic E xit B a g cau ses a peaceful
death; o n e that c o m e s from (freely ) b reath in g an atm o sp h ere
w h e re there is n o o xygen (h yp o xia ). W ith an Exit Bag, a person
b reath es easily an d p eacefully; the b ag e x p a n d s an d contracts
with each breath b u t there is v ery little o xygen present in the gas.
T h is is in stark c o n trast to th e te rro r o f su ffo cation an d is w h y
it is im p o rtan t n o t to c o n fu se th e p eaceful h y p o x ic death th a t is
p o ssib le w h e n an Exit b ag is u sed properly, w ith th e g rim death
that results fro m an obstru ctio n to th e airways.
A n d th is is w h y w e s h o u ld b e w a ry o f m e d ia r e p o r ts that
rein fo rce this confusion. F o r ex am p le, w h en referrin g in 2001
to th e im portation o f C an adian Exit b ag s, th e M u rd o ch press
( The A u stra lia n n ew sp ap er) rep o rted these bags as ' rem in iscent
o f th e K h m e r R o u g e 's s h o p p in g b ag ex ecu tion s in C a m b o d ia 's
killing f i e l d s '. Such rep orts s h o w a lack o f u n d erstan d in g o f the
p ro c e ss a n d h ave d a m a g e d the im ag e o f th e Exit Bag.
T he H y p o x ic D eath
H y p o x ia is th e term m ean in g lo w o x y g e n , an d a death that
results from inhaling insufficient o x y g en is a hy p o x ic death.
W h ile th ere are several w a y s this m ight occur, th e c o m m o n
m e th o d u s e d by th o se seek ing a peacefu l death is to sud denly
im m erse o n e s e lf in a n o n -o x y g e n en v iro n m en t. T h e sim plest
w a y to ach iev e this is b y filling a plastic b ag w ith an inert gas
and then to quickly place this bag o ver o n e 's head. T o understand
w h y th e plastic E xit b ag p ro v id e s an easy an d reliable w a y to
die, a basic u n d erstan d in g o f h u m a n p hy sio lo g y is helpful.
In norm al ev e ry d a y life, w e live in an atm o sp h e re that is 21%
oxygen. Interestingly, w h en there is a d e c lin e in th e level o f
o xygen in the air w e are breathing, w e d o n o t ex p erien ce any
p artic u la r alarm o r concern. A s long a s o n e can breath e easily,
th e sensation o n e e x p erien c es a s the o x y g en level d ro p s is one
o f diso rientation, co n fu sio n , lack o f coo rdination an d eventual
loss o f consciousness.
T h is ex p erien ce is so m etim es likened to b e in g d ru n k (alcohol
intoxication). I f the o x y g en level is to o lo w death w ill result.
A ccid en tal h y p o x ic d eath s a re n o t u n c o m m o n an d there are a
n u m b e r o f scen ario s that can b rin g th em about.
T h e R o le o f C a rb o n D io x id e (C O 2)
In n o rm a l respiration, th e h u m an b o d y uses ox ygen an d produces
a s w a s te th e g as, c a rb o n d io x id e .
C a r b o n d io x id e is then
A P eacefu l D eath
T h e best m eth o d o f u sin g an E xit B a g involves the u se o f an
inert g as, such a s H eliu m , N itro g e n o r A rgo n. In A ustralia, the
U S an d o th er countries, H eliu m an d A rg on can be purchased
in d isp o sab le con tainers. H eliu m is m a rk e te d in disp osable
con tain ers so that b allo o n s can be filled a t h o m e fo r parties (Fig
5.1), A rg on in disp osable fo rm , for u se in w e ld in g applications
( se e fig 5.5). T h e re is n o n e e d to hire a h e a v y c y lin d e r o f
c o m p r e s s e d g a s th a t n e e d s r e tu rn in g . A lte r n a tiv e ly e m p ty
cylinders can be pu rch ased an d filled w ith an appropriate am ount
o f a re a d ily a v a ila b le c o m p re s s e d g a s like N itro g e n . T h e se
cy lin d ers can then be sto red indefinitely.
A s e c o n d issu e o f c o n c e rn is th e s iz e o f th e se c o m m e rc ia l
c y lin d e rs. C o m m e rc ia l c o m p r e s s e d g as cy lin d e rs a re often
large, h e a v y an d difficult to transport. S u sp icio n m ight arise if
an elderly o r v e ry sick p erso n is seen leasing a c y lin d e r from
th eir local B O C g as outlet. I f so m e o n e else w e re to collect the
cy lin d er for th em , this o th er p erso n m a y w ell b e c o m e legally
im plicated in a ssistin g in a suicide.
T h e se c o n c e rn s turned
T h e O p tim a l G a s F lo w R a te
T o achiev e a p eaceful h y p o x ic death w ith an inert g as an d an
Exit Bag, th e op tim al g as flo w is o n e that flushes a w a y ex h aled
c arb o n dio xid e s o this g as d o e s n o t accu m u late w ith in th e bag.
T his optim al g as flow also prevents the b ag from heating up, but
is slow enough so that useful flow w ill continue for > 2 0 m inutes.
T o d e te rm in e the op tim al flow E xit ca rrie d o u t ex p erim en ts
w h e re d ifferen t flow rates o f air w ere ad m itted to a bag o v e r a
s u b je c t's head. T h e level o f c arb o n d io x id e w ith in the b ag w a s
m o n ito re d using an RKI sa m p lin g g as detector.
R esults for an 80 K g m a le taken o v e r a 5 m inute p erio d f o r tw o
g as flow rates (5 & 15 l/m in) are sh ow n in Fig 5.2
Fig 5.2: Exit Bag CO2 &O2 concentration levels for the first 5 minutes
d isp o sab le -he liu m -ta n k -w ith -p a rty -b a llo o n s-3 0 ---5 0 -p ac k )
a s w ell as C linton
Fig 5.3: Packages disposable Helium containers: Left - 420 litre, Right - 250 Litre
Fig 5.4: Flow Rate, Pressure and Volume of Helium with Time for 420 & 250 litre Cylinders
using the Exit Gas Control Jet Assembly
3 . N itrogen
N itrog en is a v e ry c o m m o n gas, m a k in g up ~ 8 0 % o f the air w e
breath. T h e g as is cheap, in no d an g er o f ru n n in g out, an d readily
available. It is not restricted an d no q u estio n s are a sk e d about
w h y o n e w o u ld w a n t a so u rce o f this gas, altho ug h o n e m ig h t
say, i f asked, that y o u are w o rk in g o n a nitrogen g as sy stem for
y o u r h o m e b e e r b re w a n d w a n t to achiev e th e fine b u b b le s an d
c ream y h ead a sso ciated w ith G u in n e ss stout (N itro g en is used
to aerate G u in n e ss stout)
A lthough disposable cylinders filled with nitrogen are n o t readily
av ailab le, th is will c h a n g e in 2 0 1 2 w i t h th e re le a se o f high
p ressure cy lin d e rs c o n tain in g 6 5 0 litres o f nitrogen.
Fig 5.6: Filling a 4Kg LPG cylinder with 400 psi of Nitrogen
A b e t t e r s t r a t e g y is to p u r c h a s e an e m p t y h i g h p r e s s u re
alu m in ium cylinder. W hile so m e g as outlets will fill this typ e o f
cylinder w ith nitrogen fo r you, others will not. T hese alum inium
cy lin d ers (see F ig 5 . 6 .1) are av ailab le in the U S by mail order
from the B everag e Factor) at: http://bit.ly/jp A 5 9 Z T h e 2 2 cu
ft (6 5 0 litre) cy lin d er pictured has a rated se rv ic e pressure o f
u p to 22 0 0 P S I/1 5 0 BA R.
R eg u la tin g th e F lo w o f N itrogen
T h e easiest w a y to regulate the flow o f nitrogen is v ia a suitable
regulator. A regu lator w ill g iv e e a s y control o f flow rate an d can
b e set to d e liv e r ~ 2 0 litre/m in. A full cy lin d er w ill g iv e a steady
flow o f nitrogen fo r a ro u n d 30 m inutes. T h e re is no n eed for
th e E xit flo w fitting that is u s e d w ith the h eliu m B alloon T im e
system . T h e d elivery ho se to take the n itrogen to the E xit Bag
fits d ire ctly o n to the regu lator outlet.
To set the flow rate, a sim p le flow g a u g e can be m a d e by u p
e n d in g a 2-litre so da bottle filled w ith w a te r an d allow ing
th e nitrogen flo w in g th ro u g h the h ose to displace th e w ater. T h e
req u ired flow ra te o f ~ 20 litres/ m in sh o u ld e m p ty the bottle
in ~ 6 sec.
O n e useful aspect o f the N itro g e n S ystem is the fact that the
cy lin d ers can be to p p e d u p i f th ere is leakage o f n itrogen o ver
tim e (the d ispo sab le H elium a n d A rg on cy lin d ers c an n o t be
refilled). N ote: the p ressu re m e a s u re m e n t n eed ed to establish
that a cy lin d er is full is p ro v id e d b y the g a u g e on th e regulator.
Fig 5.6.1
(a) 650 litre Al cylinder
(b) Nitrogen regulator
(c) Gas cylinder ready to
connect to Exit Bag
T he Exit Bag
T h e Exit plastic b ag is th e b ag w h ich is filled w ith th e inert
g as. T h e b a g is d e s ig n e d to e n a b le s im p le filling w ith no
co n tam in atio n w ith o xygen, p ro v id in g a straight fo rw ard w a y
for o n e to su d d e n ly im m erse o n e s e lf in inert gas.
1. M a k in g an Exit Bag
W hile different people m ak e slightly different bags, th e standard
Exit B ag in v o lv es a plastic b ag of:
a re a so n a b le size
a suitable s o ft plastic
a n eck b an d o f elastic that allo w s th e bag to m ak e a snug,
b u t n o t tight, fit a ro u n d a p e rso n 's neck
In th e p a s t, E xit B ag s h ave been able to be p u rch ased from
o rganization s such as R ight to Die C anad a.
A s the original
C o n stru c tio n
4.
5.
6.
7.
G a s F lo w C o n t r o l
N o m atter w h ic h g as is u s e d a flo w v e lo c ity o f ~ 15 1/min is
n e e d e d to p re v e n t th e a c cu m u latio n o f C 0 2 in the Exit bag.
Exit has investigated several m eth o d s o f c o n tro llin g g as flow.
http://bit.ly/9swOxk
F o r high pressure cylinders o f nitrogen o r helium , regulation
is essential. Regulators can be purchased from g as providers.
T h e re g u la to r s h o w n in F ig 5.9.2 g iv es th e p ressu re o f
n itrogen in the cylinder, an d allo w s th e o u tp u t flow rate to
b e set at 15 o r 2 0 litres/ m in. U s in g this regulator, flow rate
is constant thro u g h o u t th e hy p o x ic death.
F o r th e low -p ressure n itrogen system d e s c rib e d (F ig 5.6)
w ith filling p ressu res o f 2 8 0 0 k P a (4 0 0 p si), a suitable flow
rate can b e o b ta in e d u sin g a s ta n d a rd L P G re g u la to r to
restrict the outlet p ressu re to ~ 2.8kPa. A je t (size ~ 2 m m )
w ill allow a constant flow o f n itrogen at the appropriate rate.
T h e regu lator a sse m b ly w ith 2 m m j e t is s h o w n in Fig 5 . 9 . 1
Fig 5.9.2
High pressure
nitrogen regulator
with click flo w
rate output
Fig 5.9.1
LPG regulator
and 2mm jet
used to control
nitrogen flow
Fig 5.13:
Helium cylinder with
pressure gauge attached
to flow control assembly
Fig 5.14: Positioning, Inflating & Using the Exit Bag with Helium
G as P u rity
E xit o ccasio n ally receiv es repo rts o f failures b y p eo p le using
Exit Bags. A lthough this information is sketchy, the reports arc o f
p eo p le breathing the g as inside th e bag for so m e m in u tes w ith no
loss o f co n scio u sn ess. In all c ases th e g as inv olved w a s helium .
C o n tam in atio n o f th e g as h as b een su g g ested as an explanation.
T h e o n ly p o ssib le co n tam in atio n that could p ro d u c e this effect
w o u ld be th e addition o f a significant q u an tity o f o xygen to the
helium . T h e introduction o f 10% o f ox ygen w o u ld have no effect
on the m ark eted u se o f the g as - b alloons filled w ith this m ixture
w o u ld float - b u t this g as w o u ld fail in an Exit bag.
Hydrocarbons ~ 40ppm.
T h e P roced u re
T h e goal for this m e th o d is to p ro d u c e a reliable, quick and
p eacefu l death from hypoxia. T h e re are 3 stag es in this p ro cess
and these are sh ow n in th e V id eo (B etty an d th e E xit Bag) and
in fig 5.14.
A d ju st th e e lastic in ne c k o f th e b ag so that it is a firm fit
a ro u n d th e h u m an neck. T h e n p la c e the b ag on th e head
acro ss the forehead. C ru sh the b ag d o w n onto the h ead to
e x c lu d e all air then open the tap on th e H elium bottle. T h e
flo w o f H eliu m at ~15 1/min fills the b ag in a b o u t a m inute.
W h e n the b ag is filled w ith gas the H elium w ill begin to leak
a ro u n d the elastic w h ile th e b ag re m a in s fully inflated. A
q u ic k lo ok in th e m irro r w ill en ab le the b ag to be correctly
p osition ed an d full o f H elium .
To b rin g about a p eaceful death, a person w o u ld exhale
totally (fu lly e m p ty th eir lungs) a n d h o ld their b reath w hile
p u llin g the bag d o w n o v e r th eir head. W h e n the bag is o ver
th e h ead an d s n u g ly a ro u n d th e neck, th e y w o u ld take the
d e e p e s t breath possible. L o ss o f c o n s c io u sn e s s w ill o c c u r
a lm o s t im m ed iately - w ith in o n e o r tw o breaths. Death
o c c u rs few m in utes later.
C o n c lu d in g C o m m e n ts
T h e Exit B a g w ith Inert G a s is an en d o f life m eth o d that is
reliable, sim ple an d d oes n o t in vo lve illegal d ru g s o r equipm ent.
N ev erth eless, th e m eth o d d e m a n d s substantial preparation. A
d isp o sab le g as c y lin d e r needs to b e pu rchased , a lo n g w ith the
requ isite co nn ectio ns, tubing a n d a B a g m u s t be m ade.
Techn iqu e is also im p o rtan t a n d a certain d eg ree o f physical
d ex terity is required. O n th e d o w n sid e , the n e e d fo r s o m u ch
eq u ip m en t an d the unaesthetic nature o f placin g a bag ov er o n e's
h e a d p rev en ts m an y p eo p le from even c o n sid e rin g this m ethod.
T H E R P T E S T S C O R E - Exit B a g + H elium
R eliability
(R = 8/10)
T h e m e th o d is reliable b u t tech n iq u e is im p o rtan t
a n d a d eg ree o f co o rd in atio n an d dex terity is required
P eacefu ln ess
( P = 7 / 10)
(A = 5/5)
Preparation
( P r = 1/5)
C o n sid era b le a sse m b ly a n d setting u p o f eq u ip m en t
U n d ete ctability
(U = 5/5)
I f all e q u ip m e n t is re m o v e d d etectio n is rare. I f N itro g e n is the
g as used th e m e th o d is totally undetectable.
Speed
L oss o f co n scio u sn ess c o m e s quickly
(S p = 5/5)
Safety
T h e m e th o d presents n o d a n g e r to others
(S a = 5/5)
Storage
(S t = 5/5)
C o m p o n e n ts d o n o t deteriorate w ith tim e. G a s
p ressu re test can re a d ily establish helium cy lin d er is full
Total R P S c o r e
41/50
(82 % )
T H E R P T E S T S C O R E - Exit B a g + H elium
C rite ria
S core
R eliability
8/10
P ea cefu ln ess
7/10
A va ila b ility
5/5
P rep a ra tio n
1/5
U n d etecta b ility
5/5
S p e ed
5/5
S a fety
5/5
S to ra g e
5/5
T o ta l
41 (82% )
Carbon M onoxide
Introd u ction
C arb o n M o n o x id e (C O ) is o n e o f the m o st lethal g ases known.
Its toxicity is d u e to its ability to strongly bind w ith h aem oglobin
w h ic h g r e a t l y r e d u c e s th e o x y g e n - c a r r y i n g c a p a c i t y o f a
p e r s o n 's blood. A re a s o f the brain sensitive to isch a em ia (low
o x y g en level) are affected sev erely an d a rapid, p eaceful death
is the c o m m o n result. T h e g as is p articu larly d a n g ero u s, a s it
is a co lo u rle ss, o d o u rle ss a n d a n o n -irrita tin g gas. W ithout
sp ecializ ed m o n ito rin g eq u ip m en t, there is no w a y o f know ing
that c arb o n m o n o x id e is present.
Death b y p o iso n in g fro m c arb o n m o n o x id e can b e reliable,
q uick a n d peaceful, p ro v id e d the co ncentration o f th e inhaled
g as is sufficiently hig h. In th e 19 9 0s, D r Jack K ev o rk ian helped
m ore than 100 serio u sly ill p eo p le to en d th eir lives peacefully,
n early h a l f o f w h o m used c arb o n m o n o x id e . D r K evorkian
used a c y lin d e r o f co m p re ss e d carbon m o n o x id e (9 % C O in
N itro g e n ). T h e person w a n tin g to d ie sw itch e d on th e g as at
th e cy lin d er an d b reath ed through a loose-fitting face m ask . A
f e w d eep b re a th s o f the c arb o n m o n o x id e-n itro g en m ix tu re and
th e person lost co n scio u sn ess a n d d ied quickly. D r K evorkian
w o u ld then sw itch o f f th e g as an d rem o v e the cy lin d er an d face
m ask . T h o s e present a t these d eath s describ ed th e effectiveness
an d peacefu ln ess o f th e approach.
C arbon M onoxide
PPM
T im e
S ym p to m s
[C O ]
8 hours
35
M axim u m
e x p o s u r e a l l o w e d b y O S H A in t h e w o r k p l a c e o v e r a n
e ig h t h o u r period .
200
2 -3
hours
M ild h e a d a c h e , f a t i g u e , n a u s e a a n d d i z z i n e s s .
400
1-2
hours
800
4 5
m in u te s
160 0
20
m in u te s
320 0
6400
5 -10
m in u te s
1-2
hours.
H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 1 h o ur.
H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 1 h o ur.
H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 2 5 - 3 0
m in utes.
m in u te s
12,8 0 0
1-3
m in u te s
R ap id D eath
Fig 6.2
a) RKI sampling multi-gas meter
b) TPI 707 high level monoxide analyser
c)TPI 770 monitor with sampling probe
C arbon M onoxide
S ou rces o f C a r b o n M o n o x id e
From C o m m ercial G a s Suppliers:
C ylinders o f co m p re ss e d carbon m o n o x id e , either a s the pure
g as o r a s a m ix tu re (eg 5 % in N itro g e n ) are av ailab le from
scientific g as su p p ly com panies. T h e re are no special restrictions
b u t an acco u n t w ill be n eed ed . T able 6.1 lists so m e available
p a c k a g in g fo r p ure co m p re ss e d carbon m o n o x id e from HOC.
http://w w w .boc.co m
C ylinders o f sp ecial g as m ix tu res that contain lethal levels o f
m onoxide a re also used a s source gases for so m e industrial lasers
(eg 6 % C O in g as u s e d in th e Rofin C O 2 slab laser).
h t t p : //w w w .lin d e - e le c t r o n i c s . e u / s g / m i x s g / l a s e r m i x __ 6 9 0 _ e n . h t m l
Vehicle E x h au st Gas:
C arb o n M o n o x id e is p ro d u c e d a s an ex h a u s t g a s from internal
c o m b u s tio n eng ines. T h e c o n c e n tra tio n o f th e m o n o x id e in
th e ex hau st g as varies, d ep en d in g on a n u m b e r o f factors and
e stab lishin g this is critical.
U sin g F o rm ic A c i d :
C a rb o n M o n o x id e is p r o d u c e d b y a ch e m ic a l reactio n that
o ccu rs w h e n th e form ic a c id ( H C O O H ) is b ro k en d o w n into
w a te r ( H 2O ) an d c arb o n m o n o x id e (C O ). T h e catalyst for this
b reak d o w n is c o n c e n tra te d su lp h u ric acid. T h e su lp h u ric acid
r e m a in s c h e m ic a lly u n c h a n g e d b u t is d ilu te d b y th e w a te r
released.
M o n o x id e g e n eratio n ceases w h e n all o f th e fo rm ic acid is
b ro k en dow n, o r w h e n th e sulphuric acid b e c o m e s to o dilu te to
cataly ze the reaction. H eat is g e n e ra te d in th e reaction a n d this
c an lead to traces o f fo rm ic an d su lp h u ric acid in the em erg ing
carbon m onoxide. O n e m o le o f form ic acid (4 6 g m ) will produce
~ 22 litres o f carbon m onoxide.
T h e chem ical eq uation is: H C O O H H 20 + C O
C arbon M onoxide
U sin g O x alic A c i d :
C oncentrate sulphuric acid can be used to b reak do w n anhydrous
oxalic acid to pro d u ce c arb o n m o n o x id e (an d c arb o n dioxide).
A g ain th e su lp h u ric acid re m a in s c h e m ic a lly u n ch an g ed but
is d ilu te d b y the w a te r p r o d u c e d in th e reactio n . L ess heat
is g e n e ra te d in th e re a c tio n a n d th e r e is less lik elih o o d o f
con tam ination w ith v a p o u r from th e su lp h u ric acid. O n e m ole
o f oxalic acid (~ 9 0 g m ) pro du ces equal m o la r am o u n ts o f carbon
dioxide a n d c arb o n dioxide.
T h e chem ical eq uation is: H O 2C C O 2H 20H
+ C O 2+ C O
C arbon M onoxide
Fig 6.5
The early CoGen
C arbon M onoxide
Fig 6.6. COGen 4 on fume cupboard test bench with acid bottles and CO monitor
C arbon M onoxide
How th e C O G e n W orks
T h e C O G e n c o n sists o f tw o P V C c h a m b e rs ( A & C , Fig
6.7). T h e inner c h a m b e r A is m o u n te d to th e s c re w lid o f the
larger o u ter 10cm (3 .9 inch) co n tain er an d has a drip e x it F in
its base. T h e drip rate is co ntro lled b y a s c re w E .
150 m l o f 8 5 % form ic a c id is p laced in c h a m b e r ( A) w ith the
control-valve shut.
25 0m l o f c o n c e n tra te d su lp h u ric a c id (9 8 % ) is p laced in the
outer c h a m b e r D an d th e C O G e n assem bled.
O p e n in g th e s c re w E a llo w s th e fo rm ic a c id to d rip into
th e c o n c e n tra te d su lp h u ric acid. C o p io u s a m o u n ts o f carbon
m o n o x id e are released an d exit the c h a m b e r th ro u g h v e n t holes
in the lid H .
T h e V id eo sh o w s th e C O G e n b e in g a r m e d an d p la c e d in a
small car. T h e c arb o n m o n o x id e co n cen tratio n in th e c a r w a s
c o n tin u o u sly sa m p le d w ith a p ro b e p ositio ned n e a r th e head
o f th e m an n eq u in . T h e g raph (F ig 6.8 ) sh o w s the m easu red
concentration in p p m , p lo tted o v e r th e first 30 m inutes. Lethal
concentratio ns w e r e re a c h e d a few m in u te s after s w itc h in g on
th e generator. A p eak level o f ~ 3 % C O w a s recorded.
S ou rcin g th e Acids
C o n c e n tr a te d su lp h u ric a c i d ( 9 8 % ) can b e p u r c h a s e d from
chem ical su p pliers o r at h a rd w a re sto res w h e re it is s o ld as
a drain cleaner. C o n ce n trated laboratory sulphuric acid is an
oily clear liquid, w h e re a s the d rain -clean er su lp h u ric acid can
b e dark b ro w n in co lo u r b e c a u s e o f ad d itiv es, but this d o e s not
effect the g e n e r a to r's operation.
S a fety N o te
C o n c e n tra te d fo rm ic an d sulphuric acids a re co rro s iv e liquids.
T h e y sh o u ld be kep t s e c u re d in glass o r p o ly eth y len e containers
(plastic soft d rin k / sod a bottles are n o t suitable). W h e n using
su lp h u ric acid, ru b b e r g lo v es s h o u ld b e w o rn along w ith eyep ro tectin g g o g g le s an d a face-splash protector. S pills o f acids
on to th e skin sh o u ld be w a s h e d o f f im m ed iately w ith copious
a m o u n ts o f w ater. I f either o f these acid s gets in th e eyes, w ash
th e eyes con tin uo usly for several m inu tes an d th en seek m edical
assistance.
C arbon M onoxide
C arbon M onoxide
C o n clu sio n
C arbon M o n o x id e can p ro vide a p erso n w ith a peacefu l death.
The g as can be o b tain ed in a variety o f w a y s ra n g in g from
sim ple b u rn e rs to m o re sop histicated g enerating devices. Tests
sh o u ld b e m ad e to ensure that c o n cen tratio n s o f o v e r 1% can
be established.
M o st interest in this m eth o d has co m e from those w h o reject the
taking o f drugs orally (eg. for fear o f v o m itin g ) an d b y others
w h o reject th e u se o f h eliu m b ecau se o f th e n eed f o r a plastic
b ag to be p laced o v e r o n e 's head. T h e C O G e n ad d resses these
concerns.
E xit R P Test f o r C a r b o n M o n o x id e
The m e th o d lo ses p oin ts in the sub catego ries o f P reparation,
U n detectab ility an d Safety. Preparation is n o t sim ple ( P r = l ) ,
there is eq u ip m en t presen t a t th e death, an d i f u sin g a C O G en
p reparation w it h c o n c e n tra te d acid s req u ires care. T h is m etho d
m a y b e d etectab le o n in sp ectio n o f the b o d y (U = 2 ), an d can
present so m e risk to o thers ( S a = l ).
C rite ria
S co re
R e lia b ility
8 /1 0
P ea cefu ln ess
7/10
A vailability
3/5
P reparation
1/5
U n d etecta b ility
1/5
Speed
5/5
S a fe ty
1/5
S to ra g e
4/5
T o ta l
3 0 (60% )
Cyanide
T h e d e a th o f S p a n ia r d R a m o n S a m p e d r o in 1998 a n d th e
s u b se q u e n t a w a rd -w in n in g film T he S ea In sid e h as fo cu sed
attention on th e u se o f cy an id e a s an effectiv e m ean s b y w h ich
a serio u sly ill person can p u t an en d to their suffering.
S am p ed ro , a q u ad rip le g ic sin c e a d iv in g accid en t at age 26,
e n d e d his life by d rin k in g a g lass o f w a te r in w h ich soluble
p o tassiu m c y a n id e h ad b een dissolved. H e d ied quickly, and
peacefully. M a n y p eo p le w h o h av e seen The S e a In sid e have
a sk e d w h y these cy an id e salts are n o t m o re frequ en tly u s e d by
th o se w h o are serio u sly ill to p ro vide a peaceful death. In this
ch a p te r w e explain s o m e o f the difficulties in v o lv ed in using
cy an id e a n d p ro v id e so m e an sw ers. It is n o t u n re a so n a b le to
ex p ect that th e u se o f cy an id e will increase in th e future, and
it m a y y et b e c o m e an acc e p ta b le form o f the P eaceful P ill.
S o m e b a ck g ro u n d to cy a n id e
In 1814, th e c a r b o n - n itr o g e n (C N ) r a d i c a l c o m m o n to a
n u m b e r o f c h e m ic a l s u b sta n c e s w a s iso la te d a n d g iv e n the
n a m e c y a n o g e n b y th e French ch em ist J o sep h G a y Lussac.
T h e su b seq u en t n am e th e b lue g e n e ra to r referred to th e p lace
o f th e C N radical in a n u m b e r o f ch em icals that w e re u sed as
Cyanide
Cyanide
T h e A vailability o f C y a n id e
S o lub le c y a n id e salts a re g e n e ra lly hard to obtain u n less one
has a contact in th e ind ustries w h e re these su b sta n c e s are used.
T h e se salts are also heav ily reg u lated an d restricted. T h e y can
h o w e v e r be m an u factu red (w ith c a re ) fro m read ily available
in g re d ie n ts, u sin g u n s o p h is tic a te d facilities an d equip m en t.
C a re m u st be em p lo y e d in th e m an ufacture, an d th e substance
p ro d u c e d sh o u ld b e a s sa y e d to ensure the d e sire d result.
T h e M a n u fa c tu re o f S o d iu m C y a n id e
S odiu m cyan ide can be m a n u f a c t u r e d in a n u m b e r o f ways.
T w o relatively sim ple m e t h o d s ar e d e s c ri b e d in the scientific
literature. T h e first involves the use o f the re adil y available
dye, Prussian Blue (Iron III Ferro cyanide). A s e c o n d uses
the c o m m o n s w i m m i n g pool chl orin e stabiliser, cyanur ic acid.
In t h e first p r o c e s s th e
P r u s s i a n B l u e is f i r s t
c o n v e rte d to sodium
ferrocyanide. Th is is done
b y a l l o w i n g it to r e a c t
with caustic sod a in water.
Iron o x id e is precipitated
a n d s o d iu m ferro cyan id e
o b t a i n e d . T h i s s o d iu m
ferro c y a n id e (Y ellow
Prussate o f So da ) is then
c o n v e r t e d to s o d iu m
cy a n id e by a l lo w ing it to
react w ith conce ntrate d
sulphu ric acid.
Fig7.1: Forge reduces sodium cyanate with carbon
Cyanide
In this
C y a n id e - R P Test
F o r a s u b sta n c e o r dru g to be useful a s a P eacefu l Pill tw o
m ain criteria m u s t b e m et. It m u st b e , R eliable, a n d it m u s t be
Peaceful. A pp lyin g the Exit R P test to a salt like sodium cyanide
g iv es so m e encou rag em en t.
R eliability is high, few p eo p le will e v e r surviv e the ingestion o f
a sufficiently high d o s e o f sodium c y a n id e . F o r a do se o f 1gm
o f sodium cy anid e, R =10.
T h e re is a lso a co rrelation betw een th e size o f th e d ose an d the
s p e e d o f death an d this m in im ise s th e ch an ce o f an y adverse
s y m p to m s developing.
In te r m s o f P e a c e fu ln e ss , th e m ix e d a c c o u n ts m a k e th is a
difficult characteristic to assess. C le a rly th e size o f the dose
m atters, i f o n e is to m in im ise s y m p to m s. Preparation is also
im portant. T h e toxic effect is p ro d u c e d w h en sto m ach acid acts
on th e salt p ro d u cin g H C N w h ic h is th en a b so rb e d by the gut
into the b lo o d stream . T h is pro cess is facilitated b y dissolving
th e salt in c o ld w a te r a n d drin king on an e m p ty sto m ach w here
th e gastric acid co n te n t is high.
A n alternative is to p la c e the cy an id e salt into a treated gelatin
c a p s u le . T aking a 5 0 0 m g cap sule w ith an acid ic drink (lem on
ju ic e , v in eg ar) cre a te s th e o p tim u m co n d itio n s in the stom ach.
T h e delay can also u sefu lly b e em p lo y e d to induce sleep w ith
th e addition o f a stro n g soporific (sleep in g tablet).
Taken in this m a n n e r th e likeliho od o f a peacefu l cy an id e death
is increased significantly. (P = 5)
Cyanide
L o o k in g a t th e M in o r Criteria:
A vailability (2 /5 ) - S o lub le c y a n id e salts are g en erally h ard to
o b tain u n less o n e h as a c o n ta c t in the industries w h e re these
s u b s ta n c e s are u sed . T h e s e salts are h e a v ily re g u la te d and
restricted. T h e y can h o w ev er be m an u factu red (w ith care) from
read ily av ailab le ingredients, u sin g u n so p h isticated facilities
a n d eq u ip m en t. C a re m u st b e e m p lo y e d in th e m an u factu re,
a n d the su b stan ce p ro d u c e d sh o u ld be a s sa y e d to ensure the
d e sire d result.
P rep aratio n (5/5) - C y a n id e salts are c o n s u m e d a s a drink o r in
a gelatin ca p s u le . S o m e clinicians will note th e pin k c o lo u r and
a possible sm ell o f bitter alm o n d s b u t this can often b e m issed,
esp ecially in c ases w h e re th ere is u n d e rly in g seriou s illness.
U ndetectability (3/5) - at auto p sy the substance will be detected.
S p e e d (5/5) - o ptim al adm in istratio n will c a u se a v e ry quick
death.
S afety (3 /5 ) - there is little risk to others, altho u gh the glass
sh o u ld be w ashed. N o te - i f vom itin g occurs, the gastric contents
m a y giv e o f f d a n g e ro u s H C N .
S torage (5/5). W ith p ro p e r storage, th e so d iu m an d p otassium
s o lu b le cy an id e salts h av e an a lm o s t indefinite s h e lf life.
E xit R P S core fo r S o d iu m C y an id e
38 (76 % )
E xit R P Test
C rite ria
S core
R eliability
10/10
P ea cefu ln ess
5 /1 0
A va ila b ility
2/5
P rep a ra tio n
5/5
3/5
Speed
5/5
S a fe ty
3/5
S to ra g e
5/5
T o ta l
3 8 (76% )
Cyanide
C a n o n e in h a le th e h y d r o g e n c y a n id e g a s r a th e r th a n
d r in k in g th e d isso lv e d c y a n id e s a l t ?
Detergent Death
S in c e 2 0 0 9 , E x i t h a s r e c e i v e d
re q u e ste d for in fo rm atio n on the
so -c a lle d D e te rg e n t S u ic id e
m eth o d o f e n d in g o n e 's life. W h ile
a n s w e rs w e r e p r o v id e d to th o se
a s k in g th e q u e s tio n s , it w a s not
thought necessary to include details
o f the m e th o d in T h e P e a cefu l P ill
H and book.
T h is d e c is io n h as b e e n r e v ie w e d in 2011 an d th is ch a p te r
included. W e stress h o w e v e r that th e m eth o d scores p o o rly on
the Exit RP test, an d h as little to re c o m m e n d it. It is in effect
a c h e a p a n d n a sty suicide strategy, an d re a d e rs are a d v ise d to
c o n s id e r o th er b e tte r altern ativ es o u tlin ed in this book.
T h e M eth o d
T h e m e th o d m a k e s u se o f the toxic n atu re o f th e g as hydrogen
sulfide (H 2S) a n d its e a s e o f g e n eratio n fro m re a d ily available
(u n re s tric te d ) h o u s e h o ld c h e m ic a ls. H y d ro g e n S u lfid e
(c o m m o n ly k n o w n a s ' rotten eg g g a s ') is ex trem ely toxic w hen
inhaled. T h e m e c h a n is m o f actio n is sim ilar to that o f hydrogen
c y a n id e (C h a p te r 7) w h e re the g as b in d s w ith an d d estro y s the
function o f m ito c h o n d ria w ith in living cells. T h e g as is a s toxic
as h y dro gen cyanide, b u t accidental e x p o su re is u n c o m m o n
b e c a u s e o f th e stro n g a n d u n p le a sa n t smell n o te d w ith even the
sm allest c o n cen tratio n s o f th e gas.
D etergent Death
H 2S + CaCI
P r o b le m s w ith th e m eth od
W h ile th e in g re d ie n ts re q u ire d to m ak e th e g as are read ily
o btain ed, an d u nrestricted , th e u se o f th e g as to en d o n e 's life
p resents a n u m b e r o f significant problem s. O f m a jo r co n cern is
the risk to o th ers w h e n large a m o u n ts o f h y d ro g e n sulfide gas
are p ro du ced. A p a rt fro m th e lik eliho od o f a n n o y in g everyo n e
in th e area w ith th e stink, th ere are real d ang ers to those w h o
m ig h t try to en ter the a re a o r a tte m p t re su s c ita tio n . Indeed
e m erg en cy p ersonnel are tra in e d to be careful en terin g an area
w h e re this g as is su sp ected , an d n o t to attem pt m o uth to m outh
resuscitation.
C learly i f o n e is p lan n in g to use this m eth o d it is essential that a
site is chosen w h ere leakage o f the g as can not end an ger innocent
p eo p le an d p ro m in en t w a rn in g sig n s sh o u ld be displayed. The
u se o f a car p a rk e d in an o u td o o r location w ith w a rn in g signs
d isp lay ed p ro m in en tly on the w in d o w s w o u ld seem to be the
m o st respo nsib le choice.
W h ile it h as been rep o rted that a s the co ncentration o f th e gas
rise s,th ere is a rap id inhibition o f th e sense o f sm ell, s o that one
d oes n o t n ecessarily ex p erien ce the sick e n in g stench rig h t to the
point o f death, it c o u ld n o t be co n sid ered a particularly peaceful.
D etergent Death
T h e E xit R P Test
T h e m e th o d sco res p o o rly for P eacefulness (P =2), but high on
R eliability (R=10).
C o n sid erin g th e m in o r criteria: A vailability & S p eed score well
at 5/5, Preparation & S to rage a t 4/5. H o w e v e r on Safety and
Detectability, o n ly the low est score w o u ld be appropriate, giving
a total sc o re o f only 3 0 (60% ). T h e m eth o d therefore scores
on ly slig h tly better th an h a n g in g (2 8 , 5 6 % ), an d less th an the
inhalation o f carbon m o n o x id e (3 1 , 6 2 % ) (C h a p te r 4).
E xit R P Test
C rite ria
S core
Reliability'
10/10
P e a ce fu ln e ss
2 /1 0
A va ila b ility
5 /5
P rep a ra tio n
4 /5
U ndetectability
0 /5
Speed
5 /5
S a fe ty
0 /5
S to ra g e
4 /5
T o ta l
3 0 (60% )
Introduction to Drugs
Introd u ction
F o r m a n y s e rio u s ly ill p e o p le , ta k in g d r u g s o r s u b sta n c e s
o rally (b y m o u th ) is the p re fe rre d w a y to en d life. Substances
taken in this w a y (eg. veterinary liqu id N e m b u ta l) req u ire no
special equip m en t. It is this sim p licity that ex p lain s th e appeal
o f this v e rsio n o f the P eaceful Pill. T h e lack o f an y necessary
b ed side e q u ip m e n t also m eans th a t th e death is m o re likely to
b e u n d e rsto o d a s o n e from 'n atu ral c a u s e s'.
F o r e x a m p le , i f a person d y in g o f c a n c e r takes the final step by
d rin k in g veterinary liq uid N em b u tal th ey w ill look as i f they
h av e d ied in th eir sleep. M o s t e x a m in in g d o c to rs w o u ld sign
the death certificate indicating that this w a s the natural, ex p ecte d
death from th eir cancer.
O f course, i f an a u to p sy is u n d ertak en , the c a u s a tiv e d ru g will
b e discovered, b u t au to p sies are increasingly rare in situations
w h e re th e atten d in g d o c to r b eliev es the c a u se o f death is clear
(see C h a p te r 18).
H ow ev er, w h ile taking oral d ru g s m ig h t seem to be th e sim plest
w a y o f o b tain in g a peaceful an d dignified death, th e m eth od
d o e s requ ire planning. K n o w le d g e o f th e su b stan ce to be used,
its acq uisition, prep aration an d adm inistratio n arc im portant.
Introduction to D rugs
T h e R o le o f the D ru g O v erd o se
G en erally sp eakin g, d ru g s are d e v e lo p e d to p rov ide a cu re to
an illness o r to giv e r e lie f from sy m p to m s. D ru g s a re n e v e r
d e v e lo p e d to e n d life, a t le a st n o t in h um ans. Yet s o m e drugs
do c a u se death, esp ecially i f they are a d m in iste re d in w ay s
th a t w e re n e v e r intended. T h e usual w a y to m isu se a d ru g is to
ex c eed the s u g g e ste d dose: ' th e o v e rd o se '.
W h ile m o s t d r u g s h ave s id e - e f fe c ts (e ffe c ts o th e r th a n the
p u rp o se for w h ic h th ey a re desig n e d ), an d m o st sid e- effe cts a re
m o re p ro n o u n c e d w h en a d rug is m isu s e d o r taken in overdose,
a side-effect like death is a lw a y s g o in g to be a serio us problem
for a d ru g m anufacturer.
The c o m p a n y resp on sib le for m an u factu rin g a d ru g th a t w ill
cause death in o v e rd o se will a lw a y s be n e rv o u s a b o u t such a
p ro d u c t an d there will be a search to dev elo p safer alternatives.
So, w h ile there a re so m e d ru g s that do relia b ly c a u se death if
taken in this way, this n u m b e r is sm all an d d ecreasing . I f a
d ru g that cau ses d e a th in o v e rd o se re m a in s on th e m arket, it
is likely that it is an im p o rtan t d ru g f o r w h ic h there are few
current alternatives.
T h e p ro c e ss o f rep lacin g p o ten tially lethal d ru g s w ith safer
m o d e m altern ativ es g oes on all the tim e. T h e o ld-fashioned,
lethal b arbiturates h av e a lm o s t all been rep laced b y m o d e m ,
safer sleeping tablets.
The lethal tri-cyclic an tid ep ressan ts h av e a lm o st disappeared,
rep laced b y m u ch safer se ratonin u p tak e inhibitors like Prozac.
P a in -re lie v in g d ru g s like p ro p o x y p h e n e are cu rre n tly u n d e r
rev iew an d have alre a d y b een rep laced in co u n trie s su ch as the
U K , U S an d N e w Z ealan d . T h e n u m b e r o f d ru g s that are o f
practical assistan ce to a serio u sly ill person seek ing a peaceful
death d ecrease s each year.
Introduction to D rugs
D r u g s a n d V om itin g
A n y su b stan ce taken o rally can b e v o m ite d up, an d concern
about this can c a u se co n sid e rab le anxiety. A person intending
to die m u st take th e full (lethal) am o u n t, s o it is im p o rtan t to
ensure that v o m itin g d o e s n o t occur. S o m e p eo p le a re prone to
v om itin g, an d so m e d isea ses can c a u se vom itin g. In a m in ority
o f c ases v o m itin g , o r fe a r o f vo m iting , can be such a problem
that it is n o t possible to u se oral drugs.
To m in im iz e th e ris k o f v o m itin g , a n a n ti-v o m itin g ( ' a n tie m e tic ') d rug is usu ally taken for a p erio d o f tim e befo re the
co n su m p tio n o f the lethal dru g. T h e re are a n u m b e r o f drugs
u s e d for th is purpose.
T hese an ti-vo m itin g drugs are re a d ily o btained, altho ug h the
m o s t e ffe c tiv e a re p re sc rip tio n item s. T h e m o s t c o m m o n
are m e to c lo p ra m id e (M a x o lo n , P ra m in , P a sp e rtin ) a n d
p ro c h lo rp e ra z in e (S te m e til, S te m a z in e ). O n e co m m o n
procedu re is to take six tablets (ie 6 0 m g m eto c lo p ra m id e as
a ' s ta t' d o se) a b o u t 4 0 m in u te s befo re tak in g th e lethal drug.
A n o th e r p ro ced u re is to take the an ti-em etic for a full tw o days
b efo re the lethal d rug is to b e c o n s u m e d (here th e usual do se is
tw o tablets every 8 hours). W ith this m e th o d there is then no
n eed to sy nchron ise th e tim e at w h ich th e an ti-v o m itin g drugs
are taken w ith th e tak in g o f th e lethal drugs.
Introduction to D rugs
D r u g s & A lcoh ol
A lcohol is often u sed a s a su p p le m e n t w h en d ru g s a re u s e d to
en d life. It serv es several functions. Firstly, lethal d ru g s taken
orally are often b itter an d leave a p ro lo n g e d u n pleasan t after
taste. Even w hen the d ru g is co n su m ed in a f e w quick m outhfuls,
a serio u sly ill person can find this taste quite distressing. Strong
alcohol is effective in re m o v in g this after-taste. A s this is to
b e th e p e r s o n 's last d rin k a fa v o u red spirit o r liqu eur is often
chosen. P eople sip at th eir favourite S cotch o r B aileys Irish
C ream an d th e b itter taste q uickly disappears.
Secondly, alcohol p lay s a useful role in ' p o ten tiatin g ' the lethal
drug. To fo llo w th e dru g w ith an alcoholic drink w ill usually
enh an ce its s p e e d o f action an d potency. T h is is true o f m o s t o f
the c o m m o n ly -u s e d lethal, oral drugs.
Thirdly, alcoh ol is a useful c a lm in g a g e n t (an x iolytic) in w hat
is inevitably a stressful tim e. It is im p o rtan t that an y alcoh ol is
taken a fte r th e c o n su m p tio n o f th e lethal d ru g s so th a t th ere is
n o clo u d in g o f a p e r s o n 's mind.
F o r ex am p le, i f a person in ten d ed to en d th eir life by drinking
v eterinary, liqu id N em b u tal th ey w o u ld p o u r the N em b u tal into
a sm all glass, qu ickly d o w n the d rin k in a few m o u th fu ls then
im m ed iately fo llo w the N e m b u ta l d rin k w ith a shot o f alcohol.
The b itter taste o f the N em b u tal w o u ld soon b e forgotten am idst
the p leasin g flavo ur o f th eir favourite c o ck tail b efo re sleep
ov ertoo k th em . W h a t c o u ld be m o re peaceful.
People should not force th em selv es to drink, how ever, especially
i f th e y f in d th e th o u g h t o f a lc o h o l d is ta s te fu l. T h e d ru g s
described in this bo o k cause death, w ith o r w ith ou t alcohol. The
m o st lik ely effect o f e x clu d in g th e alcohol is th a t th e process
will take longer. L iq u id m o rp h in e (O rd in e ) can b e u s e d as a
su p p lem en t/p o ten tiato r b y p eo p le w ith an av ersio n to alcohol.
D ru g T o leran ce
E xp osu re to a p articular d ru g o v e r a p ro lo n g e d p erio d o f tim e
can often lead to the d e v e lo p m e n t o f an insensitivity to that
drug. If a d ru g is b e in g taken for a p artic u la r m edical p u rp o se
(eg. th e re lie f o f pain), o n e m ig h t find that after a w h ile th e sam e
pain r e lie f can o n ly b e o b tain ed b y increasing th e dose. T his
is k n o w n as to le ra n c e .
S o m e d ru g s are particularly p rone to this effect. T h e b o d y 's
resp o n se to o p ia te s like m o rp h in e o r p eth id in e is an exam ple.
A fter tak in g m o rp h in e fo r even a sh o rt tim e, th e effect o f a
p artic u la r d ose will lessen an d g re a te r a m o u n ts will b e needed
to a c h ie v e the sam e p ain -reliev in g effect.
A fter a p erio d o f f th e drugs, o n e 's sensitivity usu ally returns.
T h is explains w h y p eo p le often accid en tally d ie w h en taking
illegal narcotics like heroin. A person w h o regularly u s e s heroin
so o n d ev elo p s a tolerance for it. I f they are unable to co n tinu e
ta k in g th e d ru g - p e rh a p s b e c a u s e th e ir s u p p ly h as b ro k en
d o w n o r p erhaps th ey h av e spent tim e in an institution, they
will red ev elo p their sensitivity. W h e n a n e w su p p ly b eco m es
av ailab le, th eir g re a te r sensitivity increases the lik elih oo d o f
accidental death (se e C h a p te r 10 fo r m o re in fo rm atio n on the
opiates).
T oleran ce to a p artic u la r d ru g can be an im p o rta n t factor w hen
c h o o sin g a d ru g to en d o n e s life. I f a serio u sly ill person has
b een tak in g a dru g fo r so m e tim e an d h as d e v elo p ed a tolerance
for this p artic u la r drug, the n e c e s sa ry lethal d o s e for th e drug
c an be h ig h er than that usu ally quoted.
Introduction to D rugs
S lo w R elea se D rugs
M a n y d ru g s are m a n u fa c tu re d in a w a y that a llo w s a slow,
steady absorption from th e gut into the b lo o d stream . T h e slow
r e le a s e form s o f a d ru g are often g iv e n th e initials S R . S om e
drugs that are used to p rov ide a p eaceful d e a th are av ailab le in
SR form s, b u t o n e s h o u ld be a w a re that these form s o f th e drug
are usually le ss e ffe c tiv e th a n s ta n d a r d p re p a ra tio n s.
This is because the d ru g 's lethal effect usually depends on a rapid
rise in the level o f th e d rug in a p e rs o n s b lo o d (ie. at a rate that
is to o fast for th e b o d y 's norm al excretion m ech an ism s). S lo w
R elease fo rm s d o n o t c a u se a stee p rise in the b lo o d level o f the
drug. C ru sh in g o r d iss o lv in g th e d ru g s before co n su m p tio n is
u n lik ely to alter this. P o w d e re d , s lo w re le a se d ru g s a re s till
slo w release.
O p iates like m o rp h in e a re often p rep ared in a S R fo rm s o that
a stable level o f th e d rug form s in the b lo o d stream to give
c o n tin u o u s pain relief. T a b le t S R f o rm s o f m o rp h in e (M S
C ontin, K ap ano l) a re o f little u se f o r sudden increases in pain.
In these instances, an im m ed iate-release form o f m o rp h in e is
u s u a lly u s e d to p ro v id e rapid r e lie f (eg. O rd in e liquid).
If a serio u sly ill p erso n w ere to use m o rp hine to en d th eir life,
th e liquid fo rm w o u ld be m u ch m o re effective th an the sam e
am ou nt o f crushed, slow release tablets. A s described in C h ap ter
10, how ever, there are b e tte r d ru g s (than the o p iates) to use to
end life relia b ly an d peacefully.
Introduction to D rugs
In tra v en o u s D ru g s
M an y drugs are delivered directly into th e bo d y through a needle
or can n u la that is p laced into a vein. D rug s d eliv ered by this
route m u st b e liquids. T h e p ro ced u re o f inserting a n eed le into
a vein req u ires a d eg ree o f ex p ertise a n d this can be difficult
for p eo p le w h o h ave n o t h ad so m e m edical o r n u rsin g training.
The s p e e d o f action o f an y d ru g a d m in iste re d in this w a y is
m uch g reater th an for those ad m in istered orally. T h e rapid effect
o f su ch adm inistration can o ccasio n ally c a u se difficulty. I f the
p erso n d e c id e s to inject the d ru g th em selv es they m a y loose
co n scio u sn ess befo re th ey h av e finished pu sh in g th e syringe
plunger, an d o n ly part o f th e req u ired d ose w o u ld be delivered.
To en su re that th e full lethal d o s e is ad m in istered intravenously,
a b ag o f salin e can be u sed. T h e saline b ag is a tta c h e d to
a c a n n u la th ro u g h a s ta n d a rd in tra v e n o u s ' g iv in g s e t ' (F ig
9.2). T h e d ru g s are a d d e d to th e saline an d co n tin u e to flow,
even i f co n scio u sn ess is lost. O n e a d v an tag e o f intrav eno us
adm in istration is that it ex tend s the range o f d ru g s that can be
u sed . S o m e drugs that are n o t w ell a b so rb e d th ro u g h the gut
w h en taken orally, d ru g s like p otassium , can cause death w h en
ad m in istered intravenously.
Introduction to D rugs
O th e r c o m m o n ly -u s e d d r u g s h ave a m u c h lo n g e r w in d o w
p e r i o d w h e n i n t e r v e n t i o n c a n o c c u r . F o r th e c o m m o n
p ro p o x y p h e n e /o x a z e p a m co m b in atio n (see C h a p te r 11), this
w in d o w p e rio d m a y b e a m a tte r o f h o u rs. T h i s m e a n s that
con siderable p lan n in g m a y be n eed ed to reduce th e ch an ce o f
d iscovery d u rin g this time.
T h e p o ssib ility o f u n w a n te d intervention is w h y m a n y people
p re fe r to take lethal d ru g s in the ev en in g w h en there is less
ch an ce o f d iscovery. A p e rs o n w h o tak es N e m b u ta l in the
ev en in g will h av e d ied b y the early h o u rs o f th e follow ing day.
The risk o f d isco v e ry is g re a te r for a p erso n e n d in g th eir life
w ith the p ro po xy ph ene/ox azepam com bination. T his is because
these d ru g s take co n sid e rab ly lo n g er to w o rk . If th e d ru g s are
taken in th e ev en in g , there is a greater ch an ce the person m ay
still b e aliv e in th e early h o u rs o f th e fo llo w in g m o rn in g an d
that d isco v e ry m a y occur.
I f th e d eep ly u n co n scio u s person is fo u n d b efo re death, this
can presen t a significant pro b le m to th e person task e d w ith,
or w h o accidentally, finds them . E v e n i f th e y are a w a re o f the
u n c o n s c io u s p e r s o n 's plan, th e d isco v e rer m u st d o som eth ing
to pro tect them selves.
It w o u ld not be acceptab le, fo r ex am p le, to claim in the m orning
that y o u n o tic e d that y o u r friend o r p a rtn e r w a s un con scio us
but y o u chose to do n o th ing a b o u t it. D uring th e n ig h t a person
m ight argue that they h ad b een asleep a n d h a d n 't n o tic e d , but
in th e m o rn in g , the situation changes. A person in this position
needs to c o n s id e r th eir o p tio n s carefully.
T h e S h e lf L ife o f D ru g s
M o st d ru g s are su bject to so m e fo rm o f degradation o v e r time.
T h is m a y b e b ro ug ht a b o u t by chem ical, physical o r m icrobial
b reak d o w n . T h e m ain im pact o f deg rad ation on a d ru g is the
loss o f potency.
To ensure that d ru g s a re a s effective a s possible, m anufacturers
include storage instructions an d an ' ex p iry d a te ' w ith each item.
T h e tim e ta k e n from m an u factu re to ex p iry date is referred to
a s the d r u g 's ' s h e lf life'.
It is in th e m a n u f a c tu re r s ' in terest to m a k e th is a s lo n g as
p ossible. T h is is n o t to say that a d rug w ill not b e effectiv e after
th e stated expiry date. Rather, this date m erely indicates that if
sto red correctly, no significant c h em ical, physical o r m icrobial
deg rad atio n o f the d ru g w ill h av e o c cu rred before this date.
R esearch sh o w s that m a n y drugs rem ain h ig h ly e ffective long
after th eir expiry date a n d effectiv en ess is usually defined as
> 9 0 % potency. F o r m o d e m m ed icin es, exp iratio n d ates are
usually set fo r tw o to three years after the date o f the m anufacture
o f the drug. F o r ex am p le, veterinary liquid N e m b u ta l w ill have
a s h e lf life o f tw o y ears in adv an ce o f th e tim e o f pu rch ase
sta m p e d on th e side o f th e bottle.
A lso, th e fo rm o f th e d ru g w ill often effect its s h e lf life. F o r
ex am p le, pills a n d cap su les sto red in th eir original, air-tight
containers at cool ro o m tem peratures an d free from hum idity are
often v iab le fo r a ro u n d 10 years. T h is is m u ch lo n g er than the
stated ex p iry date. T h e p o w d e re d fo rm o f a dru g (eg. C h in ese
p o w d e r N e m b u ta l) h as s im ila r longevity, e s p e c ia lly i f it is
v a c u u m -p a c k e d (u sin g a stan d a rd kitch en fo od v a c u u m -se ale r)
a n d kep t cool a n d a w a y from light. F o r d ru g s in liqu id form ,
th e s h e lf life is c o m m o n ly shorter.
To tell i f a d ru g h as deteriorated, there are so m e c o m m o n sense
guidelines.
In the c a s e o f a liquid, th e d r u g 's ap p e a ra n c e is im portant.
O n e s h o u l d c h e c k its c o l o u r a n d c l a r i t y ( h a s it b e c o m e
cloudy); particulate m atter (eg. a re there tiny v isib le particles);
preserv ativ e co n te n t ( i f stated); sterility (has the bottle been
ta m p e re d w ith o r op en ed ) an d w h e th e r th e dru g h as interacted
w ith its en clo su re (b o ttle o r lid). I f n o n e o f these sig n s a re
presen t, then the liquid in qu estio n is m o re likely to be viable,
th an i f there w e re a n y sig n s o f degradation.
Introduction to D rugs
http://bit.ly/9swOxk
C o n clu sio n
T his C h a p te r details so m e o f the m o st im p o rtan t issues that
sh o u ld be co n sid ered i f a serio u sly ill p erso n is p lan n in g to use
drugs to a c h ie v e a peacefu l, dignified death.
Specific issues such a s preparation , adm in istration , vo m itin g,
an d th e shelf-life o f a d rug are c o m m o n to all drugs, an d an
u nd erstanding o f these issu es red uces the chance o f failure. This
C h a p te r s h o u ld be read in co n ju n ctio n w ith th e ch ap ters that
detail th e u se o f p artic u la r d ru g s (C h ap ters 1 0 - 1 5 ) .
10
Drug Options - Morphine
&
Slow Euthanasia
A s k in g f o r S lo w E u th a n a sia
The p ro c e ss o f s lo w e u th a n a s ia is a lw a y s co n tro lled b y the
doctor. B ec au se o f this, there is u s u a lly little a patient can d o to
ensure that th e option is available. O ften w h en p atien ts realize
that th ey h ave a d eterio ratin g m ed ical co n d itio n , they ask their
d o cto r w h e th e r o r n o t th e y will be able to help th em ' a t th e end.'
T h e d o cto r m a y ev en v o lu n te e r to h av e this d iscussio n an d this
is en co u rag in g - but be careful.
W h e n d o c to r an d p atient begin sp eak in g in this tan g ential way,
there is a very real ch an ce that significant m isu n d erstan d in g s
can occur. It is n o t u n c o m m o n for a d o c to r to p ro m is e ' e v e ry
assistance w h en th e tim e c o m e s ' a n d fo r th e p atient to draw
im m en se c o m fo rt from this.
A patient m ight even im agine that the doctor is saying that w hen
things deteriorate I w ill g ive y o u access to lethal d r u g s . In
reality, this is h ig h ly unlikely. F e w m edical do ctors w o u ld risk
de-registration an d a significant ja il term . T h e only assistance
likely fro m the doctor, is fo r th em to initiate s lo w euthanasia,
w ith th e p a tie n t b e in g a d m itte d to an in stitutio n , a hospital
o r h osp ice. A n d th ere m a y w ell b e a rg u m e n t a b o u t w h en the
p ro c e ss sh o u ld co m m ence.
E xit s u g g e s ts that in s itu a tio n s w h e r e s lo w e u th a n a s ia has
appeal, th a t early d iscu ssio n s b etw een p atient an d d o cto r take
p la c e . B e blunt. I f th e d o c to r p ro m ises h e lp w h en th e tim e
c o m e s , insist on k n o w in g w h o w ill d ecid e w h en that time is,
and e x a c tly w h a t sort o f help is b e in g pro m ised ?
I f there is an y attem p t to skirt o r d ism iss y o u r questions, be very
w ary. Try discussin g th e issue w ith an o th e r doctor, o r look into
an alternative e n d o f life strategy.
T h e R o le o f O p ia te s and O p ioid s
O p ia te s a re naturally occu rrin g c o m p o u n d s that o rig in ate from
th e sap o f th e poppy, p a p a v e r so m n ife ru m . S u b stan ces derived
fro m th e se c o m p o u n d s are opioids. T h e se c o m p o u n d s all effect
th e sam e recep to rs in the brain an d are g en erally used for the
con trol o f stro n g pain.
W h ile m o rp h in e is the c o m m o n e st ex am p le, o th er ex am ples
include, pethidine, codeine, m eth ad on e an d fentanyl. The illegal
d rug heroin is also an opiate. All o p iates h a v e p ro p erties that
m a k e th em difficult d ru g s for a person to u se to relia b ly end
th eir life.
T h e bigg est p ro b le m associated w ith taking opiates is predicting
the effect. There is rem arkable individual variability in sensitivity
to th e se drugs w ithin th e norm al population. P eople w h o a re
sim ila r p h y sica lly (sam e height, w eig h t, sex etc) can h ave a
v astly different resp o n se to th e a d m in istratio n o f a n opiate.
A sm all d ose o f m o rp h in e m a y h ave a lm o st no effect on one
p erso n , w h ile th a t sam e do se could kill another. P redicting
th e effect o f th e d rug on an individual is difficult. W h e n these
d ru g s are u s e d clinically the rule o f th u m b h as b een to ' start
lo w an d go s lo w ' until th e in d iv id u a l's sensitivity to th e drug
is established.
A n o th e r d ifficulty w ith o p ia te s is th e rap id d e v e lo p m e n t o f
to le ra n c e w h e n th e d ru g s are taken for an y p e rio d o f tim e.
W ithin d ays, the m o rp h in e that initially h ad a p ow erful effect
on th e pain can b e c o m e a lm o st ineffective.
T h e U se o f H eroin
E xit is o c c a s io n a lly a s k e d a b o u t w h e th e r h ero in s h o u ld be
o btained from th e s tre e t a n d u s e d to en d life. T h e se questions
are o fte n p ro m p te d by n ew s rep orts o f p eo p le d y in g from a
heroin ov erdo se. In reality, there is little to b e g ain ed b y using
heroin.
A s an o p iate heroin suffers from th e p ro b le m s o f to leran ce an d
sensitivity m e n tio n e d ab ov e. In addition there is the question
o f th e u n certain ty o f th e do se w ith heroin. B ec au se it h as been
acq u ired on th e streets, o n e can n e v e r b e e x a c tly sure w hat
o r h o w m u ch o n e h as a ctu ally p u rch ased . It also n e e d s to be
injected intravenously. In E x it's ex p e rie nce , f e w eld erly and
seriously ill p eo p le h ave th e se skills.
N o te: I f h ero in is ta ken orally, it tu rn s b a c k in to m o rp h in e in th e
g u t a n d o ffe rs n o a d v a n ta g e o v e r p rescrip tio n ta b le t m orphine,
w h ere a t le a st th e e x a c t d o se is know n.
O ne final point o n th e opiates. I f o n e d oes d ie tak in g these
drugs, th e d e a th is likely to be v e ry p eacefu l. M o rp h ia is, after
all, th e g o d d e s s o f dream s.
C o n clu sio n
In E x it's internal p ollin g o f o v e r 1000 o f o u r su pp orters, less
th an o n e percen t (0.3 % ) o f E xit m e m b e rs say that th ey w o uld
p refer slow euthanasia co m p a re d to a Peaceful Pill (89% ). Slow
e u th a n a s ia is, th erefo re, o n e o f th e least-p referred m eth o d s
o f d ying, a n d o n e that is usually a v o id e d w h en o th er options
exist. G iven a ch o ice, p eo p le p refer to h a v e co ntro l o f the d ying
process.
T h is is n o t the case w ith s lo w euth anasia. It is relatively rare
to find so m eo n e w h o w a n ts to sp e n d th eir last d a y s in a drugin d u ced com a. W h e n p eo p le d ecid e that th eir su fferin g is so
great that death is preferable, th ey w an t their passing to b e quick.
T h is is w h y slow eu thanasia is a lm o s t a lw a y s an option o f last
resort. It is the m eth o d a c cep ted w h en n o thin g e lse is on offer,
a n d th e only altern ativ e is relentless an d on g o in g suffering.
Finally, th ere rem ains a c o m m o n b e lie f th a t th e o p ia te s are the
b est d ru g s to en d life. T h is u n d eserv ed rep utatio n c o m e s from
th eir alm o st-un iversal use in s lo w eu thanasia, w h e r e doctors
h av e little choice.
W h i l e a s in g l e o v e r d o s e o f m o r p h i n e m a y c a u s e d e a th ,
individual sensitivity a n d to leran ce to these d ru g s m ak e this an
u n certain a n d u n p redictab le p ro cess. T h e o p iates are best used
to do th e j o b they are d esig n e d to do, co ntrol stro n g pain. T h ere
are b e tte r eu thanasia optio ns available.
T h e E x it R P T est fo r M o rp h in e
M o rp h in e (o r a n y o f the o th e r opiates) d o n o t score particularly
w ell on the RP Test. W h e n u s e d a s a dru g an d taken as a single
dose by a person w an tin g to die, the difficulty o f establishing the
lethal d ose significantly reduces R eliability (4/10). Peacefulness
though is g o o d (10/10).
M in o r criteria scores are patchy. A vailability (3/5), som etim es
m o rp h in e is available - i f a person is suffering from a recognised
p ainfu l disease. But th e u se o f th e o p ia te s as drugs o f addiction
an d th e ir p la c e in th e illegal n a rc o tic tra d e can a lso m ak e
th e m o c c a s i o n a l l y v e r y d if f ic u lt to o b ta in . P re p a ra tio n is
easy (5 /5 ), a lth o u g h c o n s tric te d ' p in p o in t' p u p ils can often
alert a m edical o fficer to th e p rese n c e o f th e se d ru g s in the
sy stem (U n d e te c ta b ility = 2 /5). D eath can a lso take so m e
tim e, d ep en d in g on o n e s tolerance an d resu scitation is often
straig h tfo rw ard u sin g th e o p iate an tag o n ist N alo x o n e (S p eed
= 2/5). T h e re are n o safety issu es (S afety = 5 /5), an d th e drug
has a m od erate s h e lf life (S torage = 3/5).
E x it R P T e s t - M orp h in e
C rite ria
S core
R eliability
4 /1 0
P e a ce fu ln e ss
10/10
A va ila b ility
3 /5
P rep a ra tio n
5 /5
U n d etecta b ility
2 /5
S p ee d
2 /5
S a fe ty
5 /5
S to ra g e
3 /5
T o ta l
3 4 (68% )
11
Drug Options - Propoxyphene
In tro d u ctio n
A useful, lethal d rug , still p rescrib ed in a handful o f countries,
is p ro p o x y p h en e. T h e dru g is m a rk e te d u n d e r v a rio u s nam es
an d used as an oral analgesic (pain reliever). I f p rep ared in a
certain w ay, a n d taken in co m b in atio n with a c o m m o n b e n z o diazep in e slee p in g pill su ch a s o x a z e p a m (S erep ax ), p ro p o x y p h e n e w ill p ro v id e a reliable, peaceful an d dignified death.
Fig 11.1
Propoxyphene capsules (Doloxene)
T he V ariou s F o r m s o f P ro p o x y p h en e
P ro p o x y p h en e is m a rk e te d u n d e r a n u m b e r o f nam es, e x a m
p les include D arvo n, D o lo x en e, a n d D epronal.
R eg ard less o f its nam e, th e key n ecessary ingredient is p ro
p o x y p h e n e - e ith e r a s th e hy d ro ch lo rid e o r napsylate, an d it is
im p o rtan t that the d ru g labels are re a d very carefully. In so m e
v id e o se g m e n ts in clu d ed in this ch a p te r th e n am e D o lo x e n e is
u s e d to refer to p ropoxyphene.
P ro p o x y p h en e cap su les h ave o n ly o n e active ing red ient (dextro p ro p o x y p h e ne napsylate). H ow ever, th e d ru g p ro p o x y p h e n e is often m a rk e te d in co m b inatio n w ith o th er co m m o n
an algesics such a s paracetam ol (a c e ta m in o p h e n ) an d m ark eted
as D i-G e sic (D a rv o c et).
T h e se co m b in atio n p ro d u cts are o f lim ited use. T aking a large
am o u n t o f the a sso ciated d rug can co m p licate th e p ro c e ss . The
ingestion o f a su b stan tial q u an tity o f p aracetam o l (aceta m in o p h e n ) f o r e x a m p le m a y well lead to death, b u t it w o u ld not
b e re g ard ed a s particularly peaceful.
W h en is P r o p o x y p h en e P rescrib ed ?
P ro p o x y p h en e (d ex tro p ro p o x y p h en e nap sy late) is a lm o st a l
w a y s av ailab le fro m a d o c to r on p rescription, w h e re it is used
for p ain m an ag em en t. P ro p o x y p h en e is usu ally prescribed
w h e n o v er-th e-co u n ter pain reliev ers prove in ad eq u ate and
w h en other, m o re c o m m o n prescription p ain -re liev e rs (eg.
P anadein e F orte o r T y leno l-C od ein e - a m ix tu re o f paraceta m ol an d cod eine) p ro v e unsatisfactory.
P ro p o x y p h en e can be u s e d w h e n e v e r there is a n e e d for g en
eral pain relief. B efore th eir rem o v al in late 2 0 1 0 in th e US
(a n d C an a d a), p ro p o x y p h e n e an d co m b in a tio n s w e re the 12th
m o s t p rescribed gen eric d rug (P u b lic C itizen, 2006)
H o w L eth a l is P ro p o x y p h en e?
P ro p o x y p h en e h as a v ery n a rro w th erapeutic m argin. T h e dif
feren ce in d ose betw een th a t p ro v id in g analgesia a n d th a t c a u s
ing death is small. L ike th e o p ioid s, th e o u tco m e fro m a partic
u la r do se can b e difficult to pred ict (S ee C h a p te r 10), b u t this
dru g p ro d u ces a cardio-toxic m etab olite w h e n it break s d o w n
w h ich in creases its u sefu ln ess as a s e l f d eliv eran ce agent.
W h e n an o th e r drug, the read ily-av ailab le, non-lethal sleeping
tablet, o x azep am , is add ed , a lo n g w ith alcoh ol, th e result is
certain. E xit has n o rep o rted failures from this com bination.
A s the repu tatio n o f p ro p o x y p h en e has g ro w n , so scrip t sizes
have been red u ced . T h e stan d a rd p a ck ag in g n u m b e r fo r p ro
p o x y p h e n e is n o w 50 cap sules. All cap su les co ntain the sam e
100m g o f d e x tro p ro p o x y p h e n e napsylate.
T h e R o le o f O x a zep a m
O x azep am (S erep ax ) is a m o d erately lon g-actin g, non-lethal
sleeping tablet. A n o th e r m o d e ra te ly long -acting slee p in g tab
let often u s e d in co m bin ation w ith p ro p o x y p h e n e is nitrazepam
(M og ad on ). T h e se m o d e m slee p in g tablets are m e m b e rs o f a
d ru g class kn o w n a s b en zo d iazep in es an d w h en taken b y th em
selves a re n o t u s u a lly lethal, ev en i f taken in large am ounts.
W h e n taken in co m b inatio n w ith p ro p o x y p h en e, o x a z e p a m or
n itra z e p a m reinforce the effect o f a p ro p o x y p h e n e an d a lethal
co m b ination is th e result.
N o te : D u ra tio n o f a ctio n o f th e b e n zo d ia zep in e is im p o rta n t
- s h o r te r a c tin g d ru g s lik e tem a zep a m a re n o t recom m ended.
W h en is O x a z e p a m P rescrib ed ?
Well k n o w n a s slee p in g drugs, o x a z e p a m an d n itra z e p a m are
av ailab le on p rescriptio n from a doctor. T h e y are prescribed
f o r in so m n ia (w h e n a p erso n is u n ab le to sleep). O x a z e p a m is
u su ally p rescrib ed in pack ets c o n tain in g 25 slee p in g tablets,
w h ic h co m e in tw o sizes, 15mg an d 30m g.
P eople u sin g p ro p o x y p h en e, often take a full p ack et o f 3 0 m g
o x a z e p a m tablets a s the supplem ent.
T ak in g P r o p o x y p h en e
T he drugs are taken sequentially. P rep are th e p ro p o x y p h en e
b y p ullin g apart 100 x 100m g cap su les (or cu t th em o p en w ith
scisso rs) a n d e m p ty th e 10gm w h ite dex tro p ro p o x y p h ene nap sy late p o w d e r into a glass. In an o th e r g lass p la c e 10 o r m o re
3 0 m g o x a z e p a m tablets an d c o v e r th em w ith water.
It is w ise to take an a n ti-e m e tic (eg m e to c lo p r a m id e ) e ith e r as
a sin g le stat do se o r f o r 4 8 h o u rs befo re th e p la n n e d death (see
C h a p te r 9). A fter h av in g s o m e th in g light to eat, ad d enough
w a te r to the 10g m o f p ro p o x y p h ene p o w d e r s o that stirring a l
low s th e d rug to be drunk. N o te : th e n ap sy la te d o e s not dis
so lv e in the w ater, stir with a spo on an d then drink th e s u sp en
sion o f particles. S tir the s eco n d g lass w ith th e o x a z e p a m and
w a t e r till this a lso can b e taken as a drink.
A lco h o l is useful to take a w a y th e b itter dru g after-taste and
will s p e e d the p ro c ess. S it com fortably. In 1 0 - 2 0 m inutes
s lee p w ill o c c u r a n d death will follow usually in 4 - 6 hours.
Fig 11.3
100mg pink Doloxene Capsules
S h e lf L ife o f D o lo x en e
P ro p o x y p h en e h as a relativ ely lon g s h e lf life. P rescribed cap
su les h av e an e x p iry d ate sta m p e d on each c a rd a n d this is
u su ally 2 o r 3 y e a r s into th e future. A lth ou gh this p rovides
o n ly a rough guide, in th e ab sen ce o f an y av ailab le testing o f
th e dru g, it is th e on ly indication o n e has. C ap su les that have
re a c h e d th eir ex p iry d ate sh o u ld be treated w ith cau tion (See
C h a p te r 8 for a discussion on s h e l f life).
T h e F u tu re o f P r o p o x y p h en e
P ro p o x y p h en e faces an uncertain future. T h e w ith d raw al o f the
d rug fro m th e prescription sch ed ule in th e U K in early 2005
h as led to the c o m m issio n in g o f a rep o rt on possible sim ilar
restrictio ns in A ustralia.
T h e d rug has n o w b een w ith d ra w n in the E u ro p e a n U n ion , the
US, C an a d a an d in N e w Z ealan d . In N o v e m b e r 2 0 1 0 the F D A
a n n o u n c e d that th e dru g w o u ld be also re m o v e d from the U S
m arket.
http://nyti.ms/9iPzgD
R P T est for P ro p o x y p h en e
P ro p o x y p h en e sco res w ell on th e R P Test. E xit h as no co n
firm ed rep orts o f failure an d it rates 9 /1 0 fo r Reliability. The
tim e before sleep o ccu rs is lo n g er than o th er d ru g s like N e m b
utal a n d this can c a u se anxiety. P eacefu ln ess (7/10).
In th e m in o r categories: A vailability is listed a t 4 /5 . M ost
p eo p le w h o set o u t to g et this d ru g w ill acq u ire it. R e m e m
b e r th o u g h that i f the d ru g is w ith d ra w n , availab ility will drop
to zero. P rep aratio n is m o re co m p licated than w ith o th er ingestib les (P r= 3/5). T h e d ru g is u n d etectab le - u n less there is
an autopsy, alth ou gh co n stricted p up ils m a y c a u se suspicion
(D =3/5). T h e p rocess is s lo w (S p = 2 /5 ) th e d ru g p resen ts no
risk to o th ers (S a= 5/5).
T h e d ru g h as a m o derate s h e lf life
R P Test fo r P ro p o x y p h en e
C rite ria
S core
R e lia b ility
9/10
P e a ce fu ln e ss
7/10
A vailability
4 /5
P rep a ra tio n
3 /5
U n d etecta b ility
3 /5
S p ee d
2 /5
S a fe ty
5 /5
S to ra g e
3 /5
T o ta l
3 6 (72% )
12
T h e h o rm o n e - Insulin
T h e anti-m alarial - C h lo ro q u in (S ep t 2 0 1 2 update)
A m itrip ty lin e
A m itrip ty lin e is the m o st useful in a c lass o f d ru g s k n o w n as
tricyclic an tid ep ressan ts (T C A s). T h e se d ru g s can b e lethal if
taken in a certain way.
T h e T C A s d ate b ack to th e early 1960s w h e re they established
th e m se lv e s as useful an tid ep ressan ts. H ow ever, their n arrow
th erap eu tic m arg in (the do se n eed ed for therap y a s an antidep ressan t a n d that w h ic h is toxic is clo se ) m e a n t that there w ere
d a n g e rs in prescribing th e se d ru g s, especially to depressed
p eople, fro m e ith e r accidental o r intentional overdose.
S core
R eliability
9/10
P ea cefu ln ess
7/10
A va ila b ility
2 /5
P rep a ra tio n
3 /5
U n d etecta b ility
3 /5
S p e ed
2 /5
S a fety
5 /5
S to ra g e
3 /5
T o ta l
3 4 (68 %)
In su lin
T h e re has b een a lot o f recen t interest in th e u se o f Insulin
to p ro vid e a peacefu l death. R ea so n s for this are e a s y to u n derstand . In d e v e lo p e d natio ns there is a hu g e grow th in the
n u m b e rs o f p eo p le w ith T ype 2 diabetes, an d a c o rre sp o n d ing increase in th e n u m b e r o f p eo p le w ith re a d y access to this
drug. An additional facto r is the c o m m o n chro nic co m p lic a tio n s that often a c c o m p a n y severe form s o f this disease. T hese
sy m p to m s can often s o lim it a p e rso n 's q u a lity o f life, that the
option o f a peaceful death is so u g h t. This d riv es interest in the
u se o f this drug.
In S u m m a r y
N o t reliable en o u g h to re c o m m e n d i f su b c u ta n e o u s injection is
the o n ly m eth o d o f a d m in istratio n available.
Fig 12.3 NovoRapid rapid acting insulin ampoule. 1000U in 10ml with 0.5ml
syringe for subcutaneous administration
NOTE: 20 full syringes would need to be
quickly injected to administer 1000U
13
Drug Options - Nembutal
I a m h o p in g to g e t a c c e s s to y o u r 'p e a c e fu l p i l l ' - n o t
fo r im m e d ia te use, bu t to h a v e o n h a n d s h o u ld m y health
d e te rio ra te to o m u ch in th e fu tu re . A rthur, 77 years
In tro d u ctio n
T h e barbiturate S o d iu m Pentobarbital is th e d ru g th a t co m es
closest to th e c o n c e p t o f th e P eaceful Pill.
A lthough
D rug O p tio n s - N e m b u ta l
A lo n g w ith th e o r ig in a l V eronal,
there w a s Barbital, A m ytal, Seconal,
S o n e ry l, N e m b u ta l an d several
others.
W h ile th e se b a rb itu ra te s w ere
h ig h ly effectiv e slee p in g tablets, a
s ig n if ic a n t p r o b le m w a s th e v e ry
s e rio u s sid e-effect a s so c ia te d with
th e ir o v e r d o s e - d eath . T h is w a s
fo u n d to b e e s p e c ia lly tru e i f th e
pills w ere taken with alcohol. M any
fam o u s p eo p le have d ied - som e
M a rily n M o n ro e , Jud y
B a rb itu ra te s a s D ru g s o f A b u se
In the 1960s, the im ag e o f barbiturates su ffered further w hen
they w e re fo u n d to be useful m o o d -alterin g drugs. A t this tim e,
th e d ep ressan t effect o f th e d ru g s w a s exploited. B y carefully
ad ju stin g the dose, a desirable soporific a n d tranquil state could
be achieved an d th ey b e c a m e kn o w n a s ' d o w n e rs.' A s dow ners,
barbiturates w o u ld often b e in term ix ed w ith ' u p p ers' - drugs like
am p h etam in es. T h is ty pe o f u sa g e led to a set o f slang street
te rm s fo r these d ru g s such a s P in k L a d ie s, Y ellow B u lle ts,
P e a n u ts an d D o lls (from B arbie do lls) (M en d elso n , 1980).
A s te rile f o rm o f N e m b u t a l h as a l s o p e r s is te d a s a u sefu l
co m p lete anaesthetic a g e n t that can q uick ly ren d er an anim al
unconscious for surgery. Pentobarbital continues to p lay a role in
veterinary practice to this d ay even though its u se by the m edical
profession h as all b u t disap peared . A d e v e lo p m e n t that h as led
to a resurrection o f these o u td ated d ru g s is th eir increasing use
as th e d ru g s o f ch o ice for v o lu n ta ry euthanasia.
Fig 11.5:
Sterile veterinary
Nembutal
A v a ila b le F o rm s o f N em b u ta l
F o r h u m an use, N em b u tal w a s exten siv ely m ark eted a s sleeping
tablets o r capsules in th e 1950s & 1960s. Even though N em butal
disappeared o f f the m ark et ov er a decade ago, m an y people have
o ld sto ck s w h ic h are still potent. O n e h u n d red o f these capsules
( 10 0 x 100m g = 10gm o f barbiturate) is a lethal dose.
B arbiturates are also well a b so rb e d rectally a n d so m e countries
h ave m ark eted form s o f suppositories. N o v a R ec ta l in C an ad a
is o n e such ex am p le. S terile a m p o u le s o f injectable N em butal
for in tram u scular an d intrav en ou s adm inistration a s a hypnotic,
an ti-c o n v u lsan t an d pre -o p e rative sed ativ e still find a small
p lace in m e d ic in e in so m e co u n tries in clu d in g th e US.
T h e v eterin ary fo rm s o f th e d ru g a re a lso still u sed in eith er
the sterile in jectab le form for anaesthesia, o r a no n -sterile form
(V alabarb o r L ethabarb) for an im al euthanasia.
T h e s te r ile fo rm o f th is
v eterinary barbiturate (fig 11.5)
is m a r k e t e d in s m a ll, s e a le d
10 0 m l bottles that are protected
w ith a m etal seal. T h is m etal
cap m a k e s tam p erin g obvious.
T h e N e m b u ta l inside is a clear
liquid w ith co n cen tratio n o f 60
m g/m l. Each 100ml bottle has
a total o f 6 g m o f N e m b u ta l enough to p rov id e a peaceful
death.
N o n - s t e r i l e N e m b u t a l liq u id
(L e th a b a rb F ig 11.6) is used
veterinary Nembutal (Lethabarb)
for anim al euthanasia, is colour
d y e d f o r sa fe ty , a n d h a s a m u c h h i g h e r c o n c e n t r a t i o n o f
b arb itu rate (3 0 0 m g /m l). 30m l taken o rally is lethal.
Since 2010, the pow dered form o f the drug (sodium pentobarbital)
has b e c o m e in creasin g ly available a s an a ssa y g ra d e laboratory
reagent. F o r d etails o f this useful form o f the d ru g - see C h 12.
P e n to b a rb & P h e n o b a r b - C o n fu sin g N a m es
N e m b u ta l is th e co m m ercial o r trade n am e for th e barbiturate
w h ose chem ical nam e is pentobarbital ( 'p ent-o-barb-it- l ' ). This
d ru g is d ifferen t to an o th e r barbiturate called phenobarbital.
P h eno b arb ital is a s lo w -a c tin g d rug , u s e d p re d o m in a n tly as
an an ti-c o n v u lsan t to stabilise p eo p le su fferin g fro m epilepsy.
W h ile p h e n o b a r b can b e lethal in o v e rd o se , it h as a m u ch
slo w er actio n than N e m b u ta l an d is n o t an ideal m eth o d for
self-deliverance. T hese tw o barbiturates should not be confused.
S o u r c e s o f N em b u ta l
In m o st w estern countries there are n o w n o m ed ically prescribed
b a r b itu r a te s le e p in g ta b le ts . W h a t r e m a i n s in th e p u b lic
c o n s c io u s n e s s , h o w e v e r , is th e b e l i e f th a t a n o v e r d o s e o f
slee p in g tablets - an y slee p in g tab let - will cause death. T his
m isc o n c e p tio n leads to m a n y failed suicide attem p ts a s elderly
o r serio u sly ill p eo p le often stockpile, then take, large num bers
o f m o d e m , non-lethal slee p in g tablets.
Let u s b e c l e ar. T h e re is n o p o in t in a sk in g y o u r d o c to r for
slee p in g tablets i f y o u plan to e n d y o u r life. Tablets ob tain ed
this w a y w ill n o t be b arbitu rates an d the d ru g s o b tain ed w ill be
unlikely, ev en in significant ov erd ose, to c a u se death.
T h e c o m m o n e s t s o u rc e o f life -e n d in g b a rb itu ra te s in m o st
w estern co u n tries is th e v eterin ary profession, a n d even this
s u p p ly is likely to d im in ish in tim e. T h e re is n o legitim ate or
p lau sib le reason fo r a v e t to p rov id e this d ru g to an y m e m b e r
o f th e public. You can h ard ly tell y o u r vet that y o u 'r e plan nin g
to op erate on the cat this w eekend!
N em b u ta l and Vets
Veterinary N em butal h as b een used b y vets to euthani z e anim als
o r as an anaesthetic in su rg ery for m a n y decades. B efo re 1998,
w h en N e m b u ta l w a s still b e in g p rescrib ed b y d octo rs, it m ay
ju s t h av e b een p o ssib le to argue that y o u r insom nia w a s s o bad
that o n ly th e rare an d d a n g ero u s N e m b u ta l c o u ld h elp y o u g et a
g o o d n ig h t's sleep. B u t there is sim p ly no ex cu se o n e can give
a v et to o b tain this drug!
A C a se S tu d y in N em b u ta l
W h e n a sk e d a b o u t N e m b u ta l at E xit w o rk sh o p s, I tell people
that it can b e v e ry h a n d y to k n o w a vet. S o m e tim e ago, I w a s
m a k in g a clinic v isit to the b ed side o f Harry, a dying patient.
W ith his w ife a t h is side H arry a sk e d m e a b o u t the best d r u g s ,
th e on es th a t w o u ld let him peacefully en d his o w n life.
I ex p lain ed that the b e s t d rug w a s N e m b u ta l, but that this w a s
on ly av ailab le from a vet. H o w m a n y vets d o y o u k n o w really
w e l l I asked, o n e s that w ill risk ja il helping y o u ? H is silence
an sw ered m y qu estio n, a n d w e w e n t on to talk a b o u t o th er m ore
easily available, but less effective, drugs.
A fter th e visit, 1 left th e b ed ro o m an d h ad a cu p o f tea in the
k itch en w ith H a rry 's w ife , E s m e . T entativ ely sh e said, you
k n o w w h en y o u a sk e d a b o u t k n o w in g a v e t? I looked at her,
confused. She w e n t on w e ll, I k n e w a vet, v e ry well in d e e d .
I w aited , n o t k n o w in g w h a t w a s to follow. S h e co ntinued. In
fact, s o m e tim e b ack I h ad an affair w ith a vet. M y h u sb an d
k n o w s n oth ing a b o u t it, an d I w a n t to k eep it that way. But
that v et o w e s m e s o m e b lo o d y b ig favo urs an d I 'm g o in g to
call th em in !
A few w e e k s later, H arry d ied o f h is disease. I heard that Esm e
did indeed call in the favour, obtaining th e 100ml bottle o f liquid
N em b u tal. She told m e th a t the bottle sat in the b ed ro o m w ith
H arry d u rin g his last w e e k s an d that he d rew im m e n se com fort
from k n o w in g it w a s there. A s he faced every n e w day, he w as
re a ss u re d b y the k n o w led g e that i f th e d ay b e c a m e to o difficult,
h e c o u ld leave a t an y tim e. Indeed, th e p resen ce o f the drug
p ro lo n g e d H a rry s life.
N em b u ta l and th e B la ck M ark et
E xit receiv es o ccasio nal repo rts o f p eo p le p ay in g a v e ry high
p ric e on th e b la c k m a rk e t for N e m b u ta l. D esp erate f o r the
d ru g, so m e h ave p a id o v e r $ 5 0 0 0 fo r a sin g le 100ml bottle o f
v eterin ary N e m b u ta l. T h is sam e bottle w o u ld retail to a vet
f o r less th an S50. D espite th e h u g e potential profit to a d ealer,
N e m b u ta l is rarely found this w ay. T h e usual law s o f supply
an d d e m a n d that g o v ern th e illegal d rug tra d e do n o t apply, as
n o o n e will e v e r w an t m o re than o n e bottle o f this d rug . S upply
ch ain s do n o t therefore develop.
T h e N em b u tal that d o e s find its w a y on to th e street is usually
in the form o f th e sterile veterinary liquid. It is p re su m e d that
it is o b tain ed w h e n v eterin ary clinics a re broken into b y people
loo kin g for tradeable veterinary steroids.
I f th e seal an d labelling o f a N e m b u ta l bottle is intact an d the
ex p iry date n o t ex c e e d e d , the d rug is likely to b e effective.
N e v e rth e le ss, o n e is a d v ise d to te st th e substance i f p lan n in g to
u se su ch sou rces. T h e Exit barbiturate te st kit is av ailab le at:
h ttp ://b it.ly /9 sw O x k
T h e S h e lf L ife o f L iq u id N em b u tal
E vent th o u g h m o st liquid N e m b u ta l will h a v e an e x p iry d ate o f
a ro u n d tw o years, this is o n e su b stan ce that is k n o w n to rem ain
effective f o r m u ch longer. I f sto red in a co ol p lace an d kept
in its sterile, s e a le d bottle, liqu id N e m b u ta l can be ex p e c ted to
h av e a shelf-life o f m a n y years.
A d e t a i l e d d is c u s s io n o f th e s h e l f life o f b o th liq u id an d
p o w d e re d N e m b u ta l can be found in C h a p te r 15.
N em b u ta l - S u m m a ry
T h e barbiturate pentobarbital (N em b u tal) is th e best euthanasia
d rug an d c o m e s closest to th e co n cep t o f th e P eaceful Pill. In
co u n tries w h e re it is lawful to h elp so m eo n e to d ie a n d an y dru g
o r s u b sta n c e could be used, th e ch o ice is alw ay s N em b u tal.
Yet N e m b u ta l is a h ard dru g to obtain w ith d o c to rs in m o st
w estern co u n tries no longer ab le/ w illin g to p rescribe the drug.
N e m b u ta l's restricted u se by vets m akes it in creasin g ly difficult
to access.
H ow ev er, N em b u tal can be o b tain ed from o v erseas, in South
A m erica, S E Asia, an d in p o w d e re d form from China. T h e next
ch a p te r g iv es a d etailed o u tlin e o f w h e re to g o an d h o w to buy
N em butal. T h is inform ation c h a n g e s frequently an d is regularly
u p d a te d for the o n lin e versio n o f The P e a cefu l P ill eH a n d b o o k.
E x it R P T est - N em b u ta l
C rite ria
S core
R e lia b ility
10/10
P e a ce fu ln e ss
10/10
A va ila b ility
2 /5
P rep a ra tio n
5 /5
U n d etecta b ility
4 /5
Speed
4 /5
S a fe ty
5 /5
S to ra g e
4 /5
T o ta l S co re
4 4 (88% )
14
Obtaining Nem butal
In tro d u ctio n
F o r so m e y ears n o w , N em b u tal h as b een available in a n u m b e r
o f countries. M a n y elderly p eo p le s e e k this d ru g an d lock it
a w a y as th eir insurance p o lic y for the future. In m o st w estern
c o u n tr ie s th e d ru g r e m a in s h e a v ily r e s tr ic te d w ith a n y o n e
im porting d rug a lm o st inev itably b rea kin g th e law. H ow ever,
this c rim e ten d s to be ov errid d en b y the co m fo rt o f k n o w in g
th ey are b ack in control o f th eir life (an d death). T h e option o f
a p eaceful death, sh o u ld o n e 's h ealth ' take a turn fo r th e w o rse '
g iv es significant on to log ical security. A n insurance p o licy for
th e future. P eace o f m in d for the present.
W h ile N e m b u ta l is a v a ila b le in co u n tries rang ing fro m Peru
in S outh A m e ric a to C h in a , in fo rm atio n on h o w an d w h e re to
p u rch ase th e dru g is co n sta n tly changing.
S in c e th e first ed ition o f this H a n d b o o k w a s p u b lish ed in 2006,
E xit h as e sta b lish ed a global n etw o rk o f tra v elle rs w h o have
p u rc h a se d N em b u tal a ro u n d th e w orld. S u m m arisin g , upd atin g
an d p u b lish in g this inform ation has m a d e this H a n d b o o k and
th e o n lin e P e a c efu l P ill e H a n d b o o k th e lead ing au th o rities for
su ch inform ation.
O btaining N em butal
T ypes o f N em b u ta l on Sale
N e m b u ta l (P en to barbital S o d iu m ) can b e p u rch ased bo th overth e-co u n ter an d b y m ail order, eith er in solution as a veterinary
liquid, o r as the w h ite crystalline salt. R arely the drug can still
be found as tablets o r capsules for h u m an use as a sleeping agent.
T h e liquid fo rm is a veterin ary p ro d u c t that is u sed for anim al
anaesthesia an d u s u a lly p a c k a g e d a s a sterile liquid in either
50m l o r 100ml b o ttles. It is alw ay s at th e s a m e concentration
o f 6 0 m g /m l ( ie a 5 0 m l/1 0 0 m l b o ttle c o n ta in s 3 g m /6 g m o f
N em bu tal).
T h e w h ite cry stallin e so lid p o w d e r is th e form that is generally
av ailab le fro m China.
N e m b u ta l tab lets fo r h u m a n u se are still a v a ila b le in so m e
co u n tries (eg. T h a ilan d ) on prescription as a slee p in g tablets.
D r u g L a b ellin g
W h e re veterinary N e m b u ta l is s o ld o v er-th e-co u n ter in liquid
fo rm , it is m ark eted u n d e r a range o f retail n am es. T h e key
ingredien t to look for on th e label is Pentobarbital S o d iu m .
In M ex ico, veterin ary N e m b u ta l is sold o v er-the-co un ter and
o n lin e a n d lab elled as: A n e s t e s a l , B a rb ith a l, S e d a lfo r m a ,
S ed a lf o r te , P en to vet, P e n to m a x (see F ig 14.1 - 14.9).
In Peru a n d B olivia, veterin ary N em b u tal is retailed as H alatal
o r P e n ta -H y p n o l (see F ig 14.23 - 14.24)
In T h a ilan d it is m a rk e te d a s N e m b u ta l.( see F ig 14.25)
O btaining N em butal
O btaining N em butal
O btaining N em butal
O btaining N em butal
O btaining N em butal
L e g a l Iss u e s w i th th e P u r c h a s e o f N e m b u t a l o v e r t h e N et
To date, E xit k n o w s o f o n ly o n e person w h o h as been charged
w ith im p ortation offences a n y w h e re in the w o rld . T h is person
w a s a m e m b e r o f E xit (A n n ) fro m M elb o u rn e, Australia. A nn
w a s charge d w ith im portation o f tw o b o ttles o f N e m b u ta l after
h e r c o n s ig n m e n t w a s in terc ep ted by C u s to m s an d referred to
th e A u stralian F ed eral Police (A F P ) in early 2009.
T h e first A n n w a s aw are that her N em butal w o u ld not be arriving
w a s w h e n the A F P cam e to h e r h o m e, an d s e rv e d a search
w arrant. A t h er co u rt h earin g in A pril a y e a r later, sh e pleaded
guilty. S in c e this w a s h er first o ffence, th e M a g istra te issued
h e r w ith a fine o f S500, a 12 m o n th go o d b eh av io u r b o n d and
o rd e re d she p ay $ 1 0 0 0 to the co u rt fund. N o co nv ictio n w a s
recorded.
S ee: h ttp ://b it.ly/b E C n zG
N e m b u t a l O v e r t h e I n t e r n e t : M e x ic o
S in c e 2 0 0 8 , Exit has h ig h lig h ted th e serv ices o f one M exican
m ail-ord er serv ice, M e troflog, w h ic h can b e fo u n d at:
http://www.metroflog.com/mo_cuisher
O btaining N em butal
O btaining N em butal
N e m b u ta l O v e r th e I n te rn e t: C h in a
F ro m early 20 1 0 , the s u p p ly o f p o w d e r N e m b u ta l from C hin a
b y m ail o rd er began to flourish.
M a rk e te d a s re a g e n t g ra d e p e n to b a rb ita l s o d iu m (C A S No.
57-3 3-0) this w ater-so lub le, w h ite crystalline so lid is stated as
h av in g a purity o f better than 99% . A dm inistration is a m atter o f
dissolving ~10g m o f the p o w d er in ~ 50m l o f w a te r an d drinking.
W hile the source com panies h av e long claim ed that their product
is pu re, it w a s n o t until m id 2011 that E xit w a s able to verify,
th ro u g h lab o rato ry testing, that th e N e m b u ta l s h ip p e d from
th e so u rc e s listed in this book is p u re an d h as not b een diluted
or ad u lterated pu rity stated. I f ingested in th e reco m m en d ed
am o u n ts th is N e m b u ta l leads to a relia b le an d peaceful death.
(See C h a p te r 15 for th e full discussion o f th e lab oratory test
results u n d ertak en b y Exit).
O btaining N em butal
O btaining N em butal
O btaining N em butal
http://peacefulpill.com
http://peacefulpill.com
O btaining N em butal
N o n -r e sp o n d e r s - no lo n g er re sp o n d in g to em ail enquiries
B M C h e m ic a l, H a n g zh o u
W e b : w w w .b m ch em ica l.co m
C h e m h e re C h em ica ls,
W e b : w w w .ch em h e re .co m
C h e r r y C h em ica l, H a n g zh o u
W e b : w w w .ch errych em ica l.co m
E m ail : ch e rry c h e m ic a ls@ g m a il.com
Q in g d a o H en ley C o , Q in g d a o
Em ail : in fo @ sin o h en ley.co m
W eb: w w w .sinohenley. com
K erry W in Intern ation al T ra d in g C o., S h ijia zh u a n g
W e b : w w w .kerryw in .co m /en b /in d ex.a sp
L o tu s C h em ica ls, C h o n g q in g
W e b : w w w .lo tu sch em .co m
3 B Scientific C o r p o r a tio n , W u h a n*
Em ail: sw c h sj@ h o tm a il.c o m o r helen .xia o @ 3 b sc.co m
W e b : w w w .3bsc.com
N in g b o E st C h e m ic a l C o. L td., N in gb o*
T h is c o m p a n y has recently a d v ise d Exit that it on ly supplies
for laboratory purposes.
O btaining N em butal
M azatlan
In 2 0 1 1 , Exit r e c e iv e d its first re p o rt o f th e a v a ila b ility o f
N e m b u ta l in th e b e a c h s id e re so rt o f M a z a tla n in th e state
o f S in aloa acro ss from th e Baja C alifo rn ia peninsula. A fter
u n su c c e ssfu l a tte m p ts to p u rch ase N e m b u ta l in T iju a n a the
y e a r before, an E xit m e m b e r w h o w e shall call 'B o b ' to ok a
v acation at M azatlan.
His p u rch ase w a s straight fo rw ard . T h e price w a s ex cellen t at
U S $ 30 for a 100ml, sealed bottle w ith an ex p iry d ate o f July
2013.
T h e outlet w h e re the p u rch ase w a s m ad e w a s the hole-in-thew all E l A rca d e N o e ( N o a h s A rk ) p h a rm a c y located at:
E jercito M e x ic a n o N o. 5
(n ear Playa N o rte ) area o f M azatlan
B ob s a y s that he used the p h o to s in th e H a n d b o o k to explain
to the sales atten d an t the p recise d ru g he w a s after. T h e retail
b ra n d he p u rch ased on this occasio n w a s ' Sed a lp h a rm a '.
P lay a del C a rm en
In late 2 0 1 0 , E xit receiv ed its first rep o rt o f th e availability o f
N em b u tal in th e tourist resort tow n o f P laya del C a rm e n . T h is
Exit m e m b e r wrote:
On m y recent trip to Playa del Carmen we visited 5 o r 6 shops
and were always turned away; I was about to g ive up when
the driver said he knew o f one other place. I don't remember
the nam e o f the p e t store but it was on the outskirts o f town. It
was ju s t a hole in the wall.
I told the owner I had a large dog with Displazia and he was
sympathetic and produced a 100 m l bottle o f Barbital which I
purchased fo r about US$40.
I already have a test kit fro m Exit International which I w ill use
when the tim e comes. The bottle, though, is sealed correctly,
fresh fro m the factory. I w ill keep it in a cool, dry place until
needed - i f it is needed.
I cannot thank yo u enough fo r a ll o f y o u r help and yo u r book.
I am 83 years old and I live now with a great sense o f relief.
V alladolid
Valladolid is a sm all city in Yucatan, about 2 hours drive from
C an c u n . Best kn o w n for its colonial architecture, esp ecially its
cath ed ral, th e to w n is also u s e d as a tou ring b a s e for visiting
th e n earb y M ay a ruins.
N em b u tal w a s first reported as being available ov er-the-counter
in V allado lid b ack in 20 1 0 . S in c e then, o th e r re p o rts h av e
e m e rg e d stating th e sam e, but w ith so m e variatio ns. In 2010,
th e cost o f tw o bottles o f N e m b u ta l w a s 180 p e so s e a c h . In
20 1 2 the p ric e h ad risen to 6 0 0 pesos for two.
O n e s to r e w h e r e N e m b u ta l is a v a ila b le o v e r-th e -c o u n te r is
F arm a c ia V eterinaria Los P otrillos at:
C a lle 41 177-1
Col Valladolid C entro
Yucatan
M exico
A t th is a n im a l p h a rm a c y , th e retail b r a n d o f N e m b u ta l is
P isabental. D o n 't b e su rp rised i f th e sto re d o es n o t h ave any
b ottles o n the shelves. It is n o t u n c o m m o n for a store to send
a m essen g er to the d e p o t f o r collection. F o r th e c u s to m e r this
m a y m ean a return visit in an h o u r o r tw o 's tim e.
O btaining N em butal
Tijuana
Tijuana h as a chec k e re d history as a destination fo r the over-thec o u n te r sale o f veterinary, liqu id N em b u tal. W h ile in the p a s t,
Vet p h arm acies o p en ly a d v ertised th e availability o f N em b u tal
fro m store w in d o w s , in th e past f e w y ears th is trade h as all
b u t clo se d d o w n . R ea so n s fo r this include th e o n g o in g bo rd er
v io len ce an d s u b se q u e n t d rop in to u rist trade, a s w ell as the
controversial death a f e w y ears b a c k o f A ustralian psychiatric
patient, E rin Berg. T h e ability o f travellers to b u y N em b u tal
o v er-th e-co u n ter in T ijuan a re m a in s hit an d miss.
T hat said, in early 2 0 1 0 , K en w rote:
A couple o f days ago I visited San Diego during a vacation in
the US, and look the trolley to San Ysidrof o r a short walk into
the downtown area seeking Nembutal. Being apprehensive
about approaching taxi drivers (& bearing in m ind the
Fig 14.22: A Tijuana veterinarian window si gn at the peak of the trade in 2007
O btaining N em butal
O btaining N em butal
O th e r C ities in M ex ico
In y ears g o n e by N e m b u ta l h as v a rio u sly b een av ailab le in
N u e v o Progreso, Juarez, N u e v o L aredo, N o g a le s an d C ancun.
Exit h as n o k n o w le d g e o f N em b u tal e v e r being av ailab le in
R ey n o sa, Del Rio o r M atam oros.
Film s taken o f L aredo an d Ju arez in 2 0 0 8 -9 are in clu d ed in
this Chapter.
SO U T H A M E R IC A
P u rc h a sin g N em b u ta l in P erson : Peru
F o r s o m e y ears now , E xit h as received repo rts co n firm in g the
ready, o v er-the-co un ter sale o f veterinary N em butal in P eru and
Bolivia. S o m e positive acco u n ts fro m E c u a d o r an d C o lu m b ia
h ave also b een received , an d th e se are b e in g investigated.
In Peru, so d iu m pen tob arb ital is kn o w n b y u n iq u e Peruvian
n am es. T h e m o s t c o m m o n b ra n d in this part o f th e w o rld is
H alatal. A less c o m m o n b ra n d is called P en to-H y pn o l. In
Peru (u nlike M ex ic o ) N e m b u ta l is sold in small 5 0 m l bottles
a s o p p o s e d to 100ml bottles. H ow ev er, th e concentration is the
sam e a s that for the larger M exican bottles. T h e concentration
o f bo th H alatal an d P en to-H yp no l in P eru is 6 .5 g m p e r 100ml.
L im a - Peru
A s a sp raw lin g capital city o f 10 m illio n , it is n o t surprising
that N e m b u ta l is easily av ailab le in L im a i f o n e k n o w s w h e re
to look. A s in m u ch o f S o u th A m erica, it is th e A gro-V eterin arias w h ic h readily sell N e m b u ta l over-the-counter.
T h e se sto res differ from M ex ic an F arm a c ia V eterinaria in that
th ey sp ecialise in m ed icin es an d tre atm e n ts f o r the rural secto r
a n d for farm an im als, ra th e r than dom estic pets. Such stores
are located all o v e r L im a b u t one o f th e e asiest to find is on a
b u s y intersection ad jacen t to th e N o r te (o r n o rth ern ) entran ce
o f the Estadio N a c io n a l (national stad iu m ), th e h o m e o f the
P eru national football team .
L o cated at the intersection S anta B eatriz in central Lim a, Z o o
F a rm a is a n A g ro V eterinaria w hich tak es 20-30 m inu tes by
taxi ride from the p o p u la r tourist ho tels o f the Mirafl o res district, d ep en d in g u p o n the traffic. (In Lim a, taxis are relativ ely
cheap w ith th e av erag e rate p er h o u r costing betw een 25 and
30 Peruvian soles. H otels ro u tin ely o rg an ise cabs fo r guests
w h ich is o n e w a y o f gu aran teein g g u est safety fo r the in ex p erienced traveller).
O btaining N em butal
C u zco - Peru
F o r those w h o are u p fo r ad v en tu re, th e U N E S C O w o rld herit
a g e city o f C u z c o m a k e s for an e a s y s h o p p in g trip. A n h o u r s
flight S E o f Lim a, th e c ity o f C u z c o is m o stly kn o w n a s the
ju m p in g o f f p o in t for visitors to the stu n n in g ly beautiful h id
d en Inca village o f M a c h u Picchu. T h a t C u z c o is also an e x
tre m e ly e a s y p lace to p u rch ase N e m b u ta l is a bonus.
F i g 1 4 .2 5 : M a c h u P ic c h u
O btaining N em butal
O btaining N em butal
In 2 0 1 1, J e f f fro m C an a d a reported:
I j u s t re tu r n e d fro m a o n e w e e k s ta y in C uzco, P eru w here
I w as su c c e ssfu l in o b ta in in g H a la ta l.
The s tr e e t C a lles Tres C ru ces h a s a lo n g lin e o f veteri
n a ry sh o p s ... I w e n t to A g ro veterin a ria ... There I g o t tw o
fifty m L b o ttles f o r U S $20. I h a v e to s a y th o u g h co m in g
b a c k th rough cu sto m s w as a b so lu te ly terrifying. A t C uzco
In te rn a tio n a l A irp o rt, m y b a g w a s s e a rc h e d a n d th e m an
c h e c k in g m y b a g h e ld th e tw o b o ttles u p a n d a s k e d m e
w h a t it was, a n d I re sp o n d e d 'p e r fu m e ' a n d h e le t m e go.
U.S. C u sto m s w a s even m o re te rrifyin g b e c a u se th ey
w ere se a rc h in g th e b a g s fra n tic a lly ; h o w e v e r th e m a n at
th e d e s k le t m e g o w ith o u t even lo o k in g in m y bag. Very
bizarre.
O btaining N em butal
In 20 1 2 , H e a th e r w ro te o f C uzco:
A fte r b u y in g th re e b o ttle s o f H a la ta l a t various sto res in
C a lle Tres C ru ces d e O ro (a n d a m a rv e llo u s v isit o n th e
O rien t E x p r e s s ' H ira m B in g h a m to M a ch u P icchu), I w as
s h o c k e d to b e s to p p e d b y p o lic e a t C u zco a ir p o r t on m y w ay
b a c k to Lim a.
A s it tu rn e d o u t it w a s a ra n d o m s p o t ch eck. I w as s u b je c t to
a cu rso r g o in g -th ro u g h o f m y ba g s d u r in g w hich tim e th ey
o f c o u rse fo u n d m y b o ttles o f N em b u ta l. I w a s n e v e r a sk e d
w h a t th ey w ere for, o n ly i f I h a d b een s ic k fr o m th e altitude.
W hen I n o d d e d th e b o ttles w ere c a refu lly re -w ra p p ed b y
th e p o lic e m a n in m y s w e a te r a n d th a t w as that. I m u s t s a y
I w a s in itia lly q u ite s h o c k e d to b e s in g le d out. M e - a d ru g
ru n n er - never. A t le a st n o t th e ty p e o f d ru g s th ey w ere
lo o kin g for.
O btaining N em butal
L a Paz - Bolivia
La Paz in B o livia is the
h ig h e st capital city in the
w o rld and, a s such, its
altitude m a y n o t suit all
travellers.
Like C usco,
N e m b u ta l is re a d ily av ail
able in La Paz i f y o u know
w h a t to ask for. In La Paz,
N e m b u ta l is s o ld under
th e trade n am e H a la ta l. A cab ride to a local v et store should
p ro v e a sim p le w a y to m a k e y o u r pu rch ase. If the sto re you
visit do es n o t have an y in stock, th e y sh o u ld o ffer to o rd er it in.
To p u rch ase N em b u tal in B olivia, y o u n e e d n o papers, n o p re
scription, there are few rep o rted co m p licatio n s. O n e traveller
even h a d th e v e t o ffer to d e liv e r h is N e m b u ta l o rd er to his
hotel. H e p aid U S $ 1 0 for each 5 0 m l bottle. O th e r travellers
to this co un try h ave rep o rted p ay in g u p to U S $4 0 for a 100ml
bottle. E ith er w ay, th e price is ap pro priate a n d th ere is no sign
o f profiteering.
In La Paz, o n e pentobarbital is c o m m o n ly s o u rc e d from the
v eterin ary outlet at:
Av. S aav ed ra N o 1004
Z o n a M iraflores, La Paz
A S IA
S ince 2009, Exit has receiv ed m an y positive repo rts o f the overth e -c o u n te r sale o f N e m b u ta l in Asia. H ow ev er, a s w ith South
A m erica, th e availab ility o f this d ru g se e m s to ch an g e with
a larm in g frequency. W h at w a s true last m o n th , is n o t true now.
B a n g k o k - T h a ilan d
In 2 0 1 1, repo rts o f successful p u rch ase o f N em b u tal over-theco u n te r fro m veterinary p h a rm a c ie s in B an g k o k ceased.
T h e E ien g S e w T u n g D isp en sary - on R atch apraro p R o ad in
B an g k o k that h ad been a reliable source is n o w claim in g it no
lo n g er sells N e m b u ta l, not even to T h ai nationals.
I f y o u 'd like to p rove u s w r o n g how ever, here are th e details:
E ieng S e w T u n g D ispensary
4 7 5 /9 R atchap rarop Rd,
M ak k asan , R atch atew e e , B an g k o k 10400
T e l : + 6 6 -2 2 5 1 -1 4 8 2 Fax: + 6 6 -2 2 5 1 -7 2 3 8
In the past travellers p a id 850 T h ai B ah t (U S $ 2 5 ) p e r 100 ml
bottle. T h e retail n am e w a s N e m b u ta l an d the d ru g w a s m a n u
factu red b y th e F ren ch c o m p a n y CEVA.
O btaining N em butal
Southern Thailand
E xit o c c a sio n a lly receiv es rep orts o f the availability o f liq
uid, veterin ary N e m b u ta l from v eterin ary sto res in the tow n
o f T ra n g (n ear P h u k et Island). T h e n earb y to w n o f H at Yai (a
larger to w n on th e b o rd e r o f M ala y sia) in S o uth ern T h a ila n d is
o n e o th e r n o te d possibility.
In both these tow n s, the liquid, v eterin ary N em b u tal h as been
p u rc h a se d fro m v et p h a rm a c ie s/ hospitals. Both these tow n s
arc serv iced b y airp o rts m ak in g access straig h t forw ard.
C o n c lu d in g C o m m e n ts
N e m b u ta l co n tin u es to be sold o v er-th e-co u n ter a n d o v e r the
Internet fro m several co u n tries a ro u n d th e world.
H o w ev er, w h ile th e p u rc h a s e o f N e m b u ta l m ig h t be q u ic k
a n d legal in so m e co u n tries, the im p ortation o f N em b u tal to
y o u r h o m e co u n try is a lm o st c e rta in ly ille g a l an d m a y attract
penalties. Y ou w o u ld need to ch eck th e p articular law s o f the
ju risd ictio n in w h ic h y o u resid e to be certain.
H ow ever, i f a serio u sly ill person p u rch ases N e m b u ta l law fully
in o n e co u n try a n d then takes the d ru g an d e n d s th eir life in th a t
co u n try , it is likely no law s w ill be broken.
15
A v a ila b le f o r m s o f N e m b u t a l
Since 20 1 0 , the availability o f reag en t grade so d iu m pentobarbital p o w d er
from C h in e s e m a n u fa c tu re rs h as m e a n t that this form o f the d ru g has
su p ersed ed less re a d ily av ailab le form s. (F ig 15.1)
F o r th e past d ecad e, sterile veterin ary liquid has b een the c o m m o n e st form
used for a peaceful death. (F ig 15.2)
Fig 15.1:25gm of
Chinese powdered
sodium pentobarbitol
U sing N em butal
U sing N em butal
Testing th e S a m p le B efo re U se
T h e re are a n u m b e r o f r e a s o n s w h y o n e m a y w is h to test
th e q u a lity o f th eir acq u ired N e m b u ta l befo re u sin g it fo r a
p eacefu l death. For ex am p le, the dru g m a y h ave c o m e from a
q uestionable source. O r it m a y h av e b een kept for a n u m b e r
o f y ears a n d m a y b e th e risk o f significant deterio ratio n. The
question o f reliability is o f p a ra m o u n t im portance. P eople do
n o t w an t to take a su b stan ce i f there is an y qu estio n a s to the
o u tc o m e .
T here are tw o tests o f significance:
# 1 : Is th e d ru g th e barb itu rate N em b u tal?
T h is is th e qualitative test
#2: Is the d rug pure, o r h a s it d eterio rated o r b een adulterated?
T h is is a q u antitativ e test.
U sing N em butal
U sing N em butal
U sing N em butal
U sing N em butal
Fig 15.7a
Fig 15.7b
Fig 15.7c
U sing N em butal
Fig 15.8:
Reading Spot Test Results
Fig 15.9: Digital thermometer with glass melting point capillary attached
U sin g N em b u ta l
M e lt in g P o in t Test
Fig 15.9:a Step by Step test of Nembutal Purity using melting Point Test
by htveld Exit Forum
U sing N em butal
Gas Chromatography Analytical Results
Specimen Code
Specimen Type
Pentobarbital-Na
%w/w
95.2
96.2
LossonDrying
%w/w
2.5
White Powder
White Powder
White Powder
95.2
1.8
3.2
White Powder
95.0
2.6
White Powder
95.2
2.4
White Powder
White Powder
95.6
2.7
96.0
1.9
C e r t if ic a t e o f A n a ly s is
F i g 1 5 .1 0 : G C A n a l y s i s o f 4 C h i n e s e s a m p le s a lo n g w i t h s a m p le B A n a l y s is certifa
T ak in g N em b u ta l fo r a P eacefu l D eath
U s in g N e m b u ta l to obtain a peacefu l death is straight-forw ard.
U sually, an anti-em etic (an ti-v o m itin g ) d rug is taken eith er for
2 d a y s p r io r o r a s a single stat d o s e 4 0 m in b efo re th e N em butal
is to be taken (see C h a p te r 9).
A p eaceful secu re e n v iro n m e n t w h e re o n e w ill n o t be disturbed
is re c o m m e n d e d (fo r further discu ssion , see the F A Q Is one
bottle o f N em b u tal e n o u g h ? at the en d o f this C hapter). Usually
this is b e s t a c h iev ed a t night.
H av e so m eth in g light to cat so y o u r sto m ach is n o t em pty. T h is
redu ces th e chance o f reflex vom iting from th e bitter drug. W hen
a p erso n w is h e s to die, 10 o r m o re gm o f p o w d e re d N em b u tal
can b e p laced in a glass. A ro u n d 5 0 m l o f co ld w a te r is then
add ed . T h e p o w d e r is stirred until it is fully dissolved. The
liquid in th e g lass will be clear. In the case o f veterinary liquid,
th e bottle is o p en ed b y b reak in g the seal a n d p o u rin g all the
co n ten ts (1 0 0 m l) into a clean glass.
T h e bottles arc sealed an d the liquid inside is sterile. B reaking
th e seal can so m e tim e s be difficult esp ecially i f visio n is poor,
o r o n e h as arthritis in th e hands. O n e m eth o d o f o p e n in g the
b ottle is s h o w n in the a c c o m p a n y in g video.
T h e liq uid in the glass is d ru n k q u ic k ly in 2 o r 3 sw allo w s. The
b itter after-taste can then b e alleviated b y drin kin g so m e alcohol,
usually spirits o r liqueur. T h e alco ho l n o t o n ly re m o v e s the
b itte r after-taste o f th e N e m b u ta l b u t it sp eed s the d r u g 's action.
A s th e d rug is a b s o rb e d from the sto m ach , an d the level in the
b lo o d rises, s o m e c ro sse s th e bloo d-brain b a rrier an d h as its
first effect on that part o f the brain that c o n tro ls sleep: w ithin
a f e w m in u te s o f tak in g th e drink th e p erso n falls into a deep
slee p , often q u ite suddenly, even m id-se nte nce w h e n talkin g to
friends!
U sing N em butal
A s the level o f dru g in th e b lo o d stream rises, m o re m o v e s into
the brain a n d sleep b e c o m e s d e e p e r an d deeper. A t that point,
a n o th e r area o f the brain is effected; that w h ic h controls the rate
o f breathing. T h e p e rso n 's breathing slow s, an d eventually stops
altogether. A t that point, w ith no o x y g en en terin g the lungs, the
person dies o f respiratory a rre s t, w h e r e there is n o t en ough
o x y g en in th e c irc u la tin g b lo o d to m ain tain brain function.
A nd, lastly, th e h eart sto p s beating. R arely is there an y b lad der
o r bow el m otion.
It is th e m o st p eaceful o f d e a th s to w itn ess. W ith N em b u tal,
o n e a lw a y s d ie s in th eir sleep.
U sing N em butal
b a rb itu ra te for s o m e tim e a n d h a s d e v e lo p e d a b arb ituratetole rance in this w ay. T h is is u n c o m m o n alth ou gh o ccasionally
p eo p le take th e an ti-co n v u lsan t barbiturate, p h eno b arb ital, for
lon g periods. In th e se cases, a larg er d ose o f th e N em b u tal
(12 g m p o w d e r o r 2 x 100ml b o ttles) w o u ld b e advised.
S o m e d ru g s en h an ce th e effect o f th e N e m b u ta l an d can even
b e em p lo y e d for that specific pu rp o se. An e x a m p le is th e antico nv ulsan t D ilantin (p h en y to in so d iu m F ig 15.11).
Dilantin is useful as the d ru g d isso lv es in w a te r fo rm in g an
alkali so lu tio n w h ic h is c o m p a tib le w ith the liquid N em b u tal.
I f y o u h a v e a bottle o f N e m b u ta l w h ic h is o f uncertain quality,
th e p o ten cy can b e e n h a n c e d b y disso lving 1- 2 g m o f phenytoin
sodium in th e liquid N e m b u ta l b efo re drink in g . T h is process
is sh ow n in the acco m p an y in g v id e o M a k in g N e m b u ta l even
m o re effective .
A lth o u g h Dilantin is a dru g th a t is co ntro lled , it is relatively
easily o b tain ed through Internet m ailing sources. It is n o t a drug
th a t attracts attention.
Phenobarbital
A s discussed in C h a p te r 13, phenobarbital an d pentobarbital are
d ru g s that are often co n fu se d b ecau se o f th e sim ilarity o f their
nam es. A ltho ug h both a re barbiturates, pentobarbital sodium
(N e m b u ta l) is th e fast-acting s o lu b le salt. T h is is th e euthanasia
d ru g o f ch o ice in all co u n tries that a llo w a ssisted su icid e and
euth an asia. Phe n o b arb is a d ifferent d ru g . In its usual form
p h e n o b a rb is a s lo w -actin g an ti-co n v u lsan t, p rescrib ed w h en
th ere is a risk o f co n v u lsio n s (eg. brain tra u m a etc).
S o m e p eo p le will h av e access to p h e n o b a rb , either from their
o w n d o cto r o r from o verseas pharm aceutical suppliers. 10gm (~
2 5 0 o f th e w h ite 3 0 m g tablets sh ow n in Fig 15.12 ) o f crushed
w h ic h is then m ix e d w ith w a te r an d taken as a drink w ill be
lethal.
N ote: T h e re is n o rap id loss o f co n scio u sn ess, as in the case
o f N e m b u ta l. T h e tim e to death u sin g p h en o b arb ito n e can be
sev eral hours. I f one is fo u n d befo re death, resuscitation is very
possible.
P h en o b arb can, how ever, b e m ad e m o re effective b y forcing
up th e pH o f th e solution o f the cru sh ed tablets. T h is is done
u sin g S o d iu m C a rb o n a te to co n v e rt the Phe nobarbital to the
m o re read ily -ab so rb ed so d iu m p henobarbital. I f available,
1g m o f D ilantin can be a d d e d to this d rin k w ith g o o d effect.
T o reduce the tim e from taking the drink to loss o f consciousness,
a s e c o n d d rin k m a d e fro m a b e n z o d ia z e p a m s le e p in g d ru g
is r e c o m m e n d e d ( e g , Se r a p a x , o x a z e p a m o r M o g a d o n ,
n itraz ep am ). A g ain , alcohol can b e an effective supplem ent.
U sing N em butal
F e w g et p a s t 7 before
C o n c lu d in g C o m m e n t
W h e n rig o ro u s scientific p ro cesses are u s e d to establish the
p u rity an d efficacy o f k n o w n drugs, th u s en su rin g a reliable and
p eacefu l death, the n eed f o r legislative ch an g e is significantly
d im in ish ed . T h is is b e c a u s e the act o f d y in g well a n d a t a
tim e an d p lace o f o n e 's c h o o sin g is in reach o f th o se w h o seek
it, a s lo ng a s certain ly step s are taken. T h is not o n ly rem o v es
th e dying p ro c e ss fro m th e h a n d s o f the m ed ical p ro fession but
e m p o w e rs th e eld erly an d th e serio u sly ill to m ak e th eir ow n
end-o f-life d ecisio n s, sh o u ld th e n e e d e v e r arise.
W h eth er legislation that provides controlled access to assistance
to die ex ists o r n o t, it is u n lik ely to effect th e p erso n w h o has
th eir P eaceful Pill locked in the cup bo ard. W h e n the tim e is
right, th ey w ill sim ply g o to th e cupboard!
U sing N em butal
16
T h e P eacefu l Pill P ro je c t h as ru n f o r se v e ra l y e a r s . M an y
strategies have b een ex plo red an d rejected w ith so m e significant
a d v a n c e s m ade. In this C h a p te r w e detail this E xit research
a n d discuss in m o re detail th e u se o f the d rug N em b u tal for a
p eacefu l death.
T h e syn th esis o f a barbiturate-like pill, in v o lv es the acq uisition
o f restricted an d h ard -to -g et c h e m ic a ls a n d th e u se o f processes
that are difficult an d o c c a sio n a lly d a n g e ro u s fo r th e novice.
N ev erth eless, a s th e p a th w a y s are e sta b lish ed an d sim plified,
s afer p ro cesses are d e v elo p ed an d recorded. A n ou tline o f the
step s req u ired for b arb itu rate sy n th esis an d a ssa y are described
a n d illustrated w h e re p o ssib le w ith video.
C h a n g in g Focus
Exit International la u n c h e d th e P eanut P ro je c t in early 2005.
N a m e d a f te r an o l d - f a s h i o n e d s tr e e t te rm f o r b a r b itu r a te
(Peanuts), th e Peanut Project brought together a g ro u p o f elderly
p eo p le to create th eir o w n barbiturate. C o u ld th ey synthesise
N em b u tal?
H o w c o u ld th e y m a k e so m eth in g that:
th ey c o u ld take orally
Legal Issues
S etting o u t to m a n u factu re o n e 's o w n b arb itu rate P eacefu l Pill
e x p o s e s those invo lved to significant legal risk. In Australia,
th e m a n u factu re o f b arb itu rates is g o v e rn e d b y law s such as the
D r u g M isu se a n d T rafficking A c t 1985 (N SW ) w h ich m a k e s it
a crim e to m an u facture, p o sse ss o r s u p p ly su ch a d ru g . The
p enalties that a p p ly d ep en d up o n the am o u n t o f th e prohibited
d ru g involved. I f the a m o u n t is less than 10gm , the p e n a lty is
tw o y ears j a il an d a fine o f $5,500. If am ounts greater than 20K g
are inv olv ed , the p e n a lty is life in ja il an d a fine o f $ 550,000.
In m ost w estern countries there will also be other laws that m ake
it an o ffence to m an u factu re, p ossess, sell, su p p ly an d im port
certain narcotic an d p sy ch o tro p ic drugs. P enalties w ill depend
up o n th e a m o u n t o f th e d ru g involved, an d again range from
tw o y ears ja il an d a fine, to life im prison m ent. Finally, there
is th e o th er additio nal generic legal question. I f one m e m b e r
o f th e g ro u p e v e r too k th e su b stan ce the g ro u p m a d e a n d died,
w o u ld the re m a in in g m e m b e rs be a c c u s e d o f having assisted
w ith th a t p e r s o n 's suicide?
It w a s stated cle a rly a t th e start, that n o o n e in th e initial group
w o u ld m ak e m o re than th e y n eed ed for them selves. N o one
w a s m ak in g a Pill for so m eo n e else, a n d no o n e w o u ld sell any
o f the su b stan ce m an u factu red . Finally, no o n e w o u ld acquire
m o re th an 10gm o f th e m an u factu red b arbiturate (the c o m m o n
lethal dose) a n d an y ex cess w o u ld b e destroyed.
T h e first P eanut sta g e failed w h e n a g ro u p m e m b e r b ecam e
d ise n c h a n te d w ith th e p roject an d d e n o u n c e d those involved.
T h re a ts w e re m a d e to in fo rm th e a u th o ritie s o f the g r o u p s
a c tiv itie s a n d th e p r o je c t w a s f o r c e d to c l o s e f o r se v e ra l
y ears. T h e death o f the m e m b e r in 20 1 0 led to the p ro je ct's
reestab lish m e n t in 2011.
T h e d i - s u b s ti t u t e d b a r b i tu r a t e s o f p a r t ic u la r in t e r e s t are
am ylobarbital (A m y ta l) an d pentobarbital (N em butal). T h e
p r o c e s s o f a d d in g s id e -a rm s (d i-s u b s titu tio n ) n e e d s to be
u n d ertak en before the c o n d en satio n o f th e m a lo n a te a n d urea.
In A m y tal, th e tw o alkyl side a rm s are (a) ethyl, in tro d u c e d as
e th y l-b ro m id e an d (b) 3-m eth y lb u ty l, in tro d uced a s 1-brom o3 -m e th y lb u tan e . In N e m b u ta l, the tw o alkyl sid e-arm s are (a)
ethyl, in tro d u c e d a s e th y l-b ro m id e a n d (b) 1- m e th y lb u ty l,
p rod uced from 2-brom o pentan e. In both substitution reactions
th e m a lo n a te is h eated , e ith e r in a c lo se d p ressu re system
(au to clav e) o r u n d e r reflux first w ith o n e an d then the second
alkyl brom ide. In bo th reaction s so d iu m eth o x id e is u s e d as
th e catalyst.
T h e final step in th e p ro d u ctio n o f so d iu m pento barbital or
sodium am ylobarbital is heating o f th e resultan t di-sub stitu ted
m alon ate w ith d ry u rea in an au to clav e o r u n d e r reflux for
an o th e r 12 hours. T h is is again do n e in the p resen ce o f dry
alcohol a n d sodium . E xcess alcohol is re m o v e d b y distillation
an d th e re sid u e - p r e d o m in a n tly s o d iu m p e n to b a rb ita l, or
s o d iu m a m y lo b a rb ita l - is d is s o lv e d in w a te r to f o rm the
Peaceful Pill.
In all o f the di-substitution reaction s an d in the con den satio n
w ith u rea, it is essential that there be a b s o lu te ly n o w a te r
present. C are m u st be taken to en su re n o atm o sph eric m oisture
reaches the au to clav e o r reactor vessel. All su b sta n c e s u sed
m u st b e dry. In particular, th e alcohol u sed in the production o f
the so d iu m eth o x id e needs to b e as d ry a s possible (su p e r dry).
E q u ip m e n t
In th e original p roject, the p e rio d o f p ro lo n g e d reflux w a s
carried o u t u sin g a tw o-litre glass reaction vessel w ith three
Q uickfit tap er n e c k s (2 4/2 9), fitted w ith an efficient double
surface c o n d e n s e r (F ig 16 . 1). A heating m an tle a n d a m e a n s o f
stirring th e m ix tu re an d m o n ito rin g th e tem p eratu re w e re also
required. T o p rotect the reacting sub stan ces from atm ospheric
m o istu re, calciu m ch lo rid e g u a rd tubes w e re used. T o rem o v e
ex cess alcoh ol in the final stage, the d o u b le-su rface condenser
w a s attach ed to th e rea c to r vessel b y m e a n s o f a distillation
head. T h e alcohol that w a s d istilled w a s co llected in a glass
receiv in g vessel that w a s also fitted w ith a calcium chloride
g u a rd tub e (F ig 16.5). An accu rate chem ical b alance, cap ab le
o f m easu rin g to 0 . 1g, w a s req u ired to w e ig h o u t the necessary
reactants.
In th e s u b se q u e n t S in g le S h o t p roject, a sp ecialised stainless
steel p ressu rised reaction v essel (a u to c la v e ) w a s em ployed.
T h is rep laced the g lassw are an d th e reflux co nd en ser. T his
sealed stainless steel vessel (autoclave) a llo w e d th e reaction to
take p lace u n d e r pressure, sh o rten ed reaction tim e an d reduced
the p ro b le m o f co n tam in atio n from atm o sp h eric m o istu re (F ig
16.2). P ressu re w a s read d ire ctly fro m th e g a u g e w i th the
tem perature in th e reaction vessel read v ia a th erm o c o u p le
(w ith an in frared th e rm o m e te r used as backup).
To re m o v e th e substituted m alonates from the reaction vessel a
c o n d e n s e r w a s e m p lo y e d . T h is w a s m ad e from stain less steel
tu b in g s u rro u n d e d b y a w a te r ja c k e t. C o n n e c te d to a receiving
vessel o f stainless steel this w a s th en v e n te d u sin g a calcium
chloride g u a rd tub e an d p laced u n d e r red u ced pressure in the
distillation p ro c e ss u sin g a w a te r tap v a c u u m attachm ent.
S p ecia l D an gers
A s w ith all chem ical pro cesses, care a n d attention to detail w a s
n eeded at all times. T h e equ ipm ent w a s clean an d d ry before use.
M a n y o f the liquids used in the syn th esis w e re fla m m ab le and
n a k e d flam es w e re n o t used. H eating o f the reaction vessel w a s
b y w a y o f an electric hotplate. T h e m o st d a n g e ro u s substances
u s e d in the p ro c e ss w ere m etallic sodium an d th e s tro n g ly basic
in te rm e d ia ry so d iu m etho x id e. S ta n d a rd org an ic c h em istry
tex ts (eg. S o lo m o n s & Fryhle, 2 0 0 4 ) spell o u t th e d a n g e rs o f
h an d lin g these s u b sta n c e s .
C A U T IO N : S o d iu m m u s t be han d led w ith g reat c a re an d u n d e r
no c ircu m stan ces s h o u ld th e m etal b e a llo w e d to c o m e into
contact w ith w a te r a s an e x p lo sio n a n d fire m a y result. S od ium
is sto red u n d e r paraffin o r x y len e an d sh o u ld on ly be handled
w ith tongs o r tw eezers, n o t with fingers.
Sm all w a ste o r scrap p ieces o f so d iu m can be d isp o sed o f by
placing them in a bottle containing large quantities o f m ethylated
spirits.
T h e co m m ercial so d iu m is c o v e re d w ith a n o n -m e ta llic crust.
A so d iu m p ress can be c o n stru cted to re m o v e this an d produce
clean so d iu m w ire fo r the reaction vessel. S e e B etty cooks
w ith S o d iu m F ig 16.6).
P recu rso rs
The list o f n ecessary p recu rso rs (w ith th e ir C h em ical A bstract
S ervice num b er, C A S N o . ) includes th e follow ing:
D i-ethyl m alon ate
C A S N o : 105-53-3
Alkyl sidechains:
a ) E thyl brom ide
C A S N o : 74-96-4
an d
b ) 1 -b ro m o -3 -m eth ylb utan e
C A S N o : 107-82-4
or
c) 2-B r o m o p e n t a n e
C A S N o : 107-81-3
Catalyst
S o diu m ethoxide
C A S N o : 141-52-6
or
S o diu m m etal
C A S N o : 7440 -23 -5
&
A b so lute alcohol
C A S N o : 64-17-5
U rea
C A S N o : 57-13-6
N o n e o f th e c h e m i c a l s r e q u i r e d a r e s u b j e c t to s p e c i f i c
g o v e rn m e n t restriction. A pplication to a rep u tab le chem ical
s u p p lie r for ethyl m a lo n a te an d the c h o sen sid e-ch ain alkyl
b ro m id e s is g e n e ra lly s u ccessfu l p ro v id e d o n e can detail a
legitim ate p u rp o se in th e re q u ire d e n d -u se r statem en t. S om e
e n d e a v o u r m a y be req u ired to o b tain the so d iu m m etal an d dry
ethyl alcohol. A lternatively, th e catalyst so d iu m eth o x id e can
b e purchased.
A u th o r s ' n o te - th e ch e m ic a ls req u ire d to m a k e a P e a cefu l P ill
m a y b e c la ssified a s 'p r e c u rs o rs ' f o r th e sy n th e sis o f a restricted
su b sta n ce. P o ssessio n o f sig n ific a n t q u a n titie s o f th e se item s
m a y b e a n in d ic ta b le o ffe n c e a n d c o u ld resu lt in sig n ifica n t
pen a lties.
A c q u ir in g N ecessa ry E q u ip m en t
L ab o rato ry g lassw are is b ec o m in g increasingly h a rd to obtain.
T h is is a reactio n on the part o f th e authorities to the existence
o f c la n d e s tin e la b o r a to rie s th a t m a n u f a c tu r e illegal d r u g s
( p r e d o m in a n tly a m p h e ta m in e s ) f o r c o m m e r c ia l g a in . T h e
aw ard-w inn ing T V series B reaking B a d is an excellent exam ple
o f w h a t can o c c u r in th e dark u n d erw o rld o f b lack m ark et drugs.
S o m e o f th e chem ical te c h n iq u e s used in the sy n th esis o f a
P eaceful Pill are the s a m e as those u sed to m ak e illicit drugs.
T h e syn th esis in E xit's p ro je cts req u ired a p ro lo n g e d p erio d o f
reflux (F ig 16.1). A glass reaction vessel w ith 3 Q uickfit taper
necks (2 4/29 ), fitted w ith an efficient d o u b le su rfa c e c o n d en ser
w a s needed. A heating m an tle an d a m e a n s o f stirring the m ixture
a n d m o n ito rin g the tem p eratu re w e re a lso used. T o p ro tect the
reacting substances from atm ospheric m oisture calcium chloride
g u a rd tu b es are needed. T h e d o u b le surface c o n d e n s e r can be
attach ed to th e rea c to r vessel b y m e a n s o f a d istillation head.
Step 2
S o diu m eth o x id e catalyst is again n eed ed in th e reaction vessel,
and this tim e 4 7 g o f th e m o n o su b stitu te d e s te r fro m S tep 1 is
co n v erted to a d i-su b stitu ted este r b y reflux (or reaction in an
a u to clav e) w ith th e s e c o n d s id e chain. F o r th e sy n th e sis o f
A m ytal, this s eco n d sidechain is l-b r o m o - 3 m e th y lb u tan e. In
th e case o f N e m b u ta l, it is 2 -b ro m o p en tan e, in each case 38g
is required.
A t the en d o f this sta g e the d i-su b stitu ted m a lo n a te is rem o v ed
again b y v a c u u m d istilla tio n . T h i s is 3 - m e th y l- b u ty l- e t h y l
m a lo n ic este r in the c a s e o f A m y tal syn th esis; 1-m ethyl butylethyl m alo n ic este r i f N e m b u ta l is b e in g m anufactured.
Step 3
S o diu m etho xid e is again n eed ed in the reaction vessel. F o r
this final step 5 8 g o f th e d i-su b stitu ted m alon ate fro m step 2 is
allo w ed to react w ith 15 g o f d ry urea that h as b een d iss o lv e d in
h o t d ry alcohol. T h e m ix tu re is stirred an d h eated u n d e r reflux.
A fter 4 hours, th e ex cess alcohol is b o iled o f f an d th e residue
d isso lv ed in w a te r an d acidified (w ith dilute hyd roch loric acid)
to p recip ita te th e insoluble b arbiturate cry stals w h ic h can be
w a s h e d a n d dried.
T esting th e P rodu ct
A s w ith an y h o m e -m a d e p ro du ct, careful testing is necessary.
F ull re a ss u ra n c e can on ly c o m e fro m detailed, q uantitativ e
a n a ly s is u sin g g as c h r o m a to g ra p h y a n d m a s s s p e c tro s c o p y
(G C -M S ).
E xit to o k p o sse ssio n o f this n e c e s s a ry e q u ip m e n t in 2008.
A p a rt from th e ability to test the p ro d u cts o f h o m e synthesis,
the eq u ip m en t is useful in verifying th e veracity o f o ld sto ck s o f
p rescrib ed b arbiturate sleeping tablets, o r s a m p le s o f veterinary
N em b u tal that h av e b een p u rch ased f ro m d u b io u s so urces or
h av e lon g past th eir q u o ted s h e lf life.
Finally, the Exit Barbiturate Test Kit can be u s e d to dem onstrate
the presence o f synthesised barbiturate. In addition, the purity o f
dried barbiturate crystals can b e tested u sin g a glass capillary in
an oil bath. F o r N e m b u ta l, th e m elting point s h o u ld b e 129C.
D etailed instructions on th e u se o f the N e m b u ta l m e ltin g point
test will be p ro v id e d in future e d itio n s o f the eH a n d b o o k.
17
S w itzerla n d - L a w s a n d L oo p h o les
In S w itz e rla n d , a s sis te d s u ic id e is a llo w e d b y law as long
as the person p ro v id in g th e assistan ce h as no selfish motive.
Im portantly, the person receiv in g th e assistance d o e s n o t need
to b e a S w iss citizen. G iv e n that v o lu n tary euth an asia rem ains
illegal in Sw itzerland, it is interesting that S w iss law has allowed
assisted suicide since the 1940s.
In S w itzerland, the penal cod e states that a person w h o , for
selfish m o tiv es, p e rsu a d e s o r assists an o th e r p erso n to co m m it
suicide will be p u n ish e d w ith im p riso n m en t u p to five y e a r s .
P eople o th er than th e selfish, c o m m it no crim e in assisting
others to suicide.
It is n o t s u rp risin g , then, to find that S w itz e rla n d h arb o u rs
several right to d ie o rg an izatio n s each o f w h ic h h ave th eir ow n
m e m b e rsh ip s an d differing m o d u s operandi.
Such g ro u p s in clu de th e little-know n E x i t - T h e S w iss Society
for H u m a n e D yin g an d the m u ch m o re w ell k n o w n , Dignitas.
D ignitas is th e m ain o rganization to accep t foreigners as clients.
Dignitas
D ignitas w as established
b y L u d w i g Minelli in 1998
as a S w iss,
organization.
n o n -p ro fit
A W ord o f W arn in g
W hile th e th eo ry o f allo w in g a d e m e n tia su fferer to d ecid e on
h is o r h e r o w n suicid e is o n e thing, th e reality o f d o in g this is
q u ite different. S uicide by the m en tally ill, n o t sim p ly those
affected by d isea ses such as A lz h e im e r's , is a n area fraught
w ith danger. T h e re is n o b e tte r e x a m p le o f w h a t can go w ro n g
than th e 2 0 0 8 case o f S y d n ey Exit m em b ers, S hirley Justins
an d C a re n Jenning.
In O c to b e r 2 0 0 5 , d e m e n tia su fferer G ra e m e W ylie ap p lie d to
u se the D ig n itas service to die. D ignitas c o n ta c te d the au th o r
to r e v ie w G ra e m e . In o u r report w e m a d e cle a r that although
G ra e m e suffered from significant dem entia, he retain ed insight
into h is condition. O n e m on th later, how ever, D ignitas w o u ld
reject G r a e m e 's app licatio n, say in g they h a d con cern s about his
capacity. W h ile the organization s y m p ath ized with h is w ish to
p u t an en d to h is suffering, they w e re u n c o n v in c e d that he had
th e ability to m ak e a clear a n d co n sisten t decision in reg ard to
his o w n death.
U pon rejection from D ig nitas, G r a e m e 's frien d o f 30 y e a r s C a re n J e n n in g - trav elled to M e x ic o in search on N em butal.
U p o n h er retu rn to A u stralia C a re n J e n n in g g ave G r a e m e 's
p a rtn e r o f 19 y e a r s , S h irle y J u s tin s , a b o ttle o f N e m b u ta l.
Later that w eek , S hirley Justins g av e the bottle o f N e m b u ta l to
G ra e m e W ylie, saying i f y o u d rin k this G ra e m e y o u w ill d i e .
A fter an inv estigatio n o f s o m e 18 m o n th s, a n d a court case
lastin g s e v e n w e e k s , in J u n e 2 0 0 8 th e w o m e n w e r e fo u n d
g uilty o f th e m a n s la u g h te r a n d ac c e sso ry -b e fo re -th e fact o f
m a n sla u g h te r respectively, o f G ra e m e Wylie.
N o te - S w is s a u th o ritie s in s is t th a t a t le a s t s o m e o f th e se
d o c u m e n ts a re c e r tifie d extra cts, a n d s o m e m a y n e e d to b e
w itn e sse d b y a J u s tic e o f th e P e a ce o r P u b lic N otary. O thers
m a y n e e d to h a v e b een is s u e d w ithin th e la s t 6 m onths. B e
p r e p a r e d to d o a f a i r b it o f r u n n in g a r o u n d to g a th e r th e
p a p e r w o r k together.
U p o n receipt o f this ap plication form , D ig n itas re v ie w s each
ap p lic a n t's situation. I f d e e m e d suitable, a pro visio nal letter o f
acceptance will be m ailed to the client (ca lle d th e ' green light').
It is at this point, p lan s for travel to Z u rich can be m ade.
U p on A rriv a l in Z u rich
U p o n a rriv al in Z u r ic h , th e c lie n t c o n t a c t s D ig n ita s. An
ap po intm en t is then m ad e w ith one o f a n u m b e r o f consulting
p h y s ic ia n s w h o w o r k in co n ju n ctio n w ith th e o rganization.
T h e se m ed ical do cto rs are in d ep en d en t o f D ignitas a n d w ork
from th eir o w n room s.
T h e F in al A p p o in tm e n t
T h e final ap p o in tm en t is held at the D ignitas house in an o u ter
s u b u rb o f Zurich.
T his ap p oin tm ent can take p lace quite qu ickly after the m edical
review, so m e tim e s th e fo llo w in g day. T w o D ig n itas s ta f f will
b e present.
A third m e m b e r o f th e D ignitas team m a y arrive d u rin g the
ap p o in tm en t a n d d e liv e r the d ru g s that will be used.
The Drugs
A s is th e c ase in all places (N etherlan ds, B elgium , O regon)
w h e re a ssisted suicide o r v o lu n tary e u th an asia is legal, the drug
th a t is u s e d at D ignitas is pentobarbital sodium (N em butal).
A prescription will h av e b een w ritte n o u t fo r this d rug b y the
con sultin g d o cto r w h o s a w the client. T h e p rescriptio n w o u ld
h ave b een tilled on y o u r b e h a lf by D ignitas s ta f f
It is th e D ignitas s ta f f w h o bring the N e m b u ta l to th e house for
th e final ap p ointm ent. A t th e ap p o in tm en t, s ta f f dissolve the
pentobarbital so d iu m p o w d e r in w a te r to form a drink. T his is
d o n e w h en the person indicates that it is th eir w is h to g o ah ead
w ith th eir death.
The Pentobarbital u s e d b y D ignitas is th e s o lu b le so d iu m salt
and 15gm are d isso lv ed in ~ 5 0 m l o f w a te r ju s t befo re use. The
concentration o f N em butal in th e liquid co n s u m e d is 300m g/m l.
T h e a m o u n t co n s u m e d is ~ 50 m ls w h ic h is no m o re than a few
m outhfuls. N ote: T h is d ose differs significantly in concentration
from the sterile v eterin ary anaesthetic N e m b u ta l. A naesthetic
N e m b u ta l h as a co n centratio n o f 6 0 m g /m l, about 5x w e a k e r
than that used by Dignitas.
D y in g at D ignitas
O n c e th e c lie n t a n d th e ir f a m ily a n d frie n d s a r r iv e a t th e
D ignitas house fo r th e final ap po intm en t, a few further tasks
m u s t be atten d ed to. Firstly, additional legal p ap erw o rk m u st
b e c o m p le te d c o n c e rn in g in fo rm e d co n s e n t, p o w e r o f attorney
an d fo rm s to release th e body. T h is final h u rd le clears th e w ay
f o r the death to take place.
At this tim e, th e clien t read s, a p p ro v es a n d o n c e m o re signs
p ap ers indicating th a t th e y k n o w w h a t th e y are a b o u t to do
a n d in d ic a tin g th a t th e y a re a c tin g o f th e ir o w n fre e will.
T h e ir signature is w itn essed b y those present. F o llo w in g the
p ap erw o rk , th e D ignitas s ta f f explain th a t the person can o p t out
o f the p rocess at an y tim e. T h e client is a sk e d i f t h e y 'd p refer
to s ta y seated a ro u n d th e table o r i f th e y d like to lie dow n.
E ith er w ay, it is th e client w h o d e te rm in e s w h a t h ap p en s and
h o w it happens.
T h e D ignitas ro o m s are bright, airy w e lc o m in g ro o m s. T h e y
are d eco rated in w arm colo urs. T h e re is a co ffee m a c h in e and
C D p lay er fo r those w h o w is h to h av e m u sic. A n d in case you
fo rg et to bring y o u r o w n m usic, there is even a D ignitas C D
com pilatio n o f well k n o w n relax in g p o p u la r m u sic, in case you
feel that m u sic m ig h t be a v alu ab le last m in u te addition.
I f th e clien t w is h e s to g o ahead , th e s ta f f then set u p a video
A fraid that h e w o u ld
v o m it, J o h n n eed ed
som e re a ssu ra n c e
and w as pleased
w h en he w a s able to
c o n s u m e th e 5 0 m l
drin k w i t h little
d ifficu lty . P rep ared
fo r a bitter a fte rtaste, he finished the
Nembutal, saying
that d id n 't taste too
b a d .
Because
John's
fa v o u rite d rin k w a s
Fig 17.5: Dr John Elliott and his wife Angelika in Switzerland shortly before his death
cognac, everyone
sh ared his final
moments with a
A fte r i t s O ver
After about an hour, one o f the Dignitas staff m em b ers perform ed
several sim ple tests to confirm death. O n ce this w a s established,
th e s ta f f called the police w h o arriv ed w ith a m edical d o cto r and
an officer fro m the C o r o n e r 's d ep artm en t. T h e funeral hom e
w a s also co n tacted a t this tim e. In all deaths, th o se p re se n t are
18
Introd u ction
F o r th o se left b eh in d , th e p e rio d im m ed iately fo llo w in g the
death o f a loved o n e can b e an intensely sad an d stressful time.
A n e le c te d death - a rational su icide - can p re se n t an additional
an d u n iq u e set o f circum stances.
O n the one hand, fam ily an d friends m a y be eno rm ou sly relieved
that th eir loved o n e w a s able to d ie peacefully an d w ith dignity.
O n th e o th er hand, there m a y b e feelings o f re se n tm e n t, even
a n g e r that th e person th ey loved h as c h o sen to leave them .
W h ile it is o n e th in g to k n o w th a t a p erso n y o u love is about
to d ie b y their o w n hand, it is an o th e r to be able to p red ict how
this will m a k e y o u feel.
T h e re w ill a lso b e a n u m b e r o f practical issues that those left
b e h in d h ave to confron t. In th e case o f a well p la n n e d death,
s o m e o f th e se w ill h a v e b een d iscu ssed before th e death. For
exam ple, w ill an y o n e b e respo nsib le for clearing a w a y an y used
e q u ip m e n t fro m th e scene o f d eath ? A n d w h a t about a suicide
note? W h o w ill k eep h o ld o f it, sh o u ld o n e be required?
B a ck g ro u n d to G r a e m e W ylie
In M a rc h 2 0 0 6 G ra e m e W ylie d ied drink in g a lethal do se o f
v eterin ary N e m b u ta l that his friend o f o v e r 30 y ears, C aren
Jen n in g, h ad b rou gh t back fo r h im from M exico . W h ile the
p la n a n d C a r e n s m o tiv e f o r h e lp in g h e r o ld frie n d w e re
straig h t fo rw ard , G ra e m e W y lie s death w a s alw ay s going to
b e co m p licated . In J u n e 2 0 0 8 , G ra e m e W y lie 's p a rtn e r o f 18
y ears S h irle y Justins, to g eth er with C aren , w a s found gu ilty o f
h is m a n sla u g h te r a n d a c c e s so ry to m a n sla u g h te r respectively.
T h e S u ic id e N ote
I f G ra e m e W ylie had w ritten, s ig n e d an d d a te d a suicid e note
stating that his actio n s w ere entirely his ow n, that he understood
th e co n s e q u e n c e s o f w h a t he w a s a b o u t to d o a n d g av e the
reaso ns for dying, S h irley an d C a re n w o u ld h av e been m uch
less likely to h av e fo u n d th e m se lv e s in front o f a ju d g e an d jury.
T h e law a ro u n d suicid e an d a ssisted -su ic id e is grey. T h o s e left
b eh in d b y a death are a lm o st a lw a y s at risk o f so m e form o f
inquisition from authorities. W riting a n ote an d sto ring it in a
safe place o r w ith a trusted friend m a k e s a g o o d deal o f sense.
In a w ell-p la n n e d death, a d o cto r s h o u ld sim p ly sign the death
certificate, b eliev in g that th e death is natural a n d a resu lt o f the
u nd erly in g disease. In c ases like these, th e s u ic id e no te will
n e v e r be needed.
A fter it s O ver
T he P rocess o f a D eath
I f a death takes p la c e outside o f a hospital, h o spice o r other
m ed ical institution (eg. at ho m e), it is n o rm a l practice upon
d is c o v e rin g th e death, that a d o cto r be called. U pon arriving
at the house, the d o cto r w ill then h av e tw o options.
I f th e death looks to be natural, an d th e patient h a s b een seen by
th e d o cto r in the past tw o m o n th s, th e d o c to r will certify death
and sign the death certificate citin g th e p e r s o n 's u nd erly in g
disease as the c a u se o f death. T h e re w ill b e no red tape. The
b o d y w ill be released, an d funeral a rran g em en ts can be made.
If, on the o th er han d , th e d o c to r su sp ects that the death is n o t
natu ral (eg. i f the death is p o ssib ly a suicid e o r i f the cause
o f death is u nclear) the d o cto r can c ertify death, b u t w ill not
sign th e death certificate. In this case th e d o cto r w ill call the
c o ro n e r's office an d th e police w ill be involved. T h o s e close
to th e d ec e a se d m a y be required to be interview ed b y the police
a b o u t th eir re la tio n s h ip w ith the d e c e a s e d , a n d a b o u t th eir
p o ssib le role in th e p e r s o n 's death.
C lea n in g A w ay
T h e re are sev eral practical steps that can be taken to increase
th e lik eliho od that a death w ill be seen a s n a tu ra l ( i f th a t is
w h a t th e d ece ase d person w ish ed ). T h e first o f th e se is the act
o f cleaning up after a death.
G iven that th e d eath s that w e a re talk ing a b o u t are p eaceful and
dignified, the act o f clean in g u p g en erally in v o lv es the rem oval
o f eq u ip m en t su ch a s an E xit B a g o r e m p ty dru g p a c k e ts from
th e death scene. In s o m e situations, this can b e d o n e w ell ahead
o f tim e. M an y people e n d in g their lives clean aw ay them selves.
T h e y rem o v e d ru g -p ack ag in g , a n d rinse g la sse s after a lethal
d ru g h as b een co n su m ed . I f this is do n e, th e atten d in g d o cto r
w ill be m o re likely to assu m e that the c a u se o f death is the
u n d e rly in g disease.
H ow ev er, i f th e p erso n w h o h as d ie d w a s n o t k n o w n to be
suffering fro m a life th re aten in g illness, th e a c t o f clean ing
aw ay m a y cause m o re pro blem s. In th e case o f G ra e m e W ylie,
b e c a u s e there w a s n o illness (o th er than d em en tia), th e fact that
there w a s n o o b v iou s c a u se o f death on ly serv ed to h eigh ten the
m y ste ry o f h o w he died?
C le a n in g A w a y and th e L aw
W h ile it is a c rim e to interfere w ith the circu m stan ces o f a
d e a th , in th e s ch em e o f th ing s it is n o t a p articu larly serious
crim e. F o r ex am p le, re m o v in g an Exit b ag fro m a lo v e d o n e 's
h e a d o nce th ey h ave d ie d is a v ery differen t m a tte r to helping
that sam e p erso n p u t the b ag on th eir head. It is cle a rly assisting
a su icide to h elp a person position a b ag on their head. In m ost
w estern countries, a ssistin g a suicide is a seriou s crim e.
D ea th C ertificates
U pon a rriv in g at th e scene, the atten d in g fam ily d o cto r will
p erfo rm tw o tasks. Firstly, they w ill confirm death. T h e y will
do this b y carry in g out a n u m b e r o f sim p le tests to establish that
th e person is indeed dead, n o t sim p ly in a catatonic o r com ato se
state. H av in g c o n firm ed death, th e nex t issue is th e sign in g o f
th e death certificate. T h e re are a n u m b e r o f req u irem en ts that
m u st be satisfied b efo re th is can b e do n e. T w o are o f particular
interest.
1. T h e d o c to r m u s t k n o w th e patient. U s u a lly th ere is the
r e q u i r e m e n t t h a t th e d o c t o r h a s s e e n th e p a tie n t in a
p ro fessio n al cap acity - n o t ju s t to say h ello a t th e g o l f club
2.
D y in g w ith o u t Trace
M o st d ru g s u s e d to en d life leave n o o b v io u s id entifying signs.
D eath fro m sterile veterin ary N e m b u ta l is o n e ex am p le. The
p erso n w ill a p p e a r a s i f th e y s u c c u m b e d to th eir c a n c e r o r
heart disease. H o w ever, there is also a d y e d form o f the drug,
P entobarbital (see C h a p te r 13). I f Le tho barb (the d y e d form )
is c o n su m e d , th e p e r s o n 's lips will be s ta in e d g reen ; h ence
th e n am e th e green d r e a m . G reen lips are a d ead giv eaw ay
(p ard o n th e p un ) to a death that is n o t natural. A n d rem em ber,
i f an au to p sy is perform ed, the pentobarbital will b e discovered.
Q u estio n s a b o u t its so u rce w ill inevitably be asked. T h is is true
o f an y death b ro ug ht a b o u t by a c o n s u m e d d ru g , o r an inhaled
p o iso n like c arb o n m o n o x id e.
A u to p sies
I f th ere is an y d oubt a b o u t the c a u se o f death, th e d o c to r will
contact the co ron er an d an autopsy m a y be arranged. An autopsy
in v o lv es the dissectio n o f th e b o d y b y a path olo gist, the visual
a n d m ic ro s c o p ic in sp ec tio n o f o rg an s, an d th e b io ch em ical
testing o f b o d y fluids, sto m ach co n ten ts etc.
At autopsy, the ex isten c e o f an y d ru g s (a n d alco h o l) in th e body
will be d isco v ered . I f the d rug is u n c o m m o n o r difficult to
obtain, q u estio n s w ill be a sk e d a b o u t w h e th e r o r n o t assistance
w a s p r o v id e d in o b ta in in g , p r e p a r in g o r a d m in is te r in g the
substance.
A lth o u g h perm ission f o r an au to p sy will b e sought, an d nex t o f
kin h av e the right to refuse, it is as well to re m e m b e r that refusal
can g en erally be o v errid d en (d e p e n d in g u p o n th e ju risdiction ).
A utopsies are generally only so u g h t i f there is a legal o r m edical
m y ste ry asso ciated w ith the d eath ; that is, i f there is uncertainty
a b o u t h o w o r w h y th e p erso n died. In these situations, especially
i f there is th e p ossib ility o f a crim inal act (eg. assistance), the
d ecision w ill be m a d e irrespective o f fa m ily w ishes.
G r ie f C ou n sellin g
T h e su icid e o f a serio u sly ill p erso n w ill e v o k e m ix ed reactions
in th o se close to that person. T h e b ro a d e r c o m m u n ity s reaction
m a y also be m ixed . W h ile m o s t p eo p le su pp ort th e co n cep t o f
rational su icid e there is still a significant m ino rity w h o do not.
It c an n o t be a s su m e d that th ere will alw ay s be sy m p a th y for
th o se left b eh in d so b e careful.
In m an y c ircu m stan ces w h e re a p erso n h as d ied o f their own
hand, c o u n sellin g m a y be o f assistan c e for those left behind.
T h e ability to talk thin gs th ro u g h can be therapeutic an d can
g o a long w a y to w ards easin g the in evitable g r ie f an d despair.
P r iv a te c o u n s e l l o r s list t h e i r s e r v i c e s in m o s t c o u n t r i e s '
telep h o n e directories an d o f c o u rs e online. C o m m u n ity health
centres a lso c o m m o n ly o ffer c o u n sellin g a s p a rt o f th eir range
o f health s e rv ic e s . T h e re are also often c o m m u n ity telephone
h elp lines.
A fter it s O ver
C o n c lu d in g C o m m e n ts
The P e a ce fu l P ill H a n d b o o k (P P H ) w a s first p u b lish ed in 2006.
S ince this tim e the bo o k h as b een an nu ally up d ated to include
n e w an d c h a n g e d inform ation. T h is is essential to keep u p w ith
th e d eb ate a b o u t e n d o f life ch o ic e s .
In 2008, th e fu lly-o nlin e P e a c efu l P ill e H a n d b o o k (P P eH ) w a s
also published. T h e online form at o f the eH an d b o o k h as allowed
u p d atin g w h en an d a s it is required. A t the c u rre n t tim e, the
e H a n d b o o k is u p d a te d no less th an six tim es each year.
T h e o n lin e e H a n d b o o k also co n tain s o v e r 50 p ieces o f video,
p ro v id in g hand s-on instruction an d critical detail on a diverse
ra n g e o f issues.
F o r readers o f th e P P H , E xit is p le a s e d to co n tin u e to o ffer a
c ash -b ack a rra n g e m e n t sh o u ld p urchasers u p g rad e to an online
su b scrip tio n to the PP eH .
Both b o o k s are m a d e av ailab le in the philosophical b e lie f that
know ledge is em po w erin g . W ith the academ ic literature playing
c atch -u p , E xit rem ains a c u te ly a w a re that h av in g an end -of-life
plan m akes o n e live a lo n g er a n d h app ier life. Far from pushing
p eo p le to w ards suicide, establishing o n e 's o p tio n s helps people
stop w o rry in g , an d g et on w ith living better.
F o r those with
E xit R P Test
H an g in g
D ete rg en t
R e lia b le (10)
10
10
10
10
P eac efu l ( 10 )
10
10
A v ailab le (5 )
P r e p a r a tio n (5 )
U n d e te c ta b le ( 5)
5*
S p eed (5 )
S afety (5 )
S to ra g e (5 )
T O T A L (50)
28
30
31
34
35
36
38
41
44
56%
60%
62%
68%
70%
72%
76%
82%
88%
R a tin g
M o n o x id e
M o rp h in e
E ndep
D o lo x en e
C y a n id e
I n e r t G as
N em b u tal
* N itro g e n o n ly
References
A ustralian B u reau o f S tatistics (2 0 0 0 ) S u ic id e Trends, A u s
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A ustralian V eterinary A sso ciatio n ( 2 0 0 6 ) AVA rejects
N itsch k e ad v ice a s u n e th ic a l M e d ia R elease 24 July, 2006.
B atlle, J. C. (2 0 0 3 ) Legal status o f ph y sician -assisted su ic i d c , J A M A , Vol. 2 8 9 , N o . 17, p. 2279-81.
C o m m o n w e a lth o f A u stralia (2 0 0 5 ) C rim in al C o d e A m e n d
m en t ( S u icid e R elated M aterial O ffen ce s) Act 20 0 5 N O .
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D ru g M isu se an d T rafficking Act 1985 (N S W ) at: http://
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in d ex.html
F u rniss, B., H an n afo rd , A. Sm ith, P. W. G. & A. Tatchell
(1 9 8 9 ) Vogels's T extbook o f P ra c tic a l O rg a n ic C hem istry,
H arlow , P rentice Hall.
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at: h ttp ://w w w .ex itin tern atio n al.n et/d o cu m en ts/ex it4 5 .p d f
H u m p hry , D. (1 9 9 6 ) F in a l E xit. N e w York, Dell, p. 30.
Lie be rm ann , L. (2 0 0 3 ) L e a v in g You - The C u ltu ra l M ea n in g
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M e nde lson, W. . ( 198 0) T h e U se a n d M isu se o f S lee p in g
P ills - a C lin ic a l G u id e, N e w York, P lenu m M edical Book
C om pany.
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N ation al P rescribing C entre (2 0 0 6 ) T h e w ith d raw al o f cop ro x am o l: altern ativ e an algesics for m ild to m o d e ra te p a i n
M e R e C B u lletin , Vol. 16, N o . 4.
N itsch ke, P. & S tew art, F. (2 0 0 5 ) K illin g M e S o ftly: V E a n d
th e R o a d to th e P e a c efu l P ill. M elb o u rn e, Penguin.
O 'C o n n o r, A. (2 0 0 4 ) D eath s go u n e x a m in e d a n d th e living
p ay th e p r ic e , N e w York Tim es, 2 M arch.
Public C itizen (2 0 0 6 ) Petition to the F D A to b an all p ro p o x y p h e n e (D a rv o n ) p roducts at: h ttp://w w w .citizen.org/
p u b licatio n s/release .cfm ?ID = 7 4 2 0
Routley, V. & O zan n e-S m ith , J. (1 9 9 8 ) T h e im p act o f
catalytic con verters on m o to r veh icle ex haust g as su ic id e s ,
M e d ic a l J o u r n a l o f A u stra lia . Vol. 168, p. 65-67.
Ryan, C. J. (1 9 9 6 ) D epression, d ecisio n s an d th e d esire to
d ie, M e d ic a l J o u r n a l o f A u stra lia , Vol. 165, p. 411.
S h an ah an , D. (2 0 0 1 ) M ail o rd er su icide k it. The A u s tra l
ian. 20 August.
S o lo m o n s, T. W. B. & F ry h le, . B. (2 0 0 4 ) O rg a n ic C h em istry (8th cd.), N e w Jersey, Jo h n W iley & Sons.
Stone, G. (2 0 0 1 ) S u ic id e a n d A tte m p te d S u ic id e : M ethods
a n d C o n seq u en ces, N e w York, Carroll an d Graf.
V eterinary S u rgeo ns B o ard o f th e A C T (2 0 0 3 ) N e w sle tte r
J u n e 2003
A b o u t P h i l i p N its c h k e
Dr Philip Nitschke PhD, MBBS, BSc (Hons) is a leading authority
on Voluntary Euthanasia and Assisted Suicide. As the first doctor
in the world to administer a legal, lethal, voluntary injection under
Australias short-lived Rights o f the Terminally Ill A ct, Philip has
experienced all sides o f the end-of-life choices debate.
A graduate o f Sydney University Medical School, Philip is the
Founder and Director o f Exit International, an organisation at the
forefront o f this debate. With his co-author Fiona Stewart he is also
author o f Killing M e Softly: Voluntary Euthanasia and the R oad to
the Peaceful Pill (Penguin 2005, republished Exit US 2011).
In 1997, Philip was awarded the Rainier Foundation Humanitarian
Award in the US and w as Australian Northern Territorian o f the
Year. In 1998, Philip w as Australian Humanist o f the Year and New
Zealand Humanist o f the year in 2001. He has been nominated for
Australian o f the Year eight times.
A b o u t F io n a S te w a rt
Dr Fiona Stewart PhD, MPolLaw, GradDip PubPol, BA is a public
health sociologist. As an academic, Fiona w as the recipient o f re
search grants from the Australian Research Council & the National
Health and Medical Research Council. Fiona has held various
positions outside the academy including as a journalist, columnist,
dot-com founder and media strategist. Since 2004, Fiona has been
Executive Director o f Exit International.
T h e P e a c e fu l Pill F o r u m s
Members o f Exit & Subscribers to the
Peaceful P ill eH andbook now have free access to
the Peaceful Pill Discussion Forums hosted by
Exit International US.