January 9, 2025
Assisted suicide as told by the first doctor to administer the lethal voluntary injection
The founder of Exit International, Philip Nitschke, talks about the evolution of the end of life from a political and social point of view. And what changes with technology
A revolutionary and visionary, back in the 1990s Australian physicist and former doctor Philip Nitschke was the first in the world to administer the voluntary lethal injection for assisted suicide, permitted by the North Australian euthanasia law of 1996, later repealed and annulled the following year.
But Nitschke continued his fight for human rights, including the right to die, by setting up the non-profit Exit International Association in 1997, advancing the idea that every sane adult has the right to seek and receive information about the end of his or her life, as well as to plan for it.
Then, President of the recent Swiss Association The Last Resort and inventor of the Sarco Suicide Pod Project – a removable capsule where rational suicide takes place by nitrogen asphyxiation – which was suspended in September immediately after its first use by a woman, in a reserved location in the mountains of Schaffhausen, creating major debates and legal controversies in the country on assisted suicide.
The topic of death, in particular suicide as self-determination, has always been a central philosophical issue as well as a fundamental civil rights issue.
I am thinking of intellectuals and philosophers such as Camus, Sartre or among contemporaries, Peter Singer who have led debates on the view of the ‘sanctity of life’, utilitarianism and quality of life. Has philosophical thought in any way influenced your activity as an activist?
Yes, I have been significantly influenced by the ideas on suicide of many philosophers and writers and I spoke in detail with Peter Singer and, before his death in the Netherlands, with the jurist Huib Drion who wrote so much on euthanasia, on individual autonomy for a dignified end of life.
I sympathise with psychiatrist Thomas Szasz’s view that ‘suicide is a fundamental human right, a right with which society has no moral right to interfere’, but I have found little support for this view in contemporary medicine.
Exit International operates mainly in Switzerland where assisted suicide is regulated by Law 115 of the Criminal Code of 1941. Has there been any evolution since then in political and social-ethical terms?
In Switzerland there is broad acceptance and support for this law, which is also accessible to non-residents. Although medical involvement is not required by law, the need for drugs such as Pentobarbital has led to the involvement of doctors.
This has led Swiss medical associations to lobby for restricting the supply of these drugs by doctors registered in Switzerland unless a serious illness is established.
In recent years, these pressures have increased, creating increasing difficulties for those seeking legal assistance in Switzerland for social rather than medical reasons.
Assisted suicide is permitted and regulated in a few countries in the world (in addition to Switzerland, it is permitted in Spain, Germany, Austria, Canada and Australia for example). In other international realities, however, such as Italy, it is forbidden or permitted in very rare cases.
What is your relationship with other international associations for the end of life and specifically with Italy?
I have observed the emergence of legislation in various countries around the world as they tried to address the issue of suicide assistance.
My initial involvement and support for laws based on the ‘medical model’, such as those I used in Australia in 1996, were influenced by subsequent experiences.
My organisation, Exit International, now takes a much broader approach, arguing that suicide support should be available to all rational adults.
This has generated tensions between Exit and many other organisations around the world for the right to die, which pursue medical legislative change and see our broader approach as counterproductive.
However, there are small groups in many countries that advocate for a demedicinalised approach to rights, and we have established good relations with many of them.
Examples include CLW here in the Netherlands, Ultime Liberté in France and Fen in the United States. In Italy, we have long-standing supportive contacts with Marco Cappato and the Luca Coscioni Association.
In many countries, religion has always obstructed and criticised topics relating to the self-determination of the individual (euthanasia, assisted suicide, abortion). In your experience, are there differences in ethical approach between religions regarding these issues?
Our membership is mainly in English-speaking countries with a nominally Western Christian majority (USA, UK, Canada, Australia, New Zealand, etc.).
In these countries the influence of the Catholic Church and opposition to our activities has been significant.
Membership in South East Asian countries (India, Japan, Korea) has increased in recent years, but we have not encountered significant organised religious opposition.
You are the president and one of the founders of the recent association ‘The Last Resort’ with which the ‘Sarco’ project will be presented in 2019. How does the programme differ from the practices implemented under the End of Life Law in Switzerland?
[Editor’s note: Dr Florian Willet is President of The Last Resort, not Philip Nitschke.]
The Sarco Project was initiated to support research and development of new technologies to facilitate assisted suicide.
The initial focus was on the Sarco device with the aim of using 3D printing to distribute it globally.
Other plans include the integration of artificial intelligence software that can assess a person’s ‘mental capacity’ for access to the device, eliminating the need for a traditional psychiatric evaluation; a VR display that allows people to enter a virtual Sarco and experience a virtual death; and the development of a ‘Dementia switch’, an implantable device for people with dementia that, once activated, allows them to choose the end of their life for themselves, avoiding the involvement of a third party when their decision-making capacity is compromised by the disease.
In Switzerland, the practice is to provide suicide assistance by means of the medically controlled barbiturate Pentobarbital, administered orally or intravenously.
This restricts assistance to those who are considered medically fit, i.e. sick, even though illness is not a prerequisite for receiving assistance under Swiss law. Sarco removes this restriction.
What information programmes have you set up for people who have decided to carry out assisted suicide? Are there any compulsory steps to be taken?
As we operate in Switzerland and do not use restricted drugs, we have no mandatory medical criteria for assistance. The person requesting assistance must be an adult and have mental capacity.
We have imposed an age restriction on those who have non-medical reasons for requiring assistance, 50, claiming that they must have had significant ‘life experience’ to take this last step. This age restriction of 50 was agreed by Exit for political rather than philosophical reasons
‘The Last Resort does not assist young people to die unless they have a serious physical illness (i.e. not psychiatric in nature),’ reads the Exit website. How is mental illness regularised in the freedom of choice for a dignified end of life? Is individual freedom therefore not absolute but limited?
The absolute criterion is mental capacity and not the presence or absence of a psychiatric illness. In principle we support the right of a mentally ill adult (i.e. adult) who has mental capacity to receive suicide assistance, but for practical and political complexities we try not to take this group of people.
However, there have been exceptions: the decision to assist 27-year-old Canadian Adam Maier-Clayton with severe OCD (Obsessive-Compulsive Disorder), but with mental capacity, was made because his parents did not provide support for their son’s request for death.
Again, the end of life is referred to as the ‘democratisation of death’. Can you explain what this means?
Swiss groups set up to provide suicide assistance to foreigners (e.g. Dignitas, Life Circle, Pegasos, etc.) charge a uniform fee of CHF 10,000, which many people cannot afford.
Exit sees no justification for this restrictive fee. The Last Resort was created to remove this cost restriction, making the service effectively free of charge (even if the person seeking assistance has to buy their own nitrogen for 18 Swiss francs), thus democratising assisted dying.
In Alabama, one of the countries where the death penalty still exists, there was the first execution using nitrogen. What is your social-political line on the death penalty?
I am totally against the death penalty and have campaigned for its abolition. I was informed about the intended use of nitrogen in some countries in the US and was initially sceptical about its use in such situations.
My experience with nitrogen hypoxia as a means of rapidly ending life has shown that the person using this method must physically cooperate for the process to lead to rapid loss of consciousness and a peaceful death. This would be highly unlikely in the case of an execution.
I took the opportunity to visit the Holman Correctional Facility in Alabama on 23 December when I was invited there by Kenny Smith’s lawyers. I was shown the execution room and inspected the mask they planned to use to deliver nitrogen to Kenny…they actually allowed the mask to be strapped to my face so I could experience what they had planned.
I met Kenny on death row and told him I would do everything I could to convince the Alabama authorities to abandon this method. I gave evidence the next day at the Montgomery hearings to support this case, but my objections were ignored and he was sentenced to death in January.
The adverse symptoms described by the execution witnesses can be well explained by Kenny’s lack of cooperation; these symptoms were not noticed when the Sarco device was used in September.
What is your idea of a future-oriented model of end-of-life legislation?
I would like to see countries adopt ‘rights-based’ legislation similar to that in Switzerland, where there is no attempt to define a necessary degree of illness or suffering. I hope to see the adoption and acceptance of AI screening as a means of establishing mental capacity.
