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Suicide for sale in Oregon: a “valuable service”?

Oregon is currently the scene of a controversy about the sale of so-called “suicide kits” or “helium hoods” (see here and here). These kits are sold by mail by a two-person company called The Gladd Group; one of its owners is reported to be a 91-year-old San Diego County woman who has been selling the kits for four years. The device is now receiving increased media attention following the suicide, with the help of the helium hood kit, of 29-year old Nick Klonoski, who had health-related issues that had brought him into depression, but was not terminally ill. His tragic death has now sparked a movement to outlaw the sale of those kits in Oregon. However, the woman selling the kits protests that she is providing a valuable service, and is quoted as saying that “[i]t is not my intention to hurt anybody, but to offer people comfort when they die”. Is the sale of those suicide kits a legitimate form of business, or should it be banned?

One thing I find disappointing about the media coverage of this issue is that the only people who are mentioned as advocating a ban on those suicide kits are opponents of assisted suicide more generally. One thus gets the impression that if you are in favour of assisted suicide, you should also be in favour of such kits being freely available for sale. After all, shouldn’t people be allowed to freely decide precisely when and how they wish to die?

I have defended assisted suicide in a previous entry on this blog, yet I believe that the sale of those suicide kits is a highly irresponsible practice and that there are good grounds for outlawing it. The problem with the sale of those kits is not that it represents a form of assisted suicide, but rather that it lacks appropriate controls. It means that the lives of vulnerable people, people who might need psychological support or other forms of help than help with dying, are being put at risk. Assisted suicide should be legal and provided not only to terminally ill people, but to every person who has expressed a clear desire to die over a sufficiently long period, who has had access to all relevant avenues of help, and whose quality of life is clearly compromised and cannot reasonably be expected to improve in the future. But that does not mean condoning the provision of assisted suicide for just anyone who requests it, including vulnerable young people going through a temporary bout of depression. Klonoski did suffer from an illness that defied medical diagnosis and diminished his quality of life, but it is not clear that he had received appropriate help to get over his depression (triggered by an onset of flu) and his associated desire to die. However that may be, the appropriate stance towards the sale of those suicide kits does not fundamentally depend on what the correct verdict is in Klonoski’s case. Whether or not he should have been helped to die, it seems quite clear that these kits are not being sold with appropriate safeguards.

Derek Humphry, the author of a best-selling book on assisted suicide and promoter of the helium hood kit, apparently doesn’t think it inappropriate for people in Klonoski’s situation to have free access to the kit, with accompanying instructions on how to use it. It is not clear, however, how we are to reconcile this with his professed wish that assisted suicide be made available to everyone who seeks it, “except the mentally disturbed, including the depressed”.

One cannot but regret that the debate on this issue should once more be characterized by a lack of nuance and involve a clash of equally implausible extreme views. Oregon, like many other American states and most countries in the world, should improve its legislation on assisted suicide, currently overly restrictive. In the meantime, it should ban the sale of suicide kits – popular singers from Marilyn Manson to Lady Gaga have been accused of romanticizing suicide, but such an unregulated aid to dying strikes me as much more dangerous.

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16 Comment on this post

  1. Suicide is only difficult because of the strength of our survival instincts. Otherwise it's very, very easy, and you don't need assistance or mail-order technology. None of which necessarily makes selling "suicide kits" a good or responsible thing to do, but if the argument is based on the idea that it is making something difficult easy then I don't really see how it can be convincing.

  2. Hey Alex,

    Not often I disagree with your posts here, but to defend your position it seems like you need to rely on a life = fundamental value doctrine that seems ultimately religious to me. Someone can wish to die for various reasons – i) they find living unpleasant, ii) they expect to find living unpleasant in the future, iii) they expect that not doing so will in itself cause them to find living unpleasant in the future, or iv) they can do it for ethical reasons.

    ii) and iii) are factual claims, that the individual seems much better placed to answer about themself than the state, and if they're accurate seem perfectly good reasons.
    iv) is an expression of value that doesn't directly hurt anyone else, and therefore seems inadvisable, perhaps dangerous for the government to have a say in.
    i) is what you seem to be talking about, but before I by using it as a reason I feel like I should point out that in cases like this, where you’re talking about making suicide harder, you’re making it harder for people doing it for adequate reasons, not just those doing it for allegedly poor ones.

    Re i, let’s assume it doesn’t overlap with ii (ie that they expect things to get better, but find the present so unpleasant they don’t care). It’s still not obviously unreasonable for someone to want to end their life in this position. Maybe they’ve just done a cost-benefit analysis of sorts, and think that their life won’t improve enough to make their current suffering worthwhile – as above, this is a factual claim.

    But even if they hadn’t, we’re talking about a very intrusive intervention into someone’s existence, that in itself is likely to cause a lot of immediate distress (if I want to kill myself, I’m unlikely to enjoy having to wade through a bunch of forms allowing me to do it – it’s almost this sketch in reverse: It also comes, like any law with various economic costs.

    Obviously there are other people involved, but family and friends have little legal say in other forms of potentially detrimental self-harm (body modification, extreme sports, drug-taking, refusing medical treatment) – many of these things incur a risk of debilitating injury or disease that’s arguably worse than death, so it’s not clear why we should give death special treatment in this respect.

    And in the end (and I realise this is a primarily utilitarian argument, so you might not be sympathetic), death is just the cessation of emotion. It’s not a great poke in the eye to some great moral overseer, or a fundamental change in the fabric of the universe. It’s a few cells less in a conscious state, equivalent to a few person-years of extra slow-wave sleep. Its main tragedy is the anxiety the thought of it brings us when we’re conscious – and that’s only going to be exacerbated by getting the government to drag it out and draw attention to it.

  3. It's not only anxiety Sasha, it's also the grief of those left behind. I'm convinced that there's a strong utilitarian case for suicide prevention, and I'd gladly accept the forms and economic costs to reduce the incident of suicide resulting from transient emotional states. To be honest I don't really care whether they ban the helium bags or not: I neither see the bags as significantly increasing the incidence of bad suicide (let's call it dysthanasia), nor banning them as an unacceptable curtailment of liberty. It's just politics in action. But it is almost certainly a red herring as far as suicide prevention is concerned.

  4. Peter: I think you are underestimating the risk that the availability of quick and painless means of taking their own lives might make some suicidal individuals more likely to act on their urges. I suspect that most of them would find it easier to asphyxiate themselves by inhaling helium than e.g. to jump from the top of a tall building. We also need to consider what message a legislation that permits the free sale of suicide kits is sending: namely that the state is happy to accept that the death of vulnerable, depressed members of society should be facilitated rather than avoided as much as possible.

    Sasha: I'm rather sceptical of the idea that suicidal people who are in the grip of depression usually have the capacity to engage in a rational process of cost-benefit analysis. More often, they are desperate, which wrongly leads them to see death as the only possible way out of their suffering. Many of them could, with the right kind of help, get through that phase and then have a life worth living by their own standards, on which account they will be glad they didn't kill themselves. Shouldn't a utilitarian be concerned by this loss of potential utility (besides the pain caused to relatives and friends, as you have already mentioned)?

  5. The newspaper report which opened up this story was extremely vague as to the man's illness or illnesses. It said: "For years he struggled through bouts of pain and fatigue that defied medical diagnosis and left him depressed about his inability to carry on normal daily activities and fearful that he would never regain normal health."
    I think the reporter should have investigated this aspect further so that we better understood why he took his life.
    It certainly was not a hasty action, for he bought my book 'Final Exit' nearly two years earlier, and the helium hood kit six months earlier.
    Anybody who is in constant pain is depressed by it. Of course every hastened death is sad, but it was his right if he found life unbearable.

  6. Mr. Humphry:

    Fair point about the need to have more details about this young man's situation. I'd just observe that according to one of the articles, it was a bout of flu that pushed him over the edge. So there are at least grounds for suspecting that even though Klonoski might have been thinking about suicide for some time, it was a particularly difficult, but presumably transient situation that made him take action. The problem is that given the lack of adequate regulations on the sale of those suicide kits, we might never know whether Klonoski did or not make a rational, informed decision when he took his own life.

  7. Thanks for the response Alex. I certainly take your point about what "message" we are sending by permitting this (although as far as I know nobody is proposing legislation that *explicitly* permits this particular product. I sort of take your point about "quick and painless": you could say I guess that it provides a way to circumvent our natural survival instincts. But there are similar alternatives, and probably even websites giving practical tips. You might also say that just because we can't ban these (too difficult, too problematic in relation to freedom of speech) doesn't mean we shouldn't ban the commercialisation of products, and I might agree with you, but I remain sceptical as to how much we should conclude from this isolated case in relation to the likelihood of such products significantly increasing the incidence of suicide.

    However I do take issue with Derek Humphry's assertion that *anybody* who is in constant pain is depressed by it. Without wishing to dowplay the real suffering of those who are, I just don't think that's consistent with empirical evidence. We can get used to many things, particularly with techniques like mindfulness and Ericsonian hypnosis. All in all I think it would be good if Mr Humphry found something better to do with his life than encouraging people to kill themselves.

  8. Being a survivor of a six year long depression, I find the users of these Helium bags presented in this article, <strong>stupid beyond belief.</strong> Feeling sad and depressed because you have the flu is something we all go through, but feeling the same way year after year with no end in sight, is not as common. Klonoskis condition, to the point of suicide, was not valid in my opinion. I find it hard to believe that he could have come up with the deed by himself. I am convinced that some external stimulus must have made him kill himself (using the kit) when he was in such a sensitive frame of mind.

  9. Firstly, it is, of course, horrible when anyone takes their life, and this is indeed a tragedy. I think that the attention toward a kit that can be made at home is probably not where the attention should be going, however. It seems it was the failure of modern medicine to help this man that ultimately led to this tragedy. If he had at least a proper diagnosis, perhaps he would at least had some consolation with the idea of what he was dealing with, and whether this pain would last his entire life. Of course, we know little about this due to the vague report, but it seems to me like this individual suffered quite a lot, if this was the reason he did this.

    Regarding some of the posters comments here, I have to say… I have a painful disease, and I can say that I find it abhorrent that people feel the need to say how much suffering someone should endure. To me this is a clear signal that one is not free in this society. Saying this, however, I am not implying that all suffering is equal. I agree that transient depression is not a sufficient reason to even contemplate doing this. What is a heavy burden for one individual, might not be much of an issue for another. It is strange to me that, in this culture, where for such a long time basic healthcare was taken as a privilege for the rich, that the same culture would find it confusing why someone would want to end their suffering. I know that there are plenty of situations/illnesses that life could potentially hand me, that I would absolutely not want to suffer through.

    1. "it is strange to me that, in this culture, where for such a long time basic healthcare was taken as a privilege for the rich, that the same culture would find it confusing why someone would want to end their suffering."

      I think suicide is disturbing in just about all cultures. As you say: it is horrible when anyone takes their life. And because it is disturbing, people prefer to believe that it doesn't happen (the universal human characteristic known as "wishful thinking"). So when it does we are surprised and confused. In our case we are also influenced by our Christian heritage, according to which life is sacred and suicide is a serious sin. This kind of thinking still influences even those of us who don't ourselves believe such things.

      1. My main point is that something has been lost here in the medical system, and the attention has been lost in something that doesn't appear to fix anything. The main point should be: Why did this person suffer? Why did he not get any help?

        "In our case we are also influenced by our Christian heritage, according to which life is sacred and suicide is a serious sin. This kind of thinking still influences even those of us who don’t ourselves believe such things."

        I think that is a pretty broad statement to make, and probably not relevant to this tragedy.

        This seems to fit more into the topic of whether morality is a learned behavior like in religion, or something innate. You can certainly find instances to the contrary. In fact, it is well-known that bonobos express emotions such as fear, love, empathy, and grief. Grief has even been documented in elephants when their young has died. I highly doubt feeling disturbed has a religious basis, and there is certainly no evidence for this.

        If a dog shares his food with a cat, is that considered a moral action, and how much would say religion is involved there?

        There are plenty instances of "moral" behavior exhibited in nature, particularly in those species with higher cognitive functioning, such as dolphins, apes, and elephants, that have no connection with religion. There are also plenty of people that are heavily religious that do disturbing things, and I don't think I have to cite examples. Overall, not relevant.

        1. “Why did this person suffer? Why did he not get any help?” These are good questions to ask, of course, but somewhat outside the scope of Alex’s initial post. Alex’s point was that it is selling suuicide kits such as the one used in this case is irresponsible. For my part I have expressed scepticism regarding the extent to which such practices significantly increase the incidence of suicide, as Alex appears to believe, while suggesting (in response to Derek Humphry’s comment) that there are better ways to make a living than encouraging people to kill themselves. I stand by both these points.

          Regarding the relevance (or not) of our Christian heritage in understanding why we find it confusing why someone would want to end their suffering (by killing themselves), i think it is fairly clear that morality is partly learned and partly innate. Attitudes to suicide vary across cultures, and something must be causing these variations. It seems to me implausible that our Christian heritage wouldn’t be playing some role, given the strict taboo against suicide in traditional forms of Christianity.

  10. ‘Sasha: I’m rather sceptical of the idea that suicidal people who are in the grip of depression usually have the capacity to engage in a rational process of cost-benefit analysis. More often, they are desperate, which wrongly leads them to see death as the only possible way out of their suffering.’

    Alex, how would you scientifically justify this scepticism? If we interview people who were suicidal and have recovered we risk serious bias. To begin with there’s a selection bias. The most miserable people will have tried hardest – and therefore been more likely to succeed – in their attempts at suicide. Plus given that the recoverers are presumably on their way up, there’s a risk they’ll be overpositive and no more likely to think rationally about their previous misery than the miserable people are about their possible future happiness.

    If you ask people who’ve never seriously considered suicide then obviously you’re risking problems of paternalism and the accusation that you don’t have any sense of how intense the emotions in questions are, and so have no basis for your judgement.

    Also, we’re evolved to be strongly averse to suicide, such that if you accept the idea of a net 0 welfare point, most of us would need to be a long way below it before we’d be able to overcome our genetic programming and kill ourselves – suggesting that people who are suicidal really are an acutely miserable group.

  11. What Derek Humphry decides to do with his life is not really something I'm concerned about, and I'm not sure why anyone would take an interest in him personally, such as you state.

    First let's just point out the obvious, which is that Derek Humphry’s occupation came into existence because assisted suicide (meaning involving a physician) was taken out of the cards for terminally ill. This is the entire point here. Of course, there is some debate about those in other situations, where they are suffering through something unbearable yet not terminal, but I'll come back to that with an example.

    Deciding whether to suffer for decades or not should probably fall into the category of a basic human right if we are going to call modern society a rational humanitarian and free one. People put their pets down to end their suffering, and this is taken to be an ethical decision. Why does that apply there, and not here? It makes no sense. This decision is entirely personal, and only family should interject their objections in this case.

    Instead of focusing on some ridiculous kit, perhaps we should be focusing on strengthening our social and medical support systems. Let's just note here that the U.S. just recently passed basic health care coverage and it is now 2011. That's pretty sad in my opinion.

    For the sake of argument, let's take an example. In 1942 the mathematician Felix Hausdorff, his wife, and sister and law, committed suicide because they could not avoid being sent to a concentration camp. Would you back in time to try to convince them their decision was the wrong one, knowing they could have survived? These individuals (as far as I read) were not terminally ill. This is the point here, we are talking about everyday life, and none of us can afford to be this naive.

    Again with Christianity… Not relevant. No evidence. No connection.

  12. "We can get used to many things, particularly with techniques like mindfulness and Ericsonian hypnosis."

    Indeed, if I lose a leg, half my face, and then develop blood cancer, I'm sure I'll take consolation with your assessment that I can "get used to it" and then use hypnosis to ease my suffering. I presume this is your substitute for a real answer.

  13. Sasha: I certainly don't mean to deny that most suicidal people are acutely miserable. But in reply to your request for scientific evidence, I would point to the kind of statements psychiatrists often report their depressed patients as making, e.g. "I am no good at anything" or "suicide is the only possible solution to my problem". Such statements are very rarely supported by any evidence; rather, the available evidence will typically speak against them, as many depressed people get to acknowledge themselves once they get help. I don't deny that a suicidal person might in principle carefully assess all available alternatives and end up rejecting them all as unsatisfactory, but I think it's quite clear from clinicians' experience that this is not the typical case. People in the grip of acute psychological suffering are in a poor position to carefully assess available alternatives. If you want some literature on that, see f.ex. this book:

    Are you referring to "depressive realism" when you suggest that people who recovered from depression (or from suicidal ideation) might tend to be overly positive in their thinking? I think depressive realism is an interesting idea, but even if it's correct, it refers to people with moderate depression, not to desperate individuals who want to kill themselves.

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