The two guides took with them the old man's signed statement.

It was the only evidence that they were ever there at all.

In its literature, the Final Exit Network boasts that it's "the only organization in the United States willing to help individuals who are not 'terminally ill' — six months or less to live — hasten their deaths. No other organization in the U.S. has the courage to make this commitment."

From the 2002 edition of Final Exit: How to kill yourself with helium.
From the 2002 edition of Final Exit: How to kill yourself with helium.
Dalton Baker, a senior exit guide and Final Exit's treasurer, says GBI agents and St. Louis police raided his home and took his files and computer.
Jennifer Silverberg
Dalton Baker, a senior exit guide and Final Exit's treasurer, says GBI agents and St. Louis police raided his home and took his files and computer.

"'Hasten your death' is a key term," explains Dalton Baker, a 71-year-old exit guide who lives in St. Louis and serves as the network's treasurer. "'Killing yourself' trivializes what we're doing."

"One thing everyone says — assumes — is that we do euthanasia," adds Ann Mandelstamm, 69, leader of the St. Louis chapter that formed two months ago. "We don't ever do that. No guide ever administers euthanasia. That term gets our hackles up."

Founded in 2004 as an offshoot of the Hemlock Society, which fell apart the year before, Final Exit has 3,000 members across the country, including 58 exit guides. Annual dues are $50. The network claims it has helped accelerate the deaths of between 130 and 200 terminally ill patients, most of them in New York, Florida and California.

"We're not Jack Kevorkian," says Jerry Metz, a Final Exit board member and retired physician, via telephone from his home in Addison, Maine. "We don't hook people up to a machine and say good-bye. We need to stay within the legal guidelines. There's no law that says you can't be in the same room when someone dies."

"We're operating within the law," insists the 78-year-old Dincin. "But at the margin. No one has decided the limits of assisted suicide in court."

"Some states have criminal laws against assisted suicide, others don't," observes Rebecca Dresser, a professor of law and bioethics at Washington University. (The practice is illegal in Missouri.) "The nature of common law is on a case-by-case basis. These cases are very rarely prosecuted.

"Whenever you help others commit suicide, you're vulnerable to prosecution," Dresser continues. "The requirements for material assistance are what people argue about. You could materially assist by providing knowledge, or by knowing what the person is going to do.

"But it's hard to argue that being there is 'assisting.' There's no legal requirement to be a Good Samaritan and rescue someone unless you have a special relationship, like a health-care provider or parent."

Critics say Final Exit members, especially exit guides, have a skewed moral code. "They color things for their own self-interest," says Stephen Drake, a spokesman for Not Dead Yet, a disability-rights group that vigorously opposes assisted suicide. "They confuse the public about what they're actually doing.

"If you look at the statistics for [assisted suicide], intolerable pain is not the reason most of those people want to commit suicide. They have a fear of being a burden, of future pain, of being alone. Pain is far down on the list. They have a fear of losing autonomy. So Final Exit gets to pat themselves on the back for saying they honor autonomy."

Dr. Timothy Quill, a professor of palliative care, or pain relief, at the University of Rochester School of Medicine, says it is critical that a doctor be part of any assisted suicide. "Very sick people need very sophisticated medical evaluation. It's not for volunteers and activists."

Physician-assisted suicide is legal in Oregon and, as of March 5, in Washington state as well. The requirements of the Death with Dignity Act are stringent: Patients must be within six months of death and certified as terminal by two doctors. They must also file three separate documented requests and wait fifteen days before receiving their lethal prescription. Since it went into effect in 1997, 401 Oregonians have taken advantage of the law.

"Washington and Oregon have good laws," Dincin told the St. Louis chapter at its first meeting in February. "But they don't deal with diseases like ALS [Lou Gehrig's disease] or Alzheimer's or Parkinson's when the time of death is uncertain."

"It can take five years to die from ALS," notes Baker, who is also a volunteer at BJC Hospice. "You become incapacitated. You lose muscle control, and then you eventually choke to death. It's a terrible way to die." (Baker keeps his Final Exit and hospice work separate: "I don't want people accusing me of harvesting patients.") [Editor's note: A correction ran concerning this paragraph; please see end of article.]

"I hear doctors say all pain can be managed," Baker continues. "But some pain cannot be controlled, and the only perfect answer is terminal sedation. The doctors give the patient morphine and drive him into a coma. This is an accepted medical practice. But some people don't want to go out that way. They'd rather go out with a good mind and on their own accord."

Final Exit's members refer to the period between the diagnosis of a degenerative illness and the point when a patient is physically incapable of turning the valve on a helium tank as the "window of opportunity."

Dr. Lawrence Egbert, 81, an anesthesiologist affiliated with Johns Hopkins University School of Medicine in Baltimore, is the network's medical advisor. It's his job to sign off on every case. He never actually meets the patients, but he relies on letters from their doctors and records of their initial phone conversations with first responders.

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