A suicide bag, also known as an exit bag or hood,[1][2] is part of a euthanasia device consisting of a large plastic bag with a drawcord used to die by suicide through inert gas asphyxiation. It is usually used in conjunction with a flow of an inert gas that is lighter or less dense than air, like helium or nitrogen. Continuing to breathe expels carbon dioxide and this prevents the panic, sense of suffocation and struggling before unconsciousness, known as the hypercapnic alarm response[3]:45 caused by the presence of high carbon dioxide concentrations in the blood.[3]
Self-administered and assisted suicides by asphyxiation using a plastic bag with helium were first recorded in the 1990s. Since the 2000s, guides have spread on the internet, in print and on video and the frequency of suicides by this method has increased.[4][5]
The suicide bag with inert gas method was originally developed by John Hofsess and the NuTech group, which consisted of Hofsess, Derek Humphry, engineers and physicians.[6]
In the book Final Exit by Derek Humphry, a suicide bag was described as a large plastic bag with an adjustable velcro strip around the neck.[7][8] Its use with inert gases was mentioned in the Supplement to Final Exit in 2000.[9]
The euthanasia-rights advocacy group Exit Australia distributed a manufactured version of the bag in Australia in 2002, alarming government officials and anti-abortion groups.[10][11] The Australian chapter of Right to Life expressed concern that they would be used by vulnerable people.[10][11]
In 2007, The Vancouver Sun cited Russel Ogden, Canadian criminologist and right-to-die advocate,[12] who said that the combination of a suicide bag and helium was "a method of choice" within the right-to-die movement for people who are terminally ill and that its promotion does not appear to cause an increase in the number of suicides. However, he said that he has no way of knowing if the method was being used by people with terminal illnesses or by people who are mentally ill.[13]
In 2008, Ludwig Minelli, founder of Dignitas, filmed four people dying by suicide by helium inhalation.[14] Subsequent to this, the method "has been winning supporters both in the USA and in Europe as a reliable, rapid and painless way to die".[14]
In 2009, Philip Nitschke, founder of voluntary euthanasia organisation Exit International, wrote in a member newsletter that nitrogen has a lower risk of an adverse reaction by the body than helium and is also more available than helium in Australia and New Zealand.[15] Nitschke's organisation sells suicide kits that contain nitrogen tanks and regulators.[16] He promotes the use of nitrogen and suicide bags with lectures and films, such as Doing it with Betty – in which an elderly woman describes how to make a plastic 'exit' bag,[17][18] and with published materials such as workshop handbooks.[19] Nitschke calls the suicide bag death a "hypoxic death", and likens it to pneumonia, the "old person's friend", where hypoxia occurs because pneumonic inflammation stops the lungs extracting sufficient oxygen from the air, and "a peaceful death often results".[3]
In 2015 author and right-to-die advocate Derek Humphry reported that Worthington Industries, the world's largest manufacturer of disposable helium cylinders, had announced that their helium cylinders will guarantee only 80% helium, with up to 20% air, making them inappropriate for use with a suicide bag in Humphry's opinion.[20]
In many countries it has also become increasingly difficult for private individuals to obtain cylinders of nitrogen for possible use with a suicide bag as suppliers have been alerted to this method and there are few other reasons for a private individual to seek to purchase a cylinder of nitrogen.
Dutch psychiatrist Boudewijn Chabot, in his 2015 book Dignified Dying, calls the suicide bag with inert gas method "rapid, painless and safe".[21]
Selling suicide bags is prohibited in some places. In 2011, the FBI raided a small mail-order business in California, which shut down afterwards.[22][23] In July 2011, this raid caused Oregon to be the first US state to pass legislation prohibiting the sale of kits containing suicide bags or hoods.[24]
Canadian right-to-die advocates stopped shipping suicide bags to Australia in 2001 when the Australian government announced that it would review their importation.[11] In 2002, the Queensland Police in Australia said that suicide bags did not violate any laws at that time and the Australian federal government said it would look into banning them.[10] Exit Australia gave them away to members upon request; they put warning labels on them, written as "exit bags". No instructions were included, in order to circumvent Australian laws against assisting suicide.[10][11]
Mechanism
Diagram of a suicide bag; details sourced from the books Final Exit and The Peaceful Pill Handbook
A hypoxic, carbon dioxide-free, metabolically inert gas that is less dense than air is provided for inhalation by confining the continually flowing less dense (than air) gas supply and the head in an impermeable bag which is slightly open at the lower neck, which continuously fills from the closed top down to the slightly open neck. This prevents contamination with oxygen from the surrounding air, and also flushes away any exhaled CO2, minimising the amount of gas required.[3] It will not work with inert gases like argon that are denser/heavier than air as these would just spill out the open neck of the bag and not fill it first from the sealed top downwards. (The same effect could also be reached by flooding any enclosed space with the gas, but much more gas would be needed, and this would be hazardous to a third party entering the space, an effect which is well-known as a cause of industrial fatalities.[25][26])
Inhalation of oxygen-deficient or oxygen-free gas not only fails to replenish oxygen used in normal metabolism, but causes the blood passing through the capillaries of the gas exchange regions of the lungs to lose residual oxygen in relation to the concentration difference between the oxygen in the alveolar air and in the blood in the alveolar capillaries. This causes a far quicker drop in blood oxygen level than holding the breath. The deoxygenated blood then passes through the systemic circulation to the vital organs, including the brain, and rapidly lowers oxygen concentrations below the level required to sustain consciousness, and when it is insufficient to keep the heart functioning, cardiac arrest will occur.[3][27] For the majority of people, an alveolar oxygen tension of less than 30 millimetres of mercury (40mbar) or 4% by volume at atmospheric pressure is not sufficient to support consciousness.[28]
The urge to breathe, in normal humans, is mainly controlled by blood carbon dioxide concentration and the acidity that it causes. A rise in carbon dioxide concentration caused by the inability to inhale fresh air will cause a strong reflex to breathe, accompanied by increasing distress as the level rises, culminating in panic and a desperate struggle for air. However, if the supplied breathing gas is free of carbon dioxide, the blood carbon dioxide levels will remain low while breathing occurs, and there will be no distress or urge to increase breathing rate, as the sensitivity in normal people to blood oxygen level as a breathing stimulus is very low.[3][27]
The effect of contamination of the inert gas by air or other source of oxygen is to reduce the effects of oxygen loss and the person exposed may feel weak, tired and confused, but without a strong urge to breathe or the associated respiratory distress.[3][27] The efficiency of the system for euthanasia requires minimising contamination by oxygen and carbon dioxide. Small amounts of oxygen will not affect the result, but may extend the time taken.[3]
Short-term effects
Helium and nitrogen are non-toxic and can be breathed with no ill effects over short or long term when oxygen levels are sufficient, and present no health risk to third parties except asphyxiation. The danger lies in that they are undetectable by human senses, and the first warning of their presence in asphyxiant concentrations may be loss of consciousness. Lower concentrations may cause confusion and weakness. Use of a suicide bag in a well ventilated room using either of these gases is unlikely to pose a hazard for other people, and there is no fire hazard.[27]
Propane, butane and natural gas are to varying degrees narcotic, and are a serious fire and explosion hazard, depending on concentration of the gas and of oxygen.[29] They are usually supplied with strong-smelling additives to provide a warning. These additives may be toxic in large doses, but the concentrations which are needed to indicate the presence of the gas are not dangerous over short terms. The unpleasant smell may be a deterrent to more widespread use as a euthanasia agent, but the primary purpose is a warning of fire hazard.[30]
Propane has low toxicity since it is not readily absorbed and is not biologically active. It is heavier than air and may accumulate in low places, particularly if they are poorly ventilated.[29] Non inert gases: Butane is similar to propane, and heavier, and has narcotic effects in large doses.[31] Natural gas is lighter than air and disperses quickly in a well ventilated area.
Research
Suicides using bags or masks and gases are well documented in the literature.[32][33]
Suicide bags have been used with gases other than inert gases, with varying outcomes. Examples of other gases used are propane-butane,[34] which has narcotic effects,[35] and is commonly adulterated with strong smelling additives to warn of gas leaks, and natural gas.[36]
Suicides using a suicide bag and an inert gas produce no characteristic post-mortem macroscopic or microscopic findings.[37][14] Forensic death investigations of cause and manner of death may be very difficult when people die by suicide in this manner, provided the apparatus (such as the bag, tank, or tube) is removed by someone after death.[38][14]Petechiae, which are often considered a marker of asphyxia, are present in only a small minority of cases (3%).[39] Frost reported that of the two cases he studied that featured death from inert gas asphyxiation using a suicide bag, one had "bilateral eyelid petechiae and large amounts of gastric content in the airways and that these findings challenge the assumption that death by this method is painless and without air hunger, as asserted in Final Exit."[40] A review study by Ely and Hirsch (2000) concludes that conjunctival and facial petechiae are the product of purely mechanical vascular phenomena, unrelated to asphyxia or hypoxia, and do not occur unless ligatures were also found around the neck. The authors wrote,[41]
Unless the bag is fastened around the neck by a ligature with sufficient tension to obstruct venous return from the face, in our experience, such persons never have facial or conjunctival petechiae. Persons with tight fastenings around the neck are recognizable instantly by their facial plethora of numerous petechiae. We are aware that some observers may have seen an occasional petechia in rare instances of plastic bag suicide. However, we have not seen detailed descriptions of such observations that permit another person to evaluate the variables that might have produced an isolated petechia in a rare victim. Conversely, in New York City, an average of approximately 15 persons per year accomplish suicide by plastic bag, and we never have observed petechiae in a person who did not tightly fasten the bag around his/her neck
—Ely SF, Hirsch CS, "Asphyxial deaths and petechiae: a review". J. Forensic Sci, (2000)
There are also documented cases of suicide attempts using the suicide bag that failed.[36] A case report study in 2015 discussed the risks associated with failed attempts using this method. The authors wrote, "If the process is interrupted by someone, there is no gas or the tube slips out of the bag, there is a high risk of severe hypoxia of the central nervous system" (in survivors).[14] Brain cells are very sensitive to reduced oxygen levels. Once deprived of oxygen they will begin to die off within five minutes.[42] If hypoxia results in coma, the length of unconsciousness is often indicative of long-term damage. In some cases coma can give the brain an opportunity to heal and regenerate,[43] but, in general, the longer a coma, the greater the likelihood that the person will remain in a vegetative state until death.[44]
Bioethics
Russel Ogden (2002) said that the existence of "how-to" literature involving the suicide bag has been "shown to influence the choice of suicide method but not the overall suicide rate, and that an emerging counterculture of death providers, operating outside of the traditional medicolegal framework of health care, was placing assisted death outside the normative gaze of medicine".[45] In 2010, Ogden and colleagues observed four cases of assisted suicide with helium delivered by face mask. The authors stated that a hood method might be able to play a role in "demedicalising assisted suicide".[46] Ogden views a bag and inert gas as "the quickest way to go; used properly, you're unconscious after the second breath and dead in about 10 minutes".[47]
Clinical psychologist Phillip Kleespies said that Ogden's work calls attention to some of the risks associated with covert assisted suicide using unregulated methods like the suicide bag with inert gas. He does not dispute that the method is "swift, highly lethal and painless", as claimed by Ogden and other right-to-die proponents.[13] However Kleespies feels it is an undignified, impersonal and "hurried" manner of death, which may be used by people who have not had the opportunity for appropriate counseling and that this is largely a result of more dignified methods being made illegal. He concludes by expressing the hope that with improved and more appropriate care during the dying phase of life, there will be less perceived need for these methods of self-deliverance.[48]
A study poses the dilemma for medical ethicists and the general public who "may also want to carefully weigh the unintended adverse consequences of widely disseminated suicide methods likely to appeal to some depressed persons (irrespective of their physical health status or age) against the putative benefits associated with making these methods more widely known and available".[49]
Characteristics of users
Promoters of this suicide method recommend it to terminally ill patients.[40] However, across the world, most people who use suicide bags are physically healthy.[40][49] Instead of having incurable cancer or other life-threatening physical diseases, most of the users have psychiatric disorders or substance abuse problems that might possibly be addressed through medical and psychological treatment.[40][49] The demographics of its users varies; in one survey, the method had been used mostly by middle-aged adults in failing health, who were attracted to the relative nonviolence of the method.[39]
This suicide method is also typically used by younger or middle-aged adults, rather than by older adults.[40][49] In the US, it is more commonly chosen by white males than by women or people of other races.[40][49]
Helium is a chemical element; it has symbol He and atomic number 2. It is a colorless, odorless, non-toxic, inert, monatomic gas and the first in the noble gas group in the periodic table. Its boiling point is the lowest among all the elements, and it does not have a melting point at standard pressures. It is the second-lightest and second most abundant element in the observable universe, after hydrogen. It is present at about 24% of the total elemental mass, which is more than 12 times the mass of all the heavier elements combined. Its abundance is similar to this in both the Sun and Jupiter, because of the very high nuclear binding energy of helium-4, with respect to the next three elements after helium. This helium-4 binding energy also accounts for why it is a product of both nuclear fusion and radioactive decay. The most common isotope of helium in the universe is helium-4, the vast majority of which was formed during the Big Bang. Large amounts of new helium are created by nuclear fusion of hydrogen in stars.
Inhalants are a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication, in a manner not intended by the manufacturer. They are inhaled at room temperature through volatilization or from a pressurized container, and do not include drugs that are sniffed after burning or heating.
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects all the tissues and organs, some more rapidly than others. There are many circumstances that can induce asphyxia, all of which are characterized by the inability of a person to acquire sufficient oxygen through breathing for an extended period of time. Asphyxia can cause coma or death.
Philip Haig Nitschke is an Australian humanist, author, former physician, and founder and director of the pro-euthanasia group Exit International. He campaigned successfully to have a legal euthanasia law passed in Australia's Northern Territory and assisted four people in ending their lives before the law was overturned by the Government of Australia. Nitschke was the first doctor in the world to administer a legal, voluntary, lethal injection, after which the patient activated the syringe using a computer. Nitschke states that he and his group are regularly subject to harassment by authorities. In 2015, Nitschke burned his medical practising certificate in response to what he saw as onerous conditions that violated his right to free speech, imposed on him by the Medical Board of Australia. Nitschke has been referred to in the media as "Dr Death" or "the Elon Musk of assisted suicide".
An inert gas is a gas that does not readily undergo chemical reactions with other chemical substances and therefore does not readily form chemical compounds. Though inert gases have a variety of applications, they are generally used to prevent unwanted chemical reactions with the oxygen (oxidation) and moisture (hydrolysis) in the air from degrading a sample. Generally, all noble gases except oganesson, nitrogen, and carbon dioxide are considered inert gases. The term inert gas is context-dependent because several of the inert gases, including nitrogen and carbon dioxide, can be made to react under certain conditions.
Autoerotic fatalities are accidental deaths that occur during sexual self-stimulation when an apparatus, device or prop that is being employed to enhance pleasure causes the death. Researchers only apply the term to unintentional deaths resulting from solitary sexual activity, not suicide or acts with a partner. The incidence of autoerotic fatalities in Western countries is around 0.5 per million inhabitants each year.
Dead space is the volume of air that is inhaled that does not take part in the gas exchange, because it either remains in the conducting airways or reaches alveoli that are not perfused or poorly perfused. It means that not all the air in each breath is available for the exchange of oxygen and carbon dioxide. Mammals breathe in and out of their lungs, wasting that part of the inhalation which remains in the conducting airways where no gas exchange can occur.
A breathing gas is a mixture of gaseous chemical elements and compounds used for respiration. Air is the most common and only natural breathing gas, but other mixtures of gases, or pure oxygen, are also used in breathing equipment and enclosed habitats. Oxygen is the essential component for any breathing gas. Breathing gases for hyperbaric use have been developed to improve on the performance of ordinary air by reducing the risk of decompression sickness, reducing the duration of decompression, reducing nitrogen narcosis or allowing safer deep diving.
Hypercapnia (from the Greek hyper = "above" or "too much" and kapnos = "smoke"), also known as hypercarbia and CO2 retention, is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs. Carbon dioxide may accumulate in any condition that causes hypoventilation, a reduction of alveolar ventilation (the clearance of air from the small sacs of the lung where gas exchange takes place) as well as resulting from inhalation of CO2. Inability of the lungs to clear carbon dioxide, or inhalation of elevated levels of CO2, leads to respiratory acidosis. Eventually the body compensates for the raised acidity by retaining alkali in the kidneys, a process known as "metabolic compensation".
Erotic asphyxiation is the intentional restriction of oxygen to the brain for the purposes of sexual arousal. With a partner, the act often involves strangulation. The term autoerotic asphyxiation is used when the act is done by a person to themself. Colloquially, a person engaging in the activity is sometimes called a gasper. Erotic asphyxiation can lead to accidental death due to asphyxia.
A suicide method is any means by which a person may choose to end their life. Suicide attempts do not always result in death, and a non-fatal suicide attempt can leave the person with serious physical injuries, long-term health problems, or brain damage.
A packaging gas is used to pack sensitive materials such as food into a modified atmosphere environment. The gas used is usually inert, or of a nature that protects the integrity of the packaged goods, inhibiting unwanted chemical reactions such as food spoilage or oxidation. Some may also serve as a propellant for aerosol sprays like cans of whipped cream. For packaging food, the use of various gases is approved by regulatory organisations.
Inert gas asphyxiation is a form of asphyxiation which results from breathing a physiologically inert gas in the absence of oxygen, or a low amount of oxygen, rather than atmospheric air. Examples of physiologically inert gases, which have caused accidental or deliberate death by this mechanism, are argon, helium, nitrogen and methane. The term "physiologically inert" is used to indicate a gas which has no toxic or anesthetic properties and does not act upon the heart or hemoglobin. Instead, the gas acts as a simple diluent to reduce the oxygen concentration in inspired gas and blood to dangerously low levels, thereby eventually depriving cells in the body of oxygen.
An asphyxiant gas, also known as a simple asphyxiant, is a nontoxic or minimally toxic gas which reduces or displaces the normal oxygen concentration in breathing air. Breathing of oxygen-depleted air can lead to death by asphyxiation (suffocation). Because asphyxiant gases are relatively inert and odorless, their presence in high concentration may not be noticed, except in the case of carbon dioxide (hypercapnia).
A vertical form fill sealing machine is a type of automated assembly-line product packaging system, commonly used in the packaging industry for food and many other products. Walter Zwoyer, the inventor of the technology, patented his idea for the VFFS machine in 1936 while working with the Henry Heide Candy Company. The machine constructs plastic bags and stand-up pouches out of a flat roll of film, fills them with product, and seals them. Both solids and liquids can be bagged.
A euthanasia device is a machine engineered to allow an individual to die quickly with minimal pain. The most common devices are those designed to help terminally ill people die by voluntary euthanasia or assisted suicide without prolonged pain. They may be operated by a second party, such as a physician, or by the person wishing to die. There is an ongoing debate on the ethics of euthanasia and the use of euthanasia devices.
Exit is a not-for-profit, pro-euthanasia organisation based in Scotland that lobbies for and provides information about voluntary euthanasia and assisted suicide. It has particularly focused on research and publication of works which provide information about suicide methods, including How to Die With Dignity, the first book published on the subject.
Nitrous oxide (N2O), commonly referred to as laughing gas, along with various street names, is an inert gas which can induce euphoria, dissociation, hallucinogenic states of mind, and relaxation when inhaled. Nitrous oxide has no acute biochemical or cellular toxicity and is not metabolized in humans or other mammals. Rare deaths and injuries associated with use are due to asphyxia or accidents while under the influence, or vitamin B12 deficiency. Excessive use can lead to long-term and significant neurological and haematological toxicity.
Human physiology of underwater diving is the physiological influences of the underwater environment on the human diver, and adaptations to operating underwater, both during breath-hold dives and while breathing at ambient pressure from a suitable breathing gas supply. It, therefore, includes the range of physiological effects generally limited to human ambient pressure divers either freediving or using underwater breathing apparatus. Several factors influence the diver, including immersion, exposure to the water, the limitations of breath-hold endurance, variations in ambient pressure, the effects of breathing gases at raised ambient pressure, effects caused by the use of breathing apparatus, and sensory impairment. All of these may affect diver performance and safety.
The Sarco pod is a euthanasia device or machine consisting of a 3D-printed detachable capsule mounted on a stand that contains a canister of liquid nitrogen to die by suicide through inert gas asphyxiation. "Sarco" is short for "sarcophagus". It is used in conjunction with an inert gas (nitrogen) which decreases oxygen levels rapidly which prevents panic, sense of suffocation and struggling before unconsciousness, known as the hypercapnic alarm response caused by the presence of high carbon dioxide concentrations in the blood. The Sarco was invented by euthanasia campaigner Philip Nitschke in 2017. Nitschke said in 2021 that he sought and received legal advice about the device's legality in Switzerland.
↑ Humphry D (1992). Final Exit: the Practicalities of Self-Deliverance and Assisted Suicide for the Dying. New York: Delta Trade Paperback. ISBN978-0-385-33653-6.
↑ Humphry D (2002). Final Exit: the Practicalities of Self-Deliverance and Assisted Suicide for the Dying (3rded.). New York: Delta Trade Paperback. ISBN978-0-385-33653-6.
↑ Humphry D (2000), Supplement to Final Exit, Norris Lane Press and ERGO
↑ Paul W. Fisher. "2 – High Altitude Respiratory Physiology". USAF Flight Surgeon's Guide. USAF School of Aerospace Medicine. Archived from the original on 16 March 2007. Retrieved 5 March 2015.{{cite book}}: CS1 maint: bot: original URL status unknown (link)
1 2 "Propane". The National Institute for Occupational Safety and Health (NIOSH). 2017-11-17. Retrieved 2016-05-12. Propane is a simple asphyxiant and does not present an IDLH hazard at concentrations below its lower explosive limit (LEL). The chosen IDLH is based on the LEL of 21,000 ppm rounded down to 20,000 ppm. (2% by volume)
↑ "Safety Alert: Suicide Bags"(PDF). Trenton, NJ: New Jersey Department of Community Affairs, Division of Fire safety, Office of the State Fire Marshall. August 2012. Retrieved 5 March 2018.
↑ Raymond D. Harbison, Marie M. Bourgeois, Giffe T. Johnson (2015). Hamilton and Hardy's Industrial Toxicology (6, reprinted.). John Wiley & Sons. ISBN978-1-118-83421-3.
↑ Oosting R, van der Hulst R, Peschier L, Verschraagen M (2015). "Toxicological findings in three cases of suicidal asphyxiation with helium". Forensic Sci. Int. 256: 38–41. doi:10.1016/j.forsciint.2015.06.028. PMID26298854.
↑ Richmond, T. S. (May 1997). "Cerebral Resuscitation after Global Brain Ischemia", AACN Clinical Issues 8 (2). Retrieved on 2007-04-13. Free full textArchived September 27, 2007, at the Wayback Machine
↑ Ogden R, Hamilton W, Whitcher C (Mar 2010). "Assisted suicide by oxygen deprivation with helium at a Swiss right-to-die organisation". J Med Ethics. 36 (3): 174–179. doi:10.1136/jme.2009.032490. PMID20211999. S2CID206996269.
↑ Kleespies PM (2010), "Psychological and ethical considerations concerning the debreather and assisted suicide: a commentary on Ogden", Death Studies, 34 (4): 318–324, doi:10.1080/07481181003613859, PMID24479189, S2CID25134060
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