“If you want to die, do it yourself,” says Dr Philip Nitschke. “That’s the message.”
It is an unusual message to hear from any physician. Many would consider it a dangerous one. But for Dr Nitschke, an Australian euthanasia activist and former medic sometimes known as “Dr Death”, it is the linchpin of a life spent campaigning for every person’s right to die – and the driving force behind his newest creation.
The Sarco is a personal “suicide pod” that kills by flooding its coffin-like cockpit with nitrogen gas. Designed to minimise the role of doctors in legal suicides, it has already sparked uproar from other right to die groups and horrified, fascinated discussion across the world. With its first deadly use planned for 2022 in Switzerland, Dr Nitschke now hopes to take it worldwide.
Current laws on assisted suicide, also known as assisted dying or physician-aided suicide, are likely to block the Sarco, especially in the US. But the device is designed to be 3D printed in any capable workshop around, using liquid nitrogen that most people could acquire from hardware shops or chemical suppliers.
If its blueprints spread, it could disrupt suicide laws across the world just as 3D-printed “ghost guns” have disrupted gun regulations.
“There’s lots of interest,” Dr Nitschke tells The Independent. “We talk to a lot of people who want to end their lives, and there’s quite a number who, if they had their choice, would pick something like this.” Inquiries about the Sarco, he says, have risen from several a week to several every day – from the US and beyond.
‘A plastic bag without the yuk factor’
In 1999, a retired academic named Lisette Nigot buttonholed Dr Nitschke after a workshop in Perth, Australia, and demanded to know how she could kill herself before she turned 80.
By then Dr Nitschke was already well known as the man who had administered world’s first voluntary lethal injection, triggered by the patient himself using a syringe connected to a laptop called the Deliverance Machine. His relentless campaign for voluntary death would lead to him founding the group Exit International, burning his doctor’s certificate in protest, quitting medical practice, and moving to the Netherlands.
“I said ‘Lisette, you’re not sick. Why don’t you go on a world cruise and write a book or something?’” he recalls. “She said, ‘why don’t you mind your own business? It’s got nothing to do with you, doctor. You’ve got technical information about what works and what doesn’t. What gives you the right to go around doling it out to people who satisfy your criteria of suffering?’ I was so mortified by her criticism that I gave her all the information.” Three weeks before her 80th birthday, she made use of it.
Today Dr Nitschke credits Nigot in part for persuading him that assisted deaths should not require a doctor. He distributes suicide instructions, from drugs to “exit bags”, in his Peaceful Pill Handbook, which he reluctantly restricts to customers who are over 50, seriously ill, or have some other “valid reason”.
Now resident in Amsterdam, he speaks to The Independent fresh from helping a couple die in Switzerland, which is unusual in permitting assisted suicide even for people who are not sick. One of the couple had serious cancer; the other simply did not want to live without them.
“We wanted a system whereby a person could be able to end their lives with minimal technical expertise needed,” says Dr Nitschke. “You put a person in a zero oxygen environment, and they have a peaceful death. But the usual way that’s been done is that they use a plastic bag, and plastic bags have got what we might describe as a yuk factor. People don’t like the idea of them, and they certainly don’t like the look of them.”
The Sarco, by contrast, looks like the kind of sarcophagus an Egyptian pharaoh would commission from famed former Apple designer Sir Jony Ive. Dr Nitschke says it can only be operated from the inside and only with a code provided by Exit International.
In future, Dr Nitschke hopes to further reduce medical involvement with on-board artificial intelligence (AI) that could perform the mental health check that most countries require (”I would rather personally have AI than have most of the psychiatrists I’ve met”). He also plans to make 3D printing blueprints available to Peaceful Pill subscribers, letting them print their own wherever they live for perhaps a few thousand dollars.
For now only two Sarcos exist, one a display model and one that “didn’t work out at all”. The third is being 3D-printed in Rotterdam for use in Switzerland, with its first death scheduled for 2022. “The idea will be to put it in a trailer and cart it off down to Switzerland where it can go to a nice location” – Lake Geneva, perhaps, or the Alps – “and where someone can climb in and press the button.”
After that, he adds, “we may not see it for servicing for a few months. I’m almost certain it’ll be taken away by the authorities for a close investigation”.
Swiss lawyer gives Sarco the green light
Earlier this month, misleading news stories ricocheted around claiming that the Sarco had been approved by Swiss authorities. In truth, the Sarco had merely received a green light from a lawyer hired by Exit International – but Dr Nitschke is confident it will prove legal.
Under Swiss law, no doctor may directly end someone’s life even if they ask for it, a practice known as voluntary euthanasia. Yet anyone can help another person die by their own hand if it is not for "self-serving reasons", and as long as the person is fully aware of and in control of their own decision. Nor does the law require any specific method of death.
"I have examined all the laws that could capture the capsule at first glance, and I have come to the conclusion that none of them prohibits the use of Sarco," says Dr Daniel Hürlimann, a lawyer, physician and professor at the University of St Gallen commissioned by Exit International.
"Sarco does not constitute a medical device and is therefore not covered by the Therapeutic Products Act. Sarco is also not a weapon in the sense of the Weapons Act and not covered by Product Safety Law." He adds that its use of nitrogen does not violate laws on medicines, narcotics or dangerous chemicals.
Dr Hürlimann notes the Swiss legal definition of a medical device, which includes functions such as monitoring and treating diseases or modifying the anatomy of a physiological condition, and argues that the Sarco does none. A spokesperson for SwissMedic, the Swiss statutory agency that approves drugs and medical products, told Reuters that the Sarco would not fall under its purview because it is not “medicine”.
Kerstin Noëlle Vokinger, a medical doctor and professor of health law at the University of Zurich, is not so sure. “At least to me, it’s not obvious that for sure it’s not a medical device,” she argues. “Is death also considered a medical use? Health and death, life and death, are both parts of medicine.”
She says that while the Swiss law looks simple on paper, legal precedents and other “soft law” such as doctors’ professional regulations have led to a more complex set procedures that the Sarco may have to follow. The idea of an AI medical assessment would certainly be forbidden, she says.
In this system, most legal deaths go through Swiss non-profits with stringent rules for who they help. Doctors perform a mental health assessment and prescribe sodium pentobarbital, a sedative. The person taking it states their name, date of birth and their understanding of the procedure into a video camera, then dies on film. An assistant notifies the police, who come and check the law has been followed. Established Swiss groups are not impressed by the Sarco.
“In light of this established, safe and professionally conducted practice, we would not imagine that a technologised capsule for a self-determined end of life will meet much acceptance or interest in Switzerland,” said Dignitas, one of the country’s main end-of-life groups.
Exit (no relation to Exit International) said it does not see the Sarco as a viable alternative. Another group, LifeCircle, said there was “no human warmth with this method”. The Pagasos Swiss Association told The New York Times that it was talking with Exit International but needed more information.
Dr Nitschke says he plans to be “over-careful”. If Exit International handles the first Sarco death, its user will need to get a mental health check beforehand and answer basic questions into a video camera inside the capsule before the capsule can be activated. Afterwards, an assistant will notify the police.
‘That would be a very hard sell in America’
Outside Switzerland the Sarco faces higher barriers. Dr Nitschke initially told The Independent that he “absolutely” wants to bring it to the US, where 11 states allow some form of assisted suicide, even if it had to be used under close medical supervision. American doctors have struggled to secure drugs such as sodium pentobarbital due to boycotts by European drug makers, who object to its use in criminal executions.
Later, however, Dr Nitschke relayed the advice of US experts he had contacted. “Sarco will be illegal in many US jurisdictions,” said Dr Lonny Shavelson, chairman of the American Clinicians’ Academy on Medical Aid in Dying, who confirmed the quote to The Independent.
“In particular, California requires ‘ingestion’ of the medications, defined as using the gastrointestinal tract. Some other states just say ‘take’ and each state has subtle distinctions, but all are interpreted as using the gastrointestinal tract. Under existing law, there has never been the legal use of nitrogen or other gas for medical aid in dying. Helping someone with a gas inhalation will be a considered an illegal assisted suicide in the US, unless there is further legislation or court cases to legalise it.”
Dr Nitschke added: “If that is true, nitrogen is clearly out.”
Other US non-profits backed that up. Bernadette Nunley, national policy director for the Oregon-based Compassion and Choices, described US assisted dying laws as “fundamentally different” from Swiss ones, allowing only a “medical practice” embedded in the existing health system alongside other palliative care techniques.
Nor is that likely to change, according to Judy Epstein, president of End of Life Choices California. “The United States is very resistant to medical aid and dying, and the states that have laws have fought very hard to have them. [They] agree to all these hoops that patients have to jump through in order to access medical aid in dying, because there’s so much fear of people taking taken advantage of.”
She says the idea of dying by gas would remind too many Americans of the Holocaust, or of the way some US prisoners are executed. “That would be a very hard sell in this country.”
Meanwhile, the UK’s House of Lords is still debating the Assisted Dying Bill, which would allow terminally ill adults of sound mind to get help with dying from a doctor. The current draft could potentially allow the Sarco under medical supervision, since it permits suicide via a “medical device” that administers “medicine”. Ministers would decide which medicines and delivery methods to allow.
But British right-to-die activists have reacted with horror to the device. “I cannot possibly support the so-called ‘Sarco’,” wrote campaigner Dr Stephen Duckworth in The Independent last week, “nor am I aware of any credible assisted dying campaigner who does. [It] would deprive users of human connection and replace it with a lonely, virtual reality experience.”
Ellie Ball, media and campaigns manager at the British charity Dignity in Dying, told The Independent that assisted dying should be “embedded in healthcare” so that terminally ill people could make informed decisions with advice from their family and doctors instead of killing themselves behind closed doors. “The Sarco doesn’t solve that problem, it perpetuates it,” she said.
Could Sarco’s 3D printing blueprints spread out of control?
On 27 November, a 13-year-old boy accidentally shot his older sister while attempting to defend their house in Georgia from a robbery. According to police, the thieves had not come for jewellery or electronics but for the boy’s collection of “ghost guns”, untraceable 3D-printed firearms that he was allegedly manufacturing and selling from home.
Ghost guns, so called because they lack serial numbers, illustrate the problems that 3D printing can pose. Their blueprints have spread widely across the internet, with some advocates claiming that they count as free speech, and appeared in shootings across the US. Several cities have filed lawsuits against ghost-gun makers accusing them of fuelling violence.
Dr Nitschke says openly that 3D printing the Sarco is a way to dodge legal trouble. “It was an answer to a problem we had,” he says. “The information itself is not considered to be a criminal act, as the provision of material goods would be. Giving you a Sarco and you climb in and press the button? I’m assisting your suicide, that’s a crime. You printing your own, which you then climb into and die, is not a crime.”
Or, as he put it in a promotional video on the Sarco website: “The idea can be moved anywhere in the world now. The concept can be completely transferable, and you just need a machine to be able to turn it into reality. .. they can get the idea, and they can make it themselves.”
Exit International does check the age of Peaceful Pill subscribers, but Dr Nitschke admits that he cannot control how the Sarco blueprints might spread beyond them. “Our online version of [the book] is widely pilfered,” he says.
“We find fake copies of it turning up all over the place, it’s impossible to try and restrict control of this. And so this issue of bleeding of information which can be misused is an issue that we have no easy answer to in its digital form.
“There’s several examples of vulnerable young people who have somehow or other got hold of the book, got hold of the drugs, ended their lives. Very upset family members have blamed us for giving out this information, arguing that it should never be given to anyone because it can be misused.
“Our counter to that is that we’ve got thousands of members all over the world who desperately want that information. These are rational, elderly people who have every right to this information. So why should we disenfranchise this huge number of people because there may be vulnerable individuals who find themselves caught up and accidentally harmed?”
He says that that the printable version will probably lack the safeguard software to be used in Switzerland, which requires an assistant watching by video to make it operable.
That is a prospect that alarms people on all sides of the debate. “As an attorney I can tell you that would probably skirt the law, and that’s really terrifying,” says Rita Marker, director of the anti-assisted-dying Patients’ Rights Council. She claims the device could be printed under the table and used without medical supervision, making it easier for relatives to manipulate people into dying or even allowing murders masked as suicides.
Ms Epstein is also concerned, saying: “If one of those was built ... hundreds of people could use it. It could get passed around from town to town. With the internet anything’s possible.” Final Exit Network’s director Janis Landis likewise says: “I am concerned about the availability of any device that allows vulnerable, emotionally depressed individuals to impulsively [ die by] suicide.”
Of course, even a black market Sarco would not be the easiest suicide method. It is far bigger and more technically complex than an actual plastic bag, and printing it and getting liquid nitrogen would take time and money. Dr Nitschke argues that it would make an “implausible” murder weapon.
Ms Landis points out that for most Americans it would be far easier to simply acquire a gun, already the most common suicide method in the US. Those with access to a 3D printer could simply make a ghost gun.
For Dr Nitschke, individual autonomy wins out. “If you’re over the age of 18, governments are quite keen to give you a gun and send you over to places like Iran and tell you to kill people, but not to kill yourself, so this idea that we have to protect the young is a little bit disingenuous to me...
“I’m not going to try and change your mind. If you don’t like it, you don’t like it; I’m not going to tell you to get into a Sarco. But I am going to try and tell you to stop trying to control others who wish to.”
