Last Resorts

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In May 2014, Sandy Bem, a Cornell psychology professor known for her pioneering research on the social construction of gender, drank a lethal dose of phenobarbital and a sip of wine, bringing her life and experience with Alzheimer’s Disease to a close. Following her diagnosis in 2009, Bem decided to end her life by suicide after reading books by pro-euthanasia authors like Derek Humphrey and Philip Nitschke. While Bem’s choice was clear, the means and timing of the ultimate event proved to be more opaque, as she planned her end around a loss of quality of life that did not materialize as she expected. Based in New York, Bem considered accessing assisted suicide services in Oregon, which allowed physician-assisted suicide for patients who were terminally ill (i.e., had six months or less to live due to the natural progression of their illness). Alzheimer’s patients, however, frequently lose the capacity to choose to take a lethal dose of a drug long before this timeframe. In 2013, after some deliberation with her family about how to proceed, she wrote to an international address listed in Nitschke’s book, The Peaceful Pill Handbook, and received two bottles containing a lethal dose of phenobarbital in the mail. After pronounced deterioration of her memory and functional status throughout the early months of 2014, Bem ended her life.

Society’s growing tolerance for expanding medically aided dying reflects a profound shift in attitudes toward end-of-life care. More countries and U.S. states have legalized it, the range of eligible diagnoses has broadened, and the American Medical Association has recently adopted a more permissive ethical stance. In fact, in 2022, Oregon relaxed the in-state residency requirements that were in place at the time Bem took her life, and Vermont followed in 2023. Sandy Bem approached her decision cautiously and conscientiously, from within a network of love and support of her family. However, not all patients have the time, resources, or support that shaped her experience. This disparity demands a thorough and nuanced ethical consideration of how access to medical assistance in dying (MAID) is shaped by social structures that may push those with fewer resources toward patient suicide. Without such scrutiny, what is intended to be a last resort for patients with unmanageable terminal illness risks becoming a tool of convenience in a system designed to support those with disability and illness as little as possible.

As states reconsider and ease restrictions on access and timing – factors that shaped Sandy Bem’s life-ending decisions – technological innovations in MAID risk undermining the safeguards of these medical-legislative processes, potentially circumventing them altogether. One new technology, the 3-D printed Sarco Pod, purports to honor a patient’s autonomy by delivering a more pleasant death with greater ease of access than what Sandy Bem encountered. In some ways similar to a machine designed by Dr. Jack Kevorkian, which replaced oxygen with carbon dioxide to asphyxiate the patient, the Sarco Pod is flooded with nitrogen gas to achieve the same end. While the respiratory centers of the brain are largely programmed to respond to rising carbon dioxide levels with anxiety and agitation, Nitschke’s use of nitrogen is not only meant to eliminate fear and anxiety, but also to provide a sense of euphoria as a person slips into unconsciousness. The Last Resort, the Swiss partner to Nitschke’s organization, also hopes to make the Sarco Pod design available open-source in the future, eliminating barriers to MAID such as those experienced by Sandy Bem.^[1]

In September 2024, a patient with the pseudonym ‘Ann’ ended her life using a Sarco Pod, which is designed to be transportable and placed anywhere a patient wishes to experience her last moments. Little is known about ‘Ann,’ except that she was an American woman who was diagnosed with skull base osteomyelitis (SBO) and an unspecified autoimmune disorder, which made treatment for the condition impossible. Patients with SBO, a high-mortality inflammatory condition resulting from infection of the cranial bones, can experience cranial neuropathies, persistent headaches, or even seizures unless treatment with intensive antibiotics or neurosurgeries is successful.^[2] According to Nitschke, Ann reported that she desired to end her life for at least the past two years, due to the disabling pain she experienced from the osteomyelitis. In his interviews with popular media following Ann’s death, Nitschke reported that she “hit the button almost immediately” to begin the process of flooding the pod with nitrogen gas; reportedly she died peacefully within minutes. The actual course of Ann’s demise is unknown, as the only other person present with her was arrested, but later released, following the identification of ‘strangulation marks’ on Ann’s neck. Nitschke maintains that nothing nefarious occurred in the process – which he observed only by a patchy video call that lost connection during the actual death of the patient.

Using Ann as his pilot case, Nitschke introduced a MAID technology designed to be both mobile and easily accessible for patients seeking suicide. While The Last Resort openly states its intention to make the 3-D printing plans available to ‘people qualifying,’ it does not specify what those qualifications might be.^[3] Given the largely open borders of the digital realm, it is unlikely that everyone who obtains the printing plans will have undergone The Last Resort’s screening process. Even in Sandy Bem’s case, the most detailed article fails to specify what information Bem needed to provide to the address in Mexico in order to obtain her bottles of phenobarbital. Additionally, nitrogen gas is controversial in other contexts, such as its recent use in a Louisiana execution despite the state’s ban on using the same method for pet euthanasia.

Over the past three decades, attitudes in the U.S. toward MAID have become more accepting among both the public and healthcare professionals, especially as society experiences longer lifespans and rising rates of chronic disease. However, not everyone supports Nitschke’s goals. Sources of disagreement with Nitschke’s new technology exceeded the usual expectation of disability advocates and sanctity-of-life groups. Palliative care physician Erika Preisig, herself associated with a Swiss MAID organization, cautions against the direct-to-consumer nature of Nitschke’s approach, suggesting that physicians are supports and guides, not gatekeepers, in the difficult process of choosing to end one’s life.

In Sandy Bem’s case, the support of others around her afforded her the time and ability to adapt to the changes in her functional status and quality of life, which sometimes occurred in positive ways that surprised even her. So often, in the face of uncertainty and possible death, we assume we know what our limits of tolerance are for the changes we may (or may not) experience throughout the course of a disease process. Bem assumed the same, and the course of her life over the five years of officially diagnosed Alzheimer’s Disease demonstrated that other aspects of life can contradict the losses, real and imagined, that one experiences in the course of a given disease. For Bem, she found joys that she had been unable to find in her more “abled” life as a highly successful psychologist and professor. While achieving peace and happiness may seem out of reach for some patients with various diseases, Bem’s case shows that our understanding of how we’ll confront death is often uncertain and inaccurate. Sometimes, we find joy and peace in processes we feared would only bring suffering.

Studies regarding patient perspectives on MAID display a range of justificatory factors included in their decisions: pain, loss of functional status and sense of self, and fears over the future. Further reading into the rationales of patients shows an inextricable intertwining of those symptoms and feelings with perceptions of the burdensome nature of their decline.^[4] Some patients report that adequate pain management would leave them too unable to clean themselves, thus needing to rely on family members to provide care in more intimate ways than they find comfortable. Thus, even in studies that show pain as the predominant factor in a group of patients supporting euthanasia or MAID, pain itself becomes linked with the amount of care a patient can expect to need, care that could (and should) be relegated to external social supports instead of to a patient’s loved ones.

The evolutions in assisted suicide technology and social environment that support expanded uses of MAID are not without their causes for concern. Very recently, state legislators in Oregon introduced a bill to reduce the current fifteen-day waiting period for MAID to two days. This proposal received both support and strong opposition from, among others, family members of patients with disabling illnesses and mental health professionals in the state who cite the inability to determine mental soundness for such a decision in that timeframe. In Canada, disability rights advocates issued a legal challenge to the expansion of their MAID laws to include non-terminal conditions, such as those experienced by Ann. Court challenges in Canada also succeeded in delaying their planned 2024 expansion of MAID for mental health purposes, a provision that notably excluded neurocognitive diagnoses such as Parkinson’s, Huntington’s, or Alzheimer’s Diseases, which was the basis for Sandy Bem’s case. Such exclusions make it difficult to ignore the claims of disability justice scholars that “social deprivation, poverty, and lack of essential supports”^[5] were the impetus for people with various nonterminal disabilities to seek MAID, rather than the physical aspects of their diseases. As such, allowing – or encouraging, in some cases^[6] – MAID in lieu of providing the supportive environment that sustains the choice of life suggests the persistence of eugenic logics and raises medical ethics questions.

As healthcare services scale back the availability of skilled care to those in home-based health situations, the consequence is that such feelings are likely to increase among severely disabled patients, especially within countries that do not offer financial compensation or work time concessions for caregivers. When we continue to outsource patient care to family members, it is far too easy to be unaware of the cumulative psychosocial impacts such care needs will have on the patient themselves. As technology access and social acceptance of suicide increase alongside these emotional trends, one cannot help but wonder what social divides exist in those who are more prone to opt for suicide, even at times or within diseases they might otherwise have chosen to endure. As legislation and technology continue to outpace the support available to those living with illness and disability, we risk the slide of what was intended to be a merciful and dignified last resort into the dystopian mandate that opponents feared MAID would be.

Bibliography

Dyer, Owen. “Assisted dying: Disability advocates launch legal challenge to Canada’s law.” BMJ, 387 (2024).

Dying With Dignity Canada. “MAID and Mental Illness.”

Faruqui, Ferrukh. “Death ‘is not a medical process. It shouldn’t be made one:’ Suicide pod stirs controversy among right-to-die proponents.” HealthyDebate. March 5, 2025.

Green, Aimee. “Oregon bill that would remove hurdles to medically assisted suicide runs into wall of opposition.” OregonLive. March 4, 2025.

Henig, Robin Marantz. “The Last Day of Her Life.” The New York Times. May 14, 2015.

Jackson, Nicholas. “Jack Kevorkian’s Death Van and the Tech of Assisted Suicide,” The Atlantic, June 3, 2011.

Khan, Muhammad Adnan, et al. “A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges Among Various Presentations.” Asian Journal of Neurosurgery 13 (no. 4), (Oct-Dec, 2018)

The Last Resort, “FAQs,” accessed on 10/29/2024

Marsden, Emma. “Woman Using Suicide Pod Reportedly Found With ‘Strangulation’ Marks Inside.” Newsweek, October 30 2024.

Nitschke, Philip. “Here’s Why I Invented a ‘Death Machine’ That Lets People Take Their Own Lives,” Huffington Post, April 5 2018.

Pearlman, Robert A., Clarissa Hsu, Helene Starks, Anthony L. Back, Judith R. Gordon, Ashok J. Bharucha, Barbara A. Koenig, and Margaret P. Battin. “Motivations for physician-assisted suicide: Patient and family voices.” Journal of General Internal Medicine 20 (2005): 234-239.

Rathke, Lisa. “Vermont Allows Out-of-staters to Use Assisted Suicide Law.” The Associated Press. May 2, 2023.

Rohrlich, Justin. “Nitrogen Gas is Banned in Louisiana to Euthanize Dogs. The State Plans to Kill a Death Row Inmate Next Month.” The Independent, February 26, 2025.

Salvoni, Elena. “Inside the First Sarco Pod Suicide.” The Daily Mail, September 24, 2024.

Samuel, Henry. “US Woman Dies in First Use of ‘Sarco Suicide Pod.’” The Telegraph on MSN.com. September 24, 2024.

Shivaram, Deepa. “Physician-assisted Death in Oregon is No Longer Limited to Just State residents.” NPR. March 30, 2022.

Spiegel, Alex. “How a Woman’s Plan to Kill Herself Helped Her Family Grieve.” NPR. June 23, 2014.

Notes

1. “Can I Buy a Sarco?” in FAQs, accessed at https://www.thelastresort.ch/faqs/ ↑
2. Muhammad Adnan Khan, et al. “A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges Among Various Presentations.” Asian Journal of Neurosurgery 13 (no. 4), (Oct-Dec, 2018) ↑
3. “Where Can I Find the Design Plans to the Sarco?” in FAQs, accessed at https://www.thelastresort.ch/faqs/ ↑
4. Robert Pearlman, et al. “Motivations for physician-assisted suicide: Patient and family voices.” Journal of General Internal Medicine 20 (2005): 236. ↑
5. Owen Dyer, “Assisted dying: Disability advocates launch legal challenge to Canada’s law.” BMJ, 387 (2024). ↑
6. Ibid. ↑

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Featured image caption: Courtesy Kampus Production.)