Scrutinizing the idea of Sarco pods and autonomy at the end of life

EDITOR’S NOTE: The following article discusses suicide and methods of performing suicide, especially for the terminally ill. Readers are advised to proceed with caution.

For most, a doctor’s responsibilities are predicated on deterring death and illness. As such, the extension of life is of the utmost priority in the medical field. However, there are certain situations where keeping someone alive can be much crueler.

Upon prognosis of a terminal illness, medical interventions such as organ transplants, feeding tubes, and mechanical ventilation are made available to a patient. These can extend a patient’s life expectancy anywhere from a few months to several years. However, they also come with a cost.

To live or to survive

While medical interventions are designed to forestall death, doctors see them as a double-edged sword. Nathaniel Hinerman, a psychotherapist and professor at the University of San Francisco, explains that certain problems can arise from these treatments, procedures, or technologies.

Hinerman comments that feeding tubes, for instance, can interrupt one’s natural dying trajectory. For patients with chronic illnesses such as dementia, the longer they are kept on life support, the more likely it is for their illness to progress, thus worsening the condition of the patient. In similar cases, such interventions can be counterproductive, which can also be said for other medical interventions.

While most patients tend not to go against their doctor’s advice, those suffering from terminal illnesses often realize that medical interventions cannot treat their condition or alleviate their pain, making the quality of their final days extremely poor. 

When people realized this, they started questioning whether or not they can refuse medical interventions. In 1997, controversy surrounding the right to refuse life-sustaining treatment led the Supreme Court of the United States to make a decision to address patients’ concerns. 

This is how Medical Aid in Dying (MAiD) came about. It refers to a practice of letting a terminally ill patient with less than six months to live decide to request a lethal dose of self-administered medication, which they obtain from a doctor. According to MAiD, this is a form of retaining bodily integrity.

But patients must go through a waiting period of 15 days.  During this 15-day waiting period, some states require a psychiatric evaluation to assess whether the decision of the patient to engage in MAiD was achieved through well-thought-out judgment or if it was clouded by depression.

After the 15-day process, a patient can request medication that can hasten their death. The medication takes effect in a matter of minutes, and deaths conclude within 30 minutes, as estimated.

Globally, MAiD saw a rapid change over the past two decades, allowing physicians to develop unconventional procedures administered to the terminally ill. In the Philippines, however, MAiD’s legalization is still unresolved primarily because of religious beliefs. 

The last call 

The idea of involving oneself in ending or assisting a terminally ill patient in ending their life has been a topic of great debate among ethicists and physicians. 

“The doctor told me ‘I can continue to give you chemotherapy but it’s going to be debilitating,’” Sophie* articulated, a former patient at the Princess Margaret Cancer Center. In a 2019 interview with Dr. Gary Rodin, director of the Global Institute of Psychosocial, Palliative and End-of-Life Care, Sophie reminisced how she processed the ordeal of having to face advanced stages of metastatic breast cancer and pseudocirrhosis—a rare malignant liver complication. 

At first, she was adamant to live. “I was willing to battle,” Sophie declared. But her hope diminished when she found out that there was no cure for her condition. The hospital tried to offer medical care to prolong her life, but this was not a route she wanted to take. 

“I could have long-term palliative care [but] the end would be the same—I would die,” she affirmed. Sophie knew that extending her stay would mean that little increments of who she was would gradually drift away. “I value my cognitive ability; it matters a great deal to me,” she said, adding that she did not want to forget her friends, her time as a professor at the University of Toronto, and most importantly, herself.

Once Sophie sent word of her decision to engage in MAiD, she recalled the devastation her friends felt. “I know sometimes it‘s hard for [people] to let someone go,” she opined. But since it was her final request, her choice was respected and even supported. 

“I was satisfied with my life, and I felt fortunate,” she thought, eventually accepting that this was the end for her. 

‘Compassion’ versus choice

What is often misunderstood is that patients who choose MAiD do, in fact, want to carry on with their lives. However, given the futility of modern medicine in their case, they choose to take medication to hasten their inevitable death rather than go on living with unnecessary pain.

Such cases were what pushed Dr. Philip Nitschke to invent a 3D-printed assisted suicide capsule called the “Sarco pod”, which works by replacing the oxygen inside the capsule with nitrogen gas, eventually killing its occupant. In an interview with Swissinfo, Nitschke explained that the Sarco pod can only be activated from the inside by the patient. Once inside, the patient will be required to answer a series of questions for the pod to be activated. 

Sarco pod’s design aims to suggest a sense of traveling to a new destination, but when Nitschke initially announced his plans to release the blueprints of the Sarco pod, he was widely criticized for glamorizing suicide. 

Although many see the Sarco pod as an abomination, some have come around to accept it, expressing that the terminally ill should have the final say on when and how they die.

Worldwide (in)accessibility

Despite claims that the Sarco pod has passed legal review in Switzerland, Alessandra Buera (IV, JDCTR), a paralegal, recalls that it is not qualified as a medical device in the country. Moreover, a country’s laws regarding MAiD do not necessarily influence the legality of the Sarco pod—provided that no new legislation will explicitly ban it.

“This could be problematic,” Buera says, explaining that the government would not be able to regulate it. However, Buera stipulates that different countries may have different definitions for what qualifies as a medical device, so even if the Sarco pod can be created in most places, it may not be legal in every country. 

Nitschke had intended for people from most places in the world to be able to use the machine without potential legal repercussions. By removing the need for any external assistance, it can still be built and used in countries like the Philippines where MAiD remains illegal. However, the release of blueprints would mean that anyone may have access to the device, and this access cannot be regulated. It may also be abused, and people may be coerced into using it without fully understanding what the device does. 

Furthermore, despite the blueprints being accessible to most, not everyone will have the money to build their own Sarco pod. One must first have a 3D printer that can print something large enough for them to fit in. Then, there is the issue of obtaining nitrogen gas. Thus, there are plenty of costs and legal issues that need to be taken into account.

End-of-life conversations

Despite concerns surrounding the Sarco pod, it is worth asking what its societal impacts may be if the plan to release the blueprints follows through. 

“There is kind of a macabre, dark fascination with these kinds of things,” Hinerman notes. He adds that people that are unfamiliar with the topic become anxious when hearing about the Sarco pod, but for those who are contemplating suicide, they may feel validated. 

However, it will only add a more expensive alternative to a list of options for suicide. “The mechanism or modality [of suicide] is rather unimportant,” he says, clarifying that suicidal people tend not to care about how they die. He does wish, though, that the energy put into discussing the Sarco pod may instead be put into helping the people who would want to use it—“because that’s who needs the help.”

Even if the Sarco pod is unlikely to catch on, it may still help those who are thinking about suicide by putting the end-of-life conversations in the spotlight. Hinerman suggests that more focus should also be placed on things that are able to alleviate one’s suffering toward the end of their life. 

Hospice, for instance, aims to improve a terminally ill patient’s emotional, physical, and spiritual health for free, and yet plenty of people are not aware that this option is available to them. At the end of the day, the most important thing to ask is how we can provide the highest quality of life to people that are at the end of theirs.