In the late morning, on the day she planned to die, in April 2016, Avril Henry went to get the poison from the downstairs bathroom. She walked past the padded rocking chair where she sometimes sat for hours with her feet tilted above her head to ease the swelling in her ankles. She steadied herself against the countertop before reaching up to the top shelf and feeling around for the glass bottles that she had hidden there, behind the toilet cleaner and the baby powder.
“I got it imported illegally,” Avril had said of the drug supply. “It’s quite easy to do, but very risky.” She was at her home in Brampford Speke, a small village in south-west England with 300 residents, a pub called the Lazy Toad, a church, St Peter’s, and a parish council on which Avril had served several terms, earning a reputation as brilliant and steadfast, if sometimes needlessly adversarial.
In her 80s, Avril had a loose, unformed aesthetic: all soft beige sweaters, plastic clogs, walking aids. Often, dangly silver earrings. Sometimes, a dash of lipstick. By the time she planned to die, her white hair was so long that it nearly reached her waist. Things got stuck in it: some fluff, a twig from the garden. In the mornings, it took no small effort for Avril to pull the hair back from her face and impose a kind of order on it with elastics and hair grips. By late morning, wisps of it would have escaped their restraints and fallen down around her forehead.
Avril climbed upstairs slowly, as she always did: bent over and clinging to the banister – nearly crawling, so that if she fell, she wouldn’t fall far. It had always been Avril’s intention to die in her bath, reclining and fully clothed. She had written a detailed suicide note. “I am about to take my own life,” the letter read. “I am alone. The decision is wholly mine … This has been laboriously planned.”
When everything was ready, Avril called her internet provider to explain that even though she planned to kill herself at 7pm, she wished for her account to remain active until the executors of her estate had time to tie up loose ends around the house. Her longtime lawyer, William Michelmore, would later agree that this was a reckless thing to do, all things considered. But by then, Avril had already told her friends, her handyman, her caregiver, her gardener and his wife, and her acquaintances from the local swimming pool. She had read on some online forums that it was best to tell people about your death plans. That way, they would be less traumatised by your suicide. Also, they would understand that you hadn’t acted rashly, on a very bad day; rather, you had really meant to die and wanted to be dead. When Avril told her lawyer, he wasn’t entirely surprised, knowing Avril’s personality as well as he did.
Most people, Avril said, had taken the news well, though a few had not. One friend, a former colleague at the university, had even argued with her.
“Have you considered the effect of this on your family?” he asked.
“Of course I have bloody well considered the effect,” Avril said. Then she told him about all her aches and pains and untreatable conditions and about her flagrantly incontinent bowels.
“He was appalled!” she said later, delighted. “And I’m glad he was.”
I first made contact with Avril while reporting on the subject of the right to die, and working on a documentary film for Vice. My colleagues had arranged, in February 2016, for us to take the train west from London to meet her. She sent us long, perplexing directions to her house and told us to bring slippers. “I do ask visitors to remove their shoes for the sake of my poor carpet. I hope you don’t mind.” When she answered the door, in a grey turtleneck sweater with a grey cardigan on top, she offered, “Coffee? Tea? Double brandy?” In her own mind, Avril was dying of everything and of nothing in particular. Death by what we euphemistically call “old age”; what William Osler, in his classic The Principles and Practice of Medicine, referred to as those “cold gradations of decay”.
A few weeks earlier, Avril had written an essay detailing her many symptoms, and she offered to read it aloud, as a kind of state-of-the-body address. She warned everyone that the treatise would be “tedious” and “disgusting”. Then she pulled her plastic-framed glasses down the arch of her nose and started reading.
“I’ve lived for 82 years. I’m now dysfunctional in spine, feet, hips, peripheral nervous system, bowel, bladder, elbows and hands. All combine in pain and failure to work,” she read. “The future is bleak.”
Avril had rotator cuff injuries, arthritis and a tender back. Her feet burned from peripheral neuropathy. One doctor had said he could operate on them but that it would be a difficult surgery and that Avril wouldn’t be able to walk for weeks. Well, what was the point of that?
“Not practical,” Avril said. It was getting harder to stand straight. It was getting harder to see and to hear people. Her personality had changed, too. She had become less likely to laugh. More rigid. Her moods lost their elasticity. And she fretted too much.
“I have become querulous, introverted, angry, fearful,” Avril read. “I was none of these things.” She had been an artist. An intellectual. Happy.
Nights were the worst. Because it hurt everywhere, it was hard to find a position that was comfortable enough to let her sleep. She tried lying flat on her back, with her orange quilt tucked in around her rose-coloured pyjamas. She tried supporting her neck with a foam pillow. Because her breathing was laboured, Avril slept with an oxygen mask on, its blue straps pulled tight around her forehead and cheeks. In that way, she would lie for hours, marinating in her pain. It would occur to her that she would never find relief. There would only be an excess of hours, a punishing profligacy of time. Avril was disgusted by her anatomy and scandalised by its leaky excesses. But she was more matter-of-fact than self-pitying.
“My body served me obediently for 80 years but is now, quite suddenly, in every sense, unserviceable and well past its sell-by date.”
She was still angry with the government for rejecting a bill, in 2015, which would have legalised a narrow form of assisted dying in the UK, something that, according to national polls, the overwhelming majority of British people supported. Avril had wanted very much for the law to pass, though she understood that she wouldn’t qualify to die under its strict criteria – because, after all, she wasn’t imminently dying of any one thing. She was, simply, old and getting older.
“People with a terminal illness are the lucky ones,” Avril said. “I have longed for a diagnosis of cancer.”
In his bestselling 1994 book How We Die, Dr Sherwin Nuland observed that, by the logic of hospital administrators and the US Department of Health and Human Services guidelines, “it is illegal to die of old age”. Instead, “everybody is required to die of a named entity”: cancer or heart attack, stroke or traumatic injury. Plain old age – the natural wearing down of systems, the exhaustion of finite cellular life spans, the loss of internal equilibrium – did not count as a cause of death and was never a checkbox option on official paperwork.
“I have no real quarrel with those who insist upon invoking the laboratory-bred specificity of microscopic pathology in order to satisfy the compulsive demands of their biomedical worldview,” wrote Nuland. “I simply think they miss the point.” It was age that killed, in the end. In Nuland’s view, medicine’s focus on specific pathology amounted to a “legalized evasion of the greater law of nature”. It was born of a 20th-century notion, passed down to subsequent generations of physicians, that a doctor “must never allow his patients to lose hope, even when they are obviously dying”. If old age does not kill, there are always more treatments to try.
More recently, the American physician and writer Dr Atul Gawande has written that “old age is not a diagnosis. There is always some final proximate cause that gets written down on the death certificate – respiratory failure, cardiac arrest. But in truth, no single disease leads to the end; the culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance measures and patch jobs.”
At the hospital where Gawande worked, physicians had even learned to avoid the erstwhile vocabularies of ageing. Words like “geriatrics” and “elderly” and “senior” fell out of favour; staff spoke instead of “older adult health”. In conversations between healthcare providers and their patients, the fact of death grew divorced from the ageing that preceded it.
Some historians have tied this phenomenon to a larger effort, beginning in the early 20th century, to conceptually transform old age from a natural phase of life into a stage of disease and, by extension, something to be defeated, rather than embodied or endured. In truth, increases in life expectancy have been accompanied by more years of age-induced disability. Ageing has slowed down, rather than sped up. Still, and in spite of evidence to the contrary, the heady promise of a curtailed old age endures in the popular imagination. In the US, the fight against oldness has become social ritual, enforced by private fear and social momentum and a for-profit healthcare industry.
Today, about a fifth of elderly Americans undergo surgical procedures in hospitals in the final month of their lives, often supported by loved ones who would do anything to help and who have come to see any option short of “do everything” as a kind of terrible abandonment.
Before Avril felt like she was dying, she had felt sure of herself. She had worked as a lecturer at various Oxford and Cambridge colleges and then as a professor at the University of Exeter, where she specialised in English medieval studies and Christian iconography. On paper, Avril’s thinking was exact and thorough. She was interested in aesthetics and form and what they revealed about the meaning of things.
If her father had still been alive, Avril said, she would not be killing herself. But he was long dead. So were her mother, her aunts and uncles, and her two cats. There were still a few cousins around, and their families. “I love them all, but that doesn’t in any way affect my decision,” she said. “They are not that relevant in my life.”
By 2015, Avril’s world had grown small. Her greatest pleasure, she said, came from a daily swim at the local community centre. Her doctors liked the swimming because it kept her joints loose. Avril liked it because floating in the pool was the closest she ever got to total painlessness. Years ago, Avril could do 50 lengths an hour, but that had fallen to 40 lengths and then to 30. Sometimes fewer. After each stroke, a gasp. Avril started losing track of the lengths, and her own inattention riled her. The whole thing took hours and occupied much of her day.
Philip Roth called old age “a massacre”. Jean Améry, the journalist and Holocaust survivor, said it was worse even than Auschwitz. Others found it boring. That was a peculiar thing: the way a young woman’s pain sometimes made her interesting, but an old woman’s pain just made her tiring. The former suffers; the latter languishes and complains. The economy of sympathy never favoured elderly people. Sometimes, when Avril thought about the state of her body, she was reminded of the kindly Jesuit priest who, when she was 16, had converted her to Catholicism. He had taught Avril that “hell is the pain of loss”: not a place, but a condition.
Still, the idea that she should die before growing older had only come to her at the peak of a crisis, a few years earlier. Avril had been shopping at a pharmacy in Exeter when she slipped on the escalator and fell backward. The machine tossed her from side to side. Her left leg was carried upward as her body fell further down, so that she was being pulled apart, like a wishbone. Lying with her head on the metal stairs, Avril heard a noise that was her own screaming and found it to be an ugly, harrowing sound. A staff member rushed over and pressed the emergency stop button. Someone else called an ambulance. As Avril waited, a line from a TS Eliot poem came to mind: “That is not what I meant at all; That is not it, at all.”
On 10 December 2009, Dr Michael Irwin, a British physician who had worked for more than three decades at the UN, founded the Society for Old Age Rational Suicide (Soars). On the group’s website, Irwin, who has wispy white hair and a buttery, upper-class voice, explained that he had once been a member of the Voluntary Euthanasia Society (later renamed Dignity in Dying) but had come to feel stymied by its absolute focus on terminally ill people.
“I may still not suffer from one serious specific illness – but, perhaps, from numerous, increasingly annoying health problems,” he wrote. “When the burdens of living exceed the joys of being alive, I will then be close to the tipping point in wanting to die … Surely this final decision should be mine, not made by anyone else.” Irwin imagined a world in which people in their 80s or 90s who believed that “their lives have been fully lived” could be taken at their absolute word – and offered a physician’s help to die. The name of the group, Irwin told me later, was designed to shock.
By then, the word “suicide” was effectively forbidden in mainstream right-to-die activist circles – sick patients felt affronted by it, and political advocates wanted to detach their movement from it – but Irwin said he wanted to “reclaim” suicide as a “rational and positive act when a mentally competent, very elderly individual has carefully considered the main pros and cons for wanting to stay alive”. Also, he said, Soars was an easy-to-remember acronym, since many ill, elderly individuals suffer from bedsores.
In his writing, Irwin made an effort to link his cause to a broader arc of history, reaching back to ancient Rome and Greece, to suggest evidence of “rational suicide” through the ages. The Epicureans, he wrote, felt that suicide was justified when life became unbearable. The Stoics approved of it, too. There was that brilliant Seneca quote: “I shall not abandon old age, if old age preserves me intact for myself, and intact as regards the better part of myself; but if old age begins to shatter my mind and to pull its various faculties to pieces … I shall rush out of a house that is crumbling and tottering.”
In the years after Soars’s launch, Irwin held small meetings across south England and wrote letters to local newspapers. He imagined that he would, for a while at least, be relegated to the narrow fringes of acceptable advocacy. Eventually, echoes of the Soars doctrine came from the US. In March 2015, at the annual meeting of the American Association for Geriatric Psychiatry, in a conference centre in New Orleans, the organisers held a practical session titled Rational Suicide in the Elderly: Mental Illness or Choice? At the session, psychiatrists and researchers discussed case studies “in which patients without apparent significant mental illnesses expressed a wish to kill themselves”.
The main speaker, Dr Robert McCue, a professor of psychiatry at New York University School of Medicine, acknowledged that in the vast majority of cases, about 90%, people who died by suicide had a clinically diagnosed psychiatric disorder. But some didn’t. “This puts a burden on us and makes us wonder how we’re going to treat someone who may not have an illness. How do you approach someone like that? Our patients may have information about it and may have opinions, but we have no training about this at all.” Doctors were left on their own, to muddle through.
After the presentation, attenders had argued among themselves. One doctor observed that some of his patients were refusing medical treatment “because they want to be done”. Another argued that the idea of elderly rational suicide “complicates things too much for doctors”. Dr Elissa Kolva, a young clinical psychologist who works with cancer patients, wondered if a wish to die, when someone was old and sick and compromised, could in fact be “a resilient thing” and “a sign of psychological well-being”.
Strictly speaking, there was no such thing as rational suicide. When suicide was mentioned in the Diagnostic and Statistical Manual of Mental Disorders, the profession’s most authoritative guide, it was described as a symptom of mental illness. At the conference, some doctors wondered whether the first step toward a treatment solution was a change in vocabulary; professional guidelines, they said, could be updated to distinguish suicidal ideation from a kind of suicidal thinking that was deliberate and reasonable and consistent with a person’s long-held values. In the meantime, researchers and geriatricians could use existing diagnostic tools to help them better identify and understand rational suicidal thinking.
In early 2019, Irwin started a new organisation called Ninety Plus: a discussion group built around the premise that anyone 90 years old or older should automatically be granted the right to physician-assisted death. Irwin, who was 88 at the time, told me that his selection of 90 as a cutoff age was somewhat arbitrary. For his part, Irwin was faring relatively well. He had some lower back pain and numbness in his feet, which made it difficult to walk, and he took pills for high blood pressure, but otherwise he was OK. The hardest thing to deal with, he said, was the loss of energy. What was the point of living if it was all so exhausting? “Why should I be forced to suffer?” he asked me. “Why should I have to drag on?”
In 2015, Avril said, she had asked her doctor to help her. She was frank. Too brazen, really. “Life is not worth living any more – but I’m not depressed,” she said. So would the doctor be so kind as to give her some tablets? “No,” said the doctor. Avril said she asked several others, including a surgeon whom she had seen before. “They all came back and said, ‘I would really love to help, but I cannot.’”
One evening, one of those doctors knocked on her front door. When she let him in, he said that he had been thinking about things and that he wanted to explain himself. Then he started to cry. Avril said she showed him to the living room, where he sat down on the couch. She sat in the armchair, with her feet tilted up over her head. Over the course of two hours, the doctor told Avril that he had looked for ways to help her. He had even consulted a medical lawyer, at his own expense, to see if there was something he could do, but the lawyer had said that there was not. The doctor told Avril that he admired her and that it had been a pleasure to treat her.
“I fear,” he said, as he rose to leave, “that this may result in you trying to kill yourself.”
“Yes,” Avril said. It would. Later, she told her doctors to stop contacting her. She had limited time left, she said, and they were wasting it. Avril found the right-to-die group Exit International. Seated in front of her office computer, in her enormous reading glasses, with a magnifying glass held up to the screen, she read through Exit’s website.
“Dying is not a medical process,” it said. “As such, you don’t necessarily need the white coat by the bed. Exit’s aim is to ensure that all rational adults have access to the best available information so that they may make informed decisions over when and how they die.”
The website looked professional enough, with pink and purple graphics and links to news articles. Its founder was a real medical doctor from Australia named Philip Nitschke. Avril read that the average age of Exit members was 75 years old. She also read that for $185 (£130), she could buy an annual Exit membership and a digital copy of Dr Nitschke’s handbook, which promised instruction on the different ways to end a life. Avril paid the fee and sent in an application form and was accepted. She opened the handbook right away. “In recent years, a new trend has begun to emerge,” it read. “We meet elderly people who are fit and healthy (for their age) but for whom life has become increasingly burdensome.”
The book was strange in its textbook formality: full of encyclopaedic descriptions of drugs and methods, ranked by various criteria including shelf life. Avril read it all, in the small office next to her living room. And then she picked her poison.
At 8.49pm on Friday 15 April 2016, Avril heard the phone ring. The noise startled her because the phone never rang at night. She was sitting in her office, in front of the computer. The voice on the other end of the line told Avril that he was a police officer and that it had been brought to his attention that she was planning to end her life. Avril told him that he was correct. The officer asked if he could send some colleagues to her house to speak to her. Avril said no. He couldn’t. It was dark and she never opened the front door after dark.
At 9.15pm, two police officers broke through the glass plate on Avril’s front door and stepped into her hall. Later, they would say that they rang the doorbell first and Avril would say that they didn’t. “Oh God!” she cried aloud when she heard the glass shatter. When the officers found Avril, cowering, they told her that a member of the public had reported her as a suicide risk and that they were there to perform a “wellness check”. Then the officers said something about being sent by Interpol, the International Criminal Police Organization, and asked Avril to hand over the drugs.
About midnight, the police called in a consulting doctor, who arrived at 12.07am. The officers told the doctor that Interpol “had intercepted some information” regarding a suspicious package, which they traced back to Avril’s house. Avril was tired by then, but she sat with the physician and told him about her health problems: the back pain, the poor mobility, the deafness, the incontinence. Avril explained that she had been planning her suicide for 18 months. She denied that she had ever been depressed or mentally ill. Well, she had been depressed once, but that was after her father died, so maybe that was just grief?
Later, a social worker and a psychiatrist were summoned to perform a mental health assessment. Avril took them to her bedroom and showed them the padded cloth nappies that she had to wear every day. She showed them the chamber pot under her bed. Avril thought the social worker looked embarrassed. She also let the doctors see the goodbye letters that her friends had written to her. One of Avril’s Christian friends had signed her card with a Bon Voyage! – as if Avril were planning for some exotic trip.
The two doctors and the social worker told Avril that they needed to confer privately for a moment and asked her if she could sit in the study. They stayed away for half an hour. Finally, the three experts said they believed Avril to be of sound mind. They could not, as it were, detain her under the Mental Health Act – as “unwise” as they found her behaviour to be. “Could find no evidence of depression,” the doctor wrote in his report.
As the doctor packed up his bag, he told Avril that her family doctor would be in touch soon, to arrange for a more formal mental health assessment. Avril thanked him for listening to her. Then, finally, at 4.28am, the doctor, psychiatrist, social worker and police officers left through the broken front door. Avril exhaled. What they did not know about – and what the police officers had not found – was her second supply. There were still two bottles, tucked away at the back of the white cupboard.
Later, I heard about other raids. Within weeks, Exit got reports from members about similar police checkups in London, Oxfordshire and Brighton. Years later, a spokesperson from the UK Metropolitan police confirmed that, at the time, one of the department’s “special inquiries teams” was investigating Exit and its founder, Nitschke, following a tipoff from a concerned citizen. In the end, the spokesperson told me, “numerous lines of inquiry” were opened, but “no action was taken”.
Over the next few days, Avril called her lawyer and told him to file a complaint with local police authorities. She wanted the officers to apologise and promise to never bother her again. More importantly, she wanted them to replace her front door – and not just with any front door, but with the exact same kind of front door that she had picked out, with the exact same high-quality glass. Avril had already called several local suppliers and determined that the cost would be about £185, plus tax, totalling £222 to do the job. Avril also gave her lawyer her address book, with the names and phone numbers of all her contacts written inside. Then she laid out a copy of her prepared suicide note. “I am alone. The decision is wholly mine,” the letter read. “I very much hope that, since the evidence here shows clearly that no murder has been committed, there will be no Post Mortem.”
She planned to die on 20 April, after lunch. There wasn’t much to eat in the house. Avril had not gone food shopping that week, in anticipation of her death, so all she had left were a few frozen dinners. She was even out of biscuits. Still, she thought she would eat something before making the slow journey to the upstairs bathroom.
Late that morning, Avril’s doctor’s office rang to say that the police had been in touch. Was it true that she was planning to end her life that evening? A subsequent report by the local coroner would later conclude that when Avril called her internet provider and told the employee on the line that she would soon be dead, the employee had called the police, who in turn had called Avril’s doctor, who in turn had asked his receptionist to call Avril – perhaps with a touch of exasperation because, well, everyone knew what Avril was planning, but what could be done? Avril told the receptionist to “call the dogs off ” and leave her alone.
Avril’s lawyer found her dead at 6.40 that evening. Weeks before, Avril had wondered how she would feel while lying there, in the bath. She thought she would “try to feel as little as possible”.
“What I want to avoid is taking a last look around the garden or having a long look at my beautiful pottery. That would just make it difficult and it would only hurt and it would serve no purpose.” Avril said she would remind herself that death was inevitable anyway. She did not think she would be afraid.
“How can I be scared if I don’t exist?” she asked. “Simple logic. I shall know nothing. There will be nothing.”
This is an edited extract from The Inevitable: dispatches on the right to die by Katie Engelhart, published by Atlantic.
In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.