Branching Out to Serve a Growing but Dying Market

The presence of Dignitas in Germany has also stirred a backlash from medical associations and hospice providers, who argue that the group is crossing an ethical and moral line by actively encouraging people to consider killing themselves, even those who are not terminally ill. Some Swiss officials have also expressed unease with Dignitas's plans and fear that the Alpine nation is gaining a reputation as a magnet for "death tourism."

So far, however, Dignitas has shown no signs of backing down. It is considering opening another branch office in Britain, which generates about 20 percent of the group's clients.

In Hanover, Dignitas supporters say they've been overwhelmed by calls from potential members since the office opened last month. Uwe Christian Arnold, a retired urologist who serves as vice president of Dignitas's German chapter, said the organization might need to find a bigger office and train more staff. "Demand has been growing so fast," he said. "We were not prepared."

Arnold said German physicians are frustrated by their inability to ease the suffering of patients who are determined to die. German doctors are legally bound to intervene when a patient tries try to commit suicide or takes measures to hasten death, including cases in which the person is terminally ill or in the last stages of life.

"We're pretty helpless in this country as doctors because we are restricted from doing anything that could be interpreted" as bringing on a faster death, Arnold said.

Still, he said, many physicians ignore the law and tell patients how to take matters into their own hands, such as by mixing a fatal overdose of commonly prescribed medicines. "We all do that," he said. "Because we're good doctors. We're all a little bit criminal."

Switzerland has permitted assisted suicide since 1942, although for decades the practice attracted little attention outside its borders. That changed seven years ago, when Dignitas was formed and began advertising the country's permissive laws to foreigners.

Assisted suicide is also legal in the Netherlands, but conditions there are stricter; patients must have two doctors certify that their condition is "unbearable." The Netherlands and Belgium also permit voluntary euthanasia, which allows a doctor -- rather than a patient -- to administer a lethal dose to patients with incurable diseases.

Oregon is the only U.S. state that has legalized assisted suicide; doctors can prescribe drugs for terminally ill patients with less than six months to live.

Compared with those places, Switzerland requires little paperwork or medical oversight. There are no requirements for residency, registration or a terminal disease. Patients need only visit a doctor once to receive approval, which is granted if they are deemed mentally competent, are not under suicide pressure from a third party and have considered other options, such as entering a hospice.

Dignitas says it screens its clients by reviewing their medical records and family backgrounds. Minelli, the founder, said he had personally talked many people out of killing themselves after they arrived in Switzerland, when it became clear they were merely depressed.

Minelli said about 70 percent of Dignitas members who receive approval to come to Zurich never make the trip. Most, he explained, just find it reassuring to know that they will always have suicide as an option if their lives become insufferable.

"They know the emergency exit is wide open," he said. "They know they can call us at any time for an appointment. This relieves a terrible amount of tension for them."

Some of Dignitas's allies in the debate are queasy about the group's hard-sell approach. Juergen Heise, a member of the board of directors of the German Society for Dying With Dignity, said his 35,000-member group favors assisted suicide and voluntary euthanasia but is concerned that groups such as Dignitas operate with too little oversight.

He said he also worried that Dignitas's aggressive approach could backfire with German politicians and the public: "I think the first reaction to this has gone in the opposite direction of what we wanted."

Across town from Dignitas's office in Hanover is Hospice Luise, a beautifully landscaped property with candlelit rooms for eight terminally ill patients. The director, Kurt Bliefernicht, said he had handled a steady stream of phone calls in recent weeks from people trying to get in touch with Dignitas.

Bliefernicht said he refuses to give out the number because he fervently opposes assisted suicide, which he calls "a really cheap" way out. He said he tries to chat with the callers about hospice care and other alternatives. People are most often driven to consider suicide out of fear and ignorance, he said.

"That shows that this is a real problem in Germany, as far as awareness goes," he said. "We've forgotten how to deal with death and dying. We don't know how to talk about it."