My Sister Euthanized Herself. She Shouldn’t Have Had to Do It the Way She Did.

My sister Theda had been bedridden for seven years when she first decided she wanted to die. She was 32 then, and a mysterious chronic illness had diminished her will to live. Though it wasn’t legal in Australia at the time, she wanted to die by euthanasia. Technically, this would classify the death she wished for as a suicide. But ethically—and within the family—we understood it differently.

Theda was 24 when her symptoms began. The fatigue came on first. A few years later, she developed chronic nerve pain, light and sound sensitivity, and multiple food intolerances. Our mother cared for her at home, and Theda only left the house for medical appointments. She lost any semblance of a social life, and eventually, she could no longer read, watch TV, or use a computer without getting migraines. Conversing with her became difficult because she couldn’t concentrate enough to construct sentences. Her suffering was physical, but it was also social—it affected our family and community. Nothing helped. The only change, despite so much effort, was that it got worse.

I was backpacking around India when she initially broached the topic of euthanasia. My mom had called to explain the situation, and I talked to Theda the next day from a public phone on a dirt path atop a cliff overlooking the coast. I remember some backpackers haggling with a street vendor nearby, and feeling anxious because I wasn’t sure what I would say.

Her voice came wispy and weak over a crackling connection, but it was clear enough. At first, I did most of the talking. I spoke of India and made some jokes about backpacking culture. Then she told me how things were at home. She had almost run out of treatment options. Her doctors were scratching their heads. One had diagnosed her with chronic fatigue syndrome and fibromyalgia. Others argued her problem was a mental illness with psychosomatic symptoms. Theda had chosen to follow the doctor claiming it was chronic fatigue. This doctor’s treatments were slowly bankrupting our family, and we hadn’t seen any improvements. Our father had checked out and moved away, so it was just Theda, Mom, and me.

“Khin,” she said. “I’ve read some chapters of a book about euthanasia, and it suggests asking your loved ones’ permission before you start making plans.”

This was in 2006. The book she was talking about was by Derek Humphry, a controversial figure who advocated for extending medically assisted dying to the chronically—not just terminally—ill. He offers an ethical framework and practical advice to those wishing to pursue a peaceful death, even when doing so may be illegal where they live.

I accepted my sister’s request over the phone that day. I realized as we were speaking that I couldn’t refuse her the right to die. Here I was exploring the world with a backpack and a healthy life while she’d been in bed for seven years. It was deeply troubling: Part of me resisted her wish, but another part knew that she’d proceed regardless without my blessing, which meant she’d potentially face a lonelier and more distressing death.

She assured me she wasn’t ready to give up living yet—she was just setting her ducks in a row. “Enjoy India,” she said. “I’ll see you when you get back.”

Theda didn’t follow through until six years later. In that time, her symptoms worsened. New doctors appeared, and with them came new treatments and cycles of hope and disappointment. Mom suffered two stress-related strokes, and my mental health declined. We tried mainstream medicine, and dipped into the outer reaches of alternative therapies. We got scammed by questionable people promising impossible cures. Mom lost all her retirement savings, and Theda began to experience regular psychotic breaks.

Then, in 2013, Theda found a website that sent euthanasia drugs internationally using a process called “hushmail.” For years she had followed the work of Philip Nitschke, whose organization Exit International helps people seek euthanasia in places where it’s illegal. She worried the drugs she saw online might not be real, but with advice from Nitschke’s website at her fingertips, she felt confident enough to proceed without getting scammed.

The drugs arrived in a nondescript cardboard box postmarked from Mexico. Inside were two vials of sodium pentobarbital—a clear liquid used in animal euthanasia and death row executions. She locked the vials in a petty cash box under her bed. “I’m not going to take it yet,” she told me. “It’s just comforting to know it’s there. I can go on longer knowing an escape hatch exists.” But she would use them soon enough. She took the drugs a few months later.

I had told Theda in no uncertain terms that I didn’t want her to die. My mother was hit hardest, but we both had to accept it. It’s only because of these things—our family’s embrace of Theda’s choice and the medical method she used to die—that our story is about euthanasia, not suicide. Euthanasia involves loved ones, dignity, and a peaceful method. Suicide usually is decided alone. It’s generally performed haphazardly, with uncertain and often traumatic results.

The complex ethics of euthanasia are tackled differently across the globe. Some of the most permissive assisted dying laws can be found in Belgium, the Netherlands, and Switzerland, which offer people with chronic nonterminal conditions—including mental illnesses—the right to die. These conditions can range from severe autoimmune diseases and nonterminal cancers to treatment-resistant forms of depression and schizophrenia. In Belgium and the Netherlands two doctors must deem a person’s suffering as incurable and intolerable, and they must also agree that the patient is mentally equipped to make such a request. In the United States, the debate is complicated by a lack of universal access to health care; experts point out that suffering from a chronic condition may be exacerbated or even caused by an inability to get treatment, making euthanasia a grim option. Currently, euthanasia is allowed in a small number of states, each of which has slightly different laws. In those states, only people with a terminal illness like ALS/Lou Gehrig’s disease or some forms of cancer may access the drugs, and in some cases, the patient must have been given a prognosis of having six months or less to live. This is, perhaps, the option that is easiest for the general public to get on board with: the right to dictate when one’s impending death will happen, and that it will proceed in a predictable manner.

Canada currently offers medically assisted deaths to people with terminal illnesses and chronic illnesses. The debate about whether that should extend to chronic mental illness has caused a stir. The current Canadian government has a plan to offer medically assisted death to mental illness patients on a case-by-case basis, but it hasn’t yet put it into action. A process for assessing these patients was originally slated to begin in March of this year, but it has recently been pushed back to 2027, after Canada’s next federal election.

My family tackled euthanasia from an especially troubling angle, one that falls far outside firm categories of illness. The question of whether Theda’s condition was mental or physical was constantly debated, and it initially weighed heavily on me when thinking about her right to die. Doctors who believed mental illness was at the core of her problem argued that her physical symptoms were psychosomatic. This is known as conversion disorder, where people experience physical and sensory problems because of psychological distress. Others who diagnosed her with physical conditions like chronic fatigue syndrome, fibromyalgia, and Lyme disease eschewed psychiatric explanations and treatments altogether. The tension between these two camps was never resolved. Even after her death and an autopsy, the nature of her illness remains uncertain.

That uncertainty highlights the way our culture ranks suffering in conversations about who “deserves” the right to die. We’re socialized to see some types of suffering with less sympathy. Wellcome Prize–winning neurologist Suzanne O’Sullivan discusses this prejudice in her 2016 book It’s All In Your Head, which focuses on psychosomatic illnesses. “I have come to realize that not all suffering is the same,” she writes. “It is not necessarily the greater suffering that receives the greatest consideration and sympathy. Illness is not scored in that way. Deadly disease obviously scores higher than others. After that there is an unofficial ranking system for illness in which psychiatric disorders are the out-and-out losers. Psychiatric disorders manifesting as physical disease are at the very bottom of that pile.”

This distinction between physical, psychological, and hybrid suffering didn’t matter much to Theda in the end. After 13 years of being unable to get out of bed, suffering was suffering. What we called it—or what her diagnosis was—was beside the point.

All of the diagnoses she was given, whether mental or physical, relied on clinical assessments. No blood tests or scan-based technologies were capable of definitively proving what was causing her sickness. For each possible diagnosis, a doctor would interview her about her symptoms, and she could only describe them. The symptoms she described were on lists for multiple diseases. Definitively proving any diagnosis was impossible, so she had to choose among those on offer, and then commit to a treatment plan.

Over the years, I tended to believe the doctors who attributed my sister’s condition to mental illness. I felt this way for a number of reasons, but I learned to keep my mouth shut about it because I soon realized that evoking mental illness upset her immensely. I started to think about why we stigmatize some diseases, especially those linked to mental health. Stigma affects a sick person’s life profoundly. It adds to their suffering. And it affects their family. Importantly, it can perpetuate their resistance to a diagnosis that involves the mind, keeping them from trying treatments that might help.

Part of the reason I believed Theda’s physical symptoms were connected to a deeper psychological issue was that she started to have regular psychotic breaks at the age of 26. Looking back, I see that these psychotic breaks could have been caused by her ongoing physical pain and social isolation—but psychiatrists often told us that it was the reverse. They believed her physical symptoms were “hallucinations” caused by an underlying psychiatric issue. I privately agreed with them, though I didn’t judge my sister for it as she feared some people might. “I’m not crazy!” she told me when mental illness causing physical symptoms came up once. She needn’t have worried, because I never saw her as crazy. I loved her and only wanted her to get better.

When she was psychotic, she talked to me a lot. I would be her confidant in the locked psychiatric wards in which she was sometimes committed. In these wards, she was stripped of her rights and unable to leave, so I would visit her daily. Her personality was completely transformed. Usually mild-mannered, polite, and cautious, she became melodramatic, forthright, and charismatic when a psychosis hit. She could be violent and irrational, too. We usually had to call the police to get her from my mother’s house to the hospital.

These breaks with reality came about once every nine months. She would barely recognize me as her brother during those times. She preferred to categorize people according to archetypes. I was often “the brother” or sometimes “Neo”; Mom and our father were “the mother” and “the father.” She even spoke about herself in the third person, as if commenting on a troubled twin with whom she occasionally shared a body. She’d also talk to people who weren’t there, babbling about gods and demons. It was during these times that I first heard her talk about our childhood traumas.

Theda and I grew up in a broken household with ethnic tensions. Dad was a Burmese refugee, and Mom was a working-class Englishwoman who couldn’t afford to get back to the Northern Hemisphere. Cut off from any extended family, one parent wanted us to identify as Asian, and the other as Western. Throughout adolescence, we were bullied for being dark-skinned in a predominantly white neighborhood. We lived in a suburb adjacent to where the Australian Nationalist Movement—Perth’s active white supremacy group—had set up its headquarters. We went through adolescence in a backwater part of the “world’s most isolated city” in the 1980s, and when I was 12, nearly half a million posters appeared around town stating that our “kind” were not welcome. Anti-Asian immigration had been the government policy in my country until just before Theda was born, so the bigotry in our city was still strong. Racism came at us from teachers, peers, and adults. It was implied in stories we read and the television we watched. That made for a tough and confusing childhood, leaving both Theda and me with a sense that something was intrinsically wrong with us. We internalized racism because we weren’t empowered with a language to describe what we were experiencing. We blamed ourselves. For me, that manifested as major depression from the ages of 13 to 24. For Theda, I believe it contributed to her getting sick. I later discovered research that links poor adult health to the particular kinds of developmental stress minorities often face as children.

When Theda was sane, she never talked about our childhood. Only psychotic Theda did that. During a psychosis, it was like she became another person. Her speech patterns changed—she had what psychiatrists call pressured speech, which is the constant need to talk (somewhat incoherently). She also clanged, which is a tendency to fill silence with simple rhyming speech patterns. She trusted me during these times in a way she didn’t seem to trust anyone else. She tried to communicate with me, and there were narratives in the content of her speech that I recognized. She talked a lot about her physical condition, calling it “the sickness Theda has.” She believed that her illness existed because our family was in the “wrong realm.” She mythologized our migration and ethnic experience when speaking like this, saying our parents had migrated from more agreeable realms in their “past lives.” She also commonly linked her physical illness to trauma from “a past life” in which she’d been raped and buried alive for attempting to move freely in a single-ethnicity culture while being a half-caste.

It was my sister’s personality to repress painful childhood memories, but they came tumbling out when her sanity was compromised. Most importantly, all her physical symptoms would temporarily vanish as that occurred. This is one reason I always felt her illness had psychological roots—her physical symptoms seemed capable of transforming into mythic narratives about trauma. It was remarkable to witness. Her food intolerances would stop, light and sound would no longer give her migraines, she didn’t experience any fatigue or pain, and her short-sightedness improved, quite dramatically. The abatement of symptoms would last for the duration of each psychosis, usually around 10 days. After that, her symptoms would return. This tracks with theories about how repressed trauma can drive psychosomatic illnesses. These theories, which began with Freud in the late 1800s, revolve around the idea that when people cannot consciously process trauma, their brains manifest perceptions of physical symptoms instead. When they find a way to face the trauma consciously, those physical symptoms tend to abate.

The world of psychogenic research is fascinating, sometimes counterintuitive, and often deeply resonant. Functional neurologic disorder—another name for conversion disorder—appears in the current Diagnostic and Statistical Manual of Mental Disorders and it can include symptoms like blindness, paralysis, allergies, seizures, fatigue, and pain. Once known as “hysteria” and attributed mostly to women, it still gets some bad press. Many people, including some doctors, equate it with faking or hypochondria, whereas others imagine that it simply doesn’t exist, citing sexist ignorance in past eras as the only reason such things were ever diagnosed. But psychogenic diseases do exist, and much research confirms that they aren’t the same as faking. These conditions have been recorded since ancient Egypt, and they happen to both men and women. They have been cured in some people, and they remain incurable in others. Diagnosing them is difficult, but proof often appears when a psychological treatment eliminates otherwise inexplicable physical symptoms. Research estimates that 20 percent of all neurology consultations include patients with some conversion disorder symptoms.

For many years I believed that my sister had severe conversion disorder. But as I learned more about medically inexplicable conditions, I also began to consider other possibilities. Emotional distress can change our cells, which is quite different from conversion disorder and explains why my sister’s hormone levels were often out of whack when tested. Chronic teen bullying victims, for example, can have higher levels of disease-indicating C-reactive proteins that can last a lifetime. Women who have been physically or psychologically abused by a partner show altered neurological and gastrointestinal function. Takotsubo cardiomyopathy is a strikingly illustrative example of how emotional and social distress can potentially alter our physical health through our hormones. It is a heart disease that shows up on echocardiograms as a deformation in a patient’s left ventricle, caused by spikes in their stress hormone levels. It can kill, and it occurs in in people who are struggling with grief, financial stress, or social isolation. Crohn’s disease and endometriosis are two more well-known physical conditions that have also been partially linked to psychological trauma.

Like many people, I once classified mental and physical diseases as quite distinct from each other. In my mind, a key difference involved their cause and cure. My perception was that mental illnesses were generally caused by social and familial distress, and that they could be cured with medication and/or therapy. The reality is that mental illnesses can be, for some, a lifelong burden. They have genetic factors too. And social and familial distress can cause physical illnesses just as they can cause mental illness.

When we recognize that mental and physical illnesses are not so cleanly divided, we can also question the usefulness of that “divide” for deciding on someone’s right to die. Should a person experiencing a temporary mental health episode be considered a euthanasia candidate? Everyone would agree the answer is no. Just like someone experiencing a bad case of mononucleosis shouldn’t be given the right to a medically assisted death, nor should someone experiencing an episode of depression.

But should someone’s right to die be explicitly about their diagnosis? When someone’s suffering is intolerable and without an end in sight, that should be enough of a reason to consider their right to a peaceful death, on a case-by-case basis. We should listen to people in that situation when they ask for more rights, no matter the cause of their illness, as a cause may not be able to be neatly untangled.

Stigmatizing some types of diagnoses—and seeing some terrible chronic conditions as worthy of the right to die and not others—is a form of collective victim-blaming. Social psychologist Melvin Lerner can give us insight there. He hypothesized in the 1970s that victim-blaming is driven by the “blamer’s” desire for an illusion of safety. When we imagine that someone’s misfortune is caused by their own folly, we can strike that misfortune from our own list of personal concerns. Consider how that plays into the ways we stigmatize some illnesses. Blaming the patient alleviates our anxiety about that particular sickness. Hence, mental illnesses get stigmatized because many people wish to imagine themselves immune. As noted by O’Sullivan, psychosomatic conditions attract the intense victim-blaming because they challenge the very framework separating mental and physical illnesses. This challenges our illusion of invulnerability in a significant way.

I learned to see beyond that as I went through this story with my family. My big sister’s illness was not her fault. It was an illness as real as any other, and beyond her control regardless of whether it was mental or physical in origin. It was likely caused by social trauma, but it proved untreatable. And her suffering was terrible.

In a 2023 essay for the Atlantic, David Brooks argues that the right to die should be afforded narrowly, only for people with terminal physical conditions. “You don’t have the right to make a choice you will never be able to revisit,” he writes. “Banish the question from your mind, because the answer is a simple no.” He believes sick people owe it to their ancestors and society to continue living despite their suffering. He blames modern liberal culture for prioritizing individual well-being over our responsibility to others. “Our individual choices take place within the framework of the gifts we have received, and the responsibilities to others that those gifts entail,” he continues.

I agree with Brooks that tackling the rights of chronically ill patients involves thinking about responsibility. But instead of putting the emphasis on the individual, as he does, we must think about responsibility more broadly. We need to examine how we rank illness-related suffering as a culture. That’s our responsibility. We also need to consider how social injustice plays a role in causing chronic and mental illnesses.

In the final month of my sister’s life, I traveled to America because of pressing concerns in New York. Meanwhile, Theda was back in Australia with pentobarbital under her bed. She had promised me she wouldn’t end her life without first calling me back to Australia. I knew it was a risk leaving, but I took it.

The night I arrived in New York, George Zimmerman’s trial was on a TV in the reception area of my accommodation.* It was mainstream news, and two anchors were orchestrating a conversation between talking heads in live feeds. The topic turned to growing up Black in America and how it could affect the long-term psychological well-being of people like Trayvon Martin. They argued about the impact of racial inferiority complexes. I remember watching that debate with awe. Theda and I hadn’t grown up in a society debating such ideas. We never encountered those thoughts in our social circles or on national news. Some of our ignorance came from growing up working class, and the rest was colonial Australia’s tendency to sweep discomfort under the rug rather than discussing it on TV. I’d never heard the term “racial inferiority complex” until that year, but it resonated. I remember being affected by how my sister would perceive and react to what I was seeing. Witnessing a nation discuss such things makes thinking about them possible. A robust public discourse on racism would have helped her to shine a light on the childhood experiences that she seemed to understand in her head when psychotic, and in her body when she was sane. I realized that night in New York that I was witnessing one of the ways a society can speak to the sick.

A month later, Theda euthanized herself while I was still abroad. It happened after she’d attended a medical appointment with a neurologist who implied her suffering was her fault because—that neurologist believed—it had a mental health component at its core. I was staying at an Airbnb in Ithaca at the time. I hadn’t truly imagined Theda ending her life without calling me home. That day, Mum phoned while I was at a café getting ready to catch a bus to Albany. After the call, I remember walking down the main street toward the bus station on autopilot, unsure where I was going. Mum’s voice was playing over in my head, telling me that my sister was gone. It felt like I was watching myself from outside my own flesh.

I wasn’t mad at Theda for ending her life. She had chosen euthanasia after reaching the end of what she could tolerate. I knew that it no longer mattered whether her illness had been in her body or mind. All I knew is that she was no longer suffering.

​​If you need to talk, or if you or someone you know is experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline.