A Harris/BBC World News America poll released in January 2011 showed that a majority of Americans — 70% — believe that terminally ill patients with no hope of recovery "should have the right to choose to end their lives." A more recent survey, conducted in 2013 as part of the Pew Research Center's Religion & Public Life Project, showed that 62% of adults found suicide to be morally acceptable when "a person is suffering great pain with no hope of improvement" and that 56% of adults believed that a person has the moral right to suicide if he or she "has an incurable disease." On the issue of physician-assisted suicide, however, Americans were sharply divided, according to the Pew poll, with 47% saying they approve of laws that allow the practice for terminally ill patients and 49% saying they disapproved of such laws.

In 1997, the issue went before the United States Supreme Court. At the time, Michigan pathologist Dr. Jack Kevorkian had been attracting national attention for nearly a decade for his use of a homemade device to help terminally and chronically ill patients self-administer lethal medication. Washington v. Glucksberg, however, wasn't about Kevorkian, but was born out of a challenge by Dr. Harold Glucksberg and three other physicians to Washington state's ban on assisted suicide. In its decision, the court ruled that Americans do not have the right to commit suicide or to be assisted in doing so. Chief Justice William Rehnquist delivered the opinion of the court. In it, he offered a challenge: "Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality, and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society."

In essence, the court left it to the states to decide whether or not to allow physician-assisted suicide. Since this ruling, several states have wrestled with the issue, and laws have been passed both to permit and to forbid the practice now commonly referred to by advocates not as assisted suicide, but "aid in dying."Four months after the Supreme Court handed down its decision, Oregon became the first state to enact "Death with Dignity" legislation, making it legal for doctors to prescribe to terminally ill patients a lethal dose of medication. In most cases, it's 100 bright orange Seconal capsules, their powdery contents stirred into water or mixed with applesauce or yogurt to help mask the taste.

Twelve years later, in 2009, Washington's law went into effect. That same year, a decision by the Montana Supreme Court also effectively legalized physician aid in dying, though it remains uncodified. In 2013, Vermont became the third state to enact Death with Dignity legislation.

In Oregon, Washington, and Vermont, each state's health department carefully monitors deaths that result from the legislation. Under state guidelines, patients requesting aid in dying must be at least 18 years old and diagnosed with a terminal illness, with six months or less to live. Requests made by people who appear to suffer from mental illness are screened out, and those individuals are to be referred for psychological evaluation. Death is induced at the time and place of the patient's choosing, by a lethal prescription ordered by the patient's physician, who does not have to be present at the time the medication is ingested. Each year, these states report on the number of prescriptions made and the number of deaths that have occurred as a result. The latest figures released by the state of Oregon show that since 1997, when the act went into effect, 1,050 people have received prescriptions under the law, and 673 of them have died from lethal medications. In Washington between 2009 and 2012, a total of 353 people ended their lives with medication prescribed through the act. Data from Vermont is not yet available.Death with Dignity laws in Oregon, Washington, and Vermont make the dying process bureaucratic, systematic, and regulated. Final Exit Network is bureaucratic too. However, the group operates outside of established programs and without external oversight by public health departments. It was founded in 2004 as an offshoot of the now-defunct Hemlock Society, the right-to-die group begun in 1980 by British journalist Derek Humphry in his Santa Monica, Calif., garage. At its peak, Hemlock Society had 50,000 members. Its first chapter was based in Tucson, Ariz., and the state soon hosted more than 10 local chapters. But after more than two decades, the national organization dissolved in 2003. Focus groups commissioned by Hemlock Society had shown that the public wouldn't take seriously a political movement named after the plant-based poison that killed Socrates, so the society decided it was time to reinvent itself.One faction within the original Hemlock Society went on to form End-of-Life Choices. The group later merged with another, Compassion in Dying, to form Compassion & Choices, which resolved to focus its efforts on creating laws that would allow terminally ill patients to end their lives through physician-assisted suicide, or physician-aid-in-dying.

Today, the group says it has more than 60,000 members, supporters, and volunteers across the United States.Another faction wanted to continue to focus on what it saw as the immediate needs of patients, just as it had done in Hemlock Society with the group's Caring Friends program. Let Compassion & Choices lobby for legislative change, the group reasoned, and we will work with people who want to die now. With Humphry's blessing, the group took its name from his suicide how-to manual Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Published in March 1991, the book, by August, appeared at No. 1 on the New York Times hardcover best-seller list in the Advice, How-to, and Miscellaneous category, edging out Martin Handford's oversize, illustrated children's book The Great Waldo Search.

Egbert, the physician who approved Jana's application, was one of Final Exit Network's original members. Earl Wettstein, a former advertising executive, was the group's first president. He held the post for a year but resigned in protest after another founder, Ted Goodwin, persuaded the Network to extend its services to people suffering from mental illness. "I think it makes the organization vulnerable," Wettstein told me when I asked about the group's decision to take on mental patients. "There are plenty of cases of physical pain where I don't think we need to go looking at these other ones."

Despite his resignation from the group's presidency, Wettstein, who lived in Tucson until his death by heart attack in January 2013 at the age of 81, remained devoted to the right-to-die movement.According to federal income-tax filings, Final Exit Network ended the 2012–2013 fiscal year with total net assets of $886,836 generated through membership fees, donations, and investments. The group is registered as a 501(c)(3) nonprofit organization. On the Network's website, which looks like an advertisement for a nursing home, with photos of smiling old people bathed in a heavenly backlight, the group claims to be the only right-to-die organization in the U.S. willing to work with people who are not terminally ill. The Network says that it will help people suffering from such diseases and conditions as cancer, emphysema, stroke, congestive heart failure, amyotrophic lateral sclerosis (ALS), and Parkinson's disease. The website explains the group's guiding principles: "We hold that mentally competent adults who suffer from a fatal or irreversible physical illness, from intractable physical pain, or from a constellation of chronic, progressive physical disabilities have a basic human right to choose to end their lives when they judge the quality of their life to be unacceptable." Its leadership sees the right to die as the civil rights issue of the 21st century.

In Final Exit Network, decisions about who will be accepted into the group's exit guide program are made not by an individual's doctor, but by a physician with whom the person, in most cases, has never spoken or met. Death is induced not by prescription pills dispensed at a pharmacy — as is stipulated by states with Death with Dignity laws — but by helium, a colorless, tasteless, odorless gas that cuts off the oxygen supply in the bloodstream, resulting in rapid loss of consciousness, first killing the brain and then stopping the heart. The gas goes undetected in routine autopsies. A tank of it can be purchased at Walmart or Toys 'R' Us for less than $60."Death by the method we use is absolutely certain," Jerry Dincin, a former Final Exit Network president and longtime board member, told me before his death from prostate cancer in March 2013, at the age of 82. "It's quick. It's painless. It's bloodless. You are unconscious in 20 seconds, and you are dead in 10 minutes. That's a real advantage if you don't want to put a gun in your mouth and blow your head off."

In Oregon, Washington, and Vermont, health department guidelines stipulate that the patient must make two verbal requests for lethal medication, 15 days apart. A written request must then be signed in front of two witnesses, at least one of whom is not related to the patient. The doctor must then wait 48 hours after the patient signs the final written request before filling out the prescription.Guidelines established by Final Exit Network are loose by comparison, and in some cases, the time between joining the Network and dying can be brief. An 89-year-old man in Osterville, Mass., on Cape Cod, who had suffered two heart attacks in a year and who used a cane and walker to get around, completed the group's intake interview on a Friday, was accepted into the program four days later, and died the day after that, with two exit guides by his side. "Weak arms," the first responder noted on the man's intake form. "But asserts he is able to put on and take off a hat (so should be able to handle a hood)."

Final Exit Network members vigorously deny that they help people commit suicide. They shun the s-word, preferring instead to call it self-deliverance. When I first learned about Final Exit Network, I found that I agreed with its mission, though I was disturbed by its method. A plastic bag and a helium tank just didn't seem like the best way to go out, and it struck me as far from dignified, despite the organization's claims. Still, I imagined that if I were suffering from a fatal illness or intractable pain, I'd want the choice to end my life on my own terms. I thought of my great-grandmother, who died in a nursing home, frail and shrunken at 103, after being kept alive by heart medication and begging, for years, "Let the good Lord take me." Why should a person have to suffer like that, or save up enough pills for a fatal dose? Or worse?

The difference in Jana's case is that she wasn't physically sick. She was mentally ill, and I knew something about the severity of her illness because she was one of my mother's friends.

Jana Van Voorhis had been in love with my stepfather, John, with whom she'd have a brief relationship before he married my mother. John was a part-time construction worker and carpenter who in the late 1960s performed in a local rock 'n' roll band called Poland. Jana was a groupie. I first heard her name when I was 10 years old. It was the early 1980s, and Jana called our home repeatedly one evening, crying and threatening to commit suicide. There was a small party going on at our house when she phoned, and I remember my stepfather coldly placing the receiver on the kitchen countertop and turning back to the stove to tend to a bubbling skillet of chicken cacciatore. I could hear Jana pleading on the other end of the line.