Editorials

Kevorkian and assisted death in the United States

The ethical debate drags on but fuels efforts to improve end-of-life care 

Retired pathologist Jack Kevorkian's assistance in the suicide of Janet Adkins, in June of 1990, did more than any other single action to make assisted suicide a hot button issue in the United States. Ironically, Dr Kevorkian's conviction last month on charges of second degree murder in Pontiac, Michigan, will probably have little if any impact on the further progress of the American assisted suicide "movement."

Already acquitted by juries three times on charges of assisting suicides, Kevorkian's actions this time led armchair psychiatrists to conclude that the self proclaimed "Dr Death" must have had his own death wish. He escalated his practice from assisting suicide to direct mercy killing in the case of Thomas Youk, who suffered from amyotrophic lateral sclerosis. He prepared a video showing his every action and the exact moment of Youk's death, and appeared with the video on a national television news programme, daring the authorities to prosecute him. Brought to trial on murder charges, he insisted on representing himself in courta task for which he was woefully unprepared, as was shown by the judge's refusal to allow the testimony from Youk's family, which Kevorkian was sure would win him the sympathy of the jury.

Kevorkian, who by his own count has assisted over 100 deaths, has always been a master at manipulating the American media. Early on some defenders of assisted suicide complained that Kevorkian's personality and methods had been allowed to obscure the pros and cons of the issue itself. But in the end Kevorkian apparently fell victim to the need to continually increase the shock factor in order to draw repeated media attention. Before the Youk case his most recent escalation had been to announce that he had harvested a kidney from one assisted suicide "victim" and to offer the kidney for transplant. Since he must have known that no legitimate transplant centre could accept a donor organ obtained under those conditions, the announcement could have served no purpose other than publicity. Sooner or later he was bound to overstep the tolerance of American public opinion.

Advocates for legalising assisted suicide in the United States had for many years been putting as much distance as possible between their movement and the activities of Jack Kevorkian. For his part, Kevorkian returned the favour, insisting that he was a one man show and that he would not submit to any regulations or restrictions. If anything, most legalisation advocates are secretly relieved at Kevorkian's apparent removal from the public stage (even though appeals from the trial could take months to years).

The focus for the debate over assisted suicide in the United States had, to a large extent, already shifted to the state of Oregon, where there has now been about one year's experience with legally permissible physician assisted suicide for patients judged to have six months or less to live.¹ Data have been published on the first 15 patients to avail themselves of this opportunity. Proponents claim that the data show excellent adherence to all required safeguards and a very limited use of assisted suicide by a small group of terminally ill patients whose suffering could be relieved in no other way. Opponents claim that the Oregon law is basically powerless to police or to detect cases which fall outside the legal guidelines; and so we have no idea how many other deaths may have occurred where the guidelines were ignored.

Of the various arguments against physician assisted suicide and euthanasia, the American public and policymakers have always preferred the "slippery slope" argumenta refusal to label assisted suicide as always wrong and instead a dire prediction that terrible social consequences would follow if the practice were to be permitted. This means (in theory at least) that a basically ethical and legal question could be decided, in the end, largely on empirical grounds. This was of little concern so long as no US jurisdiction permitted assisted suicide; there were then no relevant data. The long and well documented experience with euthanasia in the Netherlands could be discounted, partly because the social circumstances there were argued to be so different from those in the US and partly because the American disputants could never agree among themselves on exactly what the Dutch experience proved. With Oregon, data now exist, and the two sides in the debate have rushed to put forward their own favoured interpretation of the data. Who "wins" that argument will probably be the major determinant of whether other US states move to legalise either assisted suicide or voluntary active euthanasia.

In another important way Oregon has been the leader in the response to the assisted suicide controversy. Both proponents and opponents of legalisation can agree that the vehemence of the debate is a serious indictment of the way terminal illness is treated by the US healthcare system. Calls for assisted suicide are fed by widespread public perceptions that dying patients have unwanted aggressive treatments forced on them by uncaring doctors and hospital teams and that patients suffering from pain often go without adequate relief. Thus both proponents and opponents in Oregon can join forces to pledge that no one ought to seek assisted suicide in their state because their usual medical care offered them no other compassionate choice. By all accounts palliative care and hospice programmes received much greater attention and support in Oregon as it became clear that assisted suicide would become a legal option.² Several national efforts to highlight better symptom management and respect for patient choices at the end of life are slowly gaining momentum, fuelled to a large extent by the assisted suicide debate. Some years from now, it is quite probable that the United States will be a much better place to dieeven if, as seems likely, its citizens are no nearer than they are now to resolving the moral and policy debate over physician assisted suicide.

Howard Brody, Director. 

Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, Michigan 48824, USA (brody{at}pilot.msu.edu)

1. Chin AE, Hedberg K, Higginson GK, Fleming DW. Legalized physician-assisted suicide in Oregon: the first year's experience. N Engl J Med 1999; 340: 577-583[Abstract/Free Full Text].
2. Lee MA, Tolle SW. Oregon's assisted suicide vote: the silver lining. Ann Intern Med 1996; 124: 267-269[Free Full Text].