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Contemplating Suicide: New Questions, No Answers

by Barry Robinson**

The two American brothers were in their late 50s and suffering from the advanced stages of emphysema. They had been diagnosed within days of each other after smoking at least two packs of cigarettes a day for most of their adult Eves. Now, no longer capable of operating the family business to which both had devoted the last 20 or so years of their lives, they had been "retired" for several years.

Herman, the younger brother, was determined to survive long enough to see his adolescent children grow into adulthood. Journeying to far-off clinics and sanitariums, he consulted specialist after specialist in search of any new approach that might provide relief, if not a permanent cure. By the time he was no longer able to travel, his breathing had become almost totally dependent on a steady supply of pure oxygen from a tank in his home. And still he fought to live. Yet, after his hourly inhalation sessions, he would routinely remove the mask from his nose and mouth, and--with oxygen fumes still permeating the room's air--light up a cigarette.

Bill, the older of the two, had given up hope as soon as he learned the nature of his illness. Never fond of doctors or hospitals, he retreated with his wife to the cabin in the woods he loved, and waited there for death to come. It wasn't that he wanted to die, but more that he had lost his desire to live. He did, however, make one concession to the doctors trying to treat himmhe stopped smoking.

As it turned out, the younger brother who wanted to live was the first to die, alone and isolated from his family in an army veterans' hospital miles from his home. His health insurance benefits had been exhausted and, rather than further pauperize his family, Herman chose to leave behind the people for whom he wanted to live and entered this hospital of last resort from which he knew he would never return.

Three years later, almost totally incapacitated with only weeks or maybe a month or so left to live, Bill found himself facing the same stark alternatives from which his younger brother had been forced to choose. Instead, he reached for a third option in his favorite shotgun. He left behind a wife, an adult son, grandchildren, brothers and sisters and their children and a note to his wife in which he sought to comfort his family while explaining why he had taken his own life.

He was aware, he said in the note, that his f inal days were approaching rapidly and that he would not be able to spend them at home with his loved ones nearby, but would probably die alone in the same remote institution as his

*Barry Robinson is Associate Editor of Ageing International.

younger brother. Unable to bear even the thought o f this, he preferred to die now than have to live fo r even a short while without his wife at his side as she had been for over 30years. He wanted her to know that he loved her and his family very much, and that he was choosing to end his life at this point because he didn "t want to continue living i f it meant doing so under circumstances that would take his loved ones away f rom him. Passing the note among themselves shortly after his funeral, Bill's family members agreed that, i f there is such a thing as a suicide note that absolves the survivors o f guilt while assuaging their pain, this was such a note.

Compassion and Controversy

While these two brothers and their situations may not be totally typical, they are in some ways remarkably representa t ive o f the u n r e s o l v e d - - a n d perhaps unresolvable--issues and dilemmas to be found in the public's growing preoccupation with individuals who want to end their lives at a time when the human lifespan is being extended to unprecedented lengths. Yet, even as lawmakers, health care workers, clergy and medical ethicists etc. attempt to wrestle with the ambiguities inherent in this rapidly changing situation, new developments are occuring almost faster than they can be absorbed and dealt with.

Suddenly, self-initiated death has become one of the most pressing issues of our time, and American newspapers are filled with headlines about it:

Washington State to Vote on Euthanasia Washington Post

(February 6, 1991) Suicide among elderly on a puzzling upswing

Philadelphia Inquirer (October 1, 1991)

A How-to Book on Suicide Surges To Top of Best-Seller List in Week

The New York Times (August 9, 1991)

Suicide Doctor Aids In Two More Deaths Washington Post

(October 24, 1991) At Crossroads, U.S. Ponders Ethics of Helping Others Die

The New York Times (October 28, 1991)

It is not as though this interest occurred overnight without warning. It didn't, but the seemingly sudden convergence of indirectly related events over the last few

24 Ageing International December 1991

years has brought the trend to an unexpectedly rapid peak--at least in the United States--and observers are hard- pressed to project where it may go from here. As is frequently the case with such movements, the action has been taking place on several fronts which are at once both related and disparate, and which may be having both positive and negative effects on each other.

In November 1991, for instance, voters in the state of Washington rejected by an 8070 margin electoral Initiative 119 which would have allowed "'adult patients who are in a medically terminal condition [to] be permitted to request and receive f rom a physician aid-in-dying. "'~ For those advocating the legalization of medical euthanasia via the ballot box and/or legislative deliberation, the relatively close vote represented the greatest recognition and respectability achieved thus far by the right-to-die movement.

If the initiative had been adopted, Washington would have become the first place in the world to make it legal for doctors to kill terminally ill patients who voluntarily ask to die. Although some jurisdictions may habitually look the other way and not prosecute such conduct, almost all nations and states have laws prohibiting assisted-suicide. And many also forbid suicide itself, with some even prosecuting those who attempt unsuccessfully to take their own lives.

Under the defeated Washington state proposal, a licensed physician would have been allowed to provide "aid in dying" to terminally ill patients if:

�9 two doctors had concluded that the patient had less than six months to live; and

�9 the patient was conscious and competent, and made his or her request in writing, witnessed by two people with whom he or she had no family or financial ties; or

�9 the patient was in a coma, but had previously prepared a living will, telling in advance how he or she wanted to be dealt with under these circumstances)

In principle, it appeared, many people agreed--and may even still agree--with the initiative's intent. As recently as the weekend before the election, polls showed more than 60~ of Washington residents favoring at least the concept of physician-assisted suicide for terminally ill patients (with 30070 opposed and 10070 undecided). Earlier in the year, in a national Gallup survey, 65*70 of Americans asked had said they believed that terminally ill patients had a right to opt for suicide and that doctors should be allowed to provide "aid in dying. ''a

Yet, when the ballots were tallied, 54*70 of the votes cast were against Initiative 119 with 46*70 in favor.

Raising Questions in Voters' Minds

If ever there was an election in which the voice of the people was heard, this was it. Tens of millions of dollars had been spent trying to persuade citizens to vote for or against the intiative, so voter awareness was high on both sides, and the proposal was a popular topic of conversation. Due to the

The Promise

by Sharon Olds

With the second drink, at the restaurant holding hands on the bare table we are at it again, renewing our promise to kill each other. You are drinking gin, night-blue juniper berry dissolving in your body, I am drinking Fume, chewing its fragrant dirt and smoke, we are taking on earth, we are part soil already, and always, wherever we are, we are also in our bed, f i t ted naked closely along each other, half passed out after love, drifting back and forth across the border o f consciousness, our bodies buoyant, clasped. Your hand tightens on the table. You're a tittle afraid I'll chicken out. What you do not want is to lie in a hospital bed for a year after a stroke, without being able to think or die, you do not want to be tied to a chair like m y prim grandmother, cursing. The room is dim around us, ivory globes, pink curtains bound at the waist, and outside a weightless bright lifted-up summer twilight. I tell you you don't know me i f you think I will not kill you. Think how we have floated together eye to eye, nipple to nipple, sex to sex, the halves o f a single creature drifting up to the lip o f matter and over i t - -you know me from the bright, blood- f lecked delivery room, i f a beast had you in its jaws I would attack it, i f the ropes binding your soul are your own wrists I will cut them.

Reprinted by permission �9 1990 Sharon Olds OrisinaUy in The New Yorker.

controversial nature of the issue--and of other ballot items as well--the number of people voting was of record proportions. So this was neither a case of an indifferent electorate or one of those instances in which the only people voting were those with a vested interest in the election.

Exactly what happened to change peoples' minds is still unclear. Part of the answer may lie in the impact of events elsewhere, and of the questions they raised in the minds of voters about where the step they were being asked to consider might eventually lead.

For instance, those who had been undecided--or who may have originally been in favor of the initiative but who changed their minds and voted against i t - -may have been

Ageing International December 1991 25

alarmed and influenced by a Dutch study, made public in September, alleging that doctors in the Netherlands may be providing assistance in dying to an estimated 1,000 patients a year "without his or her persistent request. ''4

The Netherlands' informal and basically unofficial approach to dealing with euthanasia and related issues has long been pointed to as the best, most workable model for emulation. While providing assistance in committing suicide is officially illegal and punishable by a prison term of up to 12 years, it has been understood at virtually all levels of Dutch society for nearly 20 years that doctors will not be prosecuted if they adhere to guidelines similar to those in the Washington state proposal. The study was commissioned by the Dutch government and conducted by the Committee to Investigate the Medical Practice of Euthanasia to determine how well the system is working, and to learn more about the people who have chosen to die this way, their reasons for doing so, and the physicians who respond to their requests.

As it turned out, it is now beginning to appear that not everyone being assisted across death's threshold had chosen to cross it solely of their own accord, and this may very well have proven unsettling to more than a few voters in Washington state when the study became an argument used by both sides in the Initiative 119 debate. To put matters in perspective, the 1,000 questionable deaths a year are in addition to the 2,800 bona fide cases of voluntary euthanasia in which the patients explicitly request assistance (1.8070 of all deaths in the Netherlands). In addition, the questionable deaths may fall into a gray area of medical practice in which large doses of painkilling drugs are administered to alleviate suffering and/or bring about death.

The study also found that, while the patients themselves brought up the subject of euthanasia in 83~ of the cases studied, with families and friends raising it in 7~ of the cases, it was physicians themselves who had first mentioned the possibility in 10070 of the cases. At the same time, though, it was estimated that Dutch doctors complied with less than a third of the 9,000 explicit requests for euthanasia or assistance in suicide they receive annually. Surprisingly, the committee discovered that hardly any of these requests came from people in their 70s and 80s; the average age of patients seeking assistance in dying being 63 for men and 66 for women.

The spectre of poor and elderly patients being subtly--or not so subtly--coerced into having their lives taken had been raised throughout the long debate over Initiative 119, and it is quite possible that the questions raised by the Dutch report made even pro-euthanasia voters less sanguine about their decisions.

Dealing With Death Directly

Even as the Washington referendum campaign was entering its final weeks, right-to-die activists in other parts of the United States were also attracting attention to the cause

through their controversial actions and overt initiatives. Within the right-to-die community, there are now serious questions about the role these more radical elements p layed-- in tent ional ly or un in ten t iona l ly- - in the Washington proposal's defeat. It is entirely possible that, by thrusting themselves into the foreground, these unconventional activists may have caused voters to have second thoughts about the wisdom of legalized euthanasia, thus undermining the overall efforts of the right-to-die movement.

For instance, in Michigan, "Doctor Death," as Jack Kevorkian had come to be called, returned to center stage to help two middle-aged women take their lives in late October with a new version of his "suicide machine." This device had first been used by 54-year-old Janet Adkins to end her life in June 1990 after having been diagnosed as being in the early stages of Alzbeimer's Disease. The dead women this time were Sherry Miller, 43, who had been suffering from multiple sclerosis for a dozen or so years, and Marjorie Wantz, 58, who suffered from pelvic adhesions, a rare and extremely painful condition in which some of one's internal organs stick to the body's inner linings. Although both disorders are incurable, neither woman had been diagnosed as being terminally ill and likely to die within six months--a key consideration in determining eligibility for euthanasia in the defeated Washington state proposal as well as in most countries where such practices are unofficially regarded more benignly than in the United States) ,e

After having undergone ten unsuccessful surgical efforts to alleviate her suffering and attempting to commit suicide at least twice, Mrs. Wantz turned to Dr. Kevorkian, the controversial 63-year-old retired pathologist, whose suicide machine--and his unstinting promotion of it--have propelled him to prominence among the more radical right- to-die activists and to notoriety among medical ethicists and the general public. It has also been reported that Mrs. Wantz had been taking Halcion, an insomnia medication which can have the side effect of causing depression in some patients, and that some of her suicide attempts involved overdoses of this drug. 7'8'9

Dr. Kevorkian had also been approached by Ms. Miller. At first, according to his attorney, Goeffrey Fieger, he declined to assist either woman because at the time Ms. Miller's family was opposed to her plans (they later reversed themselves) and because Mrs. Wantz's condition had not been classified as completely hopeless. However, when some of the circumstances changed, he changed his mind and acceded to their requests.

The original Kevorkian suicide machine consisted of an electric clock motor with a pulley axle, a fine chain and two coils acting as electric bar magnets. To activate the machine, a user would push a button that first released anesthesia and then a heart-stopping drug. From press accounts of Miller and Wantz suicides, the new machine appears to be somewhat simpler and more varied in how it kills, administering drugs to Mrs. Wantz via an intravenous


Death and Doctors

After dealing with euthanasia and related issues on an informal ad hoc basis for nearly two decades, the Netherlands is now considering codifying and possibly modifying some of its policies and practices in this area. In preparation for this, the Dutch government created the Committee to Investigate the Medical Practice o f Euthanasia to study what are known there as "medical decisions concerning the end of life" (MDEL) issues. Three primary types of MDEL were studied:

�9 "Non-treatment decisions (NTD), the withholding or withdrawal of treatment in situations where the treatment would probably have prolonged life.

�9 "Alleviation of pain and symptoms (APS) with opioids in such dosages that the patient's life might have been shortened.

�9 "Euthanasia and related MDEL, the prescription, supply or administration of drugs with the explicit intention of shortening life, to include euthanasia at the patient's request, assisted suicide, and life-terminating acts without explicit and persistent request."

By surveying 405 physicians and studying nearly I0,000 deaths, the committee sought to answer four basic questions about each MDEL:

*"What did the physician do (or not do)? �9 "What was his or her intention when doing so? �9 "Was this action chosen at the request of or after

discussion with the patient? �9 " I f not, was the patient incapable of a dec i s ion . . . ? " In general, various degrees of MDEL were found to be

involved in at least 38070 of all deaths, a figure which rises to 5407o once deaths from acute causes are removed from consideration. Of these, 17.5070 involved a decision "not to treat a patient;" another 17.5070 involved "the use of opioids in doses high enough to kill the patient," and 1.8070 involved "the painless killing of a patient at his or her own request." In addtion, "assisted suicide, meaning that a physician intentionally prescribes or supplies lethal drugs but the patient administers them," is involved in an estimated .307o of all deaths. Sharing Their Suffering How willing are Dutch doctors to participate in ending their patients' lives?

According to the study, while "over 25,000 patients per year seek assurance from their doctors that they will assist them if suffering becomes unbearable," there are actually "9,000 explicit requests for euthanasia or assisted suicide," and less than a third of these are approved. " In most cases, althernatives are found that make life bearable again and, in some instances, the patient dies before any action has to be taken. Of the patients in the study whose request was refused, 1407o had a psychiatric illness."

However, the survey also revealed that "life termination by administering lethal drugs without an explicit and persistent request from the p a t i e n t . . , happens in about .807o of all deaths. In more than half of these cases, the decision had been discussed with the patient or the patient had in a previous phase of his or her illness expressed a wish for euthanasia should suffering become unbearable. In other cases, possibly with a few exceptions, the patients were near

in the Netherlands

to death and clearly suffering greviously, yet verbal contact had become impossible. The decision to hasten death was then nearly always taken after consultation with the family, nurses, or one or more colleagues. In most cases, the amount of time by which, according to the physician, life had been shortened was a few hours or days only. In this respect, these cases resemble APS more than euthanasia. In euthanasia, in 70070 of all cases, life was shortened by at least one week and in 8%, by more than six months."

Of those physicians who had practiced euthanasia, many reported that " they would be most reluctant to do so again, thus refuting the 'slippery slope' argument. Only in the face of unbearable suffering and with no alternatives would they be prepared to take such action. Many respondents mentioned that an emotional bond is required for euthanasia and this may be one reason why euthanasia was more common in general practice where doctor and patient have often known each other for years and the doctor has shared part of the patient's suffering."

Who Dies, and Why Although suicide rates among the elderly are rising in the United States and Japan, euthanasia and assisted suicide in the Netherlands "were more often found in relatively young m e n . . , and this may be an indication of a shift toward a more demanding attitude of patients concerning the end of life."

The average age for those seeking assistance in dying was 63 years for men and 66 for women, with such requests being rare above 75 and even rarer after 85. According to Gerrit van der Wal, a public health inspector and one of the researchers, older people may be better able to deal with the impact of illness. It is also possible, however, that older patients may be less informed or less assertive regarding euthanasia. 1

Among the reasons given by patients when asking for euthanasia were loss of dignity (cited in 5707o of requests), pain (46%), being dependent upon others (33%), or being tired of life (2307o). In only 507o of the cases studied was pain mentioned as the sole reason.

Looking to the future for which the Dutch parliament is seeking to legislate, the study predicts that "MDEL will become an issue of increasing importance for doctors because of demographic shifts toward older populations, an increasing proportion of cancer deaths, a growth in the number of life-prolonging technologies and, possibly, generational and cultural changes in attitudes of patients."

Such changes are taking place all over the world, but at the moment, it is only the Dutch who are attempting to anticipate them by studying their recent past in order to prepare for the future.

(Source: Paul J. Van der Maas; Johannes J.M. Van Detden; Loes Pijnenborg and Caspar W.M. Looman. "Euthanasia and other medical decisions concerning the end of life," Lancet, Vol. 338, No. 8768, September 14, 1991.)

Reference

XSimons, Marlise. "Dutch Survey Casts New Light on Patients Who Choose to Die," The New York Times, September 11, 1991.


tube in her arm and carbon monoxide gas to Ms. Miller via a mask. In both cases, according to Fieger, the process had to be initiated by each of the women.

Since there is no law in Michigan specifically barring anyone, including doctors, from assisting an individual in committing suicide, legal authorities there are in the often awkward position of having to utilize other laws if they wish to prosecute in such situations. Following Janet Adkins' death, Dr. Kevorkian was charged with first-degree murder, the most serious form of homicide under American law which connotes killing with premeditation, but the charge was dismissed during preliminary hearings. At the time this issue of AI went to press in early December, prosecutors were still debating what, if any, action to take regarding these latest deaths.

The state's Board of Medicine, however, acting in late November, suspending his license to practice medicine under regulations prohibiting physicians from administering drugs for other than lawful diagnostic or therapeutic purposes. Although board members hoped the license suspension, which may lead to revocation, would make it impossible for Dr. Kevorkian to prescribe or have access to medications which can be used to kill, they speculated that he may already have a stockpile of these.

Adding to the board's dilemma is the assertion from another of his lawyers, Michael Schwartz, that the retired pathologist doesn't need a license to practice his particular specialty: "Dr. Kevorkian can do anything that any unlicensed human being can do if asked for advice. ''1~

In a civil case earlier this year, Dr. Kevorkian had been forbidden by the court from using his suicide machine again. Thus, when the retired pathologist was announcing the two women's suicides, Fieger made a point of stressing to reporters that the deaths "were solely at the hands of Marjorie Wantz and Sherry Miller . . . Dr. Kevorkian, I understand was present. Dr. Kevorkian provided his expertise. Dr. Kevorkian did not participate in any way. ' '~

Nonetheless, in addition to raising the question once again of what role physicians should play in such situations, Dr. Kevorkian's latest exploits touched off the same explosion of emotional and ethical responses triggered by his participation in Janet Adkins's death the year before; often, these reactions appeared to have been influenced both by one's philosophical position on the right to die and by personal reactions to the pathologist's prickly personality.

"What we've got on our hands now is a serial mercy killer," commented Dr. Arthur Caplan, director of the University of Minnesota's Center for Biomedical Ethics, in response to questions from reporters for USA Today and The New York Times. "He is a man with a cause, and the cause is immoral, unethical and very dange rous . . . Some people will say Dr. Kevorkian is still providing an overdue service and . . . we should commend him, but I think we should jail him. ''s,6

"Here in this state, he is referred to as Doctor Death," declared Michigan State Senator Fred Dillingham, whose

legislation to make assisting suicide a felony has passed one of the state's two legislative bodies and is still being considered in the other. "We're looking at someone who wants to be Doctor God. It's a very scary concept. He violated a court order, violated medical ethics, then turns around and broadens it to the chronically ill. It makes me wonder what's next if we don't get him checked in this state.' "~

While arguing that Dr. Kevorkian "has done the nation a service by demonstrating that certain people in hopeless medical situations wish to be helped to die," Cheryl Smith, a staff attorney for the Hemlock Society, one of the major supporters of the Washington state initiative, conceded that "this type of ad hoc assistance in suicide for the dying is wide open to abuse because there are no ground rules and no criteria."s'6

The search for a reasonable middle ground was not furthered any by Dr. Kevorkian's own incendiary remarks comparing American medical ethics against assisting suicide to those of doctors in Nazi Germany who did not refuse to follow orders to torture and conduct useless experiments on concentration camp inmates during World War II. "I will not follow the example of those immoral Nazi doctors, which the rest of the doctors in this country seem to be doing," he told a Kansas City conference on secular humanism by phone approximately ten days after the two suicides (and four days before the vote on Initiative 119). "Our civilization is equally culpable because we have equally immoral laws which force doctors not to do what they should be doing. ''Is

What doctors should be doing, insists Dr. Kevorkian in his new book, Prescription: Medicide--The Goodness of Planned Death, is to follow his example and "accept planned death by euthanasia. ''~4 The book was published shortly before the Wantz and Miller suicides, and there are those among his critics who have wondered about the coincidental convergence of the two events.

"His defiant pursuit of publicity," notes Time senior editor Nancy Gibbs, "suggests a man more obsessed with the justice of his cause than with the interests of his patients. "15

"I think he's hurting the patient autonomy issue because he's the horror story everyone can point to ," commented Ken Wing, a Washington law professor active in the campaign to enact Initiative 119, shortly before the election. 16

After the votes had been counted, David Von Drehle observed in the Washington Post: "Kevorkian is extreme because none of his 'patients' were terminally ill, in the strict sense. One was in horrible pain, another was badly disabled, and the third dreaded the ravages of Alzheimer's disease. While the distinction between chronic suffering and terminal suffering is ludicrous to Kevorkian, it may have struck a chord with Washington's swing voters. Some campaign strategists speculated that the 'Suicide Doctor' came to symbolize the dangers of insufficient regulation of euthanasia."a


'The Right Decision For Her' Suicide as a Best Seller

In contrast to the almost carnivalqike atmosphere generated by Dr. Kevorkian, there was another physician who recently "went public" after helping a patient end her life. Dr. Timothy Quill, who practices medicine in Rochester, NY, normally tries to save or at least prolong lives. As far as can be determined, he had no ideological cause to promote when Diane, a 45-year-old long-term patient of his, suffering from severe leukemia and facing a painful and almost hopeless course of treatment with many adverse side effects and only a 25% chance of success, confided that she wanted to be able to take her own life when her suffering reached a point she could no longer bear. 1~

She talked to a psychologist she had seen in the past. I gradually understood the decision from her perspective and became convinced that it was the right decision for h e r . . . When the time came, she wanted to take her life in the least painful way possible. Knowing of her desire for independence and her decision to stay in control, I thought this request made perfect sense. . . I feared the consequences o f an ineffective suicide that would leave her lingering in precisely the state she dreaded so much, and the possibility that a family member would be forced to assist her, with all the legal and personal repercussions that would follow. She discussed this at length with her family. They believed that they should respect her choice. With this in mind, I told Diane that information was available from the Hemlock Society that might be helpful to h e r . . . A week later she phoned me with a request for barbiturates for sleep. Since I know that this was an essential ingredient in a Hemlock Society suicide, I asked her to come to the office to talk things ove r . . . I made sure that she knew how to use the barbiturates for sleep, and also that she knew the amount needed to commit suicide.17

After several months during which, despite treatment, her condition continued to deteriorate, the time came for one final conversation between patient and physician: "When we met, it was clear that she knew what she was doing, that she was sad and frightened to be leaving, but that she would be even more terrified to stay and suffer."

When she died two days later, Dr. Quill listed "acute leukemia" as the cause of death to protect her family from the embarrassment a suicide investigation would cause them, but later changed his mind and wrote an article for the New England Journal of Medicine about his and Diane's experience. After the article appeared, there was indeed a grand jury investigation which chose not to indict Dr. Quill.

"Should doctors be allowed to assist in the suicides of terminally ill patients?," commented a New York Times editorial. " I f they do it as carefully as Dr. Quill did, the answer is probably yes. ''18

At about the same time that the New York grand jury was clearing Dr. Quill of any wrongdoing, and Jack Kevorkian was reinserting himself and his beliefs into the public consciousness, Final Exit, right-to-die proponent Derek Humphry's new how-to-guide to taking one's life was catapulting itself to the top of The New York Times bestseller list for personal advice books. Humphry, a former newspaper reporter who is executive director of the Hemlock Society which published the book, is also the author of several other books about euthanasia, including Jean's Way in which he told about helping his first wife take her own life with medication in 1975 when she was terminally ill with cancer.19, ~~

While the suicide rate among people over age 65 continued to rise (as first reported in the Winter 1990 issue of A/), bookstore managers told reporters of seeing people in their 60s, 70s and 80s--seemingly in good health and spirits--coming into their shops to purchase the Humphry book. To Minnesota bioethicist Arthur Caplan, the sudden success of Humphry's book "is an indication of how large the issue of euthanasia looms in our s o c i e t y . . . It is the loudest statement of protest of how medicine is dealing with terminal illness and dying. ''19

Although the book includes perfunctory precautions about the use of the information it contains, it seems to proceed from the assumption that anyone reading it has already made up his or her own mind, and that it is not the author's responsibility to try to advise his readers to take another look at their lives before terminating them. Concern has been voiced about the possibility that reading about how easy committing suicide can be might serve to push someone over the edge of no return. The book says it is intended for the terminally ill, but there is nothing to keep someone who is depressed from being influenced by it.

In a telephone interview with veteran New York Times medical writer Lawrence K. Altman, Dr. Quill, who, as we have seen, has had first-hand experience with such matters, said he had "mixed feelings" about the success of Final Exit. "There 's a strong need for that kind of information," he maintained, but admitted that he was concerned about the way it is presented. "There is not control over who gets the information and whether it is used under the right circumstances."x9

Just as the public attention being paid to Final Exit was approaching its peak, Ann Wickett Humphry, Hemlock Society co-founder who had recently been divorced from the book's author, was found dead in the Oregon wilderness, an apparent suicide. Police said it was not a violent death. Although Mrs. Humphry had been suffering from breast cancer which was believed to be under control, there were also reports--confirmed by her former husband--that, at the time of her death, she was suffering from depression, an emotional problem that had plagued her most of her life. ~1


As if this news wasn't enough to confirm the fears of those concerned about the misuse of Humphry's information by mentally disturbed individuals, and perhaps to raise some questions in the minds of people getting ready to vote on Initiative 119 in Washington, it was followed three weeks later by reports of the potentially scandalous contents of the late Mrs. Humphry's suicide note. In it, she alleged that, rather than merely providing his first wife with the medication she used to take her life, Derek Humphry actually smothered her himself) 2

"He is a killer," she declared in a handwritten postscript to her typewritten note. "I know. Jean actually died of suffocation. I could never say it until now; who would believe me?"

Regardless of the truth or reliability of this charge, this accusation may have served only to add to the questions in the minds of people trying to decide what is at the very least the most difficult of issues.

The Other Side of Cruzan

There is, in the United States, a popular expression--"it's not over 'til it's over"mwhich might apply both to life itself and to the whole question of ending life. Although voters in the state of Washington chose not to make it legal for doctors to assist patients in committing suicide, efforts are already underway to place similar measures on the ballot in the states of Oregon and California.

Once again, all the old unresolved questions will be brought to the fore once more and, as has frequently been the case, there will probably be new questions, but no answers. One such question emerged in the months following the resolution of the Cruzan case which involved a request from the family and physicians of a 32-year-old auto accident victim to disconnect the tube which had been providing her body with nutrition and fluids during the seven years she had been in a persistent vegetative state. This is what is known colloquially as "pulling the plug." With the state of Missouri objecting on behalf of the hospital, the case worked its way up the judicial system to the U.S. Supreme Court which upheld the state court's ruling that the feeding tube must remain. Within months of the Supreme Court decision, Missouri withdrew its objection, and Nancy Cruzan was finally allowed to die. (A more detailed discussion of the Cruzan case may be found in the Winter 1990 issue of A/).

Although she had reportedly said on occasion that she would not generally want to be kept alive if she could not lead a normal life, Nancy Cruzan had not documented this via either a living will or a durable power of attorney. In rendering its decision, the Supreme Court decision cited the absence of "clear and convincing evidence of a person's expressed decision while competent to have hydration and nutrition withdrawn in such a way as to cause death." In other words, if Nancy Cruzan had firmly made her wishes known before the accident, her parents' request would have prevailed over the hospital's desire to continue treatment.

Even as the Cruzan decision was being handed down, another challenge to our understanding of the implications inherent in extending and/or ending life was developing in Minneapolis, Minnesota. To a very great extent, the case was the "flip side" or mirror image of the issues involved in Cruzan, and involved Helga Wanglie, an 87-year-old retired teacher who was being kept alive by a respirator and other means while in a persistent vegetative state. The principal difference here is that it was doctors and hospital officials who wanted to pull the plug, and Mrs. Wanglie's husband and family who objected on the grounds that this is not what she would have wanted. ",24

"My wife always stated to me," recalled Oliver Wanglie in a letter to the hospital, "that if anything happened to her so that she could not take care of herself, she did not want anything done to shorten or prematurely take her life. ''25 Three days after a Minnesota court sided with the family, ruling that nothing should be done to terminate her life, Helga Wanglie died of natural causes, resolving matters for her family but raising still more questions for those having to deal with such situations) 6'27

Politicizing the Personal

It is situations like this--and where they may lead in the futuremthat medical ethicists have in mind when they talk


about the dangers of senicide and geronticide in a time of expanding health care costs and shrinking resources.

"Various indexes of functioning have been explored by investigators who believe that when the patient's quality of life is very low, it is appropriate to limit medical care, particularly life-extending medical ~are," observe physician and ethicist Christine K. Cassel and psychologist Bernice L. Neugarten. "This would mean that over time medical care would be provided more often to old persons whose quality of life is relatively high--those who are often described as 'aging successfully'--than to persons whose quality of life is l o w . . . If the level of functioning were to become, for policy makers, the criterion for determining the type of medical care to be provided, the outcome would be to give more medical care to those who are physically and mentally able, and less to those who are d i sab led . . . Not only would such a policy increase inequities in the allocation of health care, but it also raises other underlying ethical questions. ''za

From all reports about the Wanglie case, economics did not play a direct role in the hospital's desire to pull the plug; Mrs. Wanglie's medical bills (which were estimated as being around $800,000) were being paid by her health insurance company which, as far as can be determined, remained neutral in the dispute. Still, the situation did engender a commentary headlined Stop wasting money on hopeless cases by medical writer Harry Schwartz, a former member of the editorial board of The New York Times, which concluded: " . . . legislatures all over the USA are ruthlessly cutting medical appropriations that help millions of people while private firms are cutting or eliminating their health insurance. But nobody dares touch the huge waste of money spent caring for people who will never wake up. The time to end this idiocy is now."~9

With increasing attention being paid to such issues, what has been up to now an individual and intensely personal matter is now becoming politicized, often to an extent beyond the control of the individuals directly involved in the situation.

Three months after the U.S. Supreme Court had handed down its ruling in the Cruzan case, at a conference convened to discuss its implications, there were repeated reports from participants about advocacy groups intervening to challenge and conceivably contravene decisions about terminating treatment that had already been made and agreed to by patients' family members, physicians and hospital administrators. In some cases, the intrusion would go as far as taking the families, doctors and hospitals to court--subjecting them to additional expense and emotional distress above and beyond their original suffering--in an effort to project their point of view on this matter, a~

In the Cruzan case, for instance, when the legal challenges to "pulling the plug" had been withdrawn and treatment had been terminated, demonstrators paraded outside the medical facility where she lay--not unlike antiabortion or "pro-l i fe" advocates blocking the entrances to clinics. Although they threatened at times to invade the

premises and reconnect Cruzan's feeding tubes, they never succeeded, and eventually she died.

There were also frequent references at the conference to the involvement of "pro-life" advocates in challenges to decisions to terminate treatment. More recently, some of the funding for efforts to defeat Initiative 119 in Washington came from the same sources, both within and outside the state, as support for defeating an abortion rights initiative being voted upon in the same election. This should not be surprising since much of the right-to-life movement's opposition to right-to-die issues springs from the same philosophical base as its opposition to abortion. Because the two issues are equally controversial and emotional, bringing out the best and worst in adherents to both pro and con positions, they will probably be equally long in reaching some form of resolution that society can live--and die--with.

To Margaret P. Battin, a University of Utah philosophy professor specializing in professional ethics and right-to-die issues, this is " the most important civil rights issue to come along: whether one has the right to determine or control the circumstances of one's own death. ''al

Predicts physician-ethicist Eric 3. Cassell: " I think it is the issue of the next 20 years. ''al

At least.

References

1Official Ballot, State of Washington, November 5, 1991.

2House Initiative 119, State of Washington, 52nd Legislature, 1991 Regular Session.

avon Drehle, David. "Suicide Initiative Defeated, Not Dead," The Washington, Post, November 7, 1991.

4Van der Maas, Paul J., Van Delden, Johannes J.M., Pijnenborg, Loes, and Looman, Caspar W.M. "Euthanasia and other medical decisions concerning the end of life," Lancet, Vol. 338, No. 8768, September 14, 1991.

5Edmonds, Patricia, and Casteneda, Carol J. "Debate over right- to-die rekindled," USA Today, October 25, 1991.

eWilkerson, Isabel. "Opponents Weigh Action Against Doctor Who Aided Suicides," The New York Times, October 25, 1991.

7Kole, Bill, Associated Press. "Two of Kevorkian's Suicide Clients Shown Speaking on Videotape," The Oregonian, Portland, Oregon, October 29, 1991.

aWire service report. "Woman on suicide machine reportedly was on Halcion," Chicago Tribune, November 5, 1991.

9Associated Press. "Halcion Label Adds Warnings," The New York Times, November 19, 1991.

l~ Edward. "Michigan Suspends License of Doctor Who Aided Suicides," The Washington Post, November 21, 1991.

tlAssociated Press. "Michigan Board Suspends License of Doctor Who Aided in Suicides," The New York Times, November 21, 1991.

12Walsh, Edward. "Michigan Officials Release 'Dr. Death' Pending Investigation of Two Suicides," The Washington Post, October 25, 1991.

(Continued on page 34)


live in this type of housing benefit greatly. Clearly then, the major obstacles in the implementation of viable granny flat programs are management issues which are mostly in government hands. It would be interesting to learn why the Canadian government has been so supportive of the

program in contrast to the governments of the other countries discussed. For not until there is a real commitment on the part of government agencies to this housing option for older persons can some of the major obstacles be overcome.

Continued from page 23

5 World Bank Report: The Challenge of Development, Washington, DC: Oxford University Press, 1991. eMamas, S.G.M. "Penduduk Indonesia dan Berberapa Proyekinya Di Masa Mendating Dalam Kaitannya Dengan Proses Transisi Demografi" (Indonesia's Population and Several Future Projections in Relation to the Demographic Transition Process). Paper presented to meeting on the Contemporary and Future Situation of Indonesia's Population and the Implications for Future Sectoral Development organized by Ministry of Population and Environment, Jakarta, 25-26 March 1991. 7Hull, T.H. and Dasvarma, G.L. "The 1985 Intercensal Survey of Indonesia: Evidence of Continuing Fertility Decline," International Population Dynamics Program Research Note No. 77, 9th July. Canberra: Department of Demography, Australian National University, 1987. s Jones, G.W. "Consequences of Rapid Fertility Decline for Old Age Security." Paper presented at Seminar on Fertility Transition in Asia: Diversity and Change, Bangkok, 28-31 March, 1988. 9Chen, A.J. and Jones, G.W. Ageing in ASEAN and its Socio Economic Consequences, Singapore: Institute of Southeast Asian Studies, 1988. l~ J.S. and Hoover, S.L. International Trends and Perspectives: Aging, Washington, DC: U.S. Department of

Continued from page 31

lSAssociated Press. "Doctor in Suicides Assails U.S. Ethics," The New York Times, November 3, 1991.

14Kevorkian, Jack. Prescription: Medicide: The Goodness of Planned Death. Amherst, NY: Prometheus Books, 1991.

lSGibbs, Nancy. "Dr. Death Strikes Again," Time, November 4, 1991. 16Knox, Richard A. "Igniting a Deadly Debate: Suicide Doctor Seen as Threat," The Boston Globe, October 27, 1991.

17Quill, Timothy E. "Sounding Board: Death and Dignity: A Case of Individualized Decision Making," The New England Journal of Medicine, Vol. 324, No. 10, March 7, 1991.

lSEditorial opinion. "Dealing Death or Mercy?," The New York Times, March 17, 1991.

19Altman, Lawrence K. "A How-to Book on Suicide Surges to Top of Best-Seller List in Week," The New York Times, August 9, 1991.

~gHumphry, Derek. Final Exit: The practicalities of self-deliverance and assisted suicide for the dying. Eugene, Oregon: The Hemlock Society, 1991.

~lUnited Press International. "Hemlock Society co-founder found dead of apparent suicide," October 9, 1991.

Commerce, Bureau of the Census (International Research Document No. 12), 1984. nHugo, G.J. "Population Mobility in West Java, Indonesia." Yogyakarta: Gadjah Mada University, 1978. t:Hugo, G.J. "The Changing Urban Situation in Southeast Asia and Australia: Some Implications for the Elderly." Paper prepared for International Conference on Aging Populations in the Context of Urbanization, Sendal, Japan, 12-16 September, 1988. lSSigit, H. "A Socio-Economic Profile of Elderly in Indonesia," Phase III ASEAN Population Program Country Report, Socio- Economic Consequences of the Ageing of the Population Jakarta: Central Bureau of Statistiks, 1988. 14Caldwell, J.C. "Toward a Restatement of Demographic Transition Theory." Population and Development Review 2(3-4): 321-366. lSEvans, J. "The Economic Status of Older Men and Women in the Javanese Household and the Influence of this upon their Nutritional Level." Journal of Cross Cultural Gerontology Vol. 5,3, 1990. lSHeisel, M.A. "Population Policies and Aging in Developing Countries." Paper presented to 13th International Congress of Gerontology, New York, July 12-17, 1985. l~Andrews, G.R., Esterman, A.J. and Rungie, C.M. Aging in the Western Pacific. Manila: World Health Organization Regional Office for the Western Pacific, 1986.

2~Associated Press. "'Smothering Alleged in Suicide Note," The Washington Post, October 28, 1991.

2SWalsh, Edward. "Recasting 'Right to Die': Public Hospital Seeks to End Life Support," The Washington Post, May 29, 1991.

:4Belkin, Lisa. "As Family Protests, Hospital Seeks An End to Woman's Life Support," The New York Times, January 10, 1991.

:~Cranford, Ronald E. "Helga Wanglie's Ventilator," Hastings Center Report, Vol. 21, No. 4, July-August 1991. :eAssociated Press. "Judge Rejects Request by Doctors To Remove a Patient's Respirator," The New York Times, July 2, 1991.

~Associated Press. "Minnesota Woman Dies After Right-to-Life Ruling," The Washington Post, July 6, 1991.

~SCassel, Christine K., and Neugarten, Bernice L. "The Goals of Medicine in an Aging Society." In Binstock, Robert H. and Post, Stephen G., Too Old for Health Care? Controversies in Medicine, Law, Economics and Ethics. Baltimore: The Johns Hopkins University Press, 1991.

~Schwartz, Harry. "An opposing view: Stop wasting money on hopeless cases," USA Today, May 30, 1991.

S~ observations by author and conversations with participants at conference on Medical Decision-Making and the "Right-to-Die" After Cruzan, Washington, DC., September 1990.

SlSteinfels, Peter. "At Crossroads, U.S. Ponders Ethics of Helping Others Die," The New York Times, October 28, 1991.


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