When Dr. Jack Kevorkian, a leading proponent of right-to-die legislation, died June 3, he may have achieved something he was unable to accomplish in his last years: perhaps return the issue of physician-assisted suicide (PAS) to a serious level of legitimate public discourse.
Public opinion polls conducted during the middle of the last decade by CBS/New York Times and the Pew Research Foundation show that Americans are pretty much split down the middle on whether PAS should be an option for dying patients and their families.
Yet in more recent years, the debate, while unsettled, seems to have subsided even though it raises very real questions about life, death and autonomy.
Kevorkian earned the nickname "Doctor Death" after a string of assisted suicides in the 1990s. He eventually served eight years of a 10-15 year sentence for second-degree murder.
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During his lifetime, Kevorkian tended to subvert objective discussion of PAS. With his eccentric antics, exemplified by his self-made "suicide machine," he became a lightning rod for opponents of the "death with dignity" movement which reached its zenith in 1997 when Oregon became the first state to legalize PAS.
Washington followed suit with a similar statute in 2009, the same year a Montana court decision effectively decriminalized the practice in that state. In the rest of the U.S., and in much of the world, PAS is prosecutable as homicide.
PAS is defined by the American Geriatrics Society as an instance in which "... a physician provides either equipment or medication, or informs the patient of the most efficacious of already available means, for the purpose of assisting the patient to end his or her own life."
In the 1969 film, They Shoot Horses Don't They?, set during the Great Depression, a young man rationalizes to authorities his assisted suicide of a depressed and exhausted woman by comparing the act to euthanizing a horse with a broken leg. The court doesn't buy his argument and he is hanged for murder.
Today the criminal justice system would no less likely regard an act to put humans "out of their misery" as humane and defensible. But in this century, some argue that with the future of Medicare as an entitlement threatened by the soaring cost of health care, PAS may provide a social — as well as humane solution — as patients opt to escape their suffering and alleviate their survivors of the financial burden of extending their deaths.
Americans spend countless hours and billions of dollars each year to better manage their lives. Death management, on the other hand, is major anathema.
Few people like to talk about death. Many obituaries sugarcoat a person's demise with euphemisms such as "gone to be with the Lord." We are conflicted about death, perceiving it at once as tragedy and blessing. But is PAS for someone who is suffering and near death mercy or murder? Should we be able to set forth conditions for our preferred means of death in the form of advanced directives while still of sound mind?
A living will, the most common form of advanced directive, is a written declaration, directed to a physician, stating that a patient wishes to forgo extraordinary treatment of a terminal illness, in order to die a natural death. The document allows competent adults to specify medical treatments to be accepted or refused if they should become incompetent.
California enacted the first living will legislation in 1976. Kentucky's Living Will Directive Act was passed in 1994. While living wills typically address a person's preferences as to whether to curtail treatments such as a respirator or feeding tube as a means of ending life, a similar advanced directive could be crafted to address PAS, if the practice became legalized in Kentucky and elsewhere.
Fundamentally, PAS appears at odds with the 2,500-year-old Hippocratic Oath which holds that the physician as healer should never administer or prescribe a lethal potion. PAS opponents argue that legalizing the practice will lead to a social policy endorsing non-voluntary euthanasia. Others contend that abetting suicide, regardless of the circumstances, is morally, inherently wrong.
For centuries, most cultures have regarded suicide as a tragic act of desperation. Some religions consider suicide as an automatic road to perdition — a final and irrevocable spiritual damnation — regardless of the value and virtue of the life ended.
Some advocates regard the alternative, life-extension beyond the arc of life's normal parameters, as an even worse moral violation — an extension of suffering and a drain of family and state financial resources. They argue that the issue centers more on autonomy and the right of self-determination than morality.
Autonomy is the self in self-determination. And perhaps it's time to consider whether that autonomy should be extended to determining when it's time to end one's temporal self.
Kevorkian's own death can't be classified as martyrdom for his crusade since he expired, apparently and ironically, of natural causes. But perhaps it will rejuvenate discussion of this literal life-or-death decision that cuts across the philosophical and professional boundaries of law, theology, medicine, ethics and morality.