The Doctor's Suicide Van

Sometimes, when ethical debates have run on interminably, it takes a shocking incident to sear the old questions back into the public consciousness. So it was with the case of the Oregon grandmother, the Detroit pathologist and his homemade suicide machine. She was diagnosed as having Alzheimer's disease--and preferred taking her life to slowly losing the mind she cherished. He was a zealot who had searched for an appropriate patient to try his controversial device. Janet Adkins read a short item about Jack Kevorkian in NEWSWEEK last fall and saw him on the "Donahue" show. She and her husband flew 2,000 miles to meet him and discuss his device over dinner. Last Monday, while her husband waited at a nearby hotel, they drove to a suburban campsite in Kevorkian's rusty Volkswagen van. He inserted a needle in her arm and started saline flowing. She pressed a button on his death machine that first sent a sedative, then deadly potassium chloride racing to her heart.

With that, Janet Adkins reignited debate over the right to die with dignity, the ethics of assisting such deaths and the alarming rate of suicide among the elderly. The case was the buzz of TV and radio shows--and the talk of nursing homes, where more than a few residents professed to be envious. "I'd pay somebody to take me out behind the barn and shoot me but this sounds a lot neater," said one octogenarian suffering from Parkinson's disease. The incident also gave a boost to a Washington state initiative to pass an assisted-suicide law. "The requests for petitions are coming in faster than we can fill them," said Karen Cooper of Washington Citizens for Death with Dignity.

Yet the case raised many disturbing questions. At 64, Janet Adkins seemed too young and vital to end her life: she had enjoyed a last romantic weekend with her husband and had beaten her grown son at tennis just the week before. Alzheimer's experts warned that her diagnosis might have been wrong--and that even if it weren't, Adkins could have enjoyed several more productive years (page 49). And, said Dr. Robert Butler, head of geriatrics at Manhattan's Mt. Sinai Hospital: "It's very demoralizing to hear of a 54-year-old giving up life when you're in your 80s and have heart disease and arthritis and some dementia and are still surviving, maybe working and taking care of your spouse."

Members of Adkins's family insisted that Janet had made the decision carefully and rationally, based on profound conviction. Adkins herself was a member of the Hemlock Society, which supports legalizing assisted suicide. She had wanted to take her own life immediately upon hearing the diagnosis, but took time to try an experimental treatment, talk with her minister and undergo family counseling with her sons. "We've been grieving for a year," husband Ronald Adkins told NEWSWEEK. "But she was the one who kept everyone up--even to the last hour." Kevorkian, too, defended his actions--even as a Michigan judge late last week issued a preliminary injunction barring him from using his death contraption again. "I'm trying to knock the medical profession into accepting its responsibilities," he told reporters earlier, "and those responsibilities include assisting their patients with death."

Feeding tube: Within medical or legal circles, that is by no means the accepted view. Doctors, ethicists, courts and ordinary citizens are grappling with a host of complex right-to-die questions, ranging from when to remove life-support systems to who should make such decisions when patients cannot. Any day now, the U.S. Supreme Court is expected to rule on whether the family of Nancy Cruzan may remove the feeding tube that has kept the 32-year-old Missouri auto-accident victim alive, but in a vegetative state, for the past seven years. Already, many physicians accept the view that terminally ill patients should not be kept alive by technical interventions. But most experts draw a sharp distinction between artificially prolonging life and overtly helping to end it. "There's a world of difference between ceasing treatment and acts of deliberate killing," says Leon Kass, a medical ethicist at the University of Chicago. Most law-enforcement officials concur. Though suicide itself is not generally illegal, most states consider aiding and abetting the act to be a crime.

Even so, the idea of assisted suicide appears to be gaining public support. A recent Hemlock Society poll conducted by the Roper Organization found that 64 percent of Americans favor the concept of medically assisted suicide for the terminally ill. Membership in the society itself has doubled, to 33,000, in the past five years--in part due to the AIDS epidemic. More than half the lawyers questioned in a 1988 American Bar Association Journal survey thought giving lethal injections to terminal patients who request it should be legal. Increasingly, prestigious medical journals are debating the question.

What is not generally known is that for years some physicians have been quietly helping terminally ill patients to die. In some cases, doctors administer painkillers that may interfere with a patient's respiration--explaining to the patient and family alike that easing the pain may bring death sooner. In others, physicians provide pills and quietly warn patients that lethal overdoses are possible. "The doctor is not saying, 'I think you should do it'," says Alexander Capron, professor of law, medicine and public policy at the University of Southern California. "The doctor is providing information that the patient wants." No one knows how often deaths result from such cases. "It's hush-hush. It's also very difficult to detect," says medical ethicist Steven Miles of the University of Minnesota.

Most experts say that such acts are markedly different from creating a death machine and using it. What occurred in Kevorkian's van fell well outside the guidelines even most euthanasia advocates suggest--for example, that the patient make a written, witnessed request, that two physicians be present and that the setting be a clinic or home. "It's not death with dignity to have to travel 2,000 miles from home and die in the back of a camper," said Hemlock Society founder Derek Humphry. Some ethicists were also troubled that Kevorkian, as a pathologist, had scant experience with living patients. His long history of controversial views included advocating that death-row prisoners be rendered unconscious and used for medical experiments. "Physicians are not supposed to be exploiting patients for their own benefit, and that's what he did," says Capron.

Critical thinking: Was Adkins an appropriate patient? As an Alzheimer's victim, perhaps not. "Among the things that are lost first in Alzheimer's are insight and memory, both of which are critical to making this decision," said Miles. An anguished cancer victim who was still completely rational might have made a better candidate.

While Adkins was far from the typical aged suicide victim, the case also focused new attention on the rising rate of suicide among the elderly. Americans over 65 are nearly twice as likely to take their own lives as the rest of the population; since 1981 the rate has increased 25 percent. Even those figures probably far underestimate the true rate. Coroners rarely do autopsies on older victims; and the statistics fail to take into account more passive forms of suicide, such as refusing to eat or take medication. In a 1984 study of nursing-home residents, gerontologist Nancy Osgood of the Medical College of Virginia concluded that when such methods were considered, the suicide rate was eight times that of the general population.

What accounts for the rise? John L. McIntosh, an Indiana University suicide expert, speculates that publicity over Alzheimer's may be spreading "exaggerated fear" and hopelessness. Some older people worry that they will end up on respirators, powerless to determine their own treatment. "The interest in euthanasia is not surprising," says Daniel Callahan, director of the Hastings Center. "We've created this high-tech [genie]. Once it's started, we don't know how to turn it off." Some older people fear burdening their children; many suffer from depression. Curiously, older white men are four times more likely to kill themselves than the rest of the population. Osgood cites the "theory of relative deprivation": "White males have had more money, power and status, the best opportunities in jobs and incomes, so when they get old, they have the most to lose, " she explains.

Given the wide range of possible reasons, many authorities say that physicians should exercise extreme caution when patients talk of wanting to take their own lives. "Very often, when patients come in and talk about wanting to terminate their lives, there's something else they are trying to say," says Nancy W. Dickey of the American Medical Association, which officially opposes physician-assisted suicide. Patients may fear pain or being left alone--concerns that a doctor may be able to mollify. Yet many death-with-dignity advocates counter that an elderly person's decision is quite often rational and well considered. "We have to find some reasonable, safe, ethical way of helping people who feel 'trapped in life,' as my mother did " says author Betty Rollin. Rollin's 76-year-old mother was painfully ill with terminal cancer when Rollin helped her end her life with sleeping pills, and wrote a book, "Last Wish," about their experience. "When a dying person wants something," she says, "we can't say pious things about how they should want to live longer or want to suffer more or to be better sports."

Better care: Still, many ethicists argue that by condoning suicide, and sanctioning its assistance, society is abandoning its responsibility to improve conditions for the hopelessly ill and elderly. "The pressure should be on doctors and on society to provide appropriate and humane treatment, and care settings like hospices that can make life worth living for people," says Capron. Alas, says geriatrician Joanne Lynn, who operates a hospice at George Washington University, "it seems more appealing to have people dead than to provide more costly care, than to have them in good housing with good nursing care."

A movement is slowly building within the health-care system to concentrate less on technologies that prolong dying and more on making natural death more comfortable. In the meantime, though, the debate over hastening such ends still rages, and no one is more eager for guidelines than doctors themselves. "The medical profession is not capable on its own of handling these situations," says Dr. Robert Carton of Rush Presbyterian St. Luke's Medical Center in Chicago. "We've got to have some kind of societal consensus." That may be a long time coming, given the complexity of the issues. But if nothing else, Janet Adkins's death may serve one purpose: bringing the debate back into sharp if unsettling focus.

Suicides are increasing among people over 65.