ROYAL OAK, MICH. -- Surely some novelist's imagination conceived this man: the unemployed pathologist, his belongings tucked into three low-ceilinged rooms where the windows are boarded from outside and admit no light. He lives in these rooms, cooks in one, sleeps in one, fills the third with his papers and his correspondence and an old armchair draped in shapeless blue cloth. He keeps his files in a cardboard box on the floor. He sends his writings to be published, but American medical journals send them back: What can you possibly be thinking of, the editors say, we will not publish this.
In these manuscripts he rails at the medical profession around him. "Self-righteous obstinacy," he writes. "Essentially irrelevant ethical codes now sustained for the most part by vacuous sentimental reverence."
He argues that lives will be saved, and scientific research advanced, if condemned prisoners are allowed to request irreversible anesthesia for their executions so their undamaged organs can be donated and experiments performed. He argues that the terminally ill and the irrevocably suicidal have a right to ask doctors for help in planning their own deaths. He argues that the management of benevolent death belongs in the hands of a new kind of physician, and that these doctors deserve a specialist's name of their own: "obitiatrist."
A European journal publishes him, but in his own country he is publicly disdained by his peers. He works alone, shunned by hospitals because he will not be silent about his upsetting ideas. He lives on his savings. He visits flea markets, collecting toys he can take apart for their small gears. At his kitchen table he begins experimenting, here a gear, here a metal frame, here a syringe, and another syringe. When he is satisfied he invites the public to examine what he has made: I have created, the pathologist declares, a suicide machine.
With my machine, the pathologist says, a person can end his own life in dignity and comfort and the presence of a licensed physician. There will be no risk of swallowing too many pills and throwing up some of them and suffering brain damage. The pathologist explains his machine to reporters and television talk shows, and in Portland, Ore., a woman with Alzheimer's disease writes down his name; she is 53, and has resolved already that she will not allow the disease to progress until she is incompetent and unable to make decisions for herself. She will use the machine. Arrangements are made. The pathologist looks for a place to accommodate his patient, but he can find no suitable indoor site, so he drives to a Michigan county park and hooks up to an electrical outlet, and there in the back of his white Volkswagen van he runs intravenous lines into the arm of the woman who has come to kill herself.
He shows her the switch to push.
"Thank you," she says.
"Have a nice trip," he says.
Every time the debate about the ending of life begins to seem familiar in its drama and its pain, along comes some new public casualty to test the boundaries of modern medical ethics all over again. Jack Kevorkian says he does not mind it that headline writers and talk-show hosts like to call him Dr. Death; over the last six months, since Janet Adkins died in his van last June, Kevorkian has been ordered to civil court, as prosecutors asked that he be stopped from using his suicide machine again, and ordered to criminal court, as prosecutors asked that he be tried for first-degree murder. The courts approved the first request, although Kevorkian is still fighting it, and denied the second. The murder charge was dismissed. But there are a lot of headlines, and a lot of talk shows, and so a lot of Dr. Death. "People who are sympathetic to what I'm doing are offended by it, and I don't know why they are," he says. "I wish they wouldn't be." He says that a couple of years ago, he was with friends, after a talk show, when someone teased him by crying Here comes Dr. Death! "And we all roared with laughter," Kevorkian says. "You know what I mean? Funny. And little did we think that in two or three years it was going to stick on me from all over the world."
They pay attention to him in Italy, Kevorkian says, and in Australia, and across the United States. When he talks about death and what he did with Janet Adkins, people sit up, Kevorkian says, and begin to argue: Is there a clear moral line that he crossed? What is the job of a physician who truly wants to end his patient's suffering? Who decides what that job will be -- the patient, the physician or society at large?
What is the difference between a physician who declines to resuscitate a 90-year-old patient, and the physicians now monitoring the court-approved withdrawal of nutrition and water for comatose Nancy Cruzan, and the physician who watches a college English teacher push a switch that lets into her veins the drugs she knows will kill her?
"Every doctor has become very defensive about this, and, what's the word, apologetic -- and I'm not," Kevorkian says. He is in his tiny apartment above a flower shop in a suburb of Detroit. At 62, he has deep-set eyes and a thin-beaked nose, and a spare, energetic frame that makes his every move filled with purpose. "What I did was ethical. It was between a patient and a doctor. The trouble today with the profession directly, not individual doctors, is that it has confused sentiment with compassion. It has become maudlin, and less compassionate. The time has come for tough love, just like tough love with children -- the time has come for tough love with patients. And that's what I did with Janet Adkins. I loved that woman. And what I had to do was tough."
There is a videotape, played during Kevorkian's preliminary hearing in a Michigan courtroom, in which Janet Adkins and Jack Kevorkian talk in a Michigan motel room about what she has asked him to do. On the tape Adkins smiles, and chuckles from time to time; she is stocky, with round glasses and a red bowed blouse. Janet Adkins's husband Ron is on the tape too, wearing suspenders and a bow tie. The three of them sit on plain wooden chairs as they talk.
"Janet," Kevorkian asks, "are you aware of your decision, and the implications of your decision?"
"Yes," Janet Adkins says.
"What does it mean?" Kevorkian asks.
"That I can get out with dignity," Janet Adkins says.
"What are you asking for?" Kevorkian says. "Can you put it in plain words? What is it you want?"
"I would like to -- " Janet Adkins begins.
"Put it in simple English," Kevorkian says.
"Self-deliver," Adkins says.
"Simpler yet," Kevorkian says. "Simpler than that. Do you want to go on?"
"No," Adkins says. "I don't want to go on."
The Doctors' Shock Six months ago, just after the first newspaper reports that Janet Adkins had died of an intravenous drug overdose in the back of Jack Kevorkian's van, the New York-based biweekly Medical Tribune ran a harshly critical editorial and front-page article about the specter of a licensed physician openly helping a patient commit suicide. Washington, D.C., internist Charles Duvall was one of the physicians quoted high in the article: "Doctors are good people, but they're not God," Duvall said. "When they start debating life and death, they're out of their league."
At the end of the article the Tribune asked physicians to call in with their thoughts on physician-assisted suicide. "We got unbelieveable letters," says Tribune editor William Ingram. "We got letters revealing that doctors themselves, who were anonymous, had been involved in these things. We got letters that went to great lengths and took religious themes, letters that revealed a lot of doubt in doctors' minds about when and how they should be doing this. And if you'll look at the bylaws of the Judicial Council for the AMA, you'll see that it is very confusing, because doctors are under a social contract to keep people alive, and at the same time to remit suffering. Try that little Solomonic thing."
In the end about 250 physicians took up the Tribune's invitation to make their feelings known, and of those, Ingram says, about 45 percent approved of what Kevorkian did. That percentage startled Ingram, he says, particularly when even some of the disapproving appended their views. "Like the Michigan doctor who said, 'I disapprove of what he did,' but added, 'When I get a little older I'll probably be calling on Dr. Kevorkian,' " Ingram says. "A lot of doctors wrote me to say, 'Why are you shocked? You just don't understand.' So I was shocked all over again."
Legal briefs and doctors' records have debated for some years now the complicated evolution of what has been come to be known as the "right to die."
The parents of Nancy Cruzan, seven years into their battle to have their 33-year-old daughter unhooked from the feeding apparatus that had sustained her after an automobile accident left her comatose, persuaded a Missouri judge last week that their daughter had once insisted she wanted no such life support measures should she ever be irreversibly incapacitated. This, courts have found, is something much of society will approve -- physicians may, with a patient's advance directive to do so, disconnect the equipment that is keeping the patient alive.
"Passive euthanasia" is the term doctors and ethicists sometimes use for this process, and everything hinges on the notion of passivity, of human beings standing by while a life is claimed by illness, or nature, or God. It is a comforting term, suggesting some clear separation from euthanasia that is "active," but every physician who works with the terminally ill has encountered the cloudy area between the two. A cancer patient lies near death, sedated by morphine out of consciousness and pain; the doctor gives him more morphine, and then a little more, knowing as he does it that the medication itself may end the patient's life.
Even James Bopp, an Indiana lawyer who serves as general counsel for the National Right to Life Committee, says he can see no real ethical problem with that -- as long as the doctor is not trying to put his patient to death under the guise of pain relief. But the passage into moral uncertainty is already underway. What if the patient is near death, and in pain, and conscious enough to ask for the lethal dose of sedative? What if the patient is near death, and moderately comfortable, but wants to skip the last grim weeks and get the lethal dose now? And what if the patient is not near death now, but is facing instead a decade of irreversible brain damage that will leave her body intact but kill off her mind?
'Self-Deliverance' "Self-deliver" was the phrase Janet Adkins used, when Kevorkian asked her on the videotape what she wanted from him. The term comes from the literature of the Oregon-based National Hemlock Society, which for the last 10 years has been arguing publicly that this country, like the Netherlands, ought to accept the idea that physicians can help terminally ill patients die at a time and place of the patients' own choosing -- "with dignity," as the Hemlock followers say. That Janet Adkins agreed with Hemlock's views has never been in dispute; both she and her husband had joined the Hemlock Society before doctors discovered she had Alzheimer's.
"One of our sons, who likes to cook, was going through Janet's recipe card box in the kitchen, and he happened to come across this card with a series of drugs that one could use to ... exit," says Janet Adkins's husband Ronald, a Portland investment broker. "That was maybe 10 years ago. I don't know whether she had gotten them from the Hemlock Society or from some of the books she had read. ... We had discussed for a number of years the concept of the right of a person, if they were terminally ill and the quality of their life was slipping away, to deliver themselves."
Derek Humphry, who founded Hemlock after helping his own wife commit suicide as she was dying of cancer, has argued that doctors should be permitted to contribute their expertise in medicine and drug dosage to this "self-deliverance." That is widely perceived to be illegal now; if the doctor deliberately administers the lethal dose himself, he is subject to prosecution for homicide, and about half the American states have laws on the books explicitly making it a crime to aid and abet a suicide. "It's a crime to assist something that's not a crime," Humphry says. "Suicide is not a crime in Western society."
But even Hemlock-supported legislative suggestions, like the "death with dignity" initiative now collecting signatures in Washington state, propose that physician-aided death be available only to terminally ill people diagnosed to be within six months of death. Janet Adkins, who had beaten her 33-year-old son at tennis two weeks before she died, plainly faced far more than six months of physical health. She left a letter and a videotape and a family convinced that her death came about just as she had wished it to, but what happened in the now-famous Volkswagen van appalled many physicians and ethicists who read the details afterward: There is a slippery slope, they declared, and Jack Kevorkian is already halfway down.
"I think Kevorkian basically did the equivalent of pointing the gun," says Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota. "The only thing he failed to do was literally pull the trigger."
"The AMA feels that a physician's obligation is to do all he or she can to return a patient to health, or to relieve suffering, and that a physician should not take a patient's life," says Texas family practitioner Nancy Dickey, former chairman of the AMA council on ethical and judicial affairs. "I think if a patient feels strongly about taking their own life, it's an entirely different issue than whether or not physicians could participate. There are actually publications that tell a patient what medications to take, and what combinations, and where to buy the medications. You don't need a medical degree to do that."
"It's a Pandora's box," says Hospice of Southeastern Michigan medical director John Finn, who works full-time with the terminally ill. "Any depressed person could just start standing in line for any reason whatsoever and get themselves done in. 'I'm getting divorced.' 'I'm claiming bankruptcy.' 'My plans didn't materialize.' So I'm going to Dr. Kevorkian and have it done professionally."
Finn is an ardent advocate of patients' rights to refuse lifesaving medical treatment; he played a role last year in the death of David Rivlin, a Michigan quadriplegic who won a court order authorizing doctors to turn off the respirator that kept him alive. "As I make house calls and encounter patients in nursing homes and hospitals, I'm fairly regularly asked if I could do something to put someone out of their misery," Finn says. "But I find that when you spend more time with the patient, you relieve pain and other physically distressing symptoms, and you address some of their financial, emotional, interpersonal and even spiritual concerns -- that patients aren't quite sure anymore that they want their lives extinguished."
Neither medicine nor society is ready for physicians to assume the executioner's role, Finn argues, even if that execution is carried out for the kindest of reasons and at the request of the person about to die. "Once you make the decision that some lives are not worth living, and Dr. Kevorkian becomes the man who makes that decision, then he is the most dangerous man in our society," says Richard Thompson, the prosecutor who filed the murder charges against Kevorkian.
Michigan has no explicit law on aiding suicide, but Thompson based his murder charge on a 1920 state supreme court ruling that upheld a murder conviction for a man who mixed the poison later drunk by his wife, who suffered from multiple sclerosis. Kevorkian's attorney argued that the 1920 ruling had been discredited by a later state Court of Appeals case, and even after a Michigan judge agreed, Thompson insisted that Michigan ought not to be seen as some gathering place for people who want to kill themselves with help.
"I think the judge was wrong," Thompson says. "Until the legislature acts, we will still look at each case to see if those facts require us to initiate a charge. ... We've already received indication from the legislature that they will be addressing the issue of assisted suicide, and some legislation making it illegal will be adopted within two to six months."
The idea that others might study Janet Adkins's death and buy their airline tickets for Michigan is not entirely far-fetched; last August, two months after Adkins died, a California couple, Ginger and Robert Harper, flew to Michigan so that Ginger Harper, who was 69, could check into a Detroit motel and kill herself. Robert Harper says his wife had inoperable cancer, and that the pain had begun making it difficult for her even to roll over in bed. A Hemlock Society book told them that Michigan had no laws against assisting suicide, Harper says, so when his wife was dead -- she took sleeping pills, he says, and then placed a plastic bag over her head -- he called the police.
"Then the roof fell in on us," Harper says. He was charged with murder, based in part on what prosecutors have said is Harper's statement that he placed the bag over his wife's head himself. A hearing is scheduled today in Harper's case, and he says has no regrets about the way his wife died. "I strongly believe that Kevorkian and me and our problems have done a great deal to bring this to the attention of people," Harper says. "If Ginger knew what was going to happen, she would have been the first one to say, 'Go public, and fight this thing, and help somebody else.' "
Weird, but Honest Right cause, wrong person: Jack Kevorkian has heard this said before, and sometimes by people he knows are sympathetic. He is an affront. He cannot hold a hospital job. He thinks too much about death. Some of his ideas alarm people. He wants to use his little machine. Even as a young pathologist in Michigan he made paintings that stirred people to unpleasant emotions: There was a painting called "Nausea," and one called "Coma," and one that was dedicated to the subject of genocide.
Kevorkian painted the genocide frame in human blood, which he got from the blood bank's outdated samples and his own arm. "There's a British helmet full of white crosses and stars of David, like a side dish, know what I mean?" Kevorkian says. "And then there's an inverted German helmet filled with machine-gun bullets, like another side dish. And on the right, two little bombs on end, like salt and pepper shakers, and a flat metal dish in front of the body, it looks like steel, and on the dish is the person's own head... ." Kevorkian stops and says he suspects this is going to sound weird, in print. He is told that he is right, and he smiles. "Could you pass that up if you walked past it?" he demands. "It's honest. Every one of those paintings is honest. And if you're honest nowadays, you come out kind of weird. You've got to sugar-coat everything. ... That's why I'm unemployed. There's too many doctors, and when you're as controversial as I am, and you've bounced around long enough, you're just not in demand anymore."
Kevorkian says all he does is say things that other doctors are afraid to say. "I'm not obsessed with death, you know," he says. "This just happens to be a field of research that interests me. How can you be obsessed with death when you want to take organs from death row prisoners to save living human beings? It's with life that I'm obsessed. What an ironic twist of fate -- a living human being who craves euthanasia, needs it, wants it, could donate two kidneys to two babies who are at the point of death? Instead of a quick euthanasia, you do a prolonged euthanasia. It's worth it. You're going to save four or five human beings, including two babies. It's worth it."
Kevorkian leans forward on the chair in his little living room, his face intent. "I'm so common-sense and rational about this that it offends people," he says. "There's no argument against it except emotions. I'm trying to allow a transfer between life and death -- from life that's going to be death. Wrest it back from death. That's my point."
Pathology first drew Kevorkian not because it often involves work with the dead, he says, but because the specialty is the study of disease. "Covered the whole field," he says. "I'm not that different from anybody else. I enjoy joking around, kidding around. I played poker the other night with friends, and we were all laughing. It's just that I have this curiosity, and the motivation, to dig into things that are called taboo, or somewhat borderline. But they're not immoral or unethical."
Kevorkian once approached Derek Humphry of the Hemlock Society with a proposal for suicide centers in which specially trained doctors, obitiatrists, would preside over the euthanasia of the terminally ill or anybody else irrevocably committed to ending his own life. Humphry said the Hemlock Society was uninterested, but Kevorkian says he still believes it is part of medicine's responsibility to help manage the ending of human life.
"Certain specified individuals, screened thoroughly, and trained thoroughly, and always under scrutiny," he says. "No fee charged."
Why doctors? "That's like saying, 'We don't need doctors for birth, we've got midwives,' " Kevorkian says. "Why one extreme and not the other? Simply because it's taboo. Doctors are the experts of health, disease, life and death. That's all you need to know. It's disagreeable. I said that on the tape with Janet Adkins. I don't like doing this."
The state of Michigan has not finished its legal business with Jack Kevorkian; the civil injunction imposed after Janet Adkins's death prohibits him from using his suicide machine on any other patient. The machine itself now stands in the evidence room of a police station in Pontiac, but Kevorkian says the courts need not have bothered with that formality; he does not intend to offer his services to anybody else, he says, until the legislature and the medical profession address this dilemma as vigorously as Kevorkian believes they must.