When he connected a woman with Alzheimer's disease to his macabre "suicide machine" this week, a Michigan doctor made himself an outcast in the medical community, but by providing a convenient -- if crude -- symbol for the right to die he may have accomplished all he had hoped for.
Few issues in medicine are more controversial or difficult to resolve. In the past 20 years, as technology has helped doctors prolong lives they cannot hope to improve, many physicians have struggled with the question of when, or whether, helping a patient to die is acceptable.
"It's really very difficult to watch vigorous people waste away and not reach the conclusion that there comes a time when they have the right to a peaceful death," said Donald Abrams, deputy director of the AIDS program at San Francisco General Hospital. "I think most of my colleagues believe there is a time when enough is enough."
Abrams and many other physicians who treat terminally ill patients say they would not purposely kill anyone, because it is against the law. But they also say that increasingly doctors will agree to supply a lethal amount of pain medication to dying patients.
"I have had occasion to give a patient pain medication we both knew would shorten her life," said Christine Cassell, professor of medicine at the University of Chicago Medical Center. "There are times when it is perfectly appropriate for doctors to help people die. So many of the people I see are desperately afraid of losing control over their lives. Nobody wants to become incompetent or die on a machine."
But like most of her colleagues, Cassell condemned Jack Kevorkian, the publicity-minded inventor of the device Elaine Adkins, a Portland, Ore., housewife, used to kill herself. "Is it really okay to kill someone you have known for a half an hour?" she asked. "What if she was misdiagnosed? She could have had many years of productive life left. What he did really cannot be condoned."
But Adkins's death has stirred deep emotions. Michigan prosecutors said they would seek a court injunction today to bar further use of Kevorkian's machine until the legal ramifications are sorted out. Officials trying to subpoena him for a hearing reported he could not be found.
Not everyone disapproves of what he did. In polls, most Americans support the right to die. And many make no distinction between passive euthanasia -- such as turning off life support machines, and active euthanasia, when a doctor gives a drug that kills a patient.
Some have likened the suicide to abortions performed in back alleys before they were made legal by the Supreme Court in 1973. They say the device Kevorkian invented, which allowed Adkins to push a button and inject herself with the drugs thiopental and potassium chloride, serves as a fitting symbol of frustration at technological fixes that have bankrupted and imprisoned the seriously ill even as they have prolonged their lives.
"The more you talk to people, the clearer it becomes that there is serious concern in this country about how we die," said Alexander Capron, professor of law and medicine at the University of Southern California, who a decade ago led a presidential panel that attempted to form guidelines on withdrawing life-sustaining equipment. "Medicine needs to respond much more clearly to the extended, frightening and expensive process of death."
That has proved very hard to do. Euthanasia is illegal in the United States, although many leading medical experts have said openly it is time to discuss it more seriously.
The American Medical Association has strongly supported passive euthanasia -- removing medical treatment from dying patients or those thought to have no chance of emerging from comas.
This month, the Supreme Court is expected to set the nation's legal course on the issue of passive euthanasia when it decides whether the parents of Nancy Cruzan, a comatose Missouri woman, have the right to withdraw the feeding tubes that keep her alive.
There are many who argue that however legitimate any individual's desire to die, a legal right to physician-assisted suicide would make it possible for thousands of people -- or more -- to be killed simply because they no longer serve a useful function in society, or because they have become a financial burden to their families.
"This is a slope that is steep and slippery, and it doesn't have any logical place to stop," said James Bopp Jr., general counsel to the National Right to Live Committee. "You cannot accept the quality of life as a standard. First you withdraw the respirators, then the food and then you actively kill people. It's a straight line from one place to the others."
Even many of those who argue strongly that patients should have a right to die -- and that physicians ought to help them at times -- agree that it can never be easy to determine when a person really no longer wants to live. There are many diseases for which the treatment is often excruciating -- chemotherapy for testicular cancer, for example -- but highly successful.
"You can often find patients saying, 'Stop that treatment, it's too painful," said Arthur L. Caplan,
director of the center for biomedical ethics at the University of Minnesota. "But should we really? Should we really just stop the chemo and let them die when we can be almost certain the drugs will cure them?
"There is a tendency to do what patients want when possible," he continued. "But you can't make those decisions in duress, or in an hour or two. This is not an easy problem to solve, and Dr. Kevorkian really didn't do anything to help solve it."