by Cina, Joshua A. Perper, Stephen J. ; Cina, Joshua A. Perper, Stephen J.
Undeterred, he continued to perform his medicides by providing his clients lethal carbon monoxide gas. A mounting debate was brewing: when does assisted suicide cross the line and become homicide?
On August 17, 1993 after helping 20 people to end their lives he was formally charged with violating Michigan law. He was jailed twice, first in November 1993 and then a month later. After his incarceration, Kevorkian went on a liquid-only hunger strike for 18 days and was released from prison in May 1994. By this time, he had gained a number of supporters in the general community and had obtained significant media exposure. Between 1990 and 1998, he carried out approximately 100 medicides.
The relatives of some of his patients claimed that he had continued his procedures even after some of his victims had asked him to stop. Further, at least one of his patients had no significant or life-threatening pathological findings at autopsy and may have suffered from a mental or psychological disease. Even if you support the concept of physician-assisted suicide, this is not the type of patient suitable for this procedure.
During the 1990s Kevorkian dubbed himself a “death consultant” and continued his activities while successfully publicizing the issues of assisted suicide and euthanasia through TV talk shows and other media outlets. His “medical” exploits resulted in national and international notoriety. Kevorkian was even featured on the cover of Time magazine in 1993. Over the course of his consulting career Dr. Kevorkian became increasingly bold. He taunted the local Medical Examiner after several medicides and in some cases dropped the bodies (literally) at the Medical Examiner’s Office. “Dr.
Death”, as he widely became known, conducted an aggressive publicity campaign for the legal recognition of assisted suicides. His continuous struggle was punctuated by intermittent prosecutions by the local State Attorney and short imprisonment terms.
Kevorkian was tried three times for manslaughter or murder but was found not guilty each time because the final act triggering death was done by the victim and not by him (or at least no one had seen him push the plunger on the syringes). Also there was no specific Michigan law prohibiting assisted suicide.
Apparently, those failures of the State prosecution emboldened Kevorkian to further defy the authorities and under the light of television cameras, he publicly performed the medicide of Thomas Youk, a 52 year-old man with terminal Lou Gehrig disease. On the videotape, Kevorkian challenged the authorities to convict him or to make him stop assisting suicides. The gruesome show was broadcast the following month in November 1998 on the CBS television program Sixty Minutes.
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This time, however, Kevorkian had administered the fatal injection of potassium chloride himself. As this action clearly crossed the line from assisted suicide into illegal voluntary euthanasia, he was successfully prosecuted in 1999 for murder and the illegal delivery of a controlled substance. He was found guilty of second-degree homicide and sentenced to 15–25 years of prison.
Kevorkian, in failing health, was granted parole in late 2006 and released in 2007 after promising not to perform any additional procedures. After his release from prison, he moved to the Detroit suburbs and in 2008 announced his intention to run for a seat in the U.S. House of Representatives. He received 2.6% of the vote.
On January 15, 2008, Kevorkian gave his largest public lecture since his parole speaking to a crowd of nearly 5,000 people at the University of Florida. The St. Petersburg Times reported that Kevorkian expressed strong support for physician-assisted suicide and voluntary euthanasia for willing patients. In explaining his own involvement, Kevorkian said “My aim in helping the patient was not to cause death, I mean that’s crazy,” the paper quoted him, “My aim was to end the suffering.” He concluded stating “I am a physician. I knew how to do it … I did it humanely.” He is still lecturing though his focus has shifted to tyranny in America.
In February 2009 he ended his speech at Nova Southeastern University by displaying an American flag with a swastika replacing the field of stars. He has apparently stopped killing people and helping people to kill themselves. As far as we know.
Legal Assisted-Suicide
In 1994 Oregon became the first state in the Union to legalize physician-assisted suicide when 51% of the voters supported the Death with Dignity Act. The Act became effective in 1997 after several legal maneuvers aimed at its repeal failed.
In 1999 there were only 27 applications for permits to commit assisted-suicide; by 2006 this number had increased to 46 in and to 49 in 2007. The voters of Washington State have approved the enactment of a similar law which became effective in March 2009. Both laws, in effect, actually authorize physician-enabled suicide rather than the type of aggressive assistance offered by Dr. Kevorkian. In these states doctors may legally prescribe lethal doses of medications to terminally ill patients. Physicians are not compelled to enable a patient’s suicide, however, if it conflicts with their religious, ethical or personal beliefs. These laws specify in great detail when assisted-suicide is permissible and the state closely monitors practitioners to make sure this practice doesn’t get out of hand.
“Excursional” Suicide
A company by the name of Dignitas legally helps gravely ill foreign nationals to commit suicide in Switzerland where this type of assistance is permissible (provided that the doctor is not killing the patient out of his own self-interest).
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Dignitas’ clients fly to Zurich where they are examined by a doctor to confirm their terminal illness and certify a sound state of mind. Patients eligible for assisted-suicide include those with cancer, quadriplegia, multiple sclerosis, and severe mental illnesses such as incurable bipolar disorder and schitzophrenia. Many patients are evaluated at Dignitas as a precaution; they want to have a means to end their suffering should it become intolerable. In fact, 70% of the visitors to Dignitas never are “treated” at the facility. If the patient decides that Dignitas offers them a viable solution to their problem, they are provided an apartment and a glass of water or juice containing sodium pentobarbital, a powerful sedative. After drinking the mixture, the patient becomes sleepy, falls into a coma, and dies of respiratory arrest in about 30 minutes.
In 2008, Dignitas assisted in the performance of 840 suicides at a charge of about $6,000 per case. For an extra couple of thousand dollars, the company would handle all funeral arrangements and registration fees. The clients predominantly came from Germany, Switzerland, and Britain but many other countries were represented. Although this company appears to be providing a service which is sought after and which people are willing to pay for (Capitalism 101) a number of former employees quit the company over ethical concerns. Some have even suggested that the corporation is simply a death mill existing solely to make a profit. Although the conservative Swiss politicians have recently proposed laws to regulate “suicide tourism” to date none of these laws have been enacted and it is business as usual at Dignitas. This lucrative business gives new meaning to the term “dying for a vacation.”
Euthanasia
Euthanasia (“Good death” in Greek from “eu” meaning good and “thanatos”
meaning death) is an action by a doctor, with presumed benevolent intentions, which causes the death of a patient having a terminal or irreversibly painful condition or who is in a state of hopeless and irreversible coma. Most cases of euthanasia are of a voluntary nature; other chapters in this book address the more nefarious
“involuntary euthanasia” imposed upon groups of people who are considered
“unfit to live” for eugenic reasons. The difference between assisted suicide and euthanasia is that the patient is not an active participant in euthanasia, except perhaps for expressing a wish to end his or her life. Voluntary euthanasia is performed by a doctor at the request of a conscious and mentally competent adult patient or at the behest of the legal next-of-kin if the patient cannot communicate
his or her wishes. It amounts to what could be defined as “suicide by proxy.” Dr. Kevorkian went to prison for an extended period of time when he crossed the line between physician-assisted suicide and voluntary euthanasia.
Euthanasia may be classified by the role or activity of the involved physician into active euthanasia and passive euthanasia. Active euthanasia most often occurs when a doctor directly causes the death of a patient by injecting fatal doses of a 166
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substance into the person. Passive euthanasia occurs when the doctor abstains from providing the patient with life saving medications, the administration of food and liquids, or from providing cardiopulmonary resuscitation. The latter situation is extremely common. Today patients can preemptively issue directives to their healthcare providers to refrain from starting resuscitation in the event that a cardiac arrest occurs (a “DNR” – do not resuscitate order). Patients can also restrict doctors from employing extraordinary means of keeping them alive in the setting of severe, irreversible injuries or terminal disease. Such directives can be accomplished either by drafting a Living Will, a formal declaration recognized by law, or upon admission to many hospitals. Other people choose to draft a Durable Power of Attorney for Health Care that assigns someone else the power to make health care decisions if the patient becomes unable to do so. This power should be delegated to someone who likes you. This representative can then tell the doctor what he or she can and cannot do to save or prolong the patient’s life. Failure to respect the choices made by the patient or designee can result in civil actions and even criminal charges.
A doctor may participate in active euthanasia based on personal beliefs, humanitarian feelings, or for professional reasons. Regardless of the motivation, the physician has performed a felonious act in most countries, including the United States, and may be prosecuted for murder. Despite these serious charges, the Courts have been lenient with most physicians accused of voluntary euthanasia. Less than two dozen doctors have been prosecuted in the United States and the convicted doctors have usually received light sentences. The only notable exception was Dr.
Kevorkian’s stiff sentence but his crime was the culmination of a pattern of behavior, not a sporadic event. Furthermore, in spite of his crystal clear premeditation and public display of intentionality, “Dr. Death” was only convicted of second degree manslaughter and not of murder and served only a relatively short, 8-year sentence. The reason for this consistent and unusual leniency of American juries and Courts is the pervasive belief that when voluntary euthanasia is committed with the clear consent or at the request of a terminal patient for credible humanitarian reasons, there is little or no moral blame attached to the act. To frame it in religious terms, although the law may have been broken no sin was committed.
A case in point is the prosecution of Dr. Peter Rosier in 1986. Dr. Rosier, a prominent physician in Fort Meyers, Florida, was indicted by a Lee County Grand Jury for the first degree murder of his 43 year-old wife Patricia, a capital offense.
Patricia had been diagnosed with lung cancer in 1985 and by 1986 the cancer had spread to her brain. Assuming that he would not be prosecuted for obeying his wife’s final wish, Dr. Rosier freely and publicly admitted that he had given his wife a lethal injection at her request in order to relieve her suffering. Rosier also described his actions in great detail in the manuscript of a book he was writing about the incident. By the time his confession caught public notice, the body had long been cremated with a death certificate listing the cause of death as cancer.
The local media quickly branded Dr. Rosier a “wife killer” and accused him of trying to draw interest to his intended book by bragging about his crime. The media coverage became so intense and excessive that the Court moved the trial up the Florida coast Karen and Terri
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to St. Petersburg in order to find unbiased jurors. The prosecution’s case was based on Dr. Rosier’s televised confession, a confession to a reporter, accounts of the murder in the manuscript, a friend’s testimony, and the testimony of Patricia’s family members who were understandably upset with Rosier. The case was presented and the jury deliberated for only 3 hours prior to finding the defendant not guilty on all counts. The Court erupted in pandemonium when the verdict was read,
“bedlam” according to the official transcript. If the prosecution could not prevail in this airtight case, how can it ever expect to win in trials in which the facts are not so clear cut?
There is another common medical practice that may also constitute a form of voluntary euthanasia, namely the administration of excessive medications to keep a dying patient comfortable. When a patient or family has requested “comfort care only” or “comfort measures” physicians will prescribe high doses of pain killers and sedatives which will be administered over a fairly short time interval. The patient’s goal is met-there is no suffering-but death is an acceptable “side effect”
of this treatment plan. These cases cannot be definitively identified as voluntary euthanasia for two main reasons. First, it cannot be proven that the intention of the physician was to end the patient’s life rather than to ease suffering. Second, because of the phenomenon of drug tolerance patients receiving chronic pain medications can withstand very high doses of painkillers that would be lethal to most people. Even in the setting of fatal drug levels in these patients, death will likely be attributed to the underlying disease process or injury that necessitated the administration of the drugs in the first place. In truth, these doctors are acting in accordance with the Hippocratic Oath in that they relieve suffering. In contrast, physicians who assist in suicides or practice active euthanasia are violating the principle of “above all do no harm.”
Karen and Terri
The deaths of Karen Ann Quinlan and Terri Schiavo illustrate vividly the conflicts inherent in discontinuing life support and the involvement of outside parties in the fray. They also serve to point out the variety of roles that physicians may play in these controversial cases. In the Quinlan case, expert medical opinions helped to clarify her diagnosis. Doctors ultimately hastened her death by first removing her from a ventilator and, years later, removing her feeding tube. The Schiavo case was even more explosive. In this case, physicians offered medical opinions which may have been partially or wholly politically motivated. While some doctors strove to meet her husband’s wishes and discontinued the means by which she could continue to “live”, other caregivers violated Terri’s rights and body by forcing her to undergo invasive procedures that her legal guardian had adamantly refused. These two cases brought up issues in medical ethics that have not yet been resolved and likely never will be. As long as physicians continue to act like other humans, with their own emotions, biases, religious beliefs, and personal philosophies, there will 168
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be doctors sitting on both sides of the fence. For some, respect for the patient’s wishes will be paramount; for others, the sacred nature of life itself will win out.
Karen Ann Quinlan
On April 15, 1975, 21 year-old Karen Ann Quinlan collapsed for unknown reasons at a party apparently after consuming alcohol and drugs. She stopped breathing at least two times each lasting about 15 minutes. She was brought unconscious to a hospital emergency room where she slipped into coma. After her condition stabilized, she had to be fed through a nasogastric tube and breathing required a respirator. She was diagnosed as being in a permanent vegetative state (i.e. having irreversible brain injury). Tests showed that she had no awareness of anything or anyone around her.
Her movements were limited to those at a primitive reflex level with some brain stem functions such as involuntary chewing motions, disjointed movements of the extremities, blinking of the eyes, grimacing, and making stereotypical cries and moans. As time progressed she became severely emaciated having lost at least 40 pounds and was contorted into a disto
rted fetal posture. Karen’s father requested to be her Court appointed guardian for the express purpose of authorizing removal of her respirator. He was opposed not only by Karen’s physicians who wished to prolong her life but by the local Prosecutor and the State Attorney General.
Quinlan’s physician argued that, in his opinion, Karen was not brain dead and that both medical standards and ethics required him to continue treating her by all means available. The government also intervened, arguing that the state’s interest in protecting the sanctity of life must be protected and that removing her from a ventilator was tantamount to criminal homicide.
The New Jersey trial court denied Mr. Quinlan’s request for guardianship and also rejected his request to terminate the use of the respirator, deciding that medical decisions pertaining to Karen rested solely with the attending physicians. The Court also discounted the argument that there is a legitimate legal distinction between ordinary and extraordinary means to sustain life. In 1976, however, the New Jersey Supreme Court reversed the decision and granted Mr. Quinlan’s request. The New Jersey Supreme Court’s ruling was based on Karen Quinlan’s right to privacy, protected by the Constitution, which was violated when her physician and the hospital refused to remove the respirator. Although the Court recognized that the state had an interest in preserving life, it found that “the individual’s right to privacy grows as the degree of bodily invasion increases and the prognosis dims.” The Court also dismissed the idea that the medical profession was required to use all means at its disposal to keep patients alive. Rather, the “focal point of the decision [to terminate treatment] was whether the patient would return to a ‘cognitive and sapient life’ or remain in a ‘biological vegetative existence.’”
Following this ruling, Karen Ann’s father had the option to remove her from life support. According to the Court, Quinlan’s right to privacy would be rendered Terri Schiavo