Michigan versus Kevorkian

Our personal reflections on the Michigan versus Kevorkian trial highlight the following issues: 1) the switch from physician-assisted suicide to euthanasia, 2) the television showing of the death, 3) the dropping of the prosecution of the charge of physician-assisted suicide, 4) Kevorkian serving as his own defense attorney, trying to argue that ALS was a secondary cause of Thomas Youk's death, 5) Kevorkian's attempt to employ a logical syllogism to demonstrate that euthanasia need not be murder, 6) Kevorkian's initial reference to the civil rights tradition but sudden change to the medical analogy of Nazi medicine: a final solution, 7) the insistence of Kevorkian on "all or nothing" sentencing, 8) the irony of Kevorkian being finally convicted by a prosecutor who was elected on a platform of not prosecuting Kevorkian, 9) Kevorkian hiring a lawyer after the verdict is in, and 10) Kevorkian's threat to starve himself to death if sent to prison.     

Who decides? The connecting thread of euthanasia,eugenics, and doctor-assisted suicide

Throughout recorded history, a series of seemingly unrelated ideas have been consistently intertwined: suicide, euthanasia, infanticide, eugenics, genocide and, most recently, the practice termed physician-assisted suicide. From Plato and Hippocrates to a pair of twentieth-century American physicians named Haiselden and Kevorkian, an examination of history shows these disparate notions always involve two troublesome questions: Which lives are not worth living? And who will decide? The same examination of history teaches that separating the worthy from the not worthy is a very dangerous proposition, especially for those whose lives are deemed marginal.     

Assisted suicide: factors affecting public attitudes

Public support for assisted suicide has been growing despite the ethical questions raised by members of the medical profession. Previous research suggests that age, gender, experience, and religiosity are factors affecting individuals' attitudes. This study examines the effect of demographic and ideological factors, as well as individuals' caregiving experiences, on attitudes toward assisted suicide. Random-digit-dialing procedures produced a sample of 156 residents of Denton, Texas, in March 1998. T-tests were conducted to measure significance, while gamma values were used to measure level of association and percent reduction in error. The data indicate that age, gender, and caregiving experience were not significant predictors of attitudes. Situational factors, including whether a physician or friend/family member should assist and whether a child or a terminally ill patient experiencing no pain should receive assistance, all were highly significant and positively associated with attitudes toward assisted suicide. Respondents were most likely to support physician-assisted suicide for individuals experiencing no pain. The data also indicated that the depth of commitment to the beliefs that suffering has meaning, that life belongs to God, and that physician-assisted suicide is murder, were highly significant and negatively associated with attitudes toward assisted suicide.     

Predictors of attitudes towards physician-assisted suicide

Psychological factors may influence an individual's acceptance of euthanasia and physician-assisted suicide (PAS). The purpose of the present investigation was to evaluate predictors of attitudes towards PAS. Data were collected from 136 college students at a private Midwestern university. In addition to demographic and family history information, respondents completed measures of attitudes toward seeking mental health services, depression, hopelessness, and PAS attitudes. Respondent age, race, and hopelessness scores emerged as the only significant predictors (R2=.20) in a multiple regression model used to identify potential predictors of PAS attitudes. Younger, non-minority respondents, and those enduring more hopelessness reported more accepting attitudes towards PAS. Data from a three month follow-up assessment supported the stability of this pattern. The findings highlight the important role that mental health professionals should play in PAS decision making. Implications for the evaluation of medically ill considering PAS and their caregivers are discussed.     

Potential psychodynamic factors in physician-assisted suicide

A number of assumptions underlying the debate over physician-assisted suicide (PAS) deserve closer scrutiny. It is often implicitly assumed that decisions as to the competency of the patient to request PAS can be accurately made, and that the treating physician's values and intrapsychic conflicts can be successfully separated from the decision to accede to or reject the patient's request. This article argues that in such an emotionally-laden decision, such factors may play a significant role, and that even were PAS to gain widespread acceptance, ignoring them may lead to errors in classifying patients either as appropriate or inappropriate for PAS.     

An update on the Kevorkian-Reding 93 physician-assisted deaths in Michigan: is Kevorkian a savior,serial-killer or suicidal martyr?

This report presents an update of the Kevorkian-Reding physician-assisted (or physician-aided) deaths to include the ninety-three publicly acknowledged cases as of November 25, 1998. These deaths are divided into ten distinct time phases. The following trends emerge. Over two-thirds of the decedents are women, the ratio of females to males varying widely with phase. The proportion of women seems to be the highest when Kevorkian is free to act as he wants and lowest when he seems to be acting under legal or political restraints. Based on autopsy results, only 29.0 percent of the cases are terminal, this percentage being higher among men (37.9%) than among women (25.4%). However, 66.7% of the decedents were disabled, no significant difference emerging between men and women. Further, five out of the six decedents showing no apparent anatomical sign of disease at autopsy were women. Over 80 percent of the physician-assisted deaths are cremated, approximately twice as high a proportion as that emerging for suicides in Michigan and four times as high as cremations occurring with regard to overall deaths. Finally, death by carbon monoxide decreases dramatically with time phase while the use of the contraption dubbed the "suicide machine" increases, suggesting an increasing routinization over time. Finally, during the ninth and tenth phases, Kevorkian's aims and his own suicidality emerge more clearly involving 1) harvesting organs and 2) threat of starving himself in prison if he is convicted. Phase 10 can be seen as an escalation from assisted death to overt euthanasia, repeating the same need for a demonstration (Thomas Youk) that was first exhibited in Phase I (Janet Adkins).     

Kevorkian,Martha Wichorek and us: a personal account

In this short article, the authors describe their attempt to do suicide-prevention with a patient that ultimately died as the result of a physician-assisted suicide. Autopsy revealed no sign of physical disease but the patient's letters indicate a preoccupation with independence as the definition of life, and conviction that people who lose independence are no longer alive.     

Effect of the doctor on college students' attitudes toward physician-assisted suicide

Ninety-six students were presented with eighteen different vignettes describing different types of active and passive observed suicide, assisted suicide, and euthanasia. Attitudes regarding the morality and desired legality of each situation were measured. Results indicated that the interaction between the doctor and the patient, and, to a lesser extent, the active or passive nature of the agent of death, were more important than the actual actions of the doctor in allowing or causing death to occur.     

Dispensing death,desiring death: an exploration of medical roles and patient motivation during the period of legalized euthanasia in Australia

A qualitative case study was conducted to explore the clinical decision making processes that underpinned the practice of euthanasia under the Rights of the Terminally Ill (ROTI) Act. The key informant for this research was Philip Nitschke, the general practitioner responsible for the legal cases of euthanasia. His information was supported by extensive document analysis based on the public texts created by patients in the form of letters and documentaries. Further collaborating sources were those texts generated by the media, rights groups, politicians, the coroner's cort, and the literature on euthanasia and assisted suicide. A key study finding was that the ROTI legislation did not adequately provide for the specific medical situation in the Northern Territory, Australia. The medical roles, as proscribed by the legislation, carried many inherent assumptions about the health care context and the availability of appropriately qualified medical staff committed to providing euthanasia. These assumptions translated into difficulties in establishing clinical practices for the provision of euthanasia. A further finding concerned the motivations of those who requested euthanasia. This article addresses the medical roles and the motivations of those seeking euthanasia.     

Psychosocial versus biomedical risk factors in Kevorkian's first forty-seven physician-assisted deaths

This article examines biomedical and psychosocial data on the first forty-seven cases of physician-assisted suicide (PAS) of Kevorkian as collected by means of both a physical autopsy and a preliminary psychological autopsy. The following patterns emerge: 1) The physical condition of these PAS patients was not typical of the conditions that lead to death in the United States. 2) Consistent with the above findings, our pilot data indicate that only 31.1 percent of these patients were terminal. While 73.9 percent were described as reporting pain, only 42.6 percent were revealed at autopsy to have a specific anatomical basis for their pain. However 36 percent were described as depressed, 66 percent as having some disability, and perhaps of key importance, 90 percent expressed a fear of dependency. Most important, our pilot data suggest the possibility of large gender differences, since 3) 68.1 percent of these forty-seven PAS's are women and only 31.9 percent are men. This represents the reverse of the gender pattern for completed suicides in the United States in 1995, resembling instead the approximate pattern for unsuccessful suicide attempts. 4) Approximately 75 percent of both men and women in the above sample were described as reporting pain. Men were almost twice as likely to have had an anatomical basis for the pain and three times as likely to be terminal. Our pilot data indicate PAS women are more likely to be described as depressed and twice as likely to have had a history of previous unsuccessful suicide attempts. 5) Kevorkian's patients were older than the typical unaided suicides in America. Reported pain decreases with age as does depression; however anatomical basis for pain increases slightly with age, and no age effect emerges for terminality. 6) Approximately two-thirds of those physician-assisted suicides were at middle SES levels. History of disability was the biggest risk factor for the low SES patients and fear of dependency for the high SES patients.     

Turkey's physicians' attitudes toward euthanasia: a brief research report

Euthanasia and assisted suicide are subject to an ongoing debate and discussed with various aspects. Because physicians are in a profession closely related to euthanasia, their attitudes toward this subject are significant. Thus, research intending to explore their opinions is carried out in many countries. In this study, opinions of the physicians regarding euthanasia's definition, contents, legal aspects, and acceptable conditions for its application are addressed. The questionnaire was given to 949 physicians, more than 1% of the total working in Turkey. Of the physicians who participated in the study, 49.9% agreed with the opinion that euthanasia should be legal in certain circumstances. In addition, 19% had come across a euthanasia request and the majority of physicians (55.9%) believed that euthanasia is applied secretly in the country despite the prohibitory legislation. In conclusion, the authors infer from the study itself and believe that euthanasia should be legal in certain circumstances and that the subject, which is not in the agenda of the Turkish population, should continue to be examined.     

The attitudes of socially marginalized men toward physician-assisted suicide

Bioethics and public policy literature suggests that socially marginalized populations may be at increased risk for overuse of physician-assisted suicide (PAS) were it to become more accepted. Yet the attitudes of socially marginalized populations toward PAS have not been widely studied. The present study surveyed a sample of men in a substance abuse recovery program. Participants completed a PAS attitude questionnaire and a religiosity measure. Support for PAS was fairly evenly split, with 52.2% indicating general opposition to PAS and 46.9% indicating general support. Greater religiosity was associated with more negative attitudes toward PAS. Higher educational level was associated with more acceptance. Overall attitudes toward PAS were considerably more negative than those of Dr. George Domino's (2003) general population sample.     

Community attitudes toward physician assisted suicide

Attitudes toward physician-assisted suicide (PAS) were assessed in a sample of 400 community adults, stratified as to gender and socioeconomic class, using a 12-item psychometric scale rather than the more typical survey question. The results indicate that the Domino scale, currently the only psychometric instrument of attitudes toward PAS, is factorially homogeneous and shows considerable internal stability. There were no gender differences, but significant socioeconomic class differences were obtained with better educated, upper class individuals more favorable in attitude than semi-skilled and unskilled poorly educated lower social class individuals. The majority of respondents support physician assisted suicide, but such support is inversely related to age.     

Why does zeno the stoic hold his breath? "Zenoism" as a new variable for studying suicide

A single misfortune may be seen as just that, or may be interpreted as Zeno the Stoic did, as a "sign" of cosmic proportion (zenoizing), which paradoxically provides a missing meaning structure. This article presents two studies testing out this new variable (zenoism): in Study One (n = 233), we explore the moderating effects of religiosity and gender on zenoism, depression, demoralization, and suicidality. In Study Two (n = 137), we explore these same moderating effects on zenoism, fear of dependency, value of life, and favorability toward physician-assisted suicide (PAS). Results indicate: 1) men and non-religious respondents (especially men) zenoize more than women and religious respondents; 2) non-religious respondents, (especially men) are more generally favorable to PAS and more suicidal; 3) Zenoism is negatively related to depression, demoralization, and value of life for non-religious respondents, and for men; 4) Zenoism is positively related to favorability toward PAS toward one's self and overall suicidality; and finally 5) general and self-specific favorability toward PAS are distinct, but both relate to overall suicidality.     

Gender,pain, and doctor involvement: high school student attitudes toward doctor-assisted suicide

The present study concentrates on the attitudes of high school students toward active doctor-assisted suicide as described in hypothetical doctor-patient scenarios, orthogonally manipulating doctor's reaction to patient's wishes to end his/her life (whether discussed, accepted or encouraged), presence of patient's physical pain, presence of patient's emotional pain, and the gender of the hypothetical patient. Doctor-assisted suicides thoroughly discussed with the patient are judged to be more moral, acceptable, and "legal" than assisted suicides that are simply accepted by the doctor or actively encouraged by him. Significantly, this is not a distinction that is relevant in the eyes of the law. Further, the presence of both physical and emotional pain on the part of the patient make the patient death more acceptable in the eyes of high school students. This latter effect is striking, given the result of the Wooddell and Kaplan (1999-2000) study showing that patient depression tends to weaken acceptability of death. Finally, respondents, both male and female, tend to view deaths of patients of the opposite gender as more acceptable than patients of the same gender.     

Preparation of chemotherapy drugs: Planning policy for reduced waiting times

This study investigates the impact of pharmacy policies on patient waiting time in the Chemotherapy Day Unit of the Netherlands Cancer Institute—Antoni van Leeuwenhoek hospital. The project evaluated whether a reduction in waiting time resulting from medication orders being prepared in advance of patient appointments was justified, given that medications prepared in advance are wasted when patients arrive too sick for treatment. Within this context, we derive analytic expressions to approximate patient waiting times and wastage costs, allowing management to see the tradeoff between these two metrics for different policies. Using a case study and a simulation model, the approximations are evaluated. The use of analytic expressions allows the analysis to be easily repeated when medication costs change or when new medications/protocols are introduced. In the same vein, other hospitals with different patient case mixes can easily complete the analysis in their settings. Finally, the outcome from this study resulted in a new policy at the cancer center which is expected to decrease the waiting time by half, while only increasing pharmacy's costs by 1-2%.     

Challenges in assessing intent to die: can suicide attempters be trusted?

Assessing a person's intent to die in a suicide attempt is crucial for risk assessment and research, yet suicidal intent is notoriously difficult to measure. People who intended to die when they hurt themselves may deny it, and others may feign intent for secondary gain. Additionally, ambivalence, memory gaps, impulsivity, and fluidity of intent can hinder accurate assessment of intent. Circumstantial evidence, such as a suicide note, may illuminate true intentions but also has substantial limitations. This article summarizes disparate challenges to the measurement of suicidal intent; describes strengths and weaknesses of circumstantial indicators; reviews evidence from studies using the Suicide Intent Scale to show that subjective and circumstantial indicators do not strongly correlate with each other; and concludes with a call to place more trust in individuals whose disclosures of suicidal intent are questionable, even if the possibility for manipulation exists.     

Hippocrates,Maimonides and the doctor's responsibility

Jack Kevorkian criticizes the Hippocratic tradition in Greek medicine, which bans the physician from giving his patient a lethal medication. He sees this prohibition as potentially bringing harm to a suffering patient and not reflective of the larger Greek society which was tolerant and even approving of suicide. However, Kevorkian's advocacy of doctor-assisted suicide can be seen as the polarity of doctor abandonment of the suffering patient rather than as an antidote to it. Both positions involve an outcome of physician removal from the suffering patient, which can be contrasted with Maimonides' command to the physician to watch over the life and death of his patients.     

The right-to-die movement: extrapolating from the National Hemlock Society U.S.A. membership survey

A national membership survey of Hemlock Society USA was conducted by Fox and Kamakahi (1995). Respondents (N=6398) were asked a variety of questions, but in this paper we perform a longitudinal analysis of the characteristics of Hemlock Society USA members. Hemlock Society USA members are divided into three 5-year cohorts: Early Joiners (11 or more years of membership), Middle Joiners (6 to 10 years membership), and Late Joiners (5 or fewer years of membership). Differences between cohorts are examined and extrapolations made regarding Hemlock Society USA and the Right-to-Die Movement. A series of one-way ANOVAs were used with Scheme post-hoc comparisons as heuristic tools for assessing between-cohort differences. Late Joiners are different from earlier members, but are more like other Hemlock Society USA members than the adult U.S. population at large. Hemlock Society USA members are essentially societal "elites" (based on socio-demographic variables) who work in social environments that are decidedly split on the issue of voluntary suicide and euthanasia.     

The Beliefs in the Inheritance of Risk Factors for Suicide Scale (BIRFSS): further results on demographic correlates, dimensionality, reliability, and validity

Convergent lines of evidence from adoption, family, geographical, immigrant, molecular genetic, surname, and twin studies of suicide point to genetic contributions to risk factors for suicidal behavior. Related mental health literacy (knowledge and beliefs) of professionals and laypersons may, however, lag behind this research progress. The purpose of this study was to further validate the 22-item Beliefs in the Inheritance of Risk Factors for Suicide Scale (BIRFSS), a novel instrument for assessing individuals' beliefs in the genetics of suicide. Data from a general population sample of 159 Austrian adults showed adequate internal scale consistency. Due to deliberate content heterogeneity, the instrument has a subscale structure, but factor analysis of items extracted a dominant first factor. BIRFSS scores were positively related to overall and specific knowledge on suicide facts (convergent validity), whereas unrelated to the Big Five personality dimensions, locus of control, social desirability, and verbal intelligence (discriminant validity). Demographic correlates of BIRFSS scores included respondents' age and religiosity (both positive ones), but not respondents' sex, educational level, or political orientation.