AS Michigan state attorneys prepare again today to prosecute accused suicide accomplice Jack Kevorkian, a quiet but far-reaching debate is unfolding in American homes and hospitals over the ethics of physician-assisted suicide.
Both opponents and advocates in the larger debate are highly critical of Dr. Kevorkian and his methods in helping 27 people kill themselves since 1990. Without the publicity surrounding Kevorkian, however, they say today's discussion might not be as widespread.
"[Kevorkian] is a terrible bedfellow, even if you are for it," says Prof. Ezekiel Emanuel, a medical ethicist at Harvard University. "On the other hand, he has raised the issue and I think a national debate is appropriate." Unless a last-minute appeal delays the case, Kevorkian will go on trial today for his role in two 1993 deaths.
The debate, which challenges the 2,500-year-old Hippocratic ethic of Western medicine, centers around whether doctors should be allowed to prescribe drugs to end the lives of requesting adult patients who are diagnosed as mentally competent and terminally ill.
Overall, support for legalizing the practice seems to be increasing among both the general public and doctors in the US, according to two studies reported in the latest issue of The New England Journal of Medicine.
In Michigan, 66 percent of adults and 56 percent of doctors surveyed approve of legalizing physician-assisted suicide; in Oregon, 60 percent of doctors said it should be legalized in some cases, the studies show.
Moreover, many doctors are already quietly breaking laws to accommodate patients who seek to die, according to the studies and experts in medical ethics. In the Oregon study, for example, 7 percent of doctors responded that they had complied with patients' requests for prescriptions for drugs with which to end their lives.
Underscoring the trend, a dozen states including Washington and California have introduced legislation or ballot initiatives in recent years to legalize physician-assisted suicide. So far only Oregon has passed a law, but the 1994 Oregon Death with Dignity Act, which won 51 percent of voter support, has not been implemented because of court challenges.
Key federal court rulings are expected later this year on the Oregon law, as well as on efforts to decriminalize physician-assisted suicide in Washington and New York States.
Medical ethicists offer different explanations for the shift in public attitudes. Some cite the aging population. Others say advancing medical technology has been successful in prolonging peoples' lives, but can add to human suffering in prolonged cases of illness. AIDs has fueled the discussion, too.
More than anything, supporters of physician-assisted suicide stress the need to relieve suffering and to allow patients to make individual choices free from intrusive doctors or a paternalistic state - what they call "death with dignity." Practically, they argue, it is better to allow assisted suicide under controlled and restricted conditions than to tolerate today's unmonitored suicides.
"People are frustrated because they have to do this secretly and quietly and sometimes alone. They say: 'We don't want a covert act. We don't want to have to lie to the coroner, these problems are bad enough without that kind of guilt,'" says Eli Stutsman, general counsel for Oregon Death with Dignity, a coalition in Portland, Ore.
"There is a greater risk of abuse if it is not legalized, if everyone acts in secret and physicians are not accountable," says the Rev. Ralph Mero, executive director of the Seattle-based Compassion in Dying. Founded in 1993, the group has challenged the constitutionality of statutes in Washington and New York that prohibit physician-assisted suicide.
Opponents, however, contend that legalizing assisted suicide would be profoundly immoral.
"It would harm the individual by predicating his dignity and final self-determination on the right to be killed by another. It would harm the community by introducing consenting adult killing as a means of relieving suffering," warns Daniel Callahan, president of the Hastings Center, a think tank devoted to medical ethics in Briarcliff Manor, N.Y.
Moreover, critics say assisted suicide would lead to widespread abuse, as financial, emotional, or other pressures compel patients to opt for an early death. The privacy of physician-patient relations, meanwhile, would make legal safeguards hard to enforce, they say.
In the Netherlands, where euthanasia has been tolerated by the courts since the 1980s, a study estimates there are 1,000 nonvoluntary cases - circumstances when an individual didn't explicitly consent to suicide, such as someone comatose - out of 2,300 to 4,000 each year, says Mr. Callahan.
Critics also contend that too little is known both about what leads patients to request suicide, and how well informed doctors are about their patients' needs. Professor Emanuel says his studies show "pain is not what's driving this."
Doctors who support suicide
In addition, studies in Michigan and elsewhere show doctors who have the least contact with patients diagnosed as terminally ill are most likely to support the legalization of assisted suicide. In Oregon, half of all the doctors were not confident of knowing what to prescribe or how long their patients would live, and a quarter were unsure whether their patients were turning to suicide because of clinical depression.
Opponents also say more emphasis should be placed on improving the alternatives to hastened death, such as better palliative care and hospice services. "Effective hospice care diminishes anyone's need for even considering assisted suicide," says David Schneider of the National Hospice Organization. Started in 1974, hospice programs now provide care each year to about 340,000 US patients diagnosed as terminally ill.