OTI Online
Spring 1994

Death takes the Stage
by Merle Hoffman


Nothing focuses the mind like the prospect of death. Contemplating the cessation of being immediately changes priorities. Always the sleeping giant on the stage, death suddenly assumes the spotlight as the rest of reality recedes into soft focus. La Rochefoucauld said that death, like the sun, should not be stared at. But I have no desire to shield myself from its power.

Now, after many years of heading CHOICES, a clinic where thousands of abortions have been performed over the last twenty three years, I feel I can look openly and freely at death and dying. Perhaps this sense of comfort and freedom comes with my having been witness to so many "little deaths," the deaths of thousands of fetuses, and all the endings that that brings -the death of possibility, the death of dreams, the death of "if only": If only I wasn't 12, if only I wasn't unmarried, if only I wanted this child at this moment. These "little deaths" allow me to be present at a time in a woman's life when there is much vulnerability, much honesty.

So it is with great interest that I notice that the issue of death has been making appearances all over the landscape of popular culture and giving command performances on the nightly news. It's been brought kicking and screaming into American consciousness in the figure of Jack Kevorkian, M.D. Thin and gaunt with a haunted look and burning eyes, he has thrust himself into our lives. Here, challenging, there, on a hunger strike, now with a strange looking machine that he has concocted to deliver deliverance to the suffering: he appears before us in full force.

Kevorkian provokes and challenges and disturbs the status quo. Non consumerist (he has lived for long periods of time on canned foods and social security), turning down up to ten thousand dollars in speaking fees because he is conducting his campaign for humanity; unsubtle to a fault, directly and publicly stating his agenda, Kevorkian insists that physician-assisted suicide, what he has termed "medicide," is a medical matter and should be considered .part of the established healing role of the physician, and he has repeatedly called for the medical profession to establish guidelines for its legal administration. Kevorkian presents death with a positive face, one of compassion and release rather than obscenity or denial. This death is an option and a choice, an ending devoutly to be wished for, a place of freedom and autonomy rather than a terminally closed door.

Jack Kevorkian is not your usual radical. And Kevorkian is a radical in the definitional sense of going to the root cause. Saint or mad prophet, as of this writing Kevorkian has assisted in twenty suicides, and after his December 17th release from a Michigan prison, has promised the judge he would not assist in any others.

The movement, philosophy, ideology that he represents is known as the "right to die" movement which of course is a misnomer, for the right to die comes with the territory of being born. What Kevorkian is calling for is the right not to suffer, the right to a death with integrity, with dignity. The intent is to provide the suffering individual with a gift of choice and autonomy in what is one's last conscious act. It is believed that the act of choosing, itself, summons a transcendence, which in some people's thinking is a special kind of grace.

The "right to die" movement shares a deep and palpable connection with another movement that defines itself as the pro-choice movement. The continual focus on the words, "right to die," obscures the philosophical context that underlies it and that is the question of choice. The movement is really about the right to choose how and when to die, just as the pro-choice movement is about the right to choose whether or not to have a child at a particular moment in time. This volitional act of choosing informs and drives the ideologies of both movements: For both, the balance must be weighed by a solitary individual within her own conscience the balance between the reality of her life weighed against a philosophical, moral or religious abstraction. In the case of abortion, the concepts of the "sanctity of life" and the "right to life" of the fetus are weighed against the quality of life and lived experience of the mother. In the case of what Kevorkian terms "medicide", the belief in "the redemptive power of suffering" and the idea that "only God can take life" is weighed against the desire to actively end one's suffering by ending one's life.

In the midst of all the hyperbolic media coverage of Kevorkian's assisted suicides, (people putting themselves to sleep in the back of Volkswagen vans and appearing on video tapes expressing the desire to die), the connection between both movements appears to have been lost.

The right-to-die and the pro-choice movements share many of the same principles, philosophical underpinnings and goals. Both are concerned with individuals as the main players in their own life dramas. Both seek to reduce the tension between individual conscience, on the one hand, and state or religious authority, on the other, by empowering the individual to make choices through legislative and legal avenues. The pro-choice movement views reproductive freedom as a fundamental civil right, without which women can never fully participate as citizens in this democracy. Kevorkian was quoted in the New York Times saying that he would push for a constitutional amendment allowing physician assisted suicide. "What I am going to do now instead is carry on a whistle stop campaign, city to city, to get this guaranteed by a vote of the people as a fundamental right." Both movements view physicians and the medical establishment as necessary allies in these sacred journeys and both share many of the same enemies.

This concept of the physician as ally or facilitator rather than paternalistic, God like figure developed its first full expression within the abortion rights movement. With the legalization of abortion, the physician came down off of his professional pedestal forever. When the Supreme Court legalized abortion in its 1973 Roe v. Wade decision, the relationship between doctor and patient was legally scripted in egalitarian terms. I called this the "Medical Equal Rights Amendment?' According to Roe, in the first trimester the decision of abortion was to be made by the woman in consultation with her physician. Historically patriarchal and powerful, established medical practice traditionally had little room for the requests, questions or personal requirements of patients, the majority of whom were women. The Supreme Court decision legalizing abortion changed that forever. It gave power, autonomy and a stronger degree of control to women patients. Of course, the more radical feminist vision that opposes physician control and regulation of abortion, and all laws touching on abortion and reproductive issues, viewed Roe as regressive at worst and minimal at best. However, the fact remains that the legalization of abortion altered the doctor patient relationship forever.

Jack Kevorkian's attempt to empower an individual in her relationship with her physician, and legally expand the physician's role to assist in the decision and the actual process of choosing when, where and how to end her life shares the drive of the pro-choice movement to equalize the doctor patient dyad. And it also forces the medical establishment to question the parameters of its power and its role. Many physicians resist the practice of abortion on moral, religious or ethical grounds, while others refuse to provide the service on the basis of what I would term a professional self image conflict. Similarly, many physicians refuse to participate in "active" euthanasia in assisting their patients to commit suicide. It is the physician as knight errant battling a primal force of nature: death. It is a classic "war" mentality; with the physician as the general, defining the strategic initiatives.

Dr. Khalili was a 61 year old physician in such unendurable pain from bone cancer that he needed a cane to walk and had a full-time morphine pump to help alleviate his suffering. On Tuesday, November 22, 1993, Dr. Khalili committed suicide by inhaling carbon monoxide in the presence of Dr. Jack Kevorkian. Dr. Khalili is the first physician to have sought Kevorkian's help, and it is believed it was an attempt to force the medical profession to deal with the issue. "His death points to a fundamental ambiguity on the part of the physician community," said Laurence O'Connell, president of the Chicago based Park Ridge Center for the Study of Health, Faith and Ethics.." Physicians have the same problems dealing with death as everyone else," said Yeates Conwell, director of the Laboratory of Suicide Studies at the University of Rochester School of Medicine in New York. "This person may have been struggling, not only as a person, but also as a doctor".

Johannes J. M. van Delden, of al, writing a follow up report to the Remmelink Study in the Hastings Center Report, November/December, 1993, reports on the Dutch experience with physician-assisted suicide, citing information obtained from approximately 10,000 deaths. Under recent rules in the Netherlands, assisted suicide technically remains a crime, but doctors are guaranteed immunity from prosecution if they follow certain procedures. Fifty-four percent of the doctors interviewed said that they performed euthanasia or assisted suicide, while a further 34 percent considered it conceivable that they would do so.

Most Dutch physicians are prepared to perform euthanasia only if certain conditions are met. In the Netherlands , it is not the patient's request alone that is the basis for the physician's decision. Physicians rejected two-thirds of all explicit requests for euthanasia or assisted suicide. The reasons were mostly that the physician saw alternatives or had objections in the particular case. "Our conclusion," van Delden writes, "is that doctors themselves are responsible moral agents, not simply instruments of the patient's will. Euthanasia, therefore, is always based on both autonomy and beneficence."

The American medical establishment, represented by the American Medical Association (AMA), has strongly condemned Kevorkian's idea that doctors should engage in assisting suicides. According to Dr. Lonnie Bristow, chairman of the AMA's board of trustees, "Placing physicians in a role of dispatching a patient is a conflict of interest that I don't think anyone in the world could resolve in a rational fashion."

Meanwhile, a Gallup opinion poll done last year found that 77 percent of Canadians supported euthanasia, if patients put their requests in writing. "It's a moral dilemma whether to give more weight to individual autonomy x the sanctity of the," said Dr. Douglas Sawyer, head of the Canadian Medical association's ethics committee. "This issue has polarized society."

The polarization of society that physician-assisted suicide is creating mirrors he abortion rights struggle. Indeed, he pro-choice movement has often been called the "Second Civil War." 3oth the "right-to-die" and the pro-choice movements deal with individual questions of morality and existence, and both are challenged on moral, ethical and religious grounds.

Detroit Archbishop Adam Maida told the national Conference of Catholic Bishops on November 15, 1993, to "aggressively" assert their opposition to assisted suicide. The conference has agreed to draft a message to be released next year on "life and death" issues, including abortion and assisted suicide. Maida said Michigan Catholic leaders already have brought newspaper ads to fight Kevorkian's position and my buy TV ads next year. "This rooted in our understanding of who we are as human beings," said Maida. "In abortion and in assisted suicide, we've got basic human rights we're trying to address.

A recent ruling on the constitutionality of Michigan's assisted suicide law had Wayne County Circuit Court Judge Richard C. Kaufman raising the abortion issue. Quoting the Supreme Court in the Casey decision, Kaufman wrote that issues "involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment."

Kaufman had asked the attorneys, "How can I say that a person's decision to kill themselves is any loss central to a person's dignity and autonomy than the decision to abort the fetus"?

Geoffrey Fieger, Kevorkian's chief attorney, said that the "right to die with dignity" is more important than the right to abortion: "There is no third party here, this is even more clearly about an individual's right to decide what he or she wants to do with his or her body."

Lynn Ashby, an Evanston Hospital (IL) resident who treats patients with brain tumors, is concerned that Kevorkian's activities and legal challenges could upset the delicate balance that currently exists among doctors and terminally ill patients. She is particularly concerned that pro-life groups like Operation Rescue could take their militant activities into intensive care units (ICUs) and chain themselves to hospital beds with patients on respirators, putting their bodies between patients and those who would attempt to relieve their final death agonies by turning off the life support machines. "I don't want to see them in the ICUs surrounding patients on ventilators," says Ashby.

Her fear is not far-fetched. The tactics of Operation Rescue members chaining themselves to operating room tables in abortion clinics and attaching themselves with a neck brace to a "cryptonite" lock in the middle of waiting rooms is not uncommon. Operation Rescue as well as many other anti-abortion groups are well aware of the parallels of the two movements, and as such are ready to oppose both in the same way.

Kevorkian once wrote, "Most physicians would agree that birth and death are the two most important events in the existence of any human being. Not too long ago the important event of birth was not part of an honorable or acceptable medical practice. The 'demeaning' activity of obstetrics was left to abject midwives and was deemed far beneath the exalted status of physicians. Currently, we blaspheme the process of exiting by not according it even the indignity of comparable midwifery."

Although Kevorkian believes that death and birth are the two most important life events, he does not equate them. "Once being unconsciously experienced, a person's birch is no longer part of his or her life. Therefore, death, which is not yet experienced, becomes paramount because everything in life is terminated by it?

Just so, because for each one of us, our deaths are so ultimately our own, so experientially unlike anything else we have known that there must be an avenue to allow individual expression. The desire for individual expression (both in abortion and medicide), allied with the need for medical assistance, is what creates the political tension for both the right-to-die and the pro-choice movements. These social and political tensions arise from the question of what the government's role should be. Should it protect life? Should it do what it can to save life? Should it determine when life begins? What life is worthy of being saved? Who decides when and how often to reproduce?

This "tension" between individual rights and state authority can only be reduced through legislation that allows the individual to make a choice. Issues so fundamental, primal and profound as reproductive freedom and dying must transcend politics. Choice is a sacred freedom. Who then has the right to desecrate it?


Merle Hoffman is publisher/editor-in-chief of On The Issues magazine and founder/president of both Choices Women's Medical Center, Inc., and Choices Mental Health Center.


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