Sunday, April 25, 2010

Kevorkian : You Don't Know Jack


Your opinion on assisted suicide for persons suffering from Alzheimer's disease?....
By Bob DeMarco
Alzheimer's Reading Room

Last night, HBO premiered its new film on Jack Kevorkian -- You Don't Know Jack.

Dr. Kevorkians' first assisted suicide patient, Janet Adkins, suffered from Alzheimer's disease.

Janet Adkins
Patient #1
Illness: Alzheimer's Disease
Her eyelids flickered a little and she looked like she was rising up to almost kiss me. I leaned over and the first thing that came to my mind is to say, Have a nice trip. That’s all. Have a nice trip. Those were the last words said. —Dr. Jack Kevorkian
She knew what she was doing, yes. But why was she doing it? Most Alzheimer’s patients don’t choose or plan suicide. Doctors who deal with the affliction report little acute mental suffering (at least in the later stages), in part because, as the disease progresses, victims lose a sense of what they’ve lost. They become more and more like childen, but not children who agonize over having once been adults.
Everything above was taken from -- Angel of Death: The Trial of the Suicide Doctor -- and in depth article that appeared in Vanity Fair, May, 1991

Angel of Death: The Trial of the Suicide Doctor

Did Dr. Jack Kevorkian do the right thing when he helped an Alzheimer’s patient end her own life with his homemade “Mercy Machine”? As the issue of medically assisted suicide hits the headlines again, he vows to continue his crusade for “planned death” for the terminally ill. But is he Socrates or Mengele? The author investigates the career of a medical heretic.

BY RON ROSENBAUM
MAY 1991
Her eyelids flickered a little and she looked like she was rising up to almost kiss me. I leaned over and the first thing that came to my mind is to say, Have a nice trip. That’s all. Have a nice trip. Those were the last words said. —Dr. Jack Kevorkian

He knew right away she was Trouble. The Wrong Woman. The Wrong Test Case. At least that’s what he says now.

He knew that if he let her have her way, let her talk him into a final, fatal rendezvous, everything he’d worked for might be jeopardized, even destroyed.

Dr. Jack Kevorkian insists he didn’t want Janet Adkins to be the first to die on his suicide machine. And he certainly didn’t want their assignation to take place the way it did, where it did. He new it would look bad, surreptitious. Even sleazy.

“I didn’t want to do it in a van,” the Doctor tells me. “Anything. Anything but the van.”

Indeed, when it looked like a Volkswagen van was the only place they could do it, when they’d been turned away by motels and funeral parlors and private homes, when there was “no room at the inn,” as Doctor likes to put it—he tried to talk her out of it. But she insisted, he says, forcing him to make a choice he didn’t want to make: between what was best for his principles and what was best for her.

Finally, he says, he succumbed. Her will to die overpowered his wish to delay.

“She was so distraught,” he says, “I decided I had to do it anyway. For the patient. That’s what a doctor is for. To hell with the goddanged ethicists. I’m a real physician.”

It was a bizarre relationship, one that resulted in the convergence of Janet Adkins and Dr. Jack Kevorkian in the back of the Doctor’s rusty old VW camper. It was a relationship that culminated in an act some have called murder, and others—notably the whole Adkins family—call a noble service to humanity. A relationship that has become the chief subject of one of the most unusual and bitter courtroom battles in the recent history of law and medicine: People of the State of Michigan v. Jack Kevorkian.

In one respect the trial is the revenge of the “goddanged ethicists” on a doctor who disdained their strictures. A parade of the medical profession’s deepest thinkers on matters of Life and Death, Healing and Killing, took the stand here in the Pontiac, Michigan, courthouse to attack what Dr. Kevorkian had done.

The defense countered by likening the Doctor to the great martyrs of intellectual and medical history persecuted for advocating ideas ahead of their time. The Doctor himself compares his ordeal to the famous Scopes trial of the twenties (in which a schoolteacher was convicted for teaching evolution). Dr. K.’s chief defense attorney, Geoffrey Fieger, goes further: “This is more than the Scopes trial. This is the trial of Socrates.”

Is this the trial of Socrates—or Dr. Mengele? Is Dr. Jack Kevorkian a brilliant if heretical philosopher or a shameless medical murderer?

It’s hard to believe the slight, gray-haired church organist (he believes in Bach, not God) sitting at the defense table could provoke such passionate and contradictory responses.

But it’s not just Dr. Jack Kevorkian on trial. It’s not just the Doctor’s presence, provocative and abrasive as he can be, that has so inflamed and embittered the courtroom combat in this remarkable trial.

No, it’s the Machine. The Device. The one the Doctor invented, the one he first dubbed “the Thanatron,” the one his media-sensitive lawyer has urged him to rename “the Mercy Machine.” The one Janet Adkins used to kill herself in the back of a van.

And indeed, it wasn’t long after the machine itself made its nerve-abrading appearance in the courtroom—as Prosecution Exhibit 10—that the smoldering bitterness between the Doctor and his accusers broke out into the open. Into a vicious exchange over—literally over—the machine. One that seemed to verge into physical violence. The Nazi Doctors incident.

All the material was bought at flea markets and garage sales and —you’re smiling, you’re breaking into a smile. I’ll admit it’s funny.… I tried toys, tearing them apart for the gears and mechanisms.

Before recounting that exceedingly ugly Nazi Doctors exchange, it might be worthwhile to look a bit more closely at the source of the ugliness—the Thanatron, a.k.a. the Mercy Machine, itself. There’s something about it, something about its crude shop-class mechanicalness, that has struck a dark chord in the national imagination.

Maybe it’s the fact that it is a machine, with gears, valves, and a switch—that it’s so obtrusively an object. Whatever it is, there’s no doubt the primitive device has the power to crystallize the emotions over otherwise abstract, technology-related right-to-die/right-to-life issues in a way that peaceful images of a comatose patient like Nancy Cruzan can’t. In the medical-ethics debates currently tormenting American courts and families, the Thanatron is the bare-boned “skull beneath the skin.”

Lead prosecutor Michael Modelski cites David Letterman jokes to exemplify the dangerous but seductive appeal of the machine. Letterman has devoted two “Top Ten” lists to it and prosecutor Modelski’s got them both at hand. One day over the phone he reeled off for me Letterman’s “Top Ten Promotional Slogans for Dr. Kevorkian’s Suicide Machine.” Number five: Claus von Bülow says, “I liked it so much, I bought the company!” Number four: “While I’m killing myself I’m also cleaning my oven!”

But the one Modelski emphasizes to me is the one that, he says, illustrates the true danger of the Thanatron, Promotional Slogan Number Eight: “Isn’t it about time you took an honest look at your miserable, stinking life?”

Modelski believes that the machine, if widely available, would become all too tempting to those suffering transient depressions, encourage them to “take the easy way out.”

Chief defense attorney Fieger counters that it’s not the prosecutor’s role to impose his “paternalist morality” on the citizenry. Fieger has his own thoughts about why the machine “gets people crazy.” He thinks it’s because “it forces people to face their own mortality, stirs up questions, feelings they don’t necessarily want to face.” (Have you taken an honest look…?) “They start asking themselves, Would I ever consider using it?” Fieger says. “It’s disturbing.”

But I’ve come to believe that it’s more than the mechanism that stirs up passions, gets people crazy. It’s the anesthetic. For those who might be deterred from blowing their brains out with a handgun by the noise and violence and bloody carnage; for those who might gag at the idea of swallowing mouthfuls of sleeping pills, hoping to take enough to extinguish and not merely maim their brains; for those who can’t face the twelve-floor leap into extinction, the Doctor’s machine offers a swift, painless two-step transition that guarantees an easy, unconscious descent into oblivion.

Almost anyone who’s ever been anesthetized in a hospital has experienced the almost instantaneous, almost pleasurable slide into unconsciousness offered by sodium pentothal. Touch a button on Dr. K.’s machine and that’s what you get: a solenoid turns a valve that releases sodium pentothal through an intravenous tube into your vein. It’s not until sixty seconds later, when you’re utterly unconscious, that a timer triggers a second solenoid, which opens a second valve and releases the chemical coup de grâce: a solution of potassium chloride that slips into the system and—when it reaches your heart—swiftly stops it dead. The promise of a painless death in that oblivious state—the promise that lured Janet Adkins halfway across the country to the Doctor’s van—well, it just makes suicide too easy, too accessible, too imaginable. An all-too-gentle touch away. What’s disturbing and frightening about Dr. Kevorkian’s Mercy Machine is that it’s just too user-friendly.

This, I believe, was the touchy emotional substratum that gave rise to the explosive Nazi Doctors exchange. It took place on the final afternoon of the final day of trial here.

This is not the murder trial; the first-degree-murder charges against Mr. Kevorkian were dismissed last December by a local judge. He ruled that the Doctor’s use of the Mercy Machine to assist the suicide of Janet Adkins—a fifty-four-year-old Alzheimer’s victim who’d begged for his help to avoid the awful indignity of the later stages of her disease—was not a crime, not homicide under Michigan law. (Michigan has no statute specifically prohibiting assisting a suicide; twenty-six states do.) This is a trial in civil court, resulting from the county prosecutor’s determination to shut the Doctor’s suicide service down whether it’s criminal or not. He’s seeking a permanent injunction to prevent the Doctor from ever using his machine in the state of Michigan and from counseling any new “patients” on how to kill themselves. Prosecutor Modelski says he’s trying to stop the Doctor from “roaming around the countryside in his van, zapping people.” And, more urgently, that he’s trying to prevent the death of at least fifty more people, the ones the Doctor has said are waiting in line to be hooked up to the Thanatron if the court permits it. In Modelski’s view, he’s asking the court to prevent the Doctor from becoming a medical serial killer—although Modelski’s preferred analogy is to the medical mass murder committed by Nazi euthanasia doctors.

Which brings us to the Nazi Doctors incident. The Nazi Doctors is a book by noted psychiatrist/historian Robert Jay Lifton subtitled Medical Killing and the Psychology of Genocide. It’s a book that’s occupied a prominent place in this trial, both physically and spiritually. Physically, the prosecutors have placed a copy of the thick black Nazi Doctors book conspicuously near the top of a stack of books on the prosecution table—a stack positioned right next to Prosecution Exhibit 10, the confiscated Thanatron. Photographers and TV cameras focusing on the machine can’t help capturing the stack of books next to it, the big bold letters on the spine of The Nazi Doctors almost serving as a caption to the image of the machine.

And spiritually, Lifton’s thesis in The Nazi Doctors is at the heart of the prosecution’s case against Dr. Kevorkian. Lifton argues that there was an inevitable progression from the “medicalization of killing” introduced by the Nazis’ involuntary-euthanasia campaign in the thirties to the mass murder in the camps in the forties. “At the heart of the Nazi enterprise,” Lifton states, in a quote that opens the prosecution’s final written argument in the Kevorkian case, “is the destruction of the boundary between healing and killing” (emphasis added).

“I read that,” Modelski tells me, “and I thought, Wow! This is where it starts.”

Modelski believes that participation by a doctor in “killing” (even if it’s only assisting a voluntary suicide) is the first step in a dangerous continuum, a “slippery slope” leading from medically assisted suicide to medically encouraged suicide (of the poor and uninsured, say) to medically pressured suicide (of those whose lives are “not worth living” but expensive to sustain) to involuntary euthanasia—the same slippery slope that led in the thirties and forties to genocide. Modelski, a tall, saturnine fellow, is particularly passionate about this because, he tells me, his father’s father (who’d served in the Polish army) and one of his father’s brothers died at Auschwitz. And because the uncle who died was a twin, Modelski suspects he may have fallen victim to the kinds of medical experiments on twins that were pursued so obsessively by Dr. Mengele in the camps.

It’s an “extreme” position, Modelski concedes to me, likening Kevorkian to a Nazi doctor. “But the lines have to be drawn somewhere.”

But not there, says the Doctor. Not that line. Throughout the trial the Doctor, a choleric fellow to begin with, has chafed at the attacks on him by prosecution witnesses. On the final day of trial he can’t take it any longer. Today the Doctor loses it in court.

It begins during an afternoon recess when Geoff Fieger, the Doctor’s flamboyant and combative attorney, tries to shove the stack of books featuring The Nazi Doctors away from the Mercy Machine—so a photographer can shoot the machine without a Nazi Doctors label.

Modelski isn’t going to let Fieger push his book around. He tells Fieger to take his hands off the book, he doesn’t have a right to touch anything on the prosecution table. I have a sense a fistfight is about to break out.

At this point a seething Dr. Kevorkian walks up to the prosecutor and asks him just what relevance The Nazi Doctors has to his case anyway.

Modelski says something to the effect of “Guys like you are in that book. My family suffered at their hands.”

“Oh really,” says the Doctor, coldly and viciously. “I didn’t know the Nazis did animal euthanasia.”

Dinner at the Golden Mushroom following the first day’s trial testimony. The Doctor is discoursing on his career as a medical iconoclast, on his controversial probes into the borderlands between life and death, science and superstition, which began with his pioneering demonstration that blood from freshly dead cadavers could be transferred into the veins of living patients. And on Bach, a particular passion—how he believes he’s discovered in the final chord of Bach’s unfinished Art of the Fugue a conscious reflection of the composer’s decision to expire upon completing that very chord. And on the final, hectic hegira he took in his Volkswagen van as he sought a peaceful place for Janet Adkins to die.

The Golden Mushroom is one of the fanciest places in Southfield (the wealthy suburb between Detroit and Pontiac), a favorite of the Doctor’s legal team of Geoff Fieger and Jon Marcus. But the Doctor doesn’t like fancy food and seems to disparage those who waste time on such frivolous indulgences. The Doctor prefers to live, according to his lawyers, on a steady diet of French fries loaded with salt.

The Doctor is a man with little use for material comforts or worldly pleasures. Since he left his last steady job as a hospital pathologist in 1982 he’s lived off his savings and Social Security. He’s now holed up in a Spartan one-bedroom rental over a florist’s shop, where he bangs out heretical theses for European medical journals under such titles as “A Comprehensive Bioethical Code for the Medical Exploitation of Humans Facing Imminent and Unavoidable Death” and “The Last Fearsome Taboo: Medical Aspects of Planned Death.”

He’s never married, although he says he came close once. (He backed out because, he’s said, his prospective bride was “too undisciplined.”) Nonetheless, I’ve seen him warm up to cocktail waitresses (and discuss extremely unscientific matters with them), and I believe it’s too easy, too reductive, to ascribe the Doctor’s interest in death merely to a lack of relish for life. Dr. K. is more complex, more vital, than that—at sixty-two he’s a feisty little spark plug of a guy who’s ascetic but not asocial or humorless. He delights in puns, writes limericks, and particularly savors the string of gags about him and his machine Jay Leno has delivered on The Tonight Show. He fills me in on some of them over dinner tonight, the first of several long dinner conversations that follow each day’s trial testimony.

The Leno gags focus on imaginary improvements the Doctor’s made on his machine, one of them being the addition of a “snooze alarm”—to allow the patient ten more minutes after he’s hit the switch. (Another would allow the Thanatron to be activated by “the Clapper.”)

Something struck me about the snooze-alarm idea. “What about it, Doc?” I asked him (everyone calls him Doc). “Why not? You know, give them one final chance to reconsider. Then there would be no doubt they really wanted to do it if they went ahead.”

“No,” he said, “because we don’t take the guard off the switches till we’re absolutely sure we’re going to go. I talk to them. After a long discussion and they’re absolutely sure I repeat, ‘You sure you don’t want to stop? You sure you don’t want to change your mind?’ And then we take the guard off. Then they hit the switch. If they still wanted to after they hit the switch, I can stop it easily. I can pull the needle out. They can pull the needle out. Before they fall asleep. Up until the last moment they have control.”

Control. That’s the key word in the value system that underlies the Doctor’s defense of his machine. The ability to control death—otherwise so undisciplined—or at least death’s time and setting. Control over death is the common theme that runs through the history of the Doctor’s medical heresies. He compares what he’s going through now to the persecution Margaret Sanger suffered when she first tried to distribute methods of contraception in the U.S. In the Doctor’s view she was martyred for birth control by the same forces persecuting him for advocating death control.

Except that the Doctor goes further. He doesn’t merely want to control death’s moment and manner; he wants to make death pay back, compensate, life for its thefts.

“That’s the biggest misunderstanding about me,” the Doctor tells me at the Golden Mushroom. “That I’m obsessed with death. I’m really pro-life. My writings are all about trying to get medical benefits from death. Life back from death. Like with Janet Adkins. She wanted to donate her organs. And if they’d allowed me to do it in the proper setting we could have saved four or five other people.”

He gets worked up now over that.

“I mean, four or five other people died with Janet Adkins! Automatic, and no one cares! No one’s even brought it up.”

“Died with Adkins, what do you mean?”

“She had a strong heart. She had two beautiful lungs. There’s three. Her liver could have been split in half and saved two babies. Two babies! Full of life, right?”

Stealing life from death. The Doctor’s goal sounds noble, but there are those who are skeptical. “Is he now saying Janet Adkins could save five lives?” Modelski asks me later. “He was up to eight for a while there. It was getting like a pyramid scheme. The more he killed, the more would live.”

Modelski doesn’t buy the idea that Dr. Kevorkian is in the lifesaving business. He compares the Doctor’s relationship with Janet Adkins to a cartoon he once saw. “There are two vultures sitting on a cactus and one says to another, ‘I’m tired of waiting. Let’s just go out and kill something.’”

Pretty vicious stuff, but there is something about the Doctor’s relentlessly unsentimental style that provokes acrid discourse. Something about his language—her liver could have been “split,” for instance. He has a fatal weakness for incredibly infelicitous neologisms. Not just “the Thanatron”; he wants to call the dying centers he proposes opening for suicide seekers “Obitoriums”—a word that suggests Orwellian slaughterhouses. But the Doctor, after a lifetime of battling against what he calls linguistic “hypocrisy,” is unwilling to make concessions to the tender sensibilities of others.

“I think you have a self-defeating harshness toward the rest of the world,” I once told him.

“Absolutely,” he said. “You’re right. My dad used to say that.”

He didn’t have any special feelings about death growing up, he tells me. “I’m as scared of dying as you are,” he says. But early on he rejected religion as a way to transcend it, quitting Sunday school when “I realized I didn’t believe in their miracles, walking on water, that sort of thing.”

He didn’t set out to be a medical heretic, he tells me, but there was a moment early in his internship that left him questioning the way doctors deal with the agony of the dying.

“I was making rounds one night and there was this woman who was dying of liver cancer. It was horrible, her belly was swollen up so much her skin was almost transparent, you could see the veins. She was in horrible, intractable pain. It looked like she was pleading for death with her eyes. But we couldn’t give her that. We had to keep her going, prolonging the agony. It was cruel and barbaric.”

He began to read in the literature of classical antiquity how doctors in Athens and Rome thought it their duty to relieve the suffering of terminally ill patients when a disease had run its course, by helping them expire peacefully. While suicide is regarded as more or less sinful in all major Western religions—a violation of the God-given “sanctity of life”—it was often accepted by the classical civilizations that shaped Western culture. This conflict in the Western mind over self-murder is reflected in the Supreme Court’s recent decision in the Cruzan case (over a comatose patient’s right to die), a conflict the court could not resolve definitively between the state’s interest in “preserving life” (which derives from life’s sanctity) and the individual’s “liberty interest” in the control over that life—and how to end it.

Critics of Dr. Kevorkian have pointed to his pathology specialty as a source of the pathology of his project: he’s a doctor who’s never regularly worked with living patients, no wonder he exhibits such sangfroid about what others speak of so reverently. Once, when I asked him his position on the “vitalist” school of biological thought, the belief that there is some indefinable something that distinguishes living from dead tissue, he snorted derisively, “I suppose you’re trying to get into that whole sanctity-of-life thing now.”

While some might call this coldness, he calls it a reluctance to be shackled by mysticism about Life—which blocks genuine lifesaving innovations. He cites as an example the superstition-based ire aroused by his “cadaver blood” transfusion experiments. First of all, he says, it’s not like he was some ghoulish Frankensteinian mad scientist dreaming this up himself. “The Russians had been doing it for thirty years.”

Back in 1961 he’d read about the Soviet medical practice of taking blood from freshly dead corpses to use for lifesaving battlefield transfusions. “At Pontiac General Hospital, we went beyond what the Russians did. We actually transfused blood from immediately dead people—from their heart through a special syringe—into the recipient.”

A May 26, 1961, Time-magazine report on the Kevorkian experiment called “Blood from the Dead” noted that “U.S. doctors have shied away from it because of a prejudice against contact with anything from a corpse.”

Nonsense, says the Doctor over free-range chicken at the Golden Mushroom. “It’s just a transplant! Blood is an organ! A liquid organ. Blood transfusions are just organ transplants. Because of the superstition, lives have been lost.”

His own life was seriously damaged by the cadaver-blood publicity. “It got me into trouble,” he says. “Jobs closed down because of that. Your curriculum vitae scares the hell out of people.”

Another of his life-from-death ideas—the Death Row Organ Harvest—led to similar trouble. “Death Row Organ Harvest” is, I’ll admit, a slightly inflammatory way to characterize the notion.

“Way back when I was a second-year resident in pathology I was dealing with condemned criminals who wanted to donate organs, wanted to be used for experiments. You know,” he says, “by choice.”

What he proposed was a forerunner of execution by lethal injection, the fatal dose being preceded by a period of deep anesthesia during which the bodies of soon-to-be-killed condemned men would be made available for the kind of risky, speculative but important experimentation that would never be performed on humans otherwise. When the experiments were over, the remaining organs would be removed for transplant purposes. The condemned men would not only be paying for the lives they took by giving back their lives, they’d be giving back something more, they’d be saving lives in the future, once again putting red ink on death’s side of the ledger.

This, too, led to unfair attacks, the Doctor says. “They say you want to take organs from criminals. They never bring up the point it’s voluntary. The medical profession’s against it. They think I’m being macabre. They told me you’ve got to drop the idea or leave the university. So I left the university.”

“Did the prisoners you worked with first suggest it to you?” I ask him.

“No, I brought it up to them,” he concedes.

The suicide machine was a late development in the Doctor’s career, yet another design to cheat death of its sting.

At the time he first became inspired to build the machine, the Doctor tells me, “I wasn’t working on euthanasia.” He wasn’t working regularly much at all, in fact, not at the practice of medicine. After he retired from his last regular hospital pathology post he devoted himself mainly to his writing. The Doctor has turned out an impressive number of books over the years, whose publishers have ranged from the reputable academic to vanity press. He’s written everything from a technical disquisition on “a coherent grid system of coordinates for precise anatomical localization” to Beyond Any Kind of God, a book of abstruse reflections on Being and Transcendence. Unfortunately, only the book jacket of Beyond is now available because the remaining copies of the book itself were lost, he says, by a storage company in California during a sojourn there in pursuit of “a film project” which he says he won’t talk about. The Doctor says he’s suing the storage company.

Still, by 1989 most American medical journals were rejecting Dr. K.’s increasingly controversial articles and few people were paying attention to him. He might have gone to his death a neglected eccentric if he hadn’t abandoned his writing desk for the workbench and constructed the Thanatron.

And he wouldn’t have invented the Thanatron if it hadn’t been for a quadriplegic ex-surfer named David Rivlin. It was Rivlin who inspired the Doctor to construct the Mercy Machine, and Rivlin remains, the Doctor believes, a far better test case than Janet Adkins—the one he wanted to go with first.

David Rivlin was a thirty-eight-year-old who was paralyzed in 1971, at the age of nineteen, in a surfing accident that severed his spine. He’d struggled bravely to make an independent, wheelchair-bound life for himself until a failed spinal operation left him confined to a nursing-home bed, unable to breathe without a respirator tube down his throat, artificially inflating and deflating his lungs. He was facing twenty or thirty more years of life as a gasping, immobile head on a paralyzed, immobile body.

He decided he wanted to die. Knew that he couldn’t do it himself, and begged his nursing-home doctors to help him. They refused, unwilling to risk the liability and controversy. Which led Rivlin to make a public appeal in a Detroit newspaper for some doctor somewhere to “come forward” and help carry out his death wish.

A court refused to forbid it, but, at first, only one doctor responded.

“I said, Well, hell, I’ll go and talk to him,” Kevorkian recalls for me toward the end of our Golden Mushroom dinner.

But the Doctor was aware that much depended on exactly how he helped David Rivlin. “I said to him, ‘Now, how can we do this so I don’t have to pull the plug? That’s illegal.’” He decided what Rivlin needed was a way of pulling the plug on himself, by himself. Rivlin could manipulate a stick held in his teeth, the Doctor reasoned. If he could create a device with a hair-trigger button that Rivlin could push with a stick, he could give the ex-surfer the ability to ride that final wave himself.

“The procedure” (as he likes to call it) he was contemplating falls into a legal and ethical gray area, an unmapped borderline realm between what medical ethicists call “passive euthanasia” and “active euthanasia.” Passive euthanasia—which is sanctioned, in carefully limited circumstances, by the A.M.A.’s Council on Medical and Judicial Affairs, and now by the Supreme Court in the Cruzan case (at least when there is “clear and convincing” evidence of patient consent)—involves a doctor withdrawing or withholding lifesaving or life-sustaining technology from a patient (such as respirators that artificially keep his lungs going, feeding tubes that prolong a persistent vegetative state in a patient who’d die otherwise). Passive euthanasia is a doctor merely stepping out of the way of death, its supporters contend. Active euthanasia involves a doctor stepping in to cause death, say, through lethal injection, the way Dutch courts allow doctors there to do it these days. Active euthanasia is condemned by the A.M.A. and most medical ethicists, although religious and right-to-life groups contend there’s little real distinction between active and passive—since both intend to cause death.

The maddening thing about Dr. K.’s machine to medical and legal ethicists is that it further blurs the distinction between active and passive euthanasia because it partakes of some qualities of each. Those who defend it point out that the patient, not the doctor, takes the final, fatal action of flicking the death switch, making the doctor even more passive than the physician who “passively” pulls a plug on a respirator or in A.M.A.-approved passive euthanasia. On the other hand, critics contend the doctor hooking up a patient to a machine is “active” in a more crucial sense: he brings into the picture the deadly drug; he doesn’t merely let death take its course, but gives it a final boost. He doesn’t pull the trigger, but he provides the bullet.

Another doctor intervenes with a more conventional solution before Kevorkian had a chance to test his new invention on David Rivlin. Newspaper reports indicate that what happened to Rivlin was something on the order of enhanced passive euthanasia. That he was removed, respirator and all, to the house of a friend, where a sympathetic doctor sedated him, and then disconnected him from the respirator, leaving him to die of asphyxiation. By all reports he died peacefully, “with dignity.”

“They killed him!” says Geoff Fieger one day in the courthouse cafeteria. “A judge in the this same building let Rivlin’s doctors kill him, yet they tried to pin a murder rap on the Doc here for letting Janet Adkins push the button herself.”

The Doctor claims this confirms an important point about the hypocrisy of the medical establishment. “They’re doing it already!” he says. “What they’ll do is give them a week’s supply of morphine painkillers and warn them solemnly, ‘Don’t take this all at once, you could kill yourself.’” (Other doctors have confirmed to me that this practice is not uncommon. On March 7 of this year news broke about a New England Journal of Medicine story by Dr. Timothy E. Quill, who described how he supplied a longtime patient with enough barbiturates to kill herself.)

“They do it all the time, but it’s done in the shadows,” the Doctor complains. And only for the privileged few with sympathetic doctors. “It’s only just come out that King George V’s doctor gave him a deliberate overdose of morphine and cocaine at the end so he could die in dignity, ‘a death fit for a monarch.’ Why shouldn’t ordinary citizens with no connections have that right?”

Convinced there was a need to be filled, the Doctor decided to go forward with the design and creation of a Mercy Machine. “I knew we needed it for people like Rivlin. I had two versions, changed it twice, then the third time it worked.”

By late September 1989 the machine was ready. All he needed was a volunteer.

And as it turned out, Janet Adkins was ready, too.

See, it was all theory before. Easy. But when you’re doing it, it’s rough. I was emotionally drained. It was the hardest decision I’ve made in my life.

Janet Adkins. She was, of course, the missing witness at the trial. In her absence, both prosecution and defense presented conflicting versions of who she really was, and what the real nature of her relationship to Dr. Kevorkian was.

Was Janet Adkins the confused, hapless victim of an ambitious medical Svengali, a vulture searching for prey, as the prosecutor implied? Or was Janet Adkins the pursuer, the seducer who overwhelmed the Doctor’s reservations about her suitability to be a test case, and caused him to risk his license and his freedom to relieve her of her suffering?

Janet Adkins was unable to testify at the trial, but she did leave behind a forty-five-minute-long videotape she’d made just forty-eight hours before she met death in the back of the Doctor’s VW van. It’s a videotape made in a motel room in a suburban-Detroit Red Roof Inn, and it features Janet Adkins, Dr. Kevorkian, and Janet’s husband, Ron Adkins, talking about the decision they were about to execute. The videotape is a disturbing, ambiguous document, the focus of much criticism by prosecution witnesses for its inadequacy as proof of Janet Adkins’s decision-making competence.

But it doesn’t, it wasn’t meant to tell the whole story, the Doctor and Ron Adkins both insist. The three of them spent the whole day, a good twelve hours of it, together. And “I was watching her all the time,” the Doctor says.

On the tape we see three people sitting facing the stationary video camera in front of pale, institutional-looking motel-room drapes. Janet Adkins, a buxom, bespectacled woman in a bright plum-colored blouse, sits next to her tweedy, bearded, bow-tied husband, Ron, who looks less like the stockbroker he is than a New England college professor. And then there’s the Doctor, the interlocutor, seeking answers from Janet, getting them mainly from Ron.

Janet Adkins seems to be enjoying robust physical health—she even talks about playing vigorous tennis the week before she left on this suicide pilgrimage. And while you can see evidence of the mental impairment Alzheimer’s has caused, there’s little evidence of the mental anguish that one looks for in someone seeking to end her life.

The Doctor begins with the traditional effort to see if the patient is located as to “time, place, and person.” He asks her where she lives and when she says, “Portland, Oregon,” he asks her:

“Where is Portland, Oregon?”

She gives an embarrassed laugh. She can’t answer it. She turns to her husband and says, “Help!”

That’s the pattern of the rest of the tape. She gives short, passive one-word or one-sentence answers, or hesitates and turns to her husband, who often jumps in with long descriptive explanations.

Prosecution witnesses at the trial criticized the fact that the two men, the Doctor and the husband, do most of the talking while the woman at issue sits smiling benignly. It’s not that she’s unaware of what’s being discussed, it’s just there’s so little passion or urgency displayed by a woman her husband has described as active, commanding, even controlling. In one key exchange, the Doctor tries to get her to say the word “death.”

“Janet, are you aware of your decision?” Dr. Kevorkian asks her.

“Yes,” she says.

“What does it mean?”

“You have to get out with dignity.”

“Just what is it you want? Put it in simple English.”

“Self-deliverance.”

“No. Simple. Simpler than that.”

She laughs. Says something inaudible.

“Do you want to go on?”

“No, I don’t want to go on.”

“What does that mean?”

“The end of … my life.”

“What’s the word for that?”

“Euthanasia.”

“No, what’s the word for the end of life?”

“You’re dead!”

“All right, is that what you wish?”

“Yes.”

She knew what she was doing, yes. But why was she doing it? Most Alzheimer’s patients don’t choose or plan suicide. Doctors who deal with the affliction report little acute mental suffering (at least in the later stages), in part because, as the disease progresses, victims lose a sense of what they’ve lost. They become more and more like childen, but not children who agonize over having once been adults.

Janet Adkins doesn’t articulate the nature of her anguish, not on the videotape, and neither does the Doctor nor her husband (who seems compelled to portray her as always upbeat) has been able to articulate it for me. The one person in the whole affair who came closest to explaining it was Dr. Kevorkian’s sister Flora. She had spent time with the Adkinses and the Doctor on the day of the videotape and, she recalls, “everyone noticed that every time Janet faltered in the exactness of a reply, she died a thousand deaths” (italics mine).

Her husband, Ron, repeatedly emphasizes on the tape and in conversation with me what an active intelligence Janet had, how “she had been the light in our lives, she was always coming up with new ideas, always abreast of new philosophical thinkings, and she just enlarged our life because of her interest and curiosity.”

The impression one gets is that Janet Adkins was a woman who felt she was losing the very quality she was most valued for by everyone in her life—her mental acuity. And that she was diagnosed at a point where she still retained sufficient self-consciousness to understand the magnitude of the loss; she still had enough identity to find the loss of her identity unbearable.

“Janet, when did you find out that’s probably what you had?” Dr. Kevorkian asks her at one point on the tape.

“Probably not till the bomb dropped, frankly,” she says.

There were warning signs before the bombshell diagnosis. The sight-reading problem, for instance. Music had been the glue of the Adkinses’ thirty-year marriage; they’d met in college when they were both studying the French horn. Now that their three sons had grown and left the house, they loved to spend their evenings together sight-reading music.

“We used to play together a lot,” Ron recalls on the videotape. “I’d play the flute. Janet would play the piano. We used to sit for hours at night sight-reading music. It got so she was having a difficult time with that. Then she had some difficulty spelling. I was suspicious something was going on. Then we thought, Maybe it’s your glasses.”

It wasn’t her eyesight. It was early-onset Alzheimer’s disease. “It was just so awful the way it was presented to us,” Janet says. The doctor “just pretty much coldly said [she’s] got a 90 percent or better chance of having Alzheimer’s,” Ron recalls. “Then he started telling us all the dire … well, you know, ‘Ron, you’re going to have to start dressing Janet.’ The whole bit.”

“Which was so awful,” Janet says. “He just kept going on. I couldn’t believe it.”

But, she says, once “the bomb dropped” she knew exactly how she was going to handle it. She was going to take control, before she lost control. She was going to take her life.

Several prosecution witnesses have made a point of attacking Janet Adkins’s choice as aberrational, inexplicable. One of her doctors testified that she had three or four “good years” ahead of her, that she still enjoyed great physical vigor, played competitive tennis (although she’d forgotten how to keep score). They suggested that Alzheimer’s had already subtly impaired her judgment, so that she was off in a kind of “la-la land,” not really cognizant of what she was doing, or perhaps suffering from “transient demoralization,” a depressive inability to accept that life with defects and loss would be better than no life at all. But, Ron Adkins says, the critics “have created a false Janet. She wasn’t in la-la land, she was a strong woman. She controlled the whole thing.”

And the whole idea of “self-deliverance” was hers from the start, he says, part of her philosophy long before she had any hint of Alzheimer’s.

It’s worth taking a closer look at Janet Adkins’s philosophy, because, for better or worse, she had closely held beliefs about death and dying before she was hit with the distressing diagnosis. Because her “new philosophical thinking” made her a subscriber to the New Age “death and dying” movement.

“She read Kübler-Ross’s On Death and Dying—a number of those books,” Ron Adkins tells me. “But she was into T’ai Chi, the Bhagavad Gita, that kind of thing. Janet believed in reincarnation,” he says. “That life is a stepping-stone in the process of existence. And she had gone to a medium and had found out she’d lived in Greece before, and had nine children, so it was a continu … it was happy … it was … she didn’t fear death.”

Others might have the opposite interpretation of such strenuous efforts to convince oneself that death is not an end but a transition to something better. I’d written critically in the past about the cultural impact of the work Elisabeth Kübler-Ross and her “Death and Dying” philosophy and how, for a time in the early 1980s, it became a spiritualist, Shirley MacLaine%#8211;like cult. (They’ve since come back down to earth.) I saw it as pseudoscience, with its whole apparatus of the “five stages of dying,” which were supposed to lead from anger to acceptance, as if that was, necessarily, a moral progress. That one should “go gentle into that good night.”

To me, Kübler-Ross and the whole New Age “pro-death” movement—with its greeting-card sentimentality and gauzily attractive visions of the afterlife—serve to make euphemistic versions of suicide like “conscious dying” and “self-deliverance” a too sweetly tempting alternative for those in pain.

Nonetheless, deplorable as I might find Janet Adkins’s philosophy, they were her beliefs, not something Dr. Kevorkian had talked her into. Kübler-Ross already had.

And Janet Adkins also had well-defined beliefs about taking control of the timing of her death long before she heard of Kevorkian. Both Janet and Ron had been longtime members of the Hemlock Society, the group that teaches the virtues and techniques of “self-deliverance” from prolonged suffering. “We would have discussions about this,” Ron Adkins tells me. “That if the quality of our life was deteriorating, did we want to sit around and wait for it to take us, or did we want to exit with whatever dignity we had?”

In fact, she’d planned the date of her death before she consulted the Doctor. She’d first planned if for November 30, 1989—“so we wouldn’t spoil Christmas for the kids,” Ron Adkins tells me.

At first, he says, two of the three kids—actually grown sons ranging from age twenty-six to thirty-two—opposed her decision. “The boys had been taught by Janet that there isn’t anything in the world you can’t accomplish if you set your mind to it.”

Her sons convinced her to consider entering an experimental drug-treatment program before giving up. She agreed, but she didn’t stop planning her death.

She was contemplating “jumping out a window and going into the water and taking pills,” her husband says, but she worried about “doing half a job on herself.” They’d thought of flying to Holland and arranging for a doctor to help her die there, but there was a problem with non–Dutch nationals’ going there for euthanasia purposes.

Then they read an article about a doctor in Michigan named Kevorkian who’d caused some controversy when a local medical-society journal refused to take an ad for a suicide device he’d invented. They saw him on Donahue demonstrating it. She realized it used the same anesthetic-then-legal-drug method the Dutch used. “Dr. Kevorkian had created a device that in a sense brought the Netherlands to Michigan,” Ron Adkins says. At his wife’s urging, he put in a call to the Doctor.

It was more than just fate that finally brought them together. When you think about it, there was a curious convergence of philosophy between Janet Adkins’s mystical New Ageism and Dr. Kevorkian’s strict scientism: neither gives its adherents any powerful reason to privilege life over death. The Doctor scoffs at any “sanctity” privileging living tissue over dead matter; the New Agers scoff at the grubby exigencies of life in this “material world” compared with the golden glow of the afterlife and the peerless wisdom the dead sages channel back to the benighted land of the living.

So the meeting of Dr. Kevorkian and Janet Adkins was a philosophic marriage of true minds. Despite the fact that it was consummated in the back of a van.

The van: that 1968 Volkswagen camper has been the focus of much of the scorn and derision of the Doctor’s critics. That he did it in the back of the van symbolizes to them his unseemly haste, his eagerness to initiate the procedure; to the prosecutor, there’s even an unsavory echo of the mobile killing vans of the Nazis. “At first,” Modelski tells me, “he said he’d have three consultations and that he was going to deal only with somebody who was terminally ill or in unbearable pain—he had this whole ethical code. And then she comes along and boom, boom, boom, they’re in the back of the van.”

It wasn’t exactly boom, boom, boom. In fact, when the Adkinses first got in touch with the Doctor he discouraged them. He had thought that the ideal test case would be a terminally ill cancer patient, that Janet Adkins’s mental as opposed to physical anguish complicated the clarity of the issue. So he encouraged her instead to go forward with the experimental drug-treatment program she was contemplating. Which she did.

“I always encourage people to go as far as they can,” he told me. “Everyone assumes that they walk in, walk up to me, and I’ll do it immediately. That’s not true.”

In fact, he contends that if his procedure were legitimized many people who consulted him about it would come away choosing to live rather than die.

“When they know that when the time comes I will be there to help them, they don’t want to go right away. They go on and on. And many die of natural causes. Because it’s the panic that drives them to suicide. They are going, ‘What do I do? Where do I turn?’ They don’t want to wait till they’re incapacitated and can’t do it—so they kill themselves. Panic drives them to suicide and premature death. This machine would actually cut the elderly suicide rate to almost zero.”

He cites a tragic recent example. The Gears were an elderly Detroit-area couple. “I think the woman was ill. The man was very ill, too. He killed her and then he shot himself—I guess to avoid prosecution, or he just didn’t want to go on living himself.” If they’d come to him, Dr. Kevorkian says, they’d both be alive now. “People, when they talk to me, are willing to go on a little longer because they realize there’s someone there to help them.” (In his statement to the court considering the preliminary injunction, Dr. Kevorkian, ever the judicious diplomat, accused the court of trying him of being guilty of “involuntary manslaughter” in the double death of the Gears, for depriving them of any alternative to blowing their brains out.)

And, in fact, Janet Adkins did go on for another six months before she contacted Dr. Kevorkian again. This time it was in April and she’d just learned that the experimental drug treatment hadn’t had any effect; she’d decided the time had come. This time she was determined to go through with it. As soon as possible.

She felt that “if she was ever going to err she’d rather err on the side of going too soon rather than too late,” Ron Adkins says. “Knowing full well that if she deteriorated too far Dr. Kevorkian wouldn’t be able to help her, because she wouldn’t be rational [enough to make a legally competent decision]. And she was so happy when he said he’d take her. When he accepted her she … a great joy came over her. Because she knew she had her exit set.”

From that point on, Ron says, his wife took control of the process. “She planned her memorial service, what music was to be played”; she arranged for a family therapist to mediate finale “closure” sessions with her three sons; she said goodbye to her friends, to her own aged mother (who later wrote Dr. Kevorkian a letter praising him).

The curious thing about Ron Adkins is that at no time—not in the Red Roof Inn video, not in the talk shows like Sally Jessy Raphaël he went on after the death to defend his wife and Dr. Kevorkian—did he ever say he’d tried to talk his wife out of the procedure, convince her to go on living. When I asked him if he’d tried to change her mind, he sounded irritated at the idea.

“What? I’m supposed to tell an intelligent person she should go to a day-care center and learn to play with blocks? Learn to wear a diaper? She didn’t want that.” My sense of it was that he was too in awe of her to disagree. He impressed me as a fairly colorless man who spent the thirty-four years of his marriage in the shadow of a colorful woman. He seemed to regard it as his duty not to disagree with her. And so they set the date and bought the plane tickets.

Meanwhile, in Detroit, Dr. Kevorkian’s planning was not going so smoothly. He was having trouble finding a place to do the procedure. It was a point of honor with him to inform each place he was trying to engage just what he planned to use it for. Which resulted in a lot of doors being slammed in his face. He tried “three or four funeral homes. Five or six empty office spaces for rent. Two or three doctors’ clinics for rent. Four or five motels.” At one point he even considered going out to Portland and performing the procedure in a boat or plane three miles off the coast, outside U.S. jurisdiction. (Modeslki calls this the “death ship” plan.)

Time was running out. The Adkinses would soon be en route to Detroit. And that’s when he hit on the idea of a vehicular venue.

“I checked about five E.M.S. vehicles, if I could rent one possibly. Which is of course impossible. I checked on a private park where I could park a vehicle and do it, and they said no. I tried every possibility for about two months. Then a friend of mine in Detroit said, ‘You can do it in my home,’ and I said fine.” He notified the Adkinses they had a place. They finalized arrangements for the memorial service.

And then, at the very last moment, Dr. Kevorkian’s friend backed out.

“He talked to a doctor friend who said, ‘Alzheimer’s disease? Oh no. No, don’t do that.’ Well, that left me in a lurch because they’d made plans and got their tickets and there was just a couple of days left, so I thought frantically, What am I going to do? I’ve got to tell them … I’m going to rent a van or a motor home and they’re going to refuse.”

Here was the turning point. Dr. Kevorkian called the Adkinses and “told them, ‘I don’t want to do it. My van is the only place. I can’t find a place.’ And Mr. Adkins called me back that day and said, ‘Janet is distraught, extremely distraught, she doesn’t care where it’s done. She wants it done without delay.’”

The way Ron Adkins remembers it, “the Doctor called me and said, ‘Ron, I can’t find any place to do it. I’ve got an old van and I can go out in a recreational-vehicle park. I have to have electricity to plug in the electrocardiogram.’ And I called Janet and Janet said, ‘Great. I don’t care where it is. I care how it is.’ You know, if you go to a penthouse in the Marriott Hotel and blow your brains out with a gun—that’s more dignified? And another aside—she liked Volkswagens.”

And so the Adkinses flew in, met the Doctor at the Red Roof Inn, had lunch, did the video, had dinner with him at a place called Uptown Charley’s.

Janet Adkins and the Doctor hit it off right away. They found they had a love in common: Bach. According to Ron, Janet found the Doctor down-to-earth, simpatico. “She had a very good sense of, you know, selecting people that are phonies from people that are real,” Ron says. “And he’s real. He rings real. He really is a man of principle. He’s doing this for mankind. We were very impressed with him.”

They said good night after making the following plan. The Adkinses would have a final day together for sight-seeing and saying good-bye to each other. Then, the morning after that, Monday morning, the Doctor’s two sisters would pick Janet up at the Red Roof Inn and drive her to the recreational-vehicle hookup area of Groveland Oaks County Park. (Ron Adkins would stay behind in the motel and wait for the call afterward; Janet didn’t want him to witness the procedure.) And Dr. Kevorkian would meet them at the park in his specially spruced-up van.

“I cleaned it out and sewed new curtains, made it real nice,” the Doctor tells me.

Early Monday the Doctor got the sodium pentothal and the lethal dose of potassium chloride out of the safe where he’d stored them; he packed the Thanatron and his EKG machine into the van. He was ready. Janet Adkins had arrived. She was ready.

But suddenly everything that could go wrong began to go wrong. First, when he was loading the sodium pentothal into vial number two, he managed to spill “the juice,” as Ron Adkins puts it. “That caused a two-hour delay,” Dr. Kevorkian says. “I had to go forty-five miles back home to get more.”

From home he also brought back little needle-nosed pliers to do some fine-tuning on the chain linkages. Finally, he was ready to hook Janet Adkins up to vial number one, the harmless saline solution. Trouble there too. He had to try four times before he was able to get a needle properly inserted into her vein. Then he worried that the saline wasn’t flowing fast enough, so he had to jury-rig a little box and raise the vial up onto it, in order to increase the pressure.

“This was done under the world’s worst conditions. Worst,” he says. “Terrible the first one had to be this way.”

All these little hitches were, cumulatively, having an effect on Janet—who was now lying down on a mattress with a needle in her arm. “She was a little apprehensive there, because she didn’t want anything to go wrong,” the Doctor told a state investigator. “She would tell me to be careful after she knew I spilled the solution. She’s lying there and she would say, ‘Watch that.’”

Finally, all was in readiness. The Doctor’s sister Flora read the Lord’s Prayer, then a few poems Janet Adkins had chosen. The time had come.

“She didn’t want to wait,” the Doctor says. “She wanted no extra conversation. And I said, ‘Are you going to hit the switch?’ And I told her how to hit it—with the flat of her hand two or three times to make sure the solenoids and valves pull really well.”

She made a few practice hits with the safety guard still on the switch. “And then I took the cap off, and I said, ‘O.K., now are you ready?’ and I started the cardiogram, which I’d attached. And she [hit the switch] and said, ‘Thank you, thank you.’”

It was at this point, the Doctor says, that Janet Adkins “looked like she was rising up to kiss me.” The prosecutor questioned him sharply about that perception at a preliminary hearing. The Doctor conceded that he couldn’t be sure: he was “guessing” that her last surge of life was meant to be a kiss.

Several minutes after the lethal potassium chloride should have kicked in and stopped her heart, the Doctor noticed there was still some anomalous activity on the EKG chart. “It was still going. With a bizarre tracing, two or three minutes later. I thought the heart was still beating.”

He was mistaken, he says now, she was already dead. But just to be sure he reached up and jiggled vial number three, the one containing the deadly potassium chloride, to make sure the lethal liquid was flowing. At last, the EKG line went flat.

At that point, the Doctor says, “I was so jangled emotionally. You panic because you … is it going well? When I did cadaver-blood work it was the same panic feeling. You know, when you’re doing something for the first time and nobody else in the country is doing it, you get scared. You know.”

The next time it’s going to be different, he says, the next time it’s going to go smoothly. The next time he’s going to use an improved model, one that’s going to be “built correctly with an engineer. I mean, that was a crude thing that I did it with.” The new-model Thanatron will, he says, be “infallible.”

Will there be a next time? That’s what this trial has been all about.

The courtroom battle was fought on three fronts:

—The conditions of the Doctor’s diagnostic process with Janet Adkins, from video to van.

—The rationality and competence of Janet Adkins’s decision to kill herself.

—And finally the real heart of the clash: the question of whether anyone under any circumstances, however ideal, has the right to commit suicide with the assistance of a doctor.

It’s important to keep in mind that the issue isn’t the right to suicide per se. Indeed, some of the prosecution witnesses conceded that they could understand certain patients’ decisions to end their lives. The questions before the court were, Did they have a right to a doctor’s help doing it, and does a doctor have the right to offer them such a service?

What it came down to in the courtroom was a clash between doctor witnesses and patient witnesses—the patients for the defense, the doctors for the prosecution.

Let’s look at the patient witnesses first because they provided the climactic emotional fireworks at the trial. Actually, waterworks might be more accurate: by the time the defense witnesses were through, Kleenex boxes were flying back and forth among the court officers, spectators were sobbing openly, and even some veteran reporters were doing it surreptitiously.

It was powerful stuff—a demonstration of why, regardless of the judge’s ultimate decision in the Kevorkian case, this issue isn’t going to go away: the kind of sufferers who took the stand to support the Doctor are going to be beseeching other doctors, besieging other courts, and embroiling us all in their terminal dramas in increasing numbers. An injunction is not going to make their pain go away.

The Doctor’s defense team had wanted to put more than patient witnesses on the stand. They’d wanted to call some doctors too, specifically some of the doctors who’d co-authored a landmark article in the prestigious New England Journal of Medicine called “The Physician’s Responsibility Toward Hopelessly Ill Patients—A Second Look.” The groundbreaking March 1989 article, which carried the byline of twelve respected doctors, caused a stir in the medical profession by endorsing “consideration” of physician-assisted suicide. Ten of the twelve co-authors stated they “believe that it is not immoral for a physician to assist in the rational suicide of a terminally ill person.… Clearly the subject of assisted suicide deserves wide and open discussion.”

The defense hoped to get at least some of the physician authors to take the stand and testify that the Doctor’s ideas—if not his actual procedure with Janet Adkins—were not beyond the pale, not a sure stepping-stone to Nazi euthanasia. Indeed, the New England Journal authors specifically noted that, while “some physicians and lay persons fear that active voluntary euthanasia, as practiced in the Netherlands, could lead to involuntary euthanasia and murder, as practiced by the Nazis, ethically, however, the difference is obvious.”

Geoff Fieger hoped to get one or more of the New England Journal authors to testify for the defense at the Doctor’s trial. The first two he reached said it would be “politically bad” for them to appear at the trial, according to Fieger.

“Doctors are cowards,” Fieger says bitterly.

Nonetheless, Fieger’s patient witnesses were pretty powerful on their own. First to take the stand was Sherry Miller, a forty-two-year-old mother of three who is so severely affected with multiple sclerosis that the only part of her wheelchair-bound body she can move is her left arm. What made her courtroom plea for death so moving was that, even in this terminally debilitated state, she’s a real firecracker, still full of life, but now using the last vestiges of the spirit that once animated her to plead for its extinction.

After being sworn in, Miller described in a loud, quavering voice only barely under her control how the disease had progressed, robbing her first of motor control, then control over her bodily functions, finally leaving her helpless, dependent on her aging parents to wash and feed her; with even her voice, her last link with the world, being slowly strangled in her throat.

How she’d wanted to find a way out of the terrible prison she’d found her body to be, and how Dr. Kevorkian, who she’d first seen on the Donahue show, seemed to her a godsend.

How, when she’d asked for his suicide services, he’d encouraged her not to take the ultimate step right away, but to seek further help; how he’d talked her into getting physical therapy and psychiatric counseling—options her own doctor had never suggested.

How relieved she had been that at last she’d found a doctor she could talk to. How she’d called him up a half-dozen times, “just to talk.” How he’d given her the strength to try those alternatives because she knew he’d be there to help her if they turned out to be of no avail.

And how bitterly disappointed she’d been when, after therapy and counseling failed to alleviate her suffering, and she renewed her request for the Doctor’s services, she’d found it was too late. The preliminary injunction against him denied her his help.

“I shoulda ended my life myself,” she said angrily toward the close of her testimony, “instead of waiting to where I can’t do anything on my own. I can’t get any pills now. I can’t get to them. I can’t get a gun. And how do you ask somebody to end your life?”

“The prosecutor says Dr. Kevorkian is a threat to you,” Fieger said. “That he’ll talk you into suicide.”

“I’m the one who is making the decision,” she said, painfully struggling to propel her words out through her recalcitrant voice muscles. “Nobody else. And I want that right … I mean, look at me! I want the right to die and I want the right to have help!”

The defense rested after the testimony of Virginia Bernero, mother of the late Victor Bernero, who died of AIDS a year ago. She described her son’s final days, how he sank deep into dementia, how the medical community “didn’t help me much, they made a lot of promises.” How she couldn’t afford nursing care, how her son had begged to be strapped to his bed in a straightjacket because he was hearing voices that told him to get a knife. How one night he was expelled from a nursing home because they couldn’t handle him. How, crazed with fear, he was handcuffed and shoved into the back of a police car, locked away in a crisis-center cell. How she wasn’t allowed in to see him for days until he was transferred to a hospital psychiatric ward.

When she came to get him, she said, “he was totally dehydrated, his lips were bleeding like an animal. It was then that he begged to die. He was frightened to death and told me, ‘I want to go now, please give me the whole bottle of pills.’ I couldn’t give it to him, simply because I didn’t think it would kill him,” Mrs. Bernero said. “I didn’t have the heart; I though it would make him more ill.”

“Why did you want to see Dr. Kevorkian?” Fieger asked.

“It was painless.… I wanted that for him.

Other doctors she consulted offered her son an “ethical” way to die that was “horrible,” she said. They told her they could withdraw the medicine and let him suffer an agonizing death.

“Do you believe Dr. Kevorkian is a threat to people such as you and your son?” Fieger asked.

“Not at all!” she said. “Dr. Kevorkian’s a wonderful, caring man. I don’t think he has a mean bone in his body.”

“But the medical ethicists say that the medical profession would be perceived as killers if they were involved in assisting suicide,” Fieger said.

“He should have had a choice,” she maintained. “Five days before he died, he said, ‘Mother, I want you to help me end this. You know what I mean.’”

“What did he mean?”

“His wish was to die at home in his bed,” she said, finally breaking into the sobs she’d been suppressing. “I’ll always feel guilty that I couldn’t give that to him.”

“I rest, your Honor,” Fieger told the court.

“No rebuttal,” said Modelski.

But, in fact, the prosecutor did have to address the question of why people like Sherry Miller and Victor Bernero must be forced to suffer the way they did and why denying them the relief they sought from Dr. K. was more important than giving them what they wanted. Why exactly would rescuing Victor Bernero from his dementia and torment lead down the slippery slope to Nazi-like euthanasia?

To answer this the prosecution relied heavily on the testimony of three nationally known “medical ethicists,” avatars of an increasingly prominent new specialty that combines law, medicine, and moral philosophy. The ethicists have been the featured players in the recurrent deathbed legal dramas of the Cruzan era.

Of the three—Dr. Nancy Dickey, former chairwoman of the A.M.A.’s Council on Ethical and Judicial Affairs; Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota; and Dr. Leon Kass, senior scholar at the University of Chicago’s Center for Clinical Medical Ethics—it was Kass’s testimony that was the most powerful and thought-provoking. It was, in part, because Kass seemed the most troubled, least dogmatic of the three. And because Kass was candid enough to admit on the stand that he had to wrestle with the doctor-assisted-suicide question in the case of his own mother. In her terminal decline, he said, his mother had begged him several times to help her die. He repeatedly turned down his own mother’s anguished pleas for relief, Kass said, a decision he claimed was vindicated when she came down with pneumonia and he asked her if she wanted to be taken to the hospital to have it treated and she said yes, she wanted treatment.

“The goal of causing death goes beyond the role of accepted medical practice,” Kass told the court. The separation between healing and killing is at the very heart of what makes doctors part of a moral profession, not a “set of hired syringes.” Breaching that separation “can lead to terrible consequences.”

One of these, Kass said, would be to subvert the trust that is the foundation of the doctor-patient relationship. Trust that would be fatally undermined if a patient knew that a doctor who came to heal him might also be considering the option of killing him.

Yet the ethicists’ claim to be guardians of the moral sanctity of the doctor-patient relationship was undermined, to my mind, when, on cross-examination, the A.M.A.’s Dr. Nancy Dickey was sharply questioned as to how her absolute separation of healing and killing applied to the doctors who pulled the plug on Nancy Cruzan. “Removing the feeding tube from Nancy Cruzan had the effect of killing her, right?” defense attorney Fieger asked Dickey.

No, she said. “Because the feeding tube was removed, the patient died.”

But does restructuring the sentence alter the reality of the deed? Dickey went on to defend this distinction-without-a-difference by claiming that removing the feeding tube didn’t have the explicit goal of causing death, it was just removing an artificial barrier to death. Passive euthanasia of an unconscious patient was ethical, Dickey said; assisting a conscious patient who wanted to kill herself was unethical.

“While it’s a very fine line,” Dickey conceded, “it’s an important line.”

Some might call this sophistry. I recently attended an informal conference of physicians and ethicists on the Kevorkian case and assisted suicide at a leading East Coast hospital (they asked that its identity not be disclosed so they could speak more frankly). I was surprised to find there was far more support for the concept of physician-assisted suicide—if not for Kevorkian’s amateurish, ad hoc procedure with Janet Adkins—among these doctors than the ethicist witnesses’ attack on it would have indicated. One doctor in particular had spent some time studying the Dutch euthanasia program, in which—under carefully restricted conditions monitored by several levels of review—terminally ill patients can get a lethal injection from their doctors.

“The Dutch say we in America are the ones who have ‘the slippery slope’ moral problem,” this doctor said. “They say that pulling the plug on unconscious patients who only ‘consent’ by proxy is far more morally questionable than complying with a dying patient’s conscious wish to end his life with dignity.” (There is, on the other hand, something a little scary about the magnitude of Dutch euthanasia practices. Extrapolating from estimates of 5,000 to 10,000 procedures a year in Holland might mean 75,000 to 150,000 euthanasia deaths here.)

For all the dancing back and forth over the “fine line,” Dr. Kass did deliver one blunt, powerful argument against giving doctors what he called a license to kill by assisting suicides. He described conversations on the subject he had had with “a colleague who for years worked in a hospice.”

The hospice doctor told Kass that the truly disturbing consequence of legitimizing doctor-assisted suicide would be that, in practice, no matter how many safeguards were set up, the individuals who would make up a disproportionate number of doctor-sanctioned suicides would be “troublesome” patients with no families, the lonely and friendless, the indigent and uninsured, who seemed not to have a life “worth living.” These would be the ones who would be “pushed into ending it” by doctors who overtly or subtly communicated to them that they’d be better off dead. That, particularly in an age of pressure for medical-economic triage, where shrinking funds have to be apportioned between the living and the dying, the “consent of the debilitated and weak and the poor might well be subtly manipulated and misconstrued.” The poor in state-supported institutions with minimal care to begin with would make up the greater share of those who “chose” to die that way.

Volunteering for the procedure, said Kass, “might be neither voluntary nor adequately informed.”

It’s an argument that’s hard to refute. And indeed the very argument Dr. Kevorkian used to try to refute it for me illustrated a disturbing deficiency in Kevorkian’s own thinking on the subject.

“What Kass is saying is that we can’t trust doctors!” Dr. K. told me indignantly. Can’t trust them not to grease the skids for the final exit of the troublesome poor. Yet, the Doctor seems blind to the irony of this position. He is, after all, the guy who reviles the entire medial profession as cowards, hypocrites, and liars.

So why should we entrust these doctors with the authority to choose who should die and when? While the Doctor claims to be supporting the principle of patient “autonomy” and “self-determination,” in reality his proposal would cede a good portion of that autonomy to the medical profession he’s so contemptuous of, giving doctors veto power over the patient’s decision to die.

His response to that is that the medical profession needs to develop a “bioethiatrics” specialty specifically trained and board-certified to deal with these difficult decisions. That ideally each decision on a patient’s request to die would have to be approved by a panel of these incorruptible “Untouchables,” as he likes to call them.

Yet he never was able to explain to me why a medical profession so corrupt to start out with, whose very best ethicists are “cowards and hypocrites,” would suddenly begin turning out legions of objective, compassionate, and wise “Untouchables.”

The Doctor’s fatal blindness to this flaw in the “pure rationality” of his theory was dramatically illustrated by a heated argument he had with his own lawyers on this issue at dinner following the final day of the trial.

It is a long, strange dinner. The Doctor seems to be in a subdued mood at the start, claiming to be certain the judge is going to rule against him. He is convinced, he tells me, that the medical establishment will succeed in “putting this back in the closet.” He despairs of ever getting his machine out of police impoundment. He seems undecided whether he’ll finish building the new machine he’s working on and take it on the road.

“I could go to another state,” he says at the bar of the Radisson Plaza Hotel. He speculates about ways to provide his “service” without using prescription drugs. (“They could yank my license and I still could do it,” he’s said before.)

What method would he use? I ask.

That’s no problem, he says. He’s got that all figured out. He has a technique tht requires no prescription drugs. It’s the method he’d use if he were planning his own suicide, he says.

Carbon monoxide gas.

“We were told in medical school,” he says later over dinner, “that carbon monoxide was the best way to commit suicide. All you do is get a tank of gas and a mask to breathe it through.”

“Wouldn’t that be pretty unpleasant, the choking and the asphyxiation?” I ask.

“No,” he says. “The gas itself offers a simple, painless, odorless death. Better than that,” the Doctor adds, “it leaves the body looking good. You look better dead than alive. Your complexion looks beautiful and pink. Gives your corpse a lovely, rosy glow.”

That final dinner ranges over many subjects before the blowup between the Doctor and his lawyers. The Doctor shows me a fugue he composed “with a whopping ending”; he shows me photocopies of some of his oil paintings (he says the originals were lost in the storage-company fiasco), hellish, Hieronymus Bosch–like allegorical landscapes with such titles as Nausea, Fever, and Genocide. (Dr. K. painted the frame of this last work with human blood, including his own.)

At one point he speaks stirringly of his empathy for the sense of loss and terror that drove Janet Adkins to seek succor from his device. “Imagine Janet Adkins,” he says. “Intelligent. Knew she liked music, couldn’t read it, couldn’t play it. She’d taught English, couldn’t even read it anymore. She realizes very soon, I won’t know who this man [she’s married to] is. I mean, that’s terrifying.”

The Doctor says he wouldn’t think twice about killing himself if he had Alzheimer’s. “I mean, you end up smearing your feces on the wall. No way. I knew why she was so anguished about this. And that’s why I wanted to help her. I felt so sorry for that woman. And who cares? Those ethicists don’t give a damn. I took a helluva risk. Don’t you think I knew what I was doing? The world’s worst condition—I knew I was going to get heat for it. But, for this anguished human being, I did it. Now, that’s what a doctor is supposed to do, right?”

He’s a man of curious contradictions. While he can display empathy on a person-to-person level, give a distraught patient like Sherry Miller the feeling she had a real human being to listen to her, nonetheless, when he starts operating on the level of “pure rationality,” as he calls it, he can sometimes sound frightening in a way that justifies even some of prosecutor Modelski’s extreme apprehensions about him.

Modelski cited to me a couple of passages from one of the Doctor’s treatises, the one called “A Comprehensive Bioethical Code for the Medical Exploitation of Humans Facing Imminent and Unavoidable Death”—what I’ve described as the Death Row Organ Harvest proposal. In one of them, Dr. K. speculates about beginning some of the death-row medical experiments without anesthesia. In another, “he starts by saying, Let’s move away from the emotionalism over the Nuremberg codes,” Modelski told me. In the final written argument the prosecutor quoted a passage in which the Doctor states that “those who can subordinate feelings of outrage and revulsion to more objective scrutiny must admit that a tiny bit of practical value for mankind did result [from the Nazi medical experiments].”

What Kevorkian calls “objective scrutiny” others might call inhumane blindness to context. His own lawyers get into a fight with the Doctor on that very issue toward the end of dinner.

The Doctor claims a number of non-death-row prisoners have expressed interest in a proposal that inmates serving terms longer than three years should have the option of asking for lethal injection or assisted suicide instead of serving out their terms.

Kevorkian’s legal team of Fieger and Marcus are outraged their client can entertain this notion. “Don’t you see how it will be perverted?” Fieger asks him. Prison authorities, guards with a grudge, can just tighten the screws on troublesome, litigious, or rebellious inmates, making their life so miserable they’ll look on the early-release option as their only escape.

“It’s one thing,” says Fieger, “for somebody who’s facing terminal illness to choose suicide. It’s another thing where a guy in prison is humiliated and horribly depressed over a prison term.”

“But guys in prison told me there are a lot of guys who would make that choice,” the Doctor replies, completely missing the point.

“First of all,” says Fieger, “this prison system is rife—I mean, you think the medical profession is capable of corruption, try the Department of Corrections. They will be eliminating people.”

Dr. K. doesn’t get it, but there’s a metaphorical connection here between his prison proposal and the medical-suicide service he’s offering. Because all the mortals are in effect condemned prisoners, condemned to live in a terminally decaying body with an unknown, but inevitable, execution date. Putting a device like the Doctor’s into the hands of corruptible prison guards or corruptible doctors ignores context, ignores the way it’s likely to become not just user-friendly but abuser-friendly. Who’s to guard the guardians?

Could it be that it’s better to let people seek suicide on their own, the old-fashioned way? Yes, it’s more difficult and painful to kill oneself without an anesthetic. But perhaps that ensures—more effectively than a snooze alarm—that only those who really want it, do it. On the other hand, what about those like David Rivlin and Sherry Miller who want to do it but can’t by themselves? Must they suffer because we can’t trust the medical profession not to abuse the procedure that gives them relief?

It’s the Doctor’s Dilemma; they owe us more persuasive and useful answers than they’ve given us so far. If we’re to respect their condemnation of Dr. Kevorkian, they have to convince us they’re doing something to fill the moral vacuum they’ve created, the one that Dr. K. rushed to fill with his Mercy Machine.

On February 5 the judge in the Kevorkian case issued a ruling against the Doctor, making her temporary injunction permanent. He is forever barred from using his machine in Michigan, and “permanently enjoined from employing any device to assist a person in committing suicide.” Nonetheless, the court did release his machine back to him, and his attorney is appealing the ruling.

At a press conference the day after the ruling was handed down the Doctor revealed that he was currently counseling a dentist dying of cancer on how to commit suicide using a Kevorkian-style device. And that despite the injunction, somewhere, sometime, somehow he planned to use his suicide machine again.

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Bob DeMarco is the editor of the Alzheimer's Reading Room and an Alzheimer's caregiver. Bob has written more than 1,400 articles with more than 9,000 links on the Internet. Bob resides in Delray Beach, FL.

Original content Bob DeMarco, the Alzheimer's Reading Room