Sunday, June 5, 2011

Jack Kevorkian: Goodbye, Good Riddance

The news of Jack Kevorkian's death brought out a large number of laudatory comments in The New York Times (laudatory about the man rather than his death, natch). "I hope that one day the world will look back on the service Dr. Kevorkian provided and will be shocked and saddened to learn that he was ostracized and incarcerated for the practice of providing dignity and some control to those in the late stages of terminal illness," SteveBnh of Virginia wrote in a representative sample of the praise heaped on the crusader for physician-assisted suicide.

Count me among the ostracizers. As the warm comments from seemingly well-informed readers demonstrates, Kevorkian was widely perceived to be a fierce advocate for patient's rights, a promoter of death with dignity, and the victim of a hypocritical and vindictive profession hellbent on maintain its Godlike power over patients. His trial, conviction, and imprisonment in 1999 for second-degree murder has the flavor of martyrdom, reinforcing the admiration of his followers and inviting comparisons to various legendary civil-rights activists.

In reality, Kevorkian was none of these things, but rather a creepy zealot obsessed with death who knew nothing about actual patient care. (I am not using the word "creepy" lightly; read on.) Although he was trained at a bonafide medical school and thus was a "doctor" in the general sense of the term, his training and subsequent practice was in pathology, where his work involved autopsies and analysis of human tissues on slides rather than actually taking care of living, breathing souls with joys and fears--making his public persona as "doctor" a bit misleading, as if he were the same as Marcus Welby, M.D. Kevorkian's nickname, "Doctor Death", didn't come from the notoriety he generated in the 1980s and '90s, but rather from perplexed and amused housestaff during his early days in a wry observation about his peculiar fixation on photographing patients' eyes at the precise moment of death. (Various blogs and websites supportive of Kevorkian state that this is because he wanted the profession to be able to distinguish the moment so that resuscitation could be performed, or something to that effect. It's utter nonsense: even in the 1950's, which some might consider the Dark Ages by medical standards, there were EKGs, a considerably more precise tool to determine death than staring into people's eyes, which seems positively medieval. Whatever his stated justifications, his "death photography" was pure fetish.) Long before he took up physician-assisted suicide as his cause, he bounced from hospital to hospital, disturbing various medical staffs with his distinctly unconventional preoccupations.

He was praised for his compassion despite the fact that he had not only not taken care of living patients except during his internship, but had never received any training of any kind in treating patients with depression (common enough among the terminally ill), palliative care, or any of the diseases that he claimed to treat. His choices reflect this very poor training: among the 130 or more cases in which he was the prescriber of death, several had no terminal illnesses nor were suffering, such as the case of Janet Adkins, who had been recently diagnosed with Alzheimer's disease but aside from mild memory loss was in otherwise reasonably good health.

Even more disturbing were the reports of the death of Judith Curren, a 43 year-old woman who not only didn't have a clear-cut underlying disorder, she had reportedly been a victim of domestic violence. These are not the only cases, but even the inclusion of these two suggests at best a sloppiness in methods, and at worst a murderous instinct hidden under the guise of medical concern for suffering. ("How could I have known?" was Kevorkian's retort after being confronted with the news of the messy life of the Curren family. Perhaps if his only acquaintance with them had not been through a questionnaire, and had been based on caring for Judith Curren in a legitimate medical practice for several years, such surprises wouldn't have popped up.)

In short, Dr. Kevorkian-the-Caring was a total media fabrication. He was a murderer, and if anything was treated gently by the justice system.

Other, far more responsible doctors have spoken out in favor of physician-assisted suicide--doctors who personally knew and ministered to their patients before taking the terrifying power into their hands and helped patients end their lives, doctors who gave such power its proper due, only arriving at that moment after slow and careful deliberation, wholly unlike Dr. Kevorkian's quickie-in-a-Volkswagen butchery. Perhaps the most famous of these doctors is Timothy Quill, a practicing doc in New York who challenged the ban on physician-assisted suicide in the State of New York which was ultimately decided by the US Supreme Court; the court decided 9-0 against Dr. Quill. Even Quill, as forceful an advocate for physician-assisted suicide as could be, found Kevorkian's behavior troubling, saying that he "is very much on the edges of what ordinary doctors do."

I have heard Timothy Quill speak on two occasions and found him an eloquent man whose concerns are ultimately for the health and happiness of his patients. That said, I still believe that physician-assisted suicide is a terrible idea. Ironically, the two times I attended lectures by Dr. Quill mark dramatic shifts in opinion I have had on the subject: the first time happened before I started medical school and was strongly in favor of his ideas, while the second time was a few years ago, after I had undergone more than a decade of medical training, and my attitude had changed considerably.

Generally, the discussions about physician-assisted suicide revolve around two themes. The first is what bizzyblog refers to as "the euthanasia theme song," or having a life that is not worth living. The second deals with the scenario of unbearable and unremitting suffering, which the supporters of physician-assisted suicide regard as the ultimate justification for the practice. This is often where the accusations of "doctors playing God" come in--docs are so invested in keeping people alive that they consider it a personal affront to allow patients to die. (In general, my experience has been the opposite, not withstanding the rather regrettable final few days of my father's life, in which we attempted in vain for several days to have his life-support removed after an episode of sudden cardiac death. Based on what I've seen, it's usually the doctors, and not the families, who see little or no value and much suffering in store for families and patients with terminal illness requiring intubation, PEG tubes and the like, and often have difficulty explaining to families the benefits of "letting nature take its course.")

It turns out that, not unlike the public misperceptions of Dr. Kevorkian, the picture of frequent, unremitting suffering of the terminally ill is for the most part a fiction. Curiously, over the past 20 or so years attitudes about physician-assisted suicide and euthanasia haven't changed a great deal among the general public or physicians in general (those numbers are different from one another, but stable over time). However, one group in which attitudes have changed significantly is among oncologists, who have had a steep drop in approval for those practices.

Why? It's hard to say with complete certainty, but it's likely because oncologists are more aware of, and tuned into, the multiple ways in which terminally ill patients can remain pain-free and finish their lives with meaning and dignity, to paraphrase the article in the link. A telling statistic: among oncologists, surgical oncologists, who deal with the long-term care of their patients far less often, were twice as likely to support physician-assisted suicide as their medical oncologist colleagues. In other words, the further away one gets from the actual practice of death and dying, the greater the fear of pain and suffering among laypeople and physicians alike, and the corresponding increase in support of physician-assisted suicide.

As for judging whether a life is worth living, that's much more straightforward. Physician's have no business judging the worth of any of their patients' lives. That is playing God.

It is not hard to kill onself in the US: over 30,000 people do it each year, and do it in a multiplicity of ways ranging from relatively peaceful to gruesome. And while there are technically laws on the books against suicide and no Supreme Court recognition of a "right to suicide," the practice is tacitly accepted. Suicides are allowed to be buried with everyone else, and the state does not seize their assets. So given the ease by which people can commit suicide, the debate around physicians being involved in the taking of lives has increasingly for me had an odd ring about it. Why must physicians be present to sanctify this process? It has the feel of approval-seeking, and docs shouldn't be in the business of approving or disapproving anything about a patient's lifestyle, except maybe smoking. Even then: maybe.

Doctors cannot take lives; it's not our job and should never be so. If we administer comfort medications that may hasten death to a suffering patient as a side effect, that is more than acceptable. If doctors withdraw tubes or machines that "artificially" keep patients alive, that's fine as well. But there's a big difference between maintaining a morphine drip and injecting a bolus of potassium chloride into a patient. The former is a drug with legitimate medical uses; the latter is never used under any conditions except to kill. Morphine is an everyday drug in hospices across the US; the potassium bolus was a "medication" unique to Dr. Kevorkian. May there never be another one like him again.
--br

3 comments:

  1. Great post. Great points.

    I updated my post with a few excerpts from here.

    Tom Blumer
    BizzyBlog.com

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  2. Great post. I'm a "liberal," and I am the ONLY person amongst all my friends who is not for euthanasia. My opinion is unpopular, to say the least.

    As a person with a chronic illness, this issue has scared me. Who gets to decide if my quality of life is good enough? Will there come a time when "people like me" are encouraged to commit suicide?

    The documentary film "The Suicide Tourist" showed Craig Colby Ewert, a seemingly responsible and sane man, carry out his suicide with the help of another seemingly rational organization, Dignitas.

    Though I hate to criticize Mr. Ewert, I fear that portrayals of people like him give the public the message that suicide is the mature and responsible thing to do when one is faced with the loss of one's normal role in life. We are not encouraged to re-envision life without optimal functioning. Needing assistance, whether that be physical, emotional, or financial, is no longer considered as a naturally interdependent (which we all are, whether well or sick), but simply a burden on resources and people.

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  3. Joseph P Arpaia, MDJune 11, 2011 at 1:56 AM

    Thanks for an eloquent post.

    ReplyDelete