Janet Adkins’s last words were “Thank you, thank you.” She addressed them to Dr. Jack Kevorkian on the afternoon of June 4, as she lay on a makeshift bed in the doctor’s rusting 1968 Volkswagen van, which was parked in a municipal campground outside Detroit. The 54-year-old Adkins, a Portland, Ore., resident and diagnosed victim of Alzheimer’s disease, was connected intravenously to a device that the doctor had assembled. Describing Adkins’s death last week, Kevorkian said that he told her to “have a good trip.” Then, Adkins pushed a button and activated a motor that pumped a powerful barbiturate and deadly potassium chloride into her bloodstream. Within seconds, said Kevorkian, the woman died of a massive heart attack. Adkins’s death reignited a long-simmering debate in North America, and throughout much of the world, over euthanasia and the right of terminally ill individuals to end their own lives.
While Michigan law enforcement officials debated whether they could charge 62-yearold Kevorkian with a criminal offence, American right-to-die activists praised his actions. The 34,000-member Eugene, Ore.-based Hemlock Society advocates doctor-assisted suicide for the terminally ill, and several affiliated organizations are attempting to have laws passed to legalize the practice in four states. But the Ottawa-based Canadian Medical Association (CMA) and the Chicago-based American Medical Association (AMA), the largest professional organizations representing doctors in the two countries, both firmly oppose active euthanasia or doctor-assisted suicide. Said Dr. John Ring, chairman of the AMA’s board of trustees: “Under no circumstances should a physician intentionally cause death.”
Despite that, both associations permit acts
of passive euthanasia—the withdrawal of life-sustaining medication or devices when a patient is considered to be permanently unconscious and beyond recovery. Eike Kluge, the CMA’s director of ethics and legal affairs, said that the association’s policy, adopted in 1987, applies essentially to patients who have suffered severe and irreversible brain damage as a result of head injuries or drug overdoses, or to patients in the advanced stages of debilitating diseases such as cancer. Since 1984,
Normally, doctors withhold treatment only
the CMA has also had a so-called do-not-resuscitate policy, which applies to terminally ill patients who suffer heart attacks. Kluge said that doctors sometimes issue DNR orders when a patient is dying from another disease, such as cancer, and has no chance of recovering. To resuscitate these patients only prolongs the dying process, he said. after consulting a patient’s next of kin or if they are following wishes that the patient expressed while conscious and mentally competent. Kluge admitted that Canadian doctors sometimes remove life-support devices without the consent of the family if there is a shortage of such equipment. Doctors only take such actions when forced to choose between a terminally ill patient who is near death and a patient who has some chance of recovering. Said Kluge: “Where we are dealing with a permanent vegetative coma, most of the time it is inappropriate to continue treatment.” Withdrawing medical treatment could become a much more complex issue in the United States when the Supreme Court issues a ruling in the Nancy Cruzan case. The 32-year-old Missouri woman has existed in what some doctors call a “persistent vegetative state” since she was involved in a car accident in 1983. Five years later, a Missouri circuit court judge gave Cruzan’s parents permission to remove the surgically implanted tube that provides her with food and fluids. But the state appealed, and the Missouri Supreme Court overturned the circuit court decision in November, 1988. The Cruzan family appealed to the Supreme Court, which agreed last July to hear a right-to-die case for the first time. Many observers predict that, if the high court rules in favor of the state of Missouri, that would allow other states to pass laws prohibiting the withdrawal of medical treatment for the terminally ill.
Still, when a competent patient can express his wishes, doctors in Canada and the United States must listen, even when the patient chooses to avoid treatment. By the end of last year, almost 40 American states had passed natural-death laws that allow individuals to prepare so-called living wills. These documents are generally drafted by lawyers and signed by witnesses. Such a document can state that a person does not want to be kept alive by breathing devices, artificial feeding or
“heroic” medical efforts if they are unlikely to recover from the extreme physical or mental disability caused by an illness or accident.
In Canada, doctors complain that living wills are often vague or poorly drafted, according to Kluge. As a result, physicians frequently consult family members or obtain legal advice before deciding whether to adhere to a living will, he added. Furthermore, no Canadian province has adopted legislation that would give such documents
legal standing. But Kluge and others point out that Canadian court decisions have established that doctors must abide by the wishes of a patient who is capable of refusing medical treatment. Margaret Somerville, director of the McGill Centre for Medicine, Ethics and Law in Montreal, said that “what has become clear, over the past five years in particular, is a very strong recognition that competent adults have the right to decide what treatment they want.”
The difficulties begin when doctors treat patients who can no longer speak for themselves. Dr. Balfour Mount, who specializes in the treatment of terminally ill cancer patients at Montreal’s Royal Victoria Hospital, said that in many cases physicians must decide whether such devices as respirators sustain life or merely prolong dying. He said doctors face a similar choice when a terminally ill patient contracts an illness like pneumonia, which could result in a quicker and less painful death if it were left untreated. Said Mount: “Where there is no reasonable expectation of regaining quality of life, I would find it difficult to prolong suffering needlessly.”
Many physicians reject what they view as aggressive treatment of terminal illness through the use of life-sustaining devices. Dr. Rory Fisher, head of the 500-bed extendedcare department at Toronto’s Sunnybrook Health Sciences Centre, said that his primary objective when treating the terminally ill is to relieve suffering by administering medication. He said that minimizing the patient’s pain and discomfort is the best compromise possible. Doing nothing would be unacceptable, he said, while the use of artificial breathing or feeding devices may prolong dying and increase an individual’s suffering.
Still, some right-to-die activists say that the medical profession’s attempts to minimize suffering ignore the patient’s right to a quick and dignified death. Derek Humphry, executive director of the Hemlock Society, said that he founded the organization 10 years ago in order to promote public awareness and acceptance of euthanasia. He said that every individual who is terminally ill should have the legal right to end his life, either in his home or in a local hospital, with the help of a co-operative doctor. Humphry predicted that active euthanasia will be a standard part of American medicine within a decade. He contends that the practice would alleviate the suffering of thousands of hopelessly ill people like Janet Adkins. Said Humphry: “It is indecent what she was forced to do by antique laws and our head-in-the-sand medical establishment.”
But Kevorkian insists that Adkins was calm and content in the days leading up to her death. He said that Adkins, her husband, Ronald, and her best friend arrived in Detroit on June 2 after a sightseeing stop in Minneapolis, and the four of them had dinner that evening at a seafood restaurant in suburban Detroit. Kevorkian said that Janet Adkins could still play tennis, but could no longer read books or play music because her mental capabilities were deteriorating. He said that Adkins told her husband and friend to stay at their hotel in a Detroit suburb rather than be present at her death. “She was a very strong woman,” said Kevorkian. “She kept us all happy prior to her death.” And while she found a peaceful solution to her problems, Janet Adkins triggered a new round of debate about a deeply rooted taboo.
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