The trouble with assisted suicide

It's rare when I start reading a magazine article knowing with dead certainty my position on an issue -- in this case doctor-assisted suicide -- and finish the article deeply uncertain. Daniel Bergner's article in the Times Magazine had exactly that affect on me today.

“Is there any way to accelerate this?” Susan Wolf’s father asked. Wolf, a professor at both the law and medical schools of the University of Minnesota who has devoted her career to bioethics, is among the nation’s most prominent thinkers about physician-assisted suicide, and I stopped in Minneapolis to see her on one of my trips to Washington. This summer, she recounted, her father lay in a hospital bed with cancer in his thyroid, lungs and liver that blocked his esophagus so that he couldn’t swallow and left his bedding soaked in blood. His question came without warning. The decision to remove life support had already been made. In agony, and with dignity having drained away, he was asking for something faster, something more.

Wolf had spent decades opposing assisted suicide. Her thinking isn’t the kind that the public tends to associate with the opposition. It is easy to see the fight against death-with-dignity laws as religiously driven, propelled by Catholics and by born-again Christians like Doug Gardner, set on defending the sanctity of life and the hegemony of God. The Catholic Church was the primary financial backer opposing the 1991 assisted-suicide initiative in Washington, and it will probably play the same role in the coming year. But progressive perspectives like Wolf’s, perspectives infused with feminism and with the politics of minority and disability rights, form some of the most influential opposition arguments. And these arguments seem to correspond with a wariness among women and minorities. National polls show Americans about evenly split on legalizing physician-assisted suicide, with majorities of women and African-Americans opposed. “Our base,” Christian Sinderman, a consultant to Gardner’s campaign, said, “is well-off, well-educated white men.”

On the same afternoon that she talked about her father’s question, Wolf, who wore a black blouse and black pants and reading glasses hooked over a beaded necklace, spoke about women: women as caretakers; women as affected by long-scripted cultural roles of sacrifice and suicide; women as prone to defer to the paternalism of their physicians, who are most often men. She looked composed as she sat in her living room filled with antiques, below a painting of a white surf rushing toward sandy cliffs, but her voice was filled with urgency.

If women are expected, above all, to care for others, for children, parents, husbands, she asked, aren’t they particularly likely to view their own lives as without value when they become so sick or disabled that they are the ones who must be cared for? Might they be especially likely, at that point, to see themselves as burdens and, if assisted suicide were legal, to request that their deaths come right away? And might this tendency be compounded by a cultural lineage exalting female suicide, a tradition going back, Wolf suggested, borrowing from the work of the French classicist Nicole Loraux, to Greek tragedy, where suicide is carried out almost exclusively by women?

“This lineage has implications,” Wolf writes. “It means that even while we debate physician-assisted suicide and euthanasia rationally, we may be animated by unacknowledged images that give the practices a certain gendered logic.” Words like these could sound academic, and Wolf’s fears could seem theoretical. But her ideas aren’t easy to dismiss when considered alongside the killings administered by Jack Kevorkian, the Michigan physician who, between 1990 and 1999, made a personal crusade of helping the suffering to die, mostly by hooking them up to his self-designed death machines, the Thanatron and the Mercitron.

The first reported patient to seek him out and receive his aid was a 54-year-old woman with Alzheimer’s disease. His first eight such patients were women, and half of them had no terminal condition. Of the reported 75 suicides Kevorkian assisted through 1997, according to research by Silvia Canetto, a psychology professor specializing in the study of suicide at Colorado State University, 72 percent were women, and more than three-quarters of those women were not terminally ill. (Multiple sclerosis affected about 30 percent of them.) The disproportionate number of women could not be explained by the fact that women generally live longer than men and so might be more likely to want to escape life at its end. The average age of Kevorkian’s female patients was a year younger than that of his men. And, Canetto noted, Kevorkian’s women were more often middle-aged than elderly.

Canetto had examined, as well, information gathered by the Hemlock Society — a death-with-dignity organization that has since evolved into Compassion and Choices and is helping to finance and advise Gardner’s campaign — on 102 mercy killings in the United States between 1960 and 1993. Sixty-five percent of those killed were women. About 90 percent of those who performed these mercy killings were men, who tended to be spouses or sons of the women and who most often used a gun. The data in this second Canetto study are problematic: the Hemlock Society information consisted mostly of collected newspaper reports, and this may have skewed the numbers for several reasons, among them that violent deaths are more likely to get the attention of the media — and are more likely to be the work of men. But there seems nothing suspect about the Kevorkian figures, and together the two studies made Wolf seem less like a professor conjuring concern from abstraction and more like a quiet prophet.

How could physicians not be affected by society’s vision of what makes women’s lives worthwhile? And how could female patients not be influenced by the societal judgments reflected in their doctors’ eyes, especially when their doctors bore the inherent power of being male and when those societal judgments were already so deeply internalized within the patients themselves? To incorporate the delivery of death into medical training would, Wolf said, cause a fundamental shift in medical consciousness; the condoning and teaching of assisted suicide would mean, in ways both subtle and significant, that such aid was encouraged. And when a doctor was confronted with a desperately ill and despairing woman, he would be more likely to think, under laws like Gardner’s, that she would be better off dead. Whether the patient requested death and the doctor swiftly agreed, or whether the doctor softly suggested it and the patient, confronting a verdict of her own worthlessness, consented, the result would be the same.

“My life, my death, my control,” Gardner liked to say, but Wolf wondered about this logic of autonomy, a logic underpinning the individual rights arguments that drive the death-with-dignity movement and that come down to a simple question: Why shouldn’t my death be my choice? Wolf wondered whether autonomy was equally available to everyone. Absolute claims of individual rights, Wolf writes, “wrongly assume that all face serious illness and disability with the resources of the idealized rights bearer a person of means untroubled by oppression. The realities of women and others whose circumstances are far from that abstraction’s will be ignored.”

Yet two months earlier her father confronted her with his reality. He had once been a lawyer with his own small practice and a love of battling large firms. “Powerful, intimidating, very much in command,” she remembered him. Now he was wasted nearly to nothing. Now he was terrified. All he had left, it seemed, was his full head of graying hair. “He looked up at me in the I.C.U.,” she recalled, “and asked — it was pathetic — what will happen? Will I see it coming or will I fade away?” And soon after that he asked if his death could be accelerated.

“It was an excruciating moment,” she said. She knew from her work that it was sometimes done; illegally, discreetly, lethal doses of drugs were administered. “No,” she told him. Her reply was reflexive, spoken before it was fully considered.

The doubt rushed in after she stepped away from his bedside. “ ‘No’ was consistent with everything I’ve said and written for two decades,” she told me, “but there was my father in that bed. Do I still believe this? Is the answer still no? Now that I’m in the fire, do I still hold to it? I did not want to see him suffer — his fear, his anxiety. I rethought everything. I really struggled.”

But the answer didn’t change. “I had a sense that there was a wall there, and that it was there for lots of reasons.” Her father had always loved it when she stroked his thick hair, and that was what she did at his bedside, over and over, while he waited.

I was an unblinking supporter of Oregon's assisted suicide statute and, had I not read this article, would have been supportive of Washington state's.

Now, I'm not so sure. With such laws in place, would someone I love, suffering from a chronic though not terminal disease, decide to end her life because I've said something like "I hate to see you like this?" Would she feel she has a responsibility to end her life because there is a law in place permitting her to.

As for Bergner's article, though, the main protagonists he chose, Booth Gardner and his son, Doug, come across as incredibly self-absorbed. The son, especially (get over your childhood, man) And the larger family group, living on some sort of Washington coast compound -- including an ex-wife -- is a very odd one. Dramatic narratives help make difficult subjects more compelling, but in this case it was mostly distracting from the more interesting ethical discussion.