Jack Kevorkian drove the debate on physician-assisted suicide

Jack Kevorkian was a highly controversial figure who confronted one of society’s most profound ethical issues: what happens at the end of an individual’s human life and whether or not a physician should take an active role in hastening that process.

Dr. Kevorkian, who died Thursday, spent eight years in a Michigan prison, but not before he had been directly involved in the suicide of more than 130 people – sometimes in the back of his old Volkswagen van using a device he had invented to administer lethal substances.

But beyond his own history of sometimes outrageous behavior as he challenged the legal and medical establishments, Kevorkian also drove the debate on physician-assisted suicide – a political and legal fight involving state courts and legislatures, the US Justice Department, and the US Supreme Court.

The first known instance of Kevorkian using his “suicide machine” involved an Oregon woman in 1990. The last was in 1998, videotaped and broadcast on “60 Minutes,” and the case for which Kevorkian was convicted of second-degree homicide.

Between those dates, the effort to legalize controlled suicide involving help from a medical doctor took form with advocacy organizations like the Hemlock Society and Compassion & Choices.

'Death with Dignity' law breaks new ground

After two ballot measures in which voters approved the procedure (the second time in a rebuff to the state legislature), Oregon’s “Death with Dignity” law became the first in the country.

The Oregon law, enacted in 1997, strictly prohibits “lethal injection, mercy killing, or active euthanasia.” But it allows mentally competent adults who declare their intentions in writing, and have been diagnosed as terminally ill, to take a doctor-prescribed lethal drug themselves, orally, after a waiting period.

Critics had predicted that vulnerable patients could be pressured by doctors or family members to end their lives, and they also warned that out-of-staters might rush to Oregon to take advantage of its law.

Apparently, neither has happened. Since 1998, 525 patients have taken their own lives under the law, averaging about 60 a year for 2008-10.

At the same time, what medical practitioners consider ideal end-of-life care has increased here, including palliative treatment for discomfort, hospice care, and care that allows patients to spend their last days at home with families and friends.

Oregonians are also more likely to have "living wills" – documents in which they ask not to be kept alive by artificial means if recovery seems improbable – and medical directives on file, and they're more likely to decline medical treatments (including feeding and hydration tubes) that prolong life.

While Oregon is unique in some ways – it's the most "unchurched" state, with residents less likely to be members of or regularly attend churches, synagogues, or mosques – it also reflects the kind of leave-me-alone libertarianism seen in parts of the West.

Few states followed Oregon's lead

Just two states have followed Oregon’s lead. Washington passed a similar law, and the Montana Supreme Court last year ruled that that neither state law nor public policy prevented doctors from prescribing lethal drugs to terminally-ill patients who want to end their lives. Efforts in other states have failed.

During the Bush administration, then-Attorney General John Ashcroft, an opponent of abortion and legalized suicide since his days as a US senator, ruled that under the federal Controlled Substances Act, doctors may not prescribe drugs for the purpose of hastening death.

The United States Conference of Catholic Bishops, antiabortion groups, and other conservative organizations hailed the attorney general's ruling. Some medical professionals argued that helping a patient take his or her own life violates the Hippocratic Oath.

In essence, legal opponents of physician-assisted suicide argued that barbiturates and morphine (the legal drugs typically used in physician-assisted suicide) should be seen in the same light as marijuana, which is an illegal drug under federal law.

US Supreme Court weighs in

But in a 6-to-3 ruling in 2006, the US Supreme Court decided that Oregon's Death With Dignity Act could not be blocked by the Bush administration's interpretation of federal drug laws.

Euthanasia, in which a doctor ends the life of a patient – either with or without that person's explicit permission – is illegal in the United States.

It has been allowed under certain circumstances in the Netherlands and Belgium. But there has been some evidence that the practice is more widespread than reported – including in the United States. In at least one case, Kevorkian admitted that it was he – and not his patient – who had operated the “suicide machine.”

Throughout his life Kevorkian remained a highly controversial figure – a death-dealing zealot to some, way ahead of the medical profession in end-of-life issues to others.

“He was involved in this because he thought it was right, and whatever anyone wants to say about him, I think that’s the truth,” Arthur Caplan, a professor of bioethics at the University of Pennsylvania, told The Washington Post. “He didn’t do it for the money, he didn’t do it for the publicity, he wasn’t living a luxurious life – he wanted change.”

“I think Jack Kevorkian was like a flare on the battlefield,” Mr. Caplan said. “He lit up the issue and everyone paid attention.”