The Kevorkian Epidemic
The Kevorkian Epidemic
By Paul R. McHugh
Paul R. McHugh is the Henry Phipps Professor and Director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and author, with Phillip R. Slavney, of The Perspectives of Psychiatry and Psychiatric Polarities. This article is printed in Christian Ethics Today with the kind permission of the editors of The American Scholar, where it appeared in the Winter, 1997 issue, and the author, Dr. McHugh.
Dr. Jack Kevorkian of Detroit has been in the papers most days this past summer and autumn helping sick people kill themselves. He is said to receive hundreds of calls a week. Although his acts are illegal by statute and common law in Michigan, no one stops him. Many citizens, including members of three juries, believe he means well, perhaps thinking: Who knows? Just maybe, we ourselves shall need his services some day.
To me it looks like madness from every quarter. The patients are mad by definition in that they are suicidally depressed and demoralized; Dr. Kevorkian is "certifiable" in that his passions render him, as the state code specifies, "dangerous to others"; and the usually reliable people of Michigan are confused and anxious to the point of incoherence by terrors of choice that are everyday issues for doctors. These three disordered parties have converged, provoking a local epidemic of premature death.
Let me begin with the injured hosts of this epidemic, the patients mad by definition. At this writing, more than forty, as best we know, have submitted to Dr. Kevorkian`s deadly charms. They came to him with a variety of medical conditions: Alzheimer`s disease, multiple sclerosis, chronic pain, amyotrophic lateral sclerosis, cancer, drug addiction, and more. These are certainly disorders from which anyone might seek relief. But what kind of relief do patients with these conditions usually seek when they do not have a Dr. Kevorkian to extinguish their pain?
Both clinical experience and research on this question are extensive–and telling. A search for death does not accompany most terminal or progressive diseases. Pain-ridden patients customarily call doctors for remedies, not for termination of life. Physical incapacity, as with advanced arthritis, does not generate suicide. Even amyotrophic lateral sclerosis, or Lou Gehrig`s disease, a harrowing condition I shall describe presently, is not associated with increased suicide amongst its sufferers. Most doctors learn these facts as they help patients and their families burdened by these conditions.
But we don`t have to rely solely upon the testimonies of experienced physicians. Recently cancer patients in New England were asked about their attitudes toward death. The investigators–apparently surprised to discover a will to live when they expected to find an urge to die–reported in the Lancet (vol. 347, pp. 1805-1810, 1996) two striking findings. First, that cancer patients enduring pain were not inclined to want euthanasia or physician-assisted suicide. In fact, "patients actually experiencing pain were more likely to find euthanasia or physician-assisted suicide unacceptable." Second, those patients inclined toward suicide–whether in pain or not–were suffering from depression. As the investigators noted: "These data indicate a conflict between attitudes and possible practices related to euthanasia and physician-assisted suicide. These interventions were approved of for terminally ill patients with unremitting pain, but these are not the patients most likely to request such interventions….There is some concern that with legislation of euthanasia or physician-assisted suicide non-psychiatric physicians, who generally have a poor ability to detect and treat depression, may allow life-ending interventions when treatment of depression may be more appropriate." (Italics added to identify mealymouthed expressions: interventions means homicides, and some means that we investigators should stay cool in our concerns–after all, it`s not we who are dying.)
None of this is news to psychiatrists who have studied suicides associated with medical illnesses. Depression, the driving force in most cases, comes in two varieties: symptomatic depression found as a feature of particular diseases–that is, as one of the several symptoms of that disease; and demoralization, the common state of mind of people in need of guidance but facing discouraging circumstances alone. Both forms of depression render patients vulnerable to feelings of hopelessness that, if not adequately confronted, may lead to suicide.
Let me first concentrate on the symptomatic depressions because an understanding of them illuminates much of the problem. By the term symptomatic, psychiatrists mean that with some physical diseases suicidal depression is one of the condition`s characteristic features. Careful students of these diseases come to appreciate that this variety of depression is not to be accepted as a natural feeling of discouragement provoked by bad circumstances–that is, similar to the downhearted state of, say, a bankrupt man or a grief-stricken widow. Instead the depression we are talking about here, with its beclouding of judgment, sense of misery, and suicidal inclinations, is a symptom identical in nature to the fevers, pains, or loss of energy that are signs of the disease itself.
A good and early example of the recognition of symptomatic depression is found in George Huntington`s classical (1872) description of the disorder eventually named after him: Huntington`s disease. Huntington had first seen the condition when he was a youth visiting patients with his father, a family doctor on Long Island. He noted that one of the characteristic features of the condition was "the tendency to…that form of insanity which leads to suicide." Even now between 7 and 10 percent of non-hospitalized patients with Huntington`s disease do succeed in killing themselves. Psychiatrists and neurologists have perceived that Parkinson`s disease, multiple sclerosis, Alzheimer`s disease, AIDS dementia, and some cerebral-vascular strokes all have this same tendency to provoke "that form of insanity which leads to suicide."
That these patients are insane is certain They are overcome with a sense of hopelessness and despair, often with the delusional belief that they are in some way useless, burdensome, or even corrupt perpetrators of evil. One of my patients with Huntington`s disease felt that Satan was dwelling within her and that she acted in accordance with his wishes. These patients lose their capacity to concentrate and reason, they have a pervasive and unremitting feeling of gloom, and a constant, even eager willingness to accept death. These characteristics of symptomatic depression recur in all the diseases mentioned above. Multiple sclerosis (MS) patients are frequently afflicted by it. Some five or six of Dr. Kevorkian`s patients had MS.
The problematic nature of symptomatic depression goes beyond the painful state of mind of the patient. Other observers–such as family member and physicians–may well take the depressive`s disturbed, indeed insane, point of view as a proper assessment of his or her situation. It was this point that Huntington, long before the time of modern anti-depressant treatment, wished to emphasize by identifying it as an insanity. He knew that failure to diagnose this feature will lead to the neglect of efforts to treat the patient properly and to protect him or her from suicide until the symptom remits.
Such neglect is a crucial blunder, because, whether the underlying condition is Huntington`s disease, Alzheimer`s disease, MS, or something else, modern anti-depressant treatment is usually effective at relieving the mood disorder and restoring the patient`s emotional equilibrium. In Michigan and in Holland, where physician-assisted suicide also takes place, these actions to hasten death are the ultimate neglect of patients with symptomatic depression; they are, really, a form of collusion with insanity.
The diagnosis of symptomatic depression is not overly difficult if its existence is remembered and its features systematically sought. But many of its characteristics–such as its capacity to provoke bodily pains–are not known to all physicians. The fact that such depression occurs in dire conditions, such as Huntington`s disease, may weigh against its prompt diagnosis and treatment. Again and again, kindly intended physicians presume that a depression "makes sense"–given the patient`s situation–and overlook the stereotypic signs of the insanity. They presume justifiable demoralization and forget the pharmacologically treatable depressions.
Over the last decade, at least among psychiatrists, the reality of symptomatic depressions has become familiar and treatment readiness has become the rule. Yet not all sick patients with life-threatening depression have symptomatic depressions. Many physically ill patients are depressed for perfectly understandable reasons, given the grueling circumstances of their progressive and intractable disease. Just as any misfortune can provoke grief and anxiety, so can awareness of loss of health and of a closed future.
Well-titled demoralization, this depression, too, has a number of attributes. It waxes and wanes with experiences and events, comes in waves, and is worse at certain times–such as during the night, when contemplating future discomforts and burdens, and when the patient is alone or uninstructed about the benefits that modern treatments can bring him.
In contrast to the symptomatic depressions that run their own course almost independent of events, demoralization is sensitive to circumstances and especially to the conduct of doctors toward the patient. Companionship, especially that which provides understanding and clear explanations of the actions to be taken in opposing disease and disability, can be immensely helpful in overcoming this state and sustaining the patient in a hopeful frame of mind.
The obverse is also true. If faced by inattentive physicians–absentee physicians most commonly–patients can become more discouraged and utterly demoralized by what they assume is their physician`s resignation from a hopeless battle. All patients afflicted with disease–curable or incurable–are susceptible to bleak assumptions about their future and their value. These susceptibilities can be magnified or diminished by the behavior of their physicians.
The therapeutic implication here is that despairing assumptions wither if directly combated and shown to be an inaccurate analysis of the situation. Demoralization is an eminently treatable mental condition. Hopeless doctors, however, ready to see patients as untreatable, produce hopeless patients. The combination of the two produces a zeal for terminating effort. "What`s the point?" becomes the cry of both patient and doctor.
This is the point: Depression, both in the form of a symptomatic mental state and in the form of demoralization, is the result of illness and circumstances combined and is treatable just as are other effects of illness. These treatments are the everyday skills of many physicians, but particularly of those physicians who are specialists in these disorders and can advance the treatments most confidently.
Most suicidally depressed patients are not rational individuals who have weighed the balance sheet of their lives and discovered more red than black ink. They are victims of altered attitudes about themselves and their situation, which cause powerful feelings of hopelessness to abound. Doctors can protect them from these attitudes by providing information, guidance, and support all along the way. Dr. Kevorkian, however trades upon the vulnerabilities and mental disorders of these patients and in so doing makes a mockery of medicine as a discipline of informed concern for patients.
Let us turn to Dr. Kevorian, the agent of this epidemic in Michigan, and consider why I think that he is "certifiably" insane, but which I mean that he suffers from a mental condition rendering him dangerous to others.
Without question, Dr. Kevorkian has proven himself dangerous, having participated in killing more than forty people already, with no end in sight. Dr. Kevorkian, by the way, does not shy fro the word killing. He prescribes it and even coined a term for his practice–medicide, that is: "the termination of life performed by…professional medical personnel (such as a doctor, nurse, paramedic, physician`s assistant, or medical technologist)." [Kevorkian, J., Prescription: Medicide, Prometheus Books, Buffalo, New York, 1991, page 202.] (Note his sense of a whole industry of killing to come, with much of it to be carried out by technicians because the doctors are busy.)
The question is whether his behavior is a product of a mental disorder. Not everyone agrees on an answer. Indeed the British Medical Journal (BMJ) described Dr. Kevorkian as a "hero."
His champions see no discernible motive for Dr. Kevorkian other than that he believes his work is fitting. The BMJ notes that greed for money or fame or some sadistic urge does not motivate Dr. Kevorkian. They make much of the fact that he does not charge a fee for killing. Because of the absence of such motives, the editors presume that he is a hero among doctors since it is only a "personal code of honor that admits of no qualification" that leads him into action.
But let us look rather more closely at "personal codes that admit no qualification." We have seen a few of them before and not all were admirable. As Dr. Kevorkian motors around Michigan carrying cylinders of carbon monoxide or bottles of potassium chloride to dispatch the sick, his is the motivation of a person with an "overvalued idea," a diagnostic formulation first spelled out by the psychiatrist Carl Wernicke in 1906. Wernicke differentiated overvalued ideas from obsessions and delusions. Overvalued ideas are often at the motivational heart of "personal codes that admit no qualification" and certainly provide a drive as powerful as that of hunger for money, fame, or sexual gratification.
An individual with an overvalued idea is someone who has taken up an idea shared by others in his milieu or culture and transformed it into a ruling passion or "monomania" for himself. It becomes the goal of all his efforts and he is prepared to sacrifice everything–family, reputation, health, even life itself–for it. He presumes that what he does in its service is right regardless of any losses that he or others suffer for it. He sees all opposition as at best misguided and at worst malevolent.
For Dr. Kevorkian, people may die before their time and the fabric of their families may be torn apart, but it`s all for the good if he can presume they were "suffering pain unnecessarily" and he has eliminated it. He scorns all opposition–in particular constitutional democratic opposition–as resting on bad faith or ignorance. Empowered by his idea, he feels free to disregard the law and any of its officers.
An overvalued idea has three characteristics: (1) it is a self-dominating but not idiosyncratic opinion, given great importance by (2) intense emotional feelings over its significance, and evoking (3) persistent behavior in its service. For Dr. Kevorkian, thinking about how to terminate the sick has become his exclusive concern. His belief in the justice of his ideas is intense enough for him to starve himself if thwarted by law.
Dr. Kevorkian thinks that all opposition to him is "bad faith" and thus worthy of contempt–a contempt he expresses with no reservation. He is fond of saying that the judicial system of our country is "corrupt," the religious members of our society are "irrational," the medical profession is "insane," the press is "meretricious."
He considers his own behavior "humanitarian." Dr. Kevorkian holds himself beyond reproach, even after killing one patient he believed had multiple sclerosis but whose autopsy revealed no evidence of that disease and another patient with the vague condition of "chronic fatigue syndrome" in whom no pathological process could be found at autopsy–only Kevorkian`s poison. He acts without taking a careful medical history, trying alternative treatments, or reflecting on how his actions affect such people as surviving family members.
Dr. Kevorkian`s is a confident business. As the news reports flow out of Michigan, it appears that his threshold for medicide is getting lower. Physician-assisted suicide that had previously demanded an incurable disease such as Alzheimer`s is now practiced upon patients with such chronic complaints as pelvic pain and emphysema, whose life expectancy cannot be specified. He can justify the active termination of anyone with an ailment–which is just what might be expected once the boundary against active killing by doctors has been breached. What`s to stop him now that juries have found his actions to be de facto legal in Michigan?
A crucial aspect of overvalued ideas is that, in contrast to delusions, they are not idiosyncratic. They are ideas that can be found in a proportion of the public–often an influential proportion. It is form such reservoirs of opinion that the particular individual harnesses and amplifies an idea with the disproportionate zeal characteristic of a ruling passion. That Dr. Kevorkian can find people in the highest places–even within the medical profession–to support his ideas and say that they see heroism in his actions is not surprising, given the passion of the contemporary debate over euthanasia. In this way the person with the overvalued idea may be seen, by those who share his opinion but not his self-sacrificing zeal, as giving expression to their hopes–disregarding the slower processes of democracy, filled with prejudice against all who resist, and pumped up with a sense of a higher purpose and justice.
People such as Dr. Kevorkian have found a place in history. With some, with the passage of time, we come to agree with the idea if not the method by which the idea was first expressed. Such as John Brown, the abolitionist, ready to hack five anonymous farmers to death in the Pottowatomi massacre to advance his cause. With others we may come to tolerate some aspect of the idea but see its expression in actual behavior as ludicrous. Such as Carry Nation, the scourge of Kansas barkeeps and boozers, who went to jail hundreds of times for chopping up saloons with a small hatchet in the cause of temperance. Finally, for some, we come to recognize the potential for horror in an overvalued idea held by a person in high authority. Such as Adolf Hitler.
But how is it that anxieties and confusions about medical practice and death can so afflict the judicious people of Michigan as to paralyze them before the outrageous behavior of Dr. Kevorkian and thus generate an environment for this epidemic? In Michigan these states of mind derive from conflicting concerns over medical decisions. The citizens—like any inexpert group–are relatively uninformed about what doctors can do for patients, even in extreme situations. Conflicting goals and unfamiliar practices–common enough around medical decisions–produce anxiety and confusion every time.
No one thinks happily about dying, especially dying in pain. Death is bad; dying can be worse. Anyone who says he does not fear dying–and all the pain and suffering tied to it–has probably not experienced much in life.
This concern, though, certainly has been exaggerated in our times, even though now much can be done to relieve the heaviest burdens of terminally ill patients. Yet through a variety of sources–such as movies, newspapers, and essays–all the negative aspects of dying have been emphasized, the agonies embellished, and the loss of control represented by disease accentuated. Horror stories feed upon one another, and rumors of medical lack of interest grow into opinions that doctors both neglect the dying and hold back relief. Doctors are regularly accused of surrendering to professional taboos or to legal advice to avoid risk of malpractice or prosecution–and in this way are presumed ready to sacrifice their patients out of selfish fear for themselves.
On the contrary, most doctors try to collaborate with patients and do listen to their wishes, especially when treatments that carry painful burdens are contemplated. As Dr. Kevorkian can demonstrate–with videotapes, no less–the patients he killed asked him repeatedly for help in dying rather than for help in living. Do not they have some right to die at their own hands steadied by Dr. Kevorkian? Is not the matter of assisted suicide simply a matter of rights and wants to which any citizen of Michigan is entitled?
The idea of a right to suicide provokes most psychiatrists. Psychiatry has worked to teach everyone that suicide is not an uncomplicated, voluntary act to which rights attach. It has shown that suicide is an act provoked, indeed compelled, by mental disorder–such as a disorienting depression or a set of misdirected, even delusionary, ideas. In that sense psychiatry taught that suicidal people were not "responsible" for this behavior–no matter what they said or wrote in final letters or testaments–any more than they would be for epileptic seizures.
This idea–generated from the careful study of the clinical circumstances and past histories of suicidal patients–gradually prevailed in civil law and even in the canon law of churches. As a result, laws against suicide were repealed–not to make suicide a "right" but to remove it from the status of a crime.
We psychiatrists thought we had done a worthy thing for our society, for families of patients, and even for patients themselves. We were not saying, not for a moment, that we approved of suicide. Far from it. We knew such deaths to be ugly and misguided–misguided in particular because the disposition to die, the wish for suicide, was, on inspection, often a symptom of the very mental disorders that psychiatry treats. Suicide in almost all cases is as far from a rational choice based on a weighing of the balance books of life as is responding to hallucinated voices or succumbing to the paranoid ideas of a charismatic madman such as dim Jones, who at Jonestown directed a gruesome exhibition of mass assisted suicide.
Psychiatrists were united in their views about suicide and shook their heads when contemplating past traditions when suicides were considered scandalous. We did not think too deeply into the consequences of our actions. For, after suicide ceased to be a crime, it soon became a right and, conceivably under some circumstances, such as when costs of care grow onerous, an obligation. Psychiatrists, who had worked for decades demonstrating that suicides were insane acts, are now recruited in Holland to assure that requests for suicide made by patients offered "no hope of cure" by their doctors are "rational."
What had begun as an effort at explanation and understanding of the tragic act of suicide has developed into complicity in the seduction of vulnerable people into that very behavior. The patients are seduced just as the victims in Jonestown were–by isolating them, sustaining their despair, revoking alternatives, stressing examples of others choosing to die, and sweetening the deadly poison by speaking of death with dignity. If even psychiatrists succumb to this complicity with death, what can be expected of the lay public in Michigan?
At the heart of the confusion lies the contention that if the aim of medicine is to eliminate suffering and if only the killing of the patient will relieve the suffering, then killing is justified. On this logic rests Dr. Kevorkian`s repeatedly successful defense before the juries of Michigan.
Yet the aim of medicine cannot simply be to prevent suffering. Not only would that be an impossible task, given the nature of human life, but it would diminish the scope of human potential–almost all of which demands some travail. The elimination of suffering is a veterinary rather than a medical goal. But veterinarians eliminate their animal subjects for other reasons than suffering. This fact can occasionally startle us.
When the race horse Cavonnier, second in the 1996 Kentucky Derby, pulled up lame during the Belmont Stakes later in the year, everyone watching on television feared that he must have broken a bone in his leg, with the inevitable consequences. His trainer provided brief comfort when he came on television to describe what had turned out to be a ligamentous rather than a bony injury to the animal. "This will probably end his racing career," he noted, "but it is not a life threatening injury." He then paused, before adding, "However, hers a gelding." An ominous comment for Cavonnier and one worth remembering when anyone says, in defense of killing infirm people, "They shoot horses, don`t they?" They do, but for many reasons other than just to protect horses from suffering. Sometimes it`s to save money. Are we ready for the Cavonnier test for ourselves?
The idea that diseases herald only mortality and death, to be hurried along if their burden, are overwhelming, is not only an ethical error but a fundamental misunderstanding of contemporary medical science. Contemporary physician/scientists do not think of diseases as "entities," "things," "maledictions;" and, in this sense, signposts to the grave, but as processes in life for which the body has ways of compensating and resisting, even if only temporarily. Diseases, in this way, are construed as forms of life under altered circumstances rather than as modes of death.
Because diseases are processes rather than entities, efforts to sustain life, alleviate symptoms, and moderate impairments represent collaborations with nature itself. These efforts remain the essence of doctoring, the whole reason for investing in the study of diseases and the body`s responses to them. Physician assisted suicide and euthanasia attack the very premises on which medical science and practice are progressing today and do so by denying the life that scientific conceptions of disease represent. Life with dignity–not death with dignity–is what doctors aim for in their practice and in their science.
Medicine is one of the practical arts–a fact old enough to be known to Aristotle among which are included navigation, economics, and architecture and for which the goal is usually obvious and unquestioned. For medicine, actions to prevent, alleviate, and cure are aimed at the obvious goal of sustaining the life and health of patients. Technical progress through scientific discoveries assists these actions, rendering them more effective. But modern techniques can seem in some circumstances to forestall the inevitable, prolong suffering, deny reality with little or no gain to the patient. Dr. Kevorkian writes and disseminates stories on this theme to justify his actions and to bolster hiss support. Allow me to present a story in which the conflict between preserving life and surrendering to disease was resolved by doctors who recognized their limits while striving to facilitate and extend a person`s best experiences.
Nelson Butters was one of America`s most distinguished neuropsychologists of the last twenty five years. He died in 1995 at age fifty eight after suffering for just under three years from the nightmare known as Lou Gehrig`s disease. This disease is a relentless and progressive wasting of the body because of an atrophic degeneration of the nerves that innervate the muscles. As the body wastes away over the course of months, the mind is customarily unaffected and witnesses these depredations. It anticipates further weakness and ultimate death from a loss of strength to breathe. Such an affliction you would not wish on your worst enemy. Dr. Jack Kevorkian lives to terminate–the earlier the better–any patient smitten by it.
My colleague and friend Nelson Butters saw it through to its natural end. In so doing–without making it his mission–he rebuked those who cannot (or will not) differentiate incurable diseases, of which there are many, from untreatable patients, of which there are few.
Nelson was a great scientist and an indomitable man. He took on all of life`s challenges, personal and professional, with vigor and courage. But when he learned that he had Lou Gehrig`s disease, he was shaken and responded with a most natural discouragement. "I`d rather die than be helpless," he said several times to his doctors. Yet he proved willing to try the assistance they offered him at each of the bad patches in his course, so that he could continue to enjoy what remained despite his illness. He had neurologists aiding him with his growing weakness, and he had psychiatrists and psychologists ready to assist him when he was tormented by his prospects.
He had bad times. They came mostly when some partial surrender to the disease was required–accepting a wheelchair, retreating to bed, undergoing a tracheotomy to facilitate breathing–but after each procedure, and despite its implicit indication that his condition was progressing, he recovered his cheer as he found himself more comfortable and able to continue his work with students and colleagues and his life with his family.
Like Stephen Hawking, Nelson toward the end made use of computers to communicate and work. This permitted him to edit a major journal in neuropsychology, even when he could move only one finger and then only one toe. With these small movements he used Email to write to colleagues everywhere–usually on professional matters, but also to transmit amusing academic gossip. Eventually, Nelson lost all his strength. He was left with only eyeblinking signals, breathing with the help of a machine. Then he asked his doctors, with his family around him, that the ventilator cease breathing for him. This was done, and on a weekend he slipped into a coma and died–thirty four months after his symptoms began.
Nelson, his family, and his doctors had achieved much together. They fought to enable him to sustain purposeful life as long as possible. They weathered distressing, powerfully painful potions of his clinical course. The doctors never suggested a poison to shorten his life. When there was still something to do, they encouraged him to try to do it and helped allay his reluctance at the prospect. And in the end they surrendered to the illness without betraying their mission or letting contemporary technology drag them along.
It was grim. Everyone who knew him was saddened to think that Nelson had to suffer so. But everyone also was struck by how he overcame the disease by staying purposeful, lively, and wittily intelligent right through to the end, teaching much to all of us.
I tell this story because many believe that permitting a progressive infirmity to continue right out to its natural end is cruel and pointless. It certainly is tough. Any gains need to be identified. In fact, the gains for Nelson Butters were several.
Most obvious among them was the continuation of Nelson`s work as a scientist, an editor, and a teacher for many months, despite his illness. This was no trivial gain, for he was an inventive scientist with deep insight into his discipline. He continued to function effectively and to enjoy his work and the accomplishments of his students.
Another gain was an extended duration of Nelson`s company to his family and his friends. Again, no trivial matter, for he was a lovable person. One of his daughters decided to help nurse him through his trials, and after his death, reflecting on all she had seen and done, she decided to take up a career in nursing incapacitated people.
Finally, there was the appreciation–to the point of amazement–on the part of his doctors of the value he fashioned from their efforts to help him. They told me how he had taken what they offered and made more of it–more than they expected and more in the form of continuing work and personal life–than they thought could be achieved. This was as true of the neurologists who offered means to offset his physical impairments as it was of the psychiatrists who at times of particular discouragement helped him keep going.
These gains were made easier because Nelson was such a good man and had such a good family to support him. Yet I sensed the awe felt by the doctors themselves for what had been accomplished in the end. Almost despite themselves and their own feelings about this awful disease, they had been partners with Nelson in a great achievement. They had carried out excellently the task set before doctors–help the patient encounter and resist the chaos of disease for as long as possible—and thus preserve the purposeful character of life to its end.
In Nelson`s life a set of interwoven but distinct purposes–husband, father, teacher, scientist–were sustained by him with the help of several doctors. And this happened despite the depredations of a crushing disease and the recurrent waves of discouragement that naturally accompany the loss of vitality and the realization of impending death.
But there was something more in Nelson`s story. For all that he was surrounded by devoted nurses, technicians, family, and physicians, death came to him alone just as it will to each of us. Its approach confronts us all with the challenge to decide what moves us, what matters most, what we love. Nelson loved life. He wanted as much of it as he could have. Through this love he won a victory over death–for himself, for his family, for all who knew him.
This is really what distinguishes him from Dr. Kevorkian, his sad victims, and those who support his cause. None of them love life the way Nelson did–not enough, certainly, to work hard and suffer much for it, not enough to appreciate it throughout its course, when it flickers just as much as when it glows. And certainly not enough to realize that sometimes we need help to protect it so that we don`t throw it away.
To be on the side of life provides a source of sanity. Be on the side of life and your course is clear, your efforts concentrated, the rules coherent. Bad patches can then be overcome, and even bad luck such as befell my friend Nelson Butters can be turned into something good. Be on the side of death and things fall apart, chaos reigns, and the fearful passions evoked by conflicting aims make malice, misdirection, sentiment, and compassion all look the same.
One can think of ways to combat the deadly convergence of madnesses in Michigan and to deter the spread of this local epidemic to other regions of our country. The suicidal patients certainly should be treated for their depressive vulnerabilities by doctors able to assist them with their underlying illnesses. Dr. Kevorkian, the agent of their extinction, should be stopped by whatever means the state has at its disposal to stay dangerous men. And the people of Michigan should be taught about the capacities of modern medicine. With this information, the hope is, they will emerge from their anxious confusions, accept mortality for what it is rather than for what they imagine, and, at last, end their support for this insanity.
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