Dr. Kevorkian leaves mixed medical legacy

The death of pathologist Jack Kevorkian, MD, left many pondering the long-term influence of a highly controversial figure and what role he may have played in transforming the nation's perception of dying.

Some think his aggressive push for physician-assisted suicide forced the medical profession to take a closer look at care of the terminally ill. But others say Dr. Kevorkian lacked a sense of proper medical ethics and that his actions were motivated more by a desire to advance his agenda than compassion for patients.

Dr. Kevorkian took part in more than 130 assisted suicides before he died of natural causes on June 3. He was 83.

"He was kind of a scary figure because he assisted people who were not very ill. He had no clinical skills to be doing what he was doing," said Timothy E. Quill, MD, a professor of medicine, psychiatry and medical humanities at the University of Rochester (N.Y.) School of Medicine and Dentistry.

More of a political activist than an ethical physician, perhaps Dr. Kevorkian's biggest contribution was that he forced many to think about death and the issues surrounding it, Dr. Quill said.

"Kevorkian's long-term legacy is the unorthodox way in which he demonstrated the problem of protracted dying to the world," said Peg Sandeen, executive director of the Death with Dignity National Center, a nonprofit organization that supports legal defense and education of Oregon's law allowing physician-assisted suicide. "He showed how bad the dying process could be, engrossing the American public in a traditionally taboo subject."

As a result, people began discussing death more openly with their families and loved ones, said Michael Paletta, MD, vice president of medical affairs for Hospice of Michigan and executive director of the hospice's Maggie Allesee Center for Quality of Life. People became more aware of end-of-life choices and were more inclined to document their wishes in living wills and advance directives.

"Those conversations were much more acceptable and much more common after Kevorkian became a public figure," Dr. Paletta said.

"A false choice"

But Dr. Kevorkian presented a false choice by making people think they had only two options -- either learn to live with their pain or have a physician end their life, Dr. Paletta said. There are other options. Research has shown that people who receive appropriate pain management are much less inclined to end their lives.

"He was definitely harmful in that he allowed his personal agenda to take precedence over what was best for his patients," Dr. Paletta said. "There is another choice. There is pain and symptom management by physicians and medical staff who are trained to do that."

Dr. Quill said it is due in part to Dr. Kevorkian's influence that patients now have more options for end-of-life care. By making people more aware of the suffering of terminally ill patients, he pushed the medical profession to offer more aggressive pain management options. For example, heavy sedation is more widely available in many parts of the country than it was a few decades ago.

"Sometimes, when people want to end their lives, it is a sign of desperation," said Dr. Quill, who supports physician-assisted death only as a last resort. "You really want to make sure people are getting the best care possible before they consider these last-resort options."

Montana, Oregon and Washington allow physician-assisted suicide. Oregon and Washington provide safeguards to ensure that patients have considered other options, such as aggressive pain management, before they consider ending their lives, he said. Montana considered enacting similar safeguards, but the Legislature tabled the legislation.

The American Medical Association opposes physician-assisted suicide, saying it "is fundamentally incompatible with the physician's role as a healer." Instead, the medical profession should work to ensure dying patients have optimal treatment for their pain and discomfort, AMA policy says.

An ongoing debate

Dr. Kevorkian was particularly harmful to people with disabilities, said Stephen Drake, a research analyst with Not Dead Yet. The Rochester, N.Y.-based organization opposes legalized assisted suicide and was founded in 1996 in response to Dr. Kevorkian's acquittal in the assisted suicides of two women with nonterminal conditions.

Dr. Kevorkian's image has been sanitized by the media, which painted him largely as a hero to the suffering, Drake said. Many ignore that before he became famous, Dr. Kevorkian wrote extensively about his desire to allow human experimentation, he said.

Another concern is that Dr. Kevorkian and the media never looked at the social factors around the people whose suicides he assisted, Drake said. Other factors, such as marital or mobility problems, may have contributed to their desperation and helplessness, he added.

Ignoring those social factors demonstrates some of society's prejudices to assume that simply having a disability would be cause enough to want to die, without looking more in-depth at the individual's personal troubles, Drake said.

A 1997 investigation by the Detroit Free Press found that 60% of the people that Dr. Kevorkian helped to die were not terminally ill. An ethical physician would have done more to investigate their conditions, Dr. Paletta said.

One thing for certain is that the debate about physician-assisted suicide is far from over, Dr. Quill said. It is an issue that will become increasingly prominent as the population ages.

"As the baby boomers get older and start facing these issues in greater numbers, I think they'll want to have as many options available to them as possible," he said.