So Long, Jack.

Jack Kevorkian is dead at the age of 83. News came in yesterday and it's taken me a little while to sum up what, if anything, I have to say about it. The media's dream, the assisted suicide movement's nightmare, Kevorkian cornered the national conversation about death. And it's hard to knock anyone who gets us talking about death. As I often write, we're in a national (and international) health care crisis. The world's population is quickly growing older, subject to medical systems and structures that are woefully unprepared for the increasing needs of this population. Our national economy will shortly be brought to a halt if meaningful health care reform isn't enacted. (No, I don't mean Obamacare. I mean real reform.) And increasingly, elders are not dying the way they want to.

While Kevorkian brought this conversation to prime time -- and everybody has an opinion on Jack Kevorkian -- and while he did it without the horrifying saccharine sweet sentimentality that impedes the meaningfulness of such conversations, he erred by allowing himself to be portrayed as a cantankerous clown. He was too easy to paint as a quack, a cantankerous fanatic obsessed with death. If there's anything I've learned in my modest time writing about death (and religion), it's that tone and sound bites have more impact than facts. In a society that packs death off to nursing homes and hospitals, we desperately can't afford dismiss-able spokesmen who allow media to relegate the conversation to spectacle.

And there's no doubt that Kevorkian became a spectacle. Patients' rights don't mean much when reduced to snuff clips on 60 Minutes. So while I strongly believe in choice at the end of life -- and sympathize strongly with Kevorkian's mission -- and while we've seen three states adopt rational, helpful laws regarding patient's rights at the end of life since Kevorkian's rise to prominence, I don't think that the life and times of Dr. Death Kevorkian has really moved the nation or the assisted suicide movement ahead in the necessary grapple that is our impending health care crisis.

Still, may he rest in peace.

More on Kevorkian's death: From his Royal Oak neighbors. From Janice Van Dyck at HuffPo's Healthy Living. Icky monomaniacal Wesley Smith at National Review. Jeff Gerritt at Detroit Free Press. Tami Abdollah at AP gets it mostly wrong. Another AP story calls Kevorkian "audacious." UK's conservative BioEdge calls Kevorkian a "suicide hero." Christian Post focuses on Kevorkian's dismissal of religion. Religion Dispatches' Susan Henking gets stuck in the nomenclature, picks out how various religions discuss suicide (and cites Durkheim!) and divides the landscapes into two erroneously-named sides, "the right-to-life" and "right-to-death" movements.

Finding Someone to Blame

And yet, guns are legal.

Rita Marker, of the dubiously-named Patients Rights Council, is of course quoted.

Elder Suicide.

Suicide among elders in nursing homes in Italy has risen.

The survey of Italian seniors living in long-term care facilities revealed that the suicide rate was nearly 19 per 100,000 people. The average rate for seniors over the age of 65 is 14 per 100,000 people, according to researchers from the University of Rochester in New York. Risk factors for suicide include depression, anxiety, and feelings of isolation or loss.

Millions of seniors in the U.S. live in assisted living or skilled nursing facilities. These institutions can help by screening for depression upon admission, monitoring a new resident's adjustment to the facility, and helping to control any pain the resident experiences, according to researchers.

Suicide Risk for Seniors in Care Facilities.

From HealthDay News via Bloomberg:

Seniors living in assisted-living and long-term care facilities may have a higher rate of suicide than those who continue living in their own homes, suggests a new report.

People over 65 commit suicide at a rate of about 14 per 100,000 people, but in a study of Italian people living in long-term care facilities, researchers found that the rate of suicide was nearly 19 per 100,000 people.

One reason may be that stressful or troubling events -- such as death of a spouse, illness or a decline in physical function -- may underlie the move to a residential care facility, the researchers say.

"The risk of suicide may be heightened during the first year," said the report's lead author, Carol Podgorski, an assistant professor of psychiatry at the University of Rochester in New York. "There's relocation stress, and that's when they're dealing with whatever caused them to move."

The report was published online May 18 in the journal PLoS Medicine.

Teasing out the exact reasons that cause the increase as well as developing potential prevention strategies is important because nearly one-quarter of all seniors will live in a residential care facility at some point, according to background information in the report.

More than one million seniors in the United States live in assisted-living facilities, most of them female (about 80 percent), the report said. The average age of residents is about 85 years. Many others live in independent-living communities, long-term care facilities, also called nursing homes, and continuing care retirement communities, which include all three.

Overall risk factors for senior suicide include anxiety, substance abuse, psychotic disorders, social dependency or isolation, family troubles or losses, an inflexible personality and access to firearms. Specific risk factors for older people living in a residential home include being widowed or divorced, having a pessimistic outlook, sleeping more than nine hours a day and drinking more than three alcoholic beverages a day.

Jack Kevorkian's Gonna Get You.

Oh nos! Anderson Cooper better watch out or Dr. Death Kevorkian's gonna get him! This from, well what do you expect, HollywoodNews.

Beyond the brave-interviewer-whose-brother-committed-suicide-meets-killer aspect of the little post, below, I find it completely fascinating that there's no room for discussion of end of life in here anywhere. What was Kevorkian doing with those 130 people? Why did they want to die? What is suicide and why did they need Kevorkian to help them. How did he find 130 people? What is the nature of care for the terminally ill? How do we discuss futile care, chronic pain, the right to die, mental illness, and suffering in death? I know, I know, I'm asking too much from a pulp.

But sometimes it takes the exaggeration to recognize the norm. Usually we look to satire for that. Or sentimentality. As we all patiently await the April 24 premier of "You Don't Know Jack", an HBO movie starring Al Pacino as Kevorkian and Susan Sarandon, we'll have a chance to see how the media frames issues of end of life care, assisted suicide, and the, yes, renegade Jack Kevorkian. Will we see the more typical binary framing -- death is shameful and bad and to be avoided at all costs vs. death will transition you to a better place -- or will we be engaged in a substantive discussion that examines end of life care in the US today?

Oh and, I thought Fox had the first interview with Kevorkian during last summer's health care debate. The frail, seemingly-senile former inmate was trotted out as a strawman for death panels.

Wasn’t Anderson Cooper just swimming with sharks last week on “60 Minutes”?

Now he’s doing something even more courageous: he’s interviewing Dr. Jack Kevorkian.

Dr. Death is giving Cooper his first post-prison interview this Friday. It’s not actually on CNN, but set for a lunch time live get together at CNN headquarters in New York.

The interview will be preceded by sandwiches and snacks, according to the invite, and a welcome from CNN’s prez, Jon Klein.

You have to give Cooper credit for doing this. His own brother, Carter, committed suicide at age 23 in July 1988. Anderson wrote about it in his blog back in 2005: http://www.cnn.com/2005/US/08/16/brother/

Talk about a charged meeting. Kevorkian has said he helped at least 130 people die of physician assisted suicide. He served 8 years of a 10 to 25 year prison sentence for second degree murder. He’ll turn 81 in May.

What Is a Natural Death?

Elana Premack Sandler at Psychology Today asks her readers what they think about assisted suicide as she feels her way through the subject in the wake of a host of publicity. I appreciate her nuanced and open willingness to examine the topic, particularly when so many do make a snap-judgement about assisted suicide. I recommend you read her entire post and comment! But there's a point in one of her paragraphs that I want to jump off from. She writes:

Does assisted suicide undermine suicide prevention? "Obviously!" you might think. Working for a suicide prevention organization, and as a suicide survivor, I really wrestle with supporting idea of suicide - at all.
Since so many people who choose assisted suicide are suffering from incurable degenerative diseases, the cessation of pain - psychache or not - is very appealing. Just as I wish that people who are in extreme emotional pain did not have to experience such terrible pain, I wish the same for people in extreme physical pain. But, will a person who dies by assisted suicide experience more dignity and peace than they would have if they had died by natural causes?

Ok, maybe a quick point. Then I'll jump off. The recent report from the first year of legalized Death with Dignity in Washington state shows that most of those terminal patients who elected for DwD said their reason was autonomy. More so than fear of pain or existing pain. I'm always suspect of polls that ask people in crisis and distress to identify what the cause is. It's almost unfair to ask a dying patient to identify why they are ready to die. But nonetheless, a majority of patients said autonomy. End of point.

What I want to take up from the above paragraph is that tired but prevalent phrase: "natural causes." Once was a time when death meant the rather simultaneous cessation of heart beat, breathing and brain function. Those days are over. Medicine now can maintain heart beat and breathing almost indefinitely. That leaves brain function. As I noted yesterday, Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo proved that many, particularly those in the extreme religious right, oppose the use of brain function as a determining factor for death. This brings the term "natural causes" to a new definition.

All three women could eventually breath on their own. All had functioning hearts. Both functions were essentially resuscitated via CPR, or other techniques that shock the heart and lungs back to operation. Prior to the invention and widespread use of defibrillators, CPR, respirators, and even 911 in the early 70s these women would have died of their initial injuries. Their lives were, after resuscitation, prolonged via artificial nutrition and hydration and the battles over their lives stemmed from their family members attempting to remove them from ANH.

The prevalence of amazing, life-prolonging technological and medical advancements does extend American lives. This is a wonderful and miraculous thing. But it has changed how we die and what we now call death. Few deaths these days can be considered natural, however. It's time we reconsider the term and in doing so, start to talk about what death now means.

Suicide Prevention and Assisted Suicide.

There's a clinical reason why advocates prefer to call it aid in dying and not assisted suicide; they recognize that there's a difference between grief, a normal and emotional reaction to trauma, and depression, an illness that with medical and psychiatric treatment can be addressed.

Yesterday Michael Gerson at the Washington Post had a well-meaning column on the prevalence of suicide in the U.S. He starts the column by noting a number of celebrities who have recently committed suicide and works to explain what it is and what signs we can detect in loved ones who may be isolated, depressed and suicidal.

Suicides outnumber homicides in America, making self-hatred more lethal than violence by others. In 2009, the Substance Abuse and Mental Health Services Administration reported that 1.1 million Americans had attempted suicide during the previous year. By one estimate, "successful" suicides have left behind 4.5 million family survivors, who live with ghosts each day.

He encourages us to reach out to those in our community who may be depressed and at risk (The National Suicide Prevention Lifeline is 1-800-273-TALK.) It's not a bad column and while Gerson is not my favorite columnist, I am pleased to see those with soapboxes addressing a tragic issue.

But then along comes Wesley J. Smith who takes up Gerson's column and does what he does best: applies absolutist and convoluted pseudo-rational thinking to conflate the idea of depression (which can cause suicide) and terminal disease. To Gerson's sentence, "For those who yield to the logic of the nightmare, it is difficult to be harsh or judgmental. Empathy, like grace, can reach to the grave," Smith writes:

But that doesn’t mean we shouldn’t criticize those pushing suicidal people toward different conclusions about self destruction. And that’s where Gerson misses the obvious–as so many similar articles do these days. There is a multi million dollar suicide promotion campaign ongoing in the country and around the world–aided and abetted by the mainstream media–that says that if you are sick, or disabled–suicide is empowering and rational. Indeed, it claims that such suicides are so right and worthy of being honored that the state should permit third parties to help make sure the suicidal person is made dead. As far as I am concerned, that is the express and implied fundamental message of assisted suicide advocacy.

It seems to me that society can’t be half against suicide and half for it. You can’t have suicide prevention and assisted suicide promotion at the same time. The former message is subsumed by the latter. Suffering suicidal people don’t think that the quality or reasons for other guy’s suffering makes suicide okay, but theirs does not.

It's an old rhetorical schtick for Smith - and other "pro-life" activists - who make their living subtracting nuance from bioethical debates for their own ideological purpose. For decades, Smith has been writing about "the culture of death," dropping anyone into that category he can and pretending that a growing segment of society is out to kill minority groups like the disabled, the brain dead, the terminally ill, the suffering, the elderly.

By confusing suicide and clinical depression with aid in dying, he capitalizes on the common use of the term "assisted suicide" to attack aid in dying supporters, much as those who deny evolution conflate the scientific term "theory" with the common use of the term meaning "unproven supposition." ("Theory" to scientists means proven fact that needs to have some details flushed out.)

I'm not personally opposed to the use of the term assisted suicide (for the medical practice as it is legalized and strictly regulated in Washington and Oregon) but I do contest the way that Smith and others use it: to perpetuate the terminal suffering of others. As medical advancements have created new definitions of death (end of a heart beat? end of consciousness? end of breathing?) so too has it created new definitions of suicide. (And pregnant, but that's another post. The definition of murder has long been understood to have many meanings.) Ignoring this fact is an absolutist, and frankly, unworkable approach to contemporary bioethical debates. Pretending that we live in a less complicated world does not move us toward ethical discussions of medicine.

This work of Smith's is irresponsible (and disingenuous) for a host of reasons, most importantly because it allows those who oppose assisted suicide to think they are addressing the important issue of suicide. And it removes the focus among his constituents from addressing the very real problem of depression to fighting the right that terminal patients should have to determine how their disease will end their lives.

The aid in dying movement in the U.S. seeks to make Death with Dignity (as the laws in Washington and Oregon are called) legal: a terminal patient with six months to live, one who is going to die because of multiple sclerosis or Lou Gehrig's disease, who is determined of sound mind and who has received the opinion of two doctors, to receive a lethal dose of medication from their doctor which they may then choose to take themselves to end their life before the disease makes it unbearable.

In every case of Death with Dignity, immanent death is certain. The patient has endured most likely years of fighting their disease with a concerted will to live. The patient does not want to die but they have realistically accepted the fact that their disease will soon kill them. Their grief at the loss of life has an absolute physical cause. And their simple objective is singular: to end suffering.

Smith's point that society is pushing isolated individuals to suicide is only correct in that we fail to distinguish the serious difference between suicide-causing depression, and say, a bad day or the natural process of grief that follows a death or an end of marriage. "I'm depressed," we say when our car breaks down. "How depressing," we say when an election is lost or a friend snubs us, detracting semantically from our ability to discern the downward spiral of serious grief that can lead to dangerous depression.

Grief is an emotional process that facilitates recovery from a loss. Depression is an illness. There's a significant and important difference that Smith misses. What he calls "half against suicide and half for it" is a false construct. "The culture of death" is a rhetorical tool used to create fear among the vulnerable and to assert influence over the easily swayed. It takes autonomy away from various patient groups like women, the disabled, the ill. "Culture of death" fear-mongering is prevalent among those who wish to assert their largely religious ideology on our pluralistic society; it seeks power and it imposes suffering.

Accepting death, as Death with Dignity patients do, is not a depression that can be cured. It is a factual analysis of the physical body in immanent, unpreventable demise. Yes it's sad, for both family members and the patient. But statistically, Death with Dignity does not leave behind the same scars as suicide from depression does.

Smith and others only distract from the serious consideration that must be given to treatment of depression.

Contrived Story: Death with Dignity and the Estate Tax.

Ok, I admit to having avoided this meme for a while now because I was unwilling to honor its absurdity with a post. But it seems to unfortunately have legs because few journalists are examining the facts and, well, get a great punch up from the emotions the "concern" garners.

The contrived story is: changes in the estate tax, or the politically termed "death" tax, which go into effect at the end of this year, will cause wealthy elders at the urging of their soon-to-be-cheated-of-millions heirs, to commit suicide using the Death with Dignity laws in Washington and Oregon.

Some writers are with-it enough to have noticed that Montana just legalized aid in dying but some, like Kay Helbling with the Oregon Business Report, quoted below, miss Montana altogether.

It's a contrived story, for a number of reasons I'll get to in a minute, but perfectly indicative of how the media irresponsibly get aid in dying wrong again and again, to the benefit of "pro-life" activists who oppose aid in dying, by illogically and unfactually slapping together cause and effect.

Helbling writes with perfect, false alarm:

In insurance it’s called a “moral hazard”. A moral hazard is the result of maximizing behavior. A person weighs the costs and benefits of an action and when benefits exceed costs, he takes the action. For example, if an accident costs the person $1000, but pays $2000, the person not only has no incentive to avoid the accident but may have an incentive to seek it out.

What has this got to do with assisted suicide? There could be “millions” in estate tax reasons why they relate. Estate taxes have long been referred to as the “death tax”, but 2010 may shine a whole new meaning on that term. Presently the estate tax is 45%. The estate tax will drop to 0% for just one year, 2010, and then return to the pre-Bush administration rate of 55% in 2011.

Opponents to the physician-assisted suicide laws have long felt there is a moral hazard to granting a person the right to chose when to die. Will the person make that choice merely because of their personal suffering, or are they going to feel obligated to do so to relieve their children of the need to care for them or because they are a financial burden. Add to the mix the possibility that by dying in 2010 they could become a financial “windfall” for their heirs and the risk of a “moral” hazard to the law rises.

Firstly, Helbling completely misses the way aid in dying works in the three states where it is legal. A patient in Washington, Oregon, or Montana must be terminal, meaning near death, to request a lethal dose from their doctor. Then they must administer the medicine themselves. Instead, she paints the laws as state-legalized suicide that allows a patient to end their life whenever convenient.

The story only exists because ignorant or politically motivated parties continue to conflate suicide - an untimely taking of ones life - with aid in dying, the ending of the suffering of a terminal patient, already sentenced to death by old age or a terminal illness. The continued popular use of "assisted suicide" doesn't help much and is perpetuated by those opposed to aid in dying.

The story that the changes to the estate tax will cause more suicides is a cloudy crystal ball - and who am I to predict the future? Certainly someone should be able to scrape up statistics about how many patients extended their lives (at the urging of relatives, on life support, a comatose vegetable until the calendar changed) until the lax Bush laws came into effect.

But murder is illegal and so too is suicide in some states, the former prevents the actor from inheriting, the latter from receiving lucrative life insurance pay outs. That aid in dying provides nefarious, evil family members with an easy way to snuff a parent is silly. Aid in dying has caused greater oversight and regulation of the end of life period than is given it in other states.

Murder and suicide have nothing to do with aid in dying, though opponents try to convince the public that they do. Assumed coercion by greedy family members is less likely in states where aid in dying is closely watched, regulated and reported on. And assuming coercion will occur is a grave injustice to the elderly and terminally ill, a discrimination against their autonomy and ability to make good decisions.

So few people die at home these days, less than 20%, that no family members, particularly those of the wealthy, are required to care for the dying at home. The assertion that the terminal elder will kill themselves or will be coerced to kill themselves by greedy heirs is a trumped up concern that has no proof - it is simply a supposition that business and "pro-life" groups have clasped onto - but certainly has nothing to do with the Death with Dignity laws.

There's an enormous difference between a dying patient requesting a lethal dose of medicine to end their last days or weeks of suffering - with the strictly government regulated oversight of their doctor - and committing a crime.

Now if only the media would leave sensationalism out of it and report according to facts.

Suicide on the Rise.

The Wall Street Journal reports on the rise in suicides in the country, up 2.3% in 2008 from 2007. The data here. From the story:

Early signs suggest the number of suicides in the U.S. crept up during the worst recession in decades, according to a Wall Street Journal survey of states that account for about 40% of the U.S. population.

Available data, still incomplete, suggest that this recession, like past ones, coincided with an uptick in suicides. The data from 19 states find an increase in suicides in the recessionary year of 2008 from 2007. Those states historically account for about half of annual suicides in the U.S. Calls to suicide hotlines are rising. And suicides in the workplace and the military -- a small sliver all of self-inflicted deaths -- were up in 2008.

Official data on suicides in the U.S. lag, and a 2008 national tally isn't yet available. In 2007, there were 33,185 suicides, according to preliminary estimates from the U.S. Centers for Disease Control and Prevention, compared with an average of about 32,800 in the previous three years.

A Journal survey of the 33 largest states by population found 19 have data for 2008. In all, those 19 reported a total of 15,335 suicides in 2008, up about 2.3% from the previous year.

Thirteen states, accounting for 30% of the U.S. population, reported more suicides in 2008. In Florida, for instance, suicides were up 6%, in Georgia, up 2.3%, and in North Carolina, up 7.8%. In six smaller states, which account for about 9.5% of the population, the number of suicides fell.