SUICIDE

To many people, suicide—intentional self-murder—is an asocial act of a private individual, yet sociology grew out of Durkheim’s argument ([1897] 1951) that suicide rates are social facts and reflect variation in social regulation and social interaction. The concept of suicide derives from the Latin sui (”of oneself”) and cide (”a killing”). Shneidman (1985) defines ”suicide” as follows: ”currently in the Western world a conscious act of self-induced annihilation best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution.” Several conceptual implications follow from this definition.

Although suicidal types vary, there are common traits that most suicides share to some extent. (Shneidman 1985). Suicides tend to

• Seek a solution to their life problems by dying

• Want to cease consciousness

• Try to reduce intolerable psychological pain

• Have frustrated psychological needs

• Feel helpless and hopeless

• Be ambivalent about dying

• Be perceptually constricted and rigid thinkers

• Manifest escape, egression, or fugue behaviors

• Communicate their intent to commit suicide or die

• Have lifelong self-destructive coping responses (sometimes called ”suicidal careers”)

Completed suicides must be differentiated from nonfatal suicide attempts, suicide ideation, and suicide talk or gestures. Sometimes one speaks of self-injury, self-mutilation, accident proneness, failure to take needed medications, and the like— where suicide intent cannot be demonstrated—as ”parasuicide.” The most common self-destructive behaviors are indirect, such as alcoholism, obesity, risky sports, and gambling. There are also mass suicides (as in Jonestown, Guyana, in 1978 and in Masada in A.D. 72-73) and murder suicides. Individual and social growth probably require some degree of partial self-destruction.

Although most suicides have much in common, suicide is not a single type of behavior. Suicidology will not be an exact science until it specifies its dependent variable. The predictors or causes of suicide vary immensely with the specific type of suicidal outcome. Suicidologists tend to recognize three to six basic types of suicide, each with two or three of its own subtypes (Maris et al. 1992, chap. 4). For example, Durkheim ([1897] 1951) thought all suicides were basically anomic, egoistic, altruistic, or fatalistic. Freud (1917 [1953]) and Menninger (1938) argued that psychoanalyti-cally, all suicides were based on hate or revenge (a ”wish to kill”); on depression, melancholia, or hopelessness (a ”wish to die”); or on guilt or shame (a ”wish to be killed”). Baechler (1979) added ”oblative” (i.e., sacrifice or transfiguration) and ”ludic” (i.e., engaging in ordeals or risks and games) suicidal types.

EPIDEMIOLOGY, RATES, AND PREDICTORS

Suicide is a relatively rare event, averaging 1 to 3 in 10,000 in the general population per year. In 1996 (the most recent year for which U. S. vital statistics are available), there were 31,130 suicides, accounting for about 1.5 percent of all deaths. This amounts to an overall suicide rate of 11.6 per 100,000. Suicide is now the ninth leading cause of death, ranking just ahead of cirrhosis and other liver disease deaths and just behind human immunodeficiency virus (HIV) deaths. Suicide also has been moving up the list of the leading causes of death in this century (Table 1).

Suicide rates in the United States vary considerably by sex, age, and race (Table 2). The highest rates are consistently observed among white males, who constitute roughly 73 percent of all suicides. White females account for about 17 percent of all suicides. American blacks, especially females, rarely commit suicide (except for some young urban males). Some scholars have argued that black suicides tend to be disguised as homicides or accidents. In general, male suicides outnumber female suicides three or four to one. Generally, suicide rates gradually increase with age and then drop off at the very oldest ages. Female suicide rates tend to peak earlier than do those of males. Note in Table 3 that from about 1967 to 1977, there was a significant increase in the suicide rate of 15- to 24-year-olds and that suicide rates among the elderly seem to be climbing again.

Typically, marrying and having children protect one against suicide. Usually suicide rates are highest for widows, followed by the divorced and the never-married or single. Studies of suicide rates by social class have been equivocal. Within each broad census occupational category, there are job types with high and low suicide rates. For example, psychiatrists have high suicide rates, but pediatricians and surgeons have low rates. Operatives usually have low rates, but police officers typically have high rates.

The predominant method of suicide for both males and females in 1992 was firearms (Table 4).

Table 1:Ten Leading Causes of Death in the United States, 1996 (total of 2,314,690 deaths)

The second most common method among males is hanging, and among females it is a drug or medicine overdose. Females use a somewhat greater variety of methods than males do. Suicide rates tend to be higher on Mondays and in the springtime (Gabennesch 1988).

Prediction of suicide is a complicated process (Maris et al. 1992). As is the case with other rare events, suicide prediction generates many false positives, such as identifying someone as a suicide when that person in fact is not a suicide. Correctly identifying true suicides is referred to as ”sensitivity,” and correctly identifying true nonsuicides is called ”specificity.” In a study using common predictors (Table 5) Porkorny (1983) correctly predicted fifteen of sixty-seven suicides among 4,800 psychiatric patients but also got 279 false positives.

Table 5 lists fifteen major predictors of suicide. Single predictor variables seldom correctly identify suicides. Most suicides have ”comorbidity” (i.e., several key predictors are involved), and specific predictors vary with the type of suicide and other factors. Depressive disorders and alcoholism are two of the major predictors of suicide. Robins (1981) found that about 45 percent of all completed suicides involved either depressed or alcoholic persons. Roughly 15 percent of all those with depressive illness and 18 percent of all alcoholics eventually commit suicide. Repeated depressive illness that leads to hopelessness is especially suicidogenic.

Table 2:Rates of Completed Suicide per 100,000 Population by Race and Gender, 1996

Nonfatal suicide attempts, talk about suicide or dying, and explicit plans or preparations for dying or suicide all increase suicide risk. However, for the paradigmatic suicide (older white males), 85 to 90 percent of these individuals make only one fatal suicide attempt and seldom explicitly communicate their suicidal intent or show up at hospitals and clinics. Social isolation (e.g., having no close friends, living alone, being unemployed, being unmarried) and lack of social support are more common among suicides than among controls. Suicide tends to run in families, and this suggests both modeling and genetic influences. Important biological and sociobiological predictors of suicide have been emerging, especially low levels of central spinal fluid serotonin in the form of 5-HIAA (Maris 1997).

HISTORY, COMPARATIVE STUDIES, AND SOCIAL SUICIDOLOGISTS

The incidence and study of suicide have a long history and were fundamental to the development of sociology. The earliest known visual reference to suicide is Ajax falling on his sword (circa 540 b.c.). Of course, it is known that Socrates (about 399 b.c.) drank hemlock. In the Judeo-Christian scriptures there were eleven men (and no women) who died by suicide, most notably Samson, Judas, and Saul. Common biblical motives for suicide were revenge, shame, and defeat in battle. Famous suicides in art history include paintings of Lucretia stabbing herself (after a rape), Dido, and work by Edvard Munch and Andy Warhol.

Suicide varies with culture and ethnicity. Most cultures have at least some suicides. However, suicide is rare or absent among the Tiv of Nigeria, Andaman islanders, and Australian aborigines and relatively infrequent among rural American blacks and Irish Roman Catholics. The highest suicide rates are found in Hungary, Germany, Austria, Scandinavia, and Japan (Table 6). The lowest rates are found in several South American, Pacific Island, and predominantly Roman Catholic countries, including Antigua,Jamaica, New Guinea, the Phillipines, Mexico, Italy, and Ireland.

The sociological study of suicide started with Durkheim ([1897] 1951) and has continued to the present day primarily in the research and publications of the following sociologists: Short, (1954), J.P. Gibbs (1964), J.T. Gibbs (1988), Douglas (1967), Maris (1969, 1981), Phillips (1974), Phillips et al. (1991), Stack (1982), Wasserman (1989), and Pescosolido and Georgianna (1989).

Durkheim ([1897] 1951) claimed that the suicide rate varied inverely with social integration and that suicide types were primarily ego-anomic. However, Durkheim did not operationally define ”social integration.” Gibbs and Martin (1964) created the concept of ”status integration” to correct this deficiency. They hypothesized that the less frequently occupied status sets would lead to lower status integration and higher suicide rates. Putting it differently, they expected status integration and suicide rates to be negatively associated. In a large series of tests from 1964 to 1988, Gibbs confirmed his primary hypothesis only for occupational statuses, which Durkheim also had said were of central importance.

Table 3:Rates of Completed Suicide per 100,000 Population by Year and Age in the United States

Short (Henry and Short 1954) expanded Durkheim’s concept of external and constraining social facts to include interaction with social psychological factors of ”internal constraint” (such as strict superego restraint) and frustration-aggression theory. Short reasoned that suicide rates would be highest when external restraint was low and internal restraint was high and that homicide rates would be highest when internal restraint was low and external restraint was high.

A vastly different sociological perspective on suicide originated with the work of enthnomethodologist Douglas. Douglas, in the tradition of Max Weber’s subjective meanings, argued that Durkheim’s reliance on official statistics (such as death certificates) as the data base for studying suicide was fundamentally mistaken (Douglas 1967). Instead, it is necessary to observe the accounts or situated meanings of individuals who are known to be suicidal, not rely on a third-party official such as a coroner or medical examiner who is not a suicide and may use ad hoc criteria to classify a death as a suicide. There are probably as many official statistics as there are officials.

Maris (1981) extended Durkheim’s empirical survey of suicidal behaviors, but not just by measuring macrosocial and demographic or structural variables. Instead, Maris focused on actual interviews (”psychological autopsies”) of the intimate survivors of suicides (usually their spouses) and compared those cases with control or comparison groups of natural deaths and nonfatal suicide attempts. Maris claimed that suicides had long ”suicidal careers” involving complex mixes of biological, social, and psychological factors.

Phillips (1974) differed with Durkheim’s contention that suicides are not suggestible or contagious. In a pioneering paper in the American Sociological Review, he demonstrated that front-page newspaper coverage of celebrity suicides was associated with a statistically significant rise in the national suicide rate seven to ten days after a publicized suicide. The rise in the suicide rate was greater the longer the front-page coverage, greater in the region where the news account ran, and higher if the stimulus suicide and the person supposedly copying the suicide were similar. In a long series of similar studies, Phillips et al. (1991) expanded and documented the suggestion effect for other types of behavior and other groups. For example, the contagion effect appears to be especially powerful among teenagers. Nevertheless, contagion accounts only for a 1 to 6 percent increase over the normal expected suicide rates in a population.

Table 4:Percent of Completed Suicides in 1987 and 1992 by Method and Gender

METHOD	1987	1992	1987 1992
Firearms (E955.0-955.4)	64.0	65	39.8 39
Drugs/medications (E950.0-950.5)	5.2	-	25.0 -
Hanging (E953.0)	13.5	16	9. 4 4
Carbon monoxide (E952.0-952.1)	9.6	-	12.6 -
Jumping from a high place (E957)	1.8	-	3.0 -
Drowning (E954)	1.1	-	2.8 -
Suffocation by plastic bag (E953.1)	0.4	-	1.8 -
Cutting/piercing instruments (E965)	1.3	1	1.4 1
Poisons (E950.6-950.9)	0.6	-	1.0 -
Other*	2.5	18	3.2 45
Totals	100.0	100.0	100.0 99.0

Phillips’s ideas about contagion dominated the sociological study of suicide in the 1980s. Works by Stack (1982), Wasserman (1989), Kessler and Strip (1984), and others have produced equivocal support for the role of suggestion in suicide (Diekstra et al. 1989). Wasserman (1989) feels that the business cycle and unemployment rates must be controlled for. Some have claimed that imitative effects are statistical artifacts. Most problematic is the fact that the theory of imitation in suicide is underdeveloped.

The most recent sociologist to study suicide is the medical sociologist Pescosolido. She has claimed, contrary to Douglas, that the official statistics on suicide are acceptably reliable and, as Gibbs said earlier, are the best basis available for a science of suicide. Her latest paper (Pescosolido and Georgianna 1989) examined Durkheim’s claim that religious involvement protects against suicide. Pescosolido and Georgianna find that Roman Catholicism and evangelical Protestantism protect one against suicide (institutional Protestantism does not) and that Judaism has a small and inconsistent protective effect. Those authors conclude that with disintegrating network ties, individuals who lack both integrative and regulative supports commit suicide more often.

Common Single Predictors of Suicide

1. Depressive illness, mental disorder

2. Alcoholism, drug abuse

3. Suicide ideation, talk, preparation, religion

4. Prior suicide attempts

5. Lethal methods

6. Isolation, living alone, loss of support

7. Hopelessness, cognitive rigidity

8. Older white males

9. Modeling, suicide in the family, genetics

10. Work problems, economics, occupation

11. Marital problems, family pathology

12. Stress, life events

13. Anger, aggression, irritability, 5-HIAA

14. Physical illness

15. Repetition and comorbidity of factors 1-14, suicidal careers  

ISSUES AND FUTURE DIRECTIONS

Much of current sociological research on suicide appears myopic and sterile compared to the early work of Durkheim, Douglas, and Garfinkel. Not only is the scope of current research limited, there is very little theory and few book-length publications. Almost no research mongraphs on the sociology of suicide were written in the 1980s. Highly focused scientific journal articles on imitation have predominated, but none of these papers have been able to establish whether suicides ever were exposed to the original media stimulus. Since suicide does not concern only social relations, the study of suicide needs more interdisciplinary syntheses. The dependent variable (suicide) must include comparisons with other types of death and violence as well as more nonsocial predictor variables (Holinger 1987).

Table 6:Suicide Rates per 100,000 Population in 62 Countries, 1980-1986

Table 6:Suicide Rates per 100,000 Population in 62 Countries, 1980-1986

A second issue concerns methods for studying suicide (Lann et al. 1989). There has never been a truly national sample survey of suicidal behaviors in the United States. Also, most suicide research is retrospective and based on questionable vital statistics. More prospective or longitudinal research design are needed, with adequate sample sizes and comparison or control groups. Models of suicidal careers should be analyzed with specific and appropriate statistical techniques such as logistic regression, log-linear procedures, and event or hazard analysis. Federal funds to do major research on suicide are in short supply, and this is probably the major obstacle to the contemporary scientific study of suicide.

Most studies of suicide are cross-sectional and static. Future research should include more social developmental designs (Blumenthal and Kupfer 1990). There is still very little solid knowledge about the social dynamics or ”suicidal careers” of eventual suicides (Maris 1990). For example, it is well known that successful suicides tend to be socially isolated at the time of death, but how they came to be that way is less well understood. Even after almost a hundred years of research the relationship of suicide to social class, occupation, and socioeconomic status is not clear.

A major issue in the study of suicide is rational suicide, active euthanasia, the right to die, and appropriate death. With a rapidly aging and more secular population and the spread of the acquired immune defiency (AIDS) virus, the American public is demanding more information about and legal rights to voluntary assisted death (see the case of Nico Speijer in the Netherlands in Diekstra et al. 1989). The right to die and assisted suicide have been the focus of a few recent legal cases (Humphry and Wickett 1986; Battin and Maris 1983). Rosewell Gilbert, an elderly man who was sentenced to life imprisonment in Florida for the mercy killing of his sick wife, was pardoned by the governor of Florida (1990). However, in 1990, the U.S. Supreme Court (Cruzon v. the State of Missouri) ruled that hospitals have the right to force-feed even brain-dead patients. The Hemlock Society has been founded by Derek Humphry to assist those who wish to end their own lives, make living wills, or pass living will legislation in their states (however, see the New York Times, February 8, 1990, p. A18). Of course, the state must assure that the right to die does not become the obligation to die (e.g., for the aged). These issues are further complicated by strong religious and moral beliefs.

Should society help some people to die, and if so, who and in what circumstances? All people have to die, after all, so why not make dying free from pain, as quick as is desired, and not mutilating or lonely? one cannot help thinking of what has happened to assisted death at the other end of the life span, when help has not been available, in the case of abortion. Women often mutilate themselves and torture their fetuses by default. The same thing usually happens to suicides when they shoot themsleves in the head in a drunken stupor in a lonely bedroom or hotel room. obviously, many abortions and most suicides are not ”good deaths.”

Euthanasia is not a unitary thing. It can be active or passive, voluntary or involuntary, and direct or indirect. A person can be against one type of euthanasia but in favor of another. ”Active euthanasia” is an act that kills, while ”passive euthanasia” is the omission of an act, which results in death. For example, passive or indirect euthanasia could consist of ”no-coding” terminal cancer or heart patients instead of resuscitating them or not doing cardiopulmonary resuscitation after a medical crisis.

”Voluntary euthanasia” is death in which the patient makes the decision (perhaps by drafting a living will), as opposed to ”involuntary euthanasia,” in which someone other than the patient (e.g., if the patient is in a coma) decides (the patient’s family, a physician, or a nurse).

”Direct euthanasia” occurs when death is the primary intended outcome, in contrast to ”indirect euthanasia,” in which death is a by-product, for example, of administering narcotics to manage pain but secondarily causes respiratory failure.

All the types of euthanasia have asssociated problems. For example, active euthanasia constitutes murder in most states. It also violates a physician’s Hippocratic oath (first do no harm) and religious rules (does all life belong to God?) and has practical ambiguities (when is a patient truly hopeless?).

Passive euthanasia is often slow, painful, and expensive. For example, the comatose patient Karen Anne Quinlan lived for ten years (she survived even after the respirator was turned off) and seemed to grimace and gasp for breath. Her parents and their insurance company spent thousands of dollars on what proved to be a hopeless case. The U.S. Supreme Court ruled in Cruzan (1990) that hospitals cannot be forced to discontinue feeding comatose patients.

In a case in which the author served as an expert, Elizabeth Bouvia, a quadriplegic cerebral palsy patient in California, sued to avoid being force-fed as a noncomatose patient. Her intention was to starve herself to death in the hospital. The California Supreme Court upheld Bouvia’s right to refuse treatment, but others called the court’s decision ”legal suicide.”

A celebrated spokesperson for euthanasia in the form of assisted suicide has been Derek Humphry, especially in his best-selling book Final Exit (1996). Rational assisted suicide (Humphry assisted in his first wife’s death and in the death of his father-in-law), even for the terminally ill within six months of death, has proved highly controversial, particularly to Catholics and the religious right. Basically, Humphry has written a ”how-to” book on the practicalities of suicide for the terminaly ill.

His preferred rational suicide technique is to ingest four or five beta-blocker tablets and 40 to 60 100-mg tablets of a barbituate (perhaps in pudding or Jell-O), taken with Dramamine (to settle the stomach), vodka (or one’s favorite whiskey), and a plastic bag over the head loosely fixed by a rubber band around the neck. Humphry recommends against guns (too messy), cyanide (too painful), hanging (too graphic), jumping (one could land on another person), and other mutilating, violent, painful, or uncertain methods.

One of the big questions about Final Exit is its potential abuses, for example, by young people with treatable, reversible depression. Having the lethal methods for suicide described in such vivid, explicit details worries many people that suicide will become too easy and thus often will be inappropriate. Yet Humphry shows that it is hard to get help with self-deliverance without fear of penalties. He argues that laws need to be changed to permit and specify procedures for physician-assisted suicide for the terminally ill under highly controlled conditions.

A few states have undertaken such reforms to permit legal assisted death. For example, Initiative 119 in the fall of 1991 in Washington and Proposition 161 in the fall of 1992 in California would have provided ”aid in dying” for a person if (1) two physicians certified that the person was within six months of (natural) death (i.e., terminally ill), (2) the person was conscious and competent, and (3) the person signed a voluntarily written request to die witnessed by two impartial, unrelated adults. Both referenda failed by votes of about 45 percent in favor and 55 percent against.

Humphry waged a similar legal battle in Oregon, first as president of the Hemlock Society and later as president of the Euthanasia Research and Guidance Organization (ERGO) and the Oregon Right to Die organization. On November 4, 1994, Oregon became the first state to permit a doctor to prescribe lethal drugs expressly and explicitly to assist in a suicide (see Ballot Measure 16). The National Right to Life Committee effectly blocked the enactment of this law until-1997, when the measure passed overwhelmingly again. On March 25, 1998, an Oregon woman in her mid-eighties stricken with cancer became the first known person to die in the United States under a doctor-assisted suicide law (most, if not all, of Dr. Jack Kervorkian’s assisted suicides have probably been illegal).

Physician-assisted suicide has been practiced for some time in the Netherlands. On February 10, 1993, the Dutch Parliment voted 91 to 45 to allow euthanasia. To be eligible for euthanasia or assist-ed-suicide in the Netherlands, one must (1) act voluntarily, (2) be mentally competent, (3) have a hopeless disease without prospect for improvement, (4) have a lasting longing (or persistent wish) for death, (5) have assisting doctor consult at least one colleague, and (6) have written report drawn up afterward.

The Dutch law opened the door for similar legislation in the United States, although the U.S. Supreme court seems to have closed that door shut in Washington and New York. Box 1 discusses reviews of Dr. Herbert Hendin’s Seduced by Death, which opposes physician-assisted death the United States and the Netherlands. While the idea of legal assisted suicide will remain highly controversial and devisive, it is quite likely that bills similar to Oregon’s Measure 16 will pass in other states in the next decade. A key issue will be safeguards against abuses (for example, Hendin argues that physicians in the Netherlands have decided on their own in some cases to euthanize patients).

THE DUTCH CASE

The following are excerpts from reviews of Dr. Herbert Hendin’s Seduced by Death, Doctors, Patients, and the Dutch Cure (Norton 1997). See Suicide and Life-Threatening Behavior 28:2, 1998.

On June 26, 1997, the United States Supreme Court handed down a unanimous decision on physician-assisted suicide. All nine justices concurred that both New York and Washington’s state bans on the practice should stand.

The picture [Hendin paints in the Netherlands] is a frightening one of excessive reliance on the judgment of physicians, a consensual legal system that places support of the physician above individual patient rights in order to protect the euthanasia policy, the gradual extension of practice to include administration of euthanasia without consent in a substantial number of cases, and psychologically naive abuses of power in the doctor-patient relationship.

[For example:] Many patients come into therapy with sometimes conscious but often more unconscious fantasies that cast the therapist in the role of executioner . . . It may also play into the therapist’s illusion that if he cannot cure the patient, no one else can either.” (Seduced by Death, p. 57)

Samuel Klagsburn, M.D., says of Hendin’s argument: “He is wrong . . . suffering needs to be addressed as aggressively as possible in order to stop unnecessary suffering.”

Hendin claims that in the Netherlands, “despite legal sanction, 60% of [physician-assisted suicide and death] cases are not reported, which makes regulation impossible.”

Hendin goes on to argue that “a small but significant percentage of American doctors are now practicing assisted suicide, euthanasia, and the ending of patients’ lives without their consent.” But one also has to wonder: what about all those patients being forced to live and suffer without the patients’ consent?

Dr. Hendin is, after all, the former Executive Director and current Medical Director of the American Foundation for Suicide Prevention. What would really be news is if Hendin came out in favor of physician-assisted death. Certainly, there are abuses of any policy. But is that enough of a reason to fail to assist fellow human beings in unremitting pain to die more easily ? Death is one the most natural things there is and often is the only relief.

One of the most controversial advocates of physician-assisted suicide (”medicide”) has been Dr. Kervorkian (Kevorkian 1991). Public awareness of assisted suicide and whether it is rational has foused largely on Kervorkian, the ”suicide doctor.” As of early 1999, Kervorkian had assisted in over 100 suicides.

Initially, with Janet Adkins, Kervorkian used a suicide machine, which he dubbed a ”mercitron.” This machine provided a motor-driven, timed release of three intravenous bottles; in succession, they were (1) thiopental or sodium pentathol (an anesthetic that produces rapid unconsciousness), (2) succinycholine (a muscle paralyzer like the curare used in Africa use in poison darts to hunt monkeys), and (3) postassium chloride to stop the heart. The metcitron was turned on by the would-be suicide. Because of malfunctions in the suicide machine, almost all of Kervorkian’s suicides after Atkins were accomplished with a simple facial mask hooked up to a hose and a carbon monoxide cannister, with the carbon monoxide flow being initiated by the suicide. For most nonnarcotic users or addicts, 20 to 30 milligrams of intravenous injected morphine would cause death.

All of Kervorkian’s first clients were women, and most were single, divorced, or widowed. Almost all were not terminally ill or at least probably would not have died within six months. The toxicology reports at autopsy (by Frederick Rieders; the author spoke with Dr. Dragovic, the oakland County, Michigan, medical examiner to obtain these data) showed that only two of the eight assisted suicides had detectable levels of antide-pressants in their blood at the time of death. It could be concluded that Kervorkian’s assisted suicides were for the most part not being treated for depressive disorders.

Given Kervorkian’s zealous pursuit of active euthanasia, one suspects that at least his early assisted suicides were not adequately screened or processed, for example, in accordance with the Dutch rules (above) or other safeguards. Strikingly, Hugh Gale is reputed to have asked Kervorkian to take off the carbon monoxide mask and terminate the dying process and perhaps was ignored by Kervorkian.

It is difficult to be objective about assisted suicide. Paradoxically, Kevorkian may end up setting euthanasia and doctor-assisted suicide back several years. Not only has he lost (1991) his Michigan medical license (he was a pathologist) and been charged with murder (after videotaping the dying of an assisted suicide for a television program), but Michigan and many other states (including South Carolina) have introduced bills to make previously legal assisted suicide a felony, with concurrent fines and imprisonment.

These new laws may have a chilling effect on both active and passive euthanasia, even in the case of legitimate pain control (”palliative care”) previously offered to dying patients by physicians and nurses. For example, in Michigan it is now a felony to assist a suicide. People who want self-deliverance from their final pain and suffering will be more likely to mutilate themselves, die alone and disgraced, and feel generally abandoned in their time of greatest need.

Kervorkian needs to be separated from the issue of assisted suicide. However, the issue of physician-assisted suicide or death itself is not silly and transitory.

Everyone has to die eventually, and many people will suffer machine-prolonged debilitating illness and pain that diminishes the quality of their lives. Suicide and death and permanent annnihilation of consciousness (if there is no afterlife) are effective means of pain control. This refers primarily to physical pain, but psychological pain also can be excruciating. Pain cannot always be controlled short of death. Most narcotics risk respiratory death. Furthermore, narcotics often cause altered consciousness, nightmares, nausea, panic, long periods of disrupted consciousness and confusion, and addiction.

Pain control technology is progressing rapidly (e.g., spinal implant morphine pumps). There are hospices that encourage the use classic painkilling drinks such as Cicely Saunder’s ”Brompton’s cocktail” (a mixed drink of gin, Thorazine, cocaine, heroin, and sugar). It is also possible to block nerves or utilize sophisticated polypharmacy to soften pain.

However, some pain is relatively intractable (e.g., that from bone cancer, lung disease with pneumonia, congestive heart failure in which patients choke to death on their own fluids, gastrointestinal obstructions, and amputation). A few physicians have made the ludricrous death-in-life proposal to give hopeless terminally ill patients general anesthesia to control their pain. People do always get well or feel better. Sometimes they just need to die, not be kept alive to suffer pointlessly. Anyone deserves to be helped to die in such instances.