Assisted suicide and older poeple - a deadly combination: ethical problems in permitting assisted suicide.

• Author: Osgood, Nancy J.

On June 4, 1990, fifty-four-year-old Janet Adkins ended her life lying on a cot in the back of a Volkswagen van parked in a Michigan suburb. Aided by a retired pathologist, Dr. Jack Kevorkian, Adkins was hooked up to his homemade "suicide machine." She had a needle inserted in her arm, which first started saline flowing and, then, when she pressed the button on the macabre death machine, sent first a sedative and then deadly potassium chloride flowing into her veins.

An active woman with loving children and grandchildren, Adkins had flown two thousand miles from her Oregon home to Michigan to seek Kevorkian's assistance in ending her life when she was diagnosed with Alzheimer's disease. Adkins was an active member of the Hemlock Society, an organization that supports legalizing assisted suicide in America. She made a deliberate decision to end her life rather than face the mental decline associated with senile dementia.(1) Kevorkian, a long-time proponent of physician-assisted suicide, took that opportunity to use his suicide machine as a way of making a public statement to the medical community and the larger society that suicide is acceptable and that doctors should be willing to assist those who choose to die. Kevorkian was not charged with any crime, although a temporary restraining order was issued, forbidding him to use his suicide machine again.(2) Ignoring the order, Kevorkian helped two other women to kill themselves in October 1991.(3) Since 1990 Kevorkian has helped twenty-one people to commit suicide.(4)

These assisted suicides have brought dramatically to the nation's attention the debate over the right to die with dignity and the ethics of helping others to commit suicide. Suicide and assisted suicide are issues particularly relevant to older members of our society. Compared to other age groups, older persons are the group most at risk of committing suicide or double suicide, and they are one of the groups most likely to request assistance in ending their lives. Those under age twenty-five years make up 16% of the U.S. population and account for 16% of all suicides. Those aged sixty-five years and over make up 12% of the population but account for 21% of all suicides.(5) In 1990 the suicide rate for the United States population was 12.4 per 100,000. The suicide rate for individuals aged fifteen to twenty-four years was 13.2 per 100,000. The suicide rate for people sixty-five and older was 20.5 per 100,000. Figure 1 below graphically compares suicide rates by sex and age groups. The positive relationship between age and suicide, particularly in males, is striking. The old are also among those most likely to be suffering from a terminal illness or to be dying. Seventy percent of the two million people who died in 1985 were sixty-five or older. Not surprisingly, the majority of people involved in euthanasia cases are old. According to Humphry and Wickett, 64% were over sixty, while 51% were over seventy.(6)

Dramatic medical advances have greatly increased life expectancy but also have increased the period of chronic illness and disability. There are currently many more older individuals in our population than at any previous time in history. Today there are approximately 31 million people sixty-five and older in the United States population. The number of those over the age of sixty-five exceeds the number of teenagers in the United States. It is projected that the number of older persons will double in twenty years to 60 million. However, the oldest-old cohort are the fastest-growing age group in the country and are expected to triple in number during that same time span. The rate of increase in the oldest-old population has been truly impressive. For example, there are now twenty times as many people over eighty-five as there were at the turn of this century. In 1960, there were 0.9 million people in that age category or above; this number increased to 2.3 million in 1980, a gain of 156% in twenty years. It is estimated that in the year 2000 the number of persons eighty-five years and older will increase to 5.4 million; it will reach 7.6 million by 2020 and is expected to reach or exceed 13 million by the year 2040.(7) The oldest-old are among those groups who, in the future, will demand the most health care resources and who have the least to offer society in terms of labor, productive work, and economic benefits. A growing population of older citizens places considerably greater financial and social demands on society. The rapid rate of cultural change, resulting in a situation in which older people may have outlived their previous roles and sources of value and meaning, has spawned moral and ethical dilemmas about suicide and assisted suicide among the old.

Older Adults--Victims of Ageism and a Burden on Society

The fact that we have created a society that is so harsh to its old that ever-increasing numbers are choosing suicide as a solution to their problems is a sad commentary on America. To argue for the right to suicide and assisted suicide for older persons is a symbol of our devaluation of old age and our own ageism and fear of aging. This position endorses the belief that the answer to the problems of old age is suicide. Moreover, it may in fact be setting up conditions that rob older people of their right to live. Older people, living in a suicide-permissive society characterized by ageism, may come to see themselves as a burden on their families or on society and feel it is incumbent on them to take their own lives. Others may be pressured into suicide by uncaring or greedy family members. Those who need expensive medical technology to live may be denied help and die. The right to die then becomes not a right at all but rather an obligation. We may create a climate in which suicide is viewed as a rational choice. In a society that devalues old age and old people, in which older adults are seen as "expendable" and as an economic burden on younger members, older people may come to feel it is their social duty to kill themselves. As in more primitive societies in earlier historical periods, the old in America may be sacrificed for the good of the society.

Elderly Suicide In Primitive Societies

The position that suicide and assisted suicide should be available for older people is not new, nor is it unique to America. Pliny the Elder considered the existence of poisonous herbs proof of a kindly providence because it allowed people to die painlessly and quickly and thus avoid the pain and sickness of old age. Zeno, the founder of Stoic philosophy, similarly advocated suicide to avoid the pain and sickness of late life; at age ninety-eight, when he fell down and pulled his toe out of joint, he hanged himself. Socrates, who drank hemlock at seventy, also cited old age as one reason for taking his own life. In primitive societies, it was conventional, and occasionally obligatory, for old people to commit suicide or to be assisted in dying if, because of infirmity, they had become a burden on their society. The ancient Scythians regarded suicide as the greatest honor when they became too old for the nomadic life. They had themselves buried alive as soon as age or sickness troubled them.(8) On the island of Cheos in Greek antiquity it was normal for the old and weak to commit suicide.(9) Among the Yuit of the St. Lawrence Islands in northern Canada, older adults, usually males, communicated their desire to die to their families and sought their assistance. Three methods of execution (assisted suicide) were used: hanging, shooting, and stabbing. The older person was dressed in funeral clothing and carried to the place of destruction, where the execution was carried out in public. The institution served to eliminate members of the society who were diminished by age or sickness and to preserve more of the scarce resources found in the harsh Arctic climate for younger, more able members of the society.(10) It was normal for Amassalik Eskimos in Greenland to kill themselves when they felt they were a burden on the community.(11) An ancient custom in Japan, where the villages were so poor that in order to survive older people felt they had to commit suicide, was to carry the old, weak members up to the "mountains of death" and abandon them there to die.

In a recent cross-cultural study of death-hastening behaviors directed toward decrepit old people in nonindustrial societies, Anthony Glascock found such behaviors existed in about 50% of the societies contained in a probability sample taken from the human relations area files.(12) Glascock found frequent examples of killing and abandoning of old people when they became mentally or physically diminished to the point of decrepitude. Forsaking the decrepit old also was practiced in some societies, where food was denied to those old people who were viewed as useless or nonproductive. These examples, drawn from widely different societies in the world, confirm that death-hastening behavior is directed toward a specific type of older person--the one who has experienced changes in health to the degree that he or she is no longer able to productively contribute to the well-being of the social group.

Ageism in America

In America today our core attitude about older people is that they are useless people whose lives are over. In an attempt to discover what it is like to be old in America, a young industrial designer assumed the appearance and character of an eighty-five year old woman. In 1979 Pat Moore, author of the book Disguised, began a three-year journey into the world of the old in America.(13) With the help of a makeup artist, Moore learned to apply heavy prosthetic makeup to add decades to her twenty-six-year-old face. She bought jowls, crow's feet, under-eye bags, and extra neck skin. A white wig covered her hair. To complete the look, she wore a pair of heavy orthopedic shoes, used white gloves to hide her young hands, walked with a...