The issue of whether or not to legalize physician-assisted suicide (PAS) has been front and center as a public policy issue around the world. Unfortunately, much of the debate regarding this issue has been ideological and indicative of a clash of paradigms rather than truly empirically based. Many proponents and opponents of PAS are largely operating on assumptions as to why people participate in PAS with only a limited amount of empirical support for their attitudes. These assumptions can be stated as hypotheses. Proponents of PAS often assume that people participate in PAS for primarily rational and biomedical reasons stemming from physical illnesses (Humphrey, 1987; Werth, 1996). Opponents of PAS, in contrast, often assume that participants in PAS are motivated primarily by psychosocial factors not so different from those emerging in more typical suicidal behavior, and push for suicide prevention intervention (Smith, 1997; Hendin, 1998) Clearly one's outlook toward PAS depends a great deal on the lenses through which one views it.
The present essay has two purposes. First, we will summarize some of the data emerging from the PAS sample we have been studying in Michigan (Kaplan, 2000). These data are striking in a number of important ways and are important in themselves in an attempt to characterize motivations of people who seek PAS. These data have been presented in detail in several recent articles published both by our research team (Kaplan, Lachenmeier et. al., 2000; Kaplan, O'Dell et. al., 2000) and others (Canetto and Hollenshead, 2000). Here we summarize these data around gender in a particular way to meet the second purpose of our paper: to place these particular data set in a more general model of PAS world-wide, focusing on differences in gender-ratios across these samples. This model will introduce the conception of the degree of physician control as an ordering principle and will examine its relationship to the gender ratio of the PAS participants. In other words, degree of physician control will be treated as an independent variable, ranging across various data sets from unassisted suicide (no doctor involvement) on the one-hand to full euthanasia (full doctor control) on the other. The proportion of women versus men participating in hastened death will be treated as a dependent variable.
1. The Michigan PAS Sample
Generally, researchers agree that the relationship between physical illness and psychiatric symptamotology is complicated (Fawcett, 1972; Murphy, 1977; Conwell et. al., 1990). The present research report presents data to determine the relative roles of psychosocial versus biomedical factors in the PAS cases in Michigan performed by Dr. Kevorkian and his team. Specifically, we focus on the question of gender differences in this regard.
Sample. The Michigan data derives from our own IRB approved research on the PAS conducted by Dr. Kevorkian and his team. Our research team, in conjunction with the Detroit Free Press, has identified 93 of these cases, and there is evidence that even with Kevorkian presently in prison, other members of his team have continued to perform additional PAS both in Michigan and in other states (Detroit Free Press, May 13, 1999). From these 93 cases, we have administered a psychological autopsy to friends and relatives of the first 47 of these decedents who were assisted in their death in the period June 4, 1990 to February 2, 1997. This psychological autopsy technique has been widely used in the study of suicide and allows the reconstruction of the psychological profile of the decedent in a manner parallel to a physical autopsy (Barraclough et. al., 1974; Hagnell and Rorsman, 1979; Fowler et. al., 1986; Clark and Horton-Deutsch, 1992). This will be discussed in more detail below.
We have also collected more cursory data gleaned from the death certificates and from the judgments of the medical examiners of the …