To me alone there came a thought of grief:
A timely utterance gave that thought relief. . .
How has death
As the decade comes to da close, it is an opportune time to reflect on death and dying in America. As I write, Jack Kevorkian-the figure perhaps most identified with the death with dignity movement-has just been sentenced to ten to twentyfive years in a Michigan jail for second-degree murder. Although Kevorkian will almost certainly appeal his conviction, his sentencing to prison time makes it highly likely that his involvement in our nation's dialogue about death and dying is fast coming to a close. This occurrence is a milestone because Kevorkian's initial physician-assisted suicides sparked our national debate about this contentious issue.
This story could be said to have begun in June 1990, when we read that the retired pathologist had helped a 54-year-old woman with a presumptive diagnosis of Alzheimer's disease to end her life (Belkin, 1990). After playing a game of tennis and writing a note to her family explaining her actions, Janet Adkins was connected to Dr. Kevorkian's suicide machine to receive a lethal injection of medication in his now famous Volkswagen microbus.
The story seems to have ended on April 13, 1999, when Kevorkian was sentenced to ten to twentyfive years for seconddegree murder of Thomas Youk. With overwhelming media coverage, the nation watched as Kevorkian received his first conviction after three acquittals and one mistrial. As the Kevorkian chapter appears to be coming to a conclusion, it is a good time to reflect on where we have been this past decade in order to predict where we might be headed in the next.
A DECADE RETROSPECTIVE
It could be argued that we have made remarkable progress since Kevorkian's first assisted suicide. Although his actions are not responsible for these accomplishments, they did help set the stage for greater receptivity to the work of more mainstream investigators and policy makers concerned with the care that people who are dying receive. It is worth cataloguing these activities to fully appreciate the scope of our efforts over the past ten years and to predict future trends.
Medicine and the law. At least within the profession of medicine, it could be argued that the most significant event of the decade was the publication in I995 of the massive Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), finded with $28 million from the prestigious Robert Wood Johnson Foundation. The SUPPORT study found that a disproportionate number of critically ill hospitalized patients received inadequate pain relief and that their preferences regarding end-of-life care were either unknown or ignored.
In the wake of SUPPORT, it was not uncommon to read in leading newspapers that advance directives did not work, that physicians ignored pain, and that they were often unaware of their patients' end-of-life care preferences (Gilbert, I995; Colburn, I995; Winslow, I995). SUPPORTS conclusions, which were sometimes accurately described and sometimes misrepresented in the professional and lay press, helped to further a desire for the legalization of physician-assisted suicide that had begun in earnest with Timothy Quill's 1991 New England Jounal of Medicine account of how he helped his patient "Diane" end her life. Quill's mainstream reflections in the nation's leading medical journal-coupled with Kevorkian's libertarian practices-led prominent physicians and medical ethicists to propose guidelines to legally regulate this practice (Quill, Cassel, and Meier, I992; Miller and Fletcher, I993; Miller et al., 1994). Although many advocated improved palliative care as the appropriate response to these deficiencies in care (Sach et al., 1995), others read the SUPPORT results as a justification for the legalization of physicianassisted suicide. …