Physician-assisted suicide in the United States is a controversial issue which has garnered much attention from medicine, law, and many social interest groups. The influence of technological change on social acceptance and opposition of assisted suicide will be examined in this chapter. Jack Kevorkian, or "Dr. Death" as he is commonly called, was responsible for elevating the issue of physician-assisted suicide to the national spotlight in the United States. The career of this polarizing pioneer offers a valuable case study through which the issue will be explored.
Suicide Case Studies
The British Coal-Gas Story
Throughout generations prior to the 1970s in Great Britain, families heated their homes with coal-gas furnaces. The gas, in its unburned form, released high levels of toxic carbon monoxide. Because of this, 'sticking one's head in the oven,' as it was called, became a preferred method of suicide in England.
In the 1960s the British government began phasing out coal-gas in favor of the cleaner burning natural gas. By 1971, nearly 70% of the gas reaching consumer households was natural gas. Furthermore, by 1975, the portion of carbon monoxide in the gas entering the average consumer's home was less than one percent. Throughout the 1960s, at the same time that the carbon monoxide was being reduced, the suicide rate dropped in Britain. By 1971, the overall suicide rate for men of all ages had dropped by about 16%.
Why is that removing one method of self-harm has such a profound rippling effect? Norman Kreitman, in his report on the coal-gas story published in 1976, writes that "There is no shortage of exits from this life; it would seem that anyone bent on self-destruction must eventually succeed, yet it is also quite possible...that a failed attempt serves as a catharsis leading to profound psychological change."
A Tale of Two Bridges
The Duke Ellington Bridge and the Taft Bridge are two bridges in Washington D.C. which both cross over the Rock Creek gorge. In 1985, the Ellington Bridge accounted for four suicides each year, which was half of all jumping suicides in the city. The Taft Bridge averaged fewer than two suicides per year.  This disparity was quite unexpected, considering two important similarities between the two bridges. First, both bridges stand at approximately 125 feet tall, essentially guaranteeing death as a result of jumping. This precludes the hypothesis that one bridge was more desirable due to an increased chance of death. Second, the bridges are located only several hundred yards from each other. Thus, neither was in a region of a higher general jumping suicide rate than the other.
On a particularly tragic 10-day period in 1985, three people committed suicide by jumping off the Ellington Bridge. Certain groups of citizens lobbied strongly for the construction of an anti-suicide barrier on the bridge. Opposition groups like the National Trust for Historic Preservation claimed that such a barrier would be useless, founding their argument on the assumption that those people intent on committing suicide would simply go elsewhere. Their argument was strengthened by the fact that the Taft Bridge was just yards away. The barrier was constructed in January 1986 and completely eliminated suicides at the Ellington Bridge--four deaths per year to zero. The overall suicide rate in Washington dropped by a similar amount. Meanwhile, the suicide rate on the Taft Bridge saw only a slight increase, from 1.7 deaths per year to 2.
Experts attempted to determine the cause for this phenomenon. Why had the construction of a barrier on one bridge (of 330 total in Washington) nearly eliminated the four suicides per year for which it was formerly responsible? They concluded that the initially lower barrier (knee-high) on the Ellington Bridge, relative to that on the Taft Bridge (chest-high), was the primary factor. Its lack of height offered potentially suicidal people the option to kill themselves quickly and easily in an impulsive moment. On the other hand, suicide on the Taft Bridge took more time and effort, significantly impeding impulsive suicides.
Both the British coal gas story and the Washington D.C. bridges case imply that the availability of the means to commit suicide can profoundly influence a person's ultimate decision. Studies on other suicide methods have revealed similar implications. A 2005 international study found a strong correlation between the availability of firearms and firearm suicides. A similar effect was discovered in suicide by pesticide ingestion in developing countries.
Legality of Physician-Assisted Suicide
In the United States, physician-assisted-suicide is legal in Oregon, Washington, and Montana. The processes of applying for physician assisted suicide varies between in each state, and in somes cases the steps can be quite arduous. In all three states, a physician may legally provide a patient with a lethal dose of prescription drugs which the patient is then responsible for taking independently. In this way, the physician is absolved from any liability and the case cannot be labeled as euthanasia.
Oregon was the first state in the United States to legalize physician-assisted-suicide. The Oregon Death with Dignity Act (ODWDA) was passed in 1994 amidst strong public support. Under ODWDA, upon first meeting a set of qualifying criteria, a patient may submit a request for a dose of a lethal prescription. The patient must also submit two oral requests to his physician at least 15 days apart from one another. The ODWDA has faced numerous legal battles since its enactment in 1994. In 2006, the ODWDA was upheld by the Oregon Supreme Court by a vote of 6-3.
The Washington Death with Dignity Act mirrors that of Oregon and has been active since 2009..
Unlike the cases of Oregon and Washington where public support led to the enactment of the Death With Dignity Acts, the legality of physician-assisted-suicide in Montana is based on the judicial resolution of a lawsuit, Baxter v. Montana.  In this decision, a Montana judge ruled that the right to physician-assisted-suicide was protected by Montana's state constitution.
Dr. Jack Kevorkian was trained as a pathologist and publicly demonstrated an unusual interest in death throughout his career. He published and presented on controversial topics such as medical experimentation on willing capital punishment subjects, blood transfusion from cadavers, and the ethics of euthanasia. He was dismissed from his residency at the University of Michigan for his discordant opinions and research interests. Kevorkian is best known for his work as a right-to-die activist, assisting in the deaths of over 130 patients throughout the 1990s.
Kevorkian never shied from the public light, insisting on the importance of patient autonomy in the doctor-patient relationship. He once showed up to a court hearing dressed as Thomas Jefferson in a protest that his rights had been violated.
Kevorkian's first patient, which received much public scrutiny, was 54-year old Janet Adkins, who suffered from Alzheimer's disease.Kevorkian required that his patients be terminally ill and consult a pain professional before he would agree to treat them. Kevorkian stated once that he turned away "four out of [every] five" patients that desired his services .
Thanatron, meaning "death machine" in Greek, was the name given Kevorkian gave to his first death machine. It was assembled from spare parts Kevorkian collected at garage sales. Normal saline flowed continuously as the patient initiated administration of a rapidly acting potassium chloride solution to stop the heart. These are the same drugs used in capital punishment lethal injections. Kevorkian was forced to discontinue use of the Thanatron in 1991 when he lost his medical license and access to controlled drugs.
Kevorkian invented the Mercitron as a means for assisting patients with suicide after his medical license was revoked. The Mercitron featured a gas mask connected to a tank of carbon monoxide stored in the back of Kevorkian's van. Kevorkian would fit the mask over the patient's mouth and direct the patient's hand to a handle on the device that, when pulled by the patient, would begin the flow of carbon monoxide to the mask. The process could take up to ten minutes before death set in.
Convicted of Murder
Thomas Youk was a patient of Kevorkian's who suffered from multiple sclerosis. In 1998, Kevorkian assisted in Youk's suicide. In this case, however, the patient was unable to administer the drugs himself, so Kevorkian administered the drugs to Youk. To complicate matters, Kevorkian filmed the entire procedure and sent it to 60 Minutes, taunting the authorities to try him and put him in jail. He was convicted of second-degree murder and sentenced to jail in 1999 and was not released until 2007. Kevorkian would later disclose that the Youk case was not the first in which he had caused the death of the patient rather than allowing the patient to perform the act on their own. 
Exit International is a registered non-profit group headquartered in Australia dedicated to advancing information and advocating for end-of-life choices. Exit's main goal is enacting legal reform to support physician-assisted-suicide. Exit believes that the Swiss model of PAS is the standard that should be sought after.
Death with Dignity National Center
The Death with Dignity National Center is a non-profit organization committed to protecting and preserving the rights established by the Death with Dignity laws in the United States. Additionally, their aim is to extend the Death with Dignity laws protected in Oregon and Washington to states throughout the country. 
Many religious groups are opposed to physician-assisted suicide because they believe that it violates the sanctity of life. The Christian Medical and Dental Association's position statement conveys the generally pervasive view among conservative faith groups: "We, as Christian physicians and dentists, believe that human life is a gift from God and is sacred because it bears God's image. We oppose active intervention with the intent to produce death for the relief of pain, suffering, or economic considerations, or for the convenience of patient, family, or society." Religious groups also commonly propose that the authority of their respective religious figures trumps patient autonomy, disallowing physician-assisted suicide.
Opponents citing the "slippery slope" argument claim that allowing physician-assisted suicide provides doctors with less motivation to exhaust every alternative option before turning to death. Others say that there is little if no difference between physician-assisted-suicide and doctor-induced euthanasia. A more extreme proposition made by a journalist opposing legalization of physician-assisted suicide is that the procedures would "become routine" and that "comfort would make us want to extend the option to others who, in society's view, are suffering and leading purposeless lives."
Implications of Technology in Physician-Assisted Suicide
The bioethics principle of non-maleficence states that a healthcare provider has a duty to do no harm. The termination of a person's life to alleviate suffering prior to exhaustive assessment and treatment of the underlying causes of suffering is a violation of this principle. Reduction of a potential suicide subject's suffering to the point where death is no longer desired is clearly preferable over hasty suicide. This underlies the arguments of critics who contend that Kevorkian's seemingly swift process may have indicated a neglect for potentially beneficial non-suicide treatments. Those societies which accept physician-assisted suicide as an ethical medical practice generally do so subject to the condition that the cause of the patient's suffering is untreatable. In such a case, it is actually inaction which is considered to be malicious towards the patient. Physician-assisted suicide is justified as a means of reducing suffering in lieu of any other realistic option.
Suicide-enabling technology, including firearms, chemical toxins, and Kevorkian's inventions, has varied consequences, depending on the context of its use. For example, there may be a case where extreme, incurable suffering renders suicide to be the least malignant course of action. If law allows physician-assisted suicide, painless suicide techniques clearly offer favorable alternatives to more brutal, potentially painful methods. However, the existence of more "advanced" suicide technologies can also enable egregious violations of non-maleficence. As the British coal gas and D.C. bridges case studies showed, available technology can influence and even encourage suicidal behavior. Thus, the decision to opt for suicide may come hastily and in place of more beneficial treatments. In other words, the patient may not have chosen such a drastic end if the means were less attractive or available. Although physician-assisted suicide technology can be beneficial in enabling an escape from suffering, it also has the potential to distort medical decision-making and, at its worst, encourage suicide.
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