Full text of DOI:10.1093/geront/41.4.439

The Gerontologist
Vol. 41, No. 4, 439–446
Copyright 2001 by The Gerontological Society of America
A Comparison of Characteristics of Kevorkian
Euthanasia Cases and Physician-Assisted
Suicides in Oregon
Lori A. Roscoe, PhD,1 Julie E. Malphurs, PhD,2 L. J. Dragovic, MD,3
and Donna Cohen, PhD2
Purpose: The sociodemographic and clinical characteris-
tics of Kevorkian euthanasia cases were compared with
Oregon physician-assisted suicide (PAS) cases and U.S.
mortality data. Design and Methods: Two hundred
variables were coded from medical examiner reports on
all 69 Kevorkian euthanasia cases who died and were
autopsied by the Oakland County Medical Examiner.
Data on the 43 Oregon PAS cases in the first two years
and U.S. mortality data were obtained from published
sources. Results: Only 25% of patients euthanized by
Kevorkian were terminally ill as compared to 100% of
Oregon PAS cases. PAS cases were significantly more
likely to have cancer (72%) than euthanasia cases (29%).
Women and those who were divorced or had never mar-
ried were significantly more likely to seek euthanasia
than would have been predicted by national mortality
statistics. Implications: Gender and marital status ap-
peared to influence decisions to seek an assisted death,
and research on the role of these factors in end-of-life de-
cision making is merited.
lay, & Knox, 1992; Breitbart, Rosenfeld, & Passik,
1996; Brown, Henteleff, Barakat, & Rowe, 1986;
Chochinov et al., 1995; Cohen, Fihn, Boyko, Jonsen,
& Wood, 1994; Duberstein, Conwell, Cox, Podgor-
ski, Glazer, & Caine, 1995; Emanuel, Fairclough,
Daniels, & Clarridge, 1995; Fried, Stein, O’Sullivan,
Brock, & Novack, 1993; Ganzini, Johnston, McFar-
land, Tolle, & Lee, 1998; Lee et al., 1996; Seidlitz,
Duberstein, Cox, & Conwell, 1995; Shapiro, Derse,
Gottlieb, Schiedermayer, & Olson, 1994). There are
many complex concerns, ranging from the individ-
ual’s ethical right to choose when to die to the appro-
priateness and availability of safeguards to protect
vulnerable populations.
Empirical data about the circumstances and char-
acteristics of patients who successfully sought PAS
and euthanasia as well as physician practices in these
situations have been difficult to ascertain in the
United States due to the illegal status of these acts in
all states except Oregon. Oregon legalized PAS in
1997, allowing terminally ill patients who meet cer-
tain criteria to receive lethal prescriptions from phy-
sicians for the purpose of ending their lives. Euthana-
sia, or assisting the suicide of another person through
other means, such as a lethal injection, is illegal in all
50 states. Although sometimes used interchangeably,
the terms euthanasia and PAS describe distinctly dif-
ferent types of assisted deaths. As legally defined in
Oregon, PAS refers to a death caused by ingesting a
lethal dose of medication obtained by prescription
from a physician for the purpose of ending one’s life.
In contrast, euthanasia refers to deaths that occur as
a result of more direct intervention.
Key Words: Death and dying, End-of-life decision
making, Physician-assisted suicide, Euthanasia
Euthanasia and physician-assisted suicide (PAS)
continue to be controversial issues. Attitude surveys
of physicians as well as patient and community pop-
ulations have confirmed the diverse perceptions and
beliefs about the acceptability and morality of PAS
and euthanasia (Bachman et al., 1996; Blendon, Sza-
At least three major U.S. studies that relied upon
voluntary physician reports have begun to identify
the characteristics of patients who wanted to die as
well as physicians who responded to their requests
(Back, Wallace, Starks, & Pearlman, 1996; Emanuel
et al., 1999; Meier et al., 1998).
Back and associates (1996) sent questionnaires to
1,453 primary care and subspeciality physicians; of
the 828 responding physicians, 12% reported ex-
plicit requests to help patients die. Subsequent inter-
views led to 207 case descriptions of patients who
This research is funded in part by a grant from the Retirement Research
Foundation awarded to Donna Cohen, PhD, and an NIH Predoctoral Fel-
lowship awarded to Julie E. Malphurs, PhD. We acknowledge the
invaluable assistance of Drs. Noshir Contractor and Beth Hui Han.
Address correspondence to Lori Roscoe, PhD, Office of Curriculum
and Medical Education, College of Medicine, University of South Florida,
12901 Bruce B. Downs Blvd., MDC 54, Tampa, FL 33612. E-mail:
lroscoe@hsc.usf.edu
1Office of Curriculum and Medical Education, College of Medicine,
University of South Florida, Tampa.
2Department of Aging and Mental Health, Louis de la Parte Florida
Mental Health Institute, University of South Florida, Tampa.
3Chief Medical Examiner, Oakland County, Pontiac, MI.
Vol. 41, No. 4, 2001
439

were given a lethal prescription or lethal injection.
More than half of these patients were men over age
65 who had been under the care of their physicians
for more than a year. Most were expected to live less
than 6 months, which is the standard medical defini-
tion for terminal illness, and 73% were diagnosed
with either cancer or HIV/AIDS. Patients who re-
quested lethal injections rather than lethal prescrip-
tions were in severe pain or physical discomfort, de-
pendent on others for personal care, or confined to
bed. Emanuel and colleagues (1999) surveyed 355
oncologists, of whom 56 reported participating in
PAS. Of the 38 case descriptions provided, more
than half were women, all were expected to live less
than 6 months, and 97% could not perform self-care
or had unremitting pain despite narcotic analgesia.
Finally, Meier and associates (1998) mailed ques-
tionnaires to 3,102 physicians in 10 specialties; of
the 1,902 who returned questionnaires, a total of 81
cases of assisted death were identified. Of the 38 pa-
tients given a lethal prescription, almost all were men
expected to live less than 6 months. More than half
were in severe pain, 70% had cancer as a primary di-
agnosis, and 19% were depressed. Of the 43 patients
who received a lethal injection, more than half were
men and nearly all were expected to live less than 6
months; 23% had cancer and 16% had AIDS.
Results from the first 2 years of experience with
legalized PAS in Oregon have provided a limited so-
ciodemographic profile of these patients (Chin, Hed-
berg, Higginson, & Fleming, 1999; Sullivan, Hed-
berg, & Fleming, 2000). Of 43 patients who died
after ingesting a lethal dose of medication obtained
with a legal prescription, half were men, cancer was
the predominant diagnosis, and all had been certified
as terminally ill and free from depression or other
factors that would compromise decision making.
The purpose of this study was to identify and clar-
ify the characteristics of another known group who
sought assistance in ending their lives: persons whose
deaths were assisted illegally by Dr. Jack Kevorkian
in Oakland County, Michigan. The deaths assisted
by Kevorkian were classified as euthanasia, as these
men and women died either from carbon monoxide
poisoning or from the intravenous administration of
lethal drugs; Kevorkian’s last patient died from a le-
thal injection. Thus, throughout this study, euthana-
sia refers to deaths caused by the direct intervention
of others, specifically deaths assisted by Jack Kevorkian.
PAS refers to deaths in which physicians prescribed
lethal doses of medication in keeping with legal stat-
utes in Oregon.
tients in Oregon, extensive data on the clinical and
psychosocial characteristics of Kevorkian’s patients
are available from medical examiner investigative re-
ports. Although many of these cases have been re-
viewed for legal and political purposes (Anstett et al.,
1997), this is the first descriptive clinical analysis. A
brief summary of the characteristics of the Kevorkian
cases was reported in a letter to the editor of the
New England Journal of Medicine (Roscoe, Mal-
phurs, Dragovic, & Cohen, 2000).
PAS and euthanasia remain controversial issues,
and it is not the intent of the authors or the purpose
of this study to justify the inclusion of assistance in
dying as an end-of-life choice, nor to vilify or canon-
ize Jack Kevorkian. Rather, our goal is to identify
and clarify the characteristics of persons for whom
assisted death was the selected option in the hope of
expanding our knowledge to improve end-of-life
care. The specific aims of this study were: (1) to ana-
lyze the sociodemographic and clinical characteristics
of Kevorkian euthanasia cases who died and were in-
vestigated in Oakland County, Michigan, from 1990
to 1998; (2) to compare the characteristics of the
Kevorkian cases to patients who died in Oregon as a
result of a lethal prescription; and (3) to examine risk
factors for death by euthanasia relative to national
mortality statistics for persons who died in the
United States in 1997, the last year data were avail-
able.
Methods
Sample
Euthanasia cases were all 69 persons whose deaths
were assisted by Jack Kevorkian in Oakland County,
Michigan, between 1990 and 1998. Persons who
died with Kevorkian’s assistance but were autopsied
outside Oakland County were excluded from the
analysis to minimize reporting bias, because the uni-
form procedures and protocols used by the Oakland
County medical examiner were not standardized
across other medical examiner districts. Data on the
43 individuals who died in Oregon in 1998–1999 as
a result of legal drug overdoses were obtained from
published summary data based on physician reports
as required by Oregon law (Chin et al., 1999; Sulli-
van et al., 2000). No post-mortem data are available
for the Oregon cases, because autopsies are not required.
U.S. mortality data were also obtained from pub-
lished sources (Hoyert, Kochanek, & Murphy, 1999).
Data Collection
Kevorkian’s behavior in assisting patients’ deaths
is not comparable to the standards of U.S. physician
practices, and the individuals euthanized lacked the
protection of clinical safeguards such as those in place
in Oregon. However, an analysis of the Kevorkian
cases is valuable to identify persons who are vulnera-
ble to seeking euthanasia and physician assistance in
dying. Unlike the previous U.S. studies relying on
voluntary physician selection, recollection, and re-
porting, or the limited clinical descriptions of pa-
Data on the Kevorkian euthanasia cases were ab-
stracted and coded from medical examiner files, which
included investigative reports, autopsy findings, toxi-
cology results, death certificates, medical records, let-
ters from physicians, police records, and, where
available, court proceedings and transcripts of inter-
views with family members. The data coding and
collection methodology was adapted from the U.S.
Air Force autopsy protocol modified by Cohen and
440
The Gerontologist

associates to study suicide and homicide–suicide in
older men and women (Cohen, Llorente, & Eisdor-
fer, 1998). A total of 203 variables in seven domains
were coded: 10 variables describing data sources; 10
incident identification variables; 6 sociodemographic
variables; 32 variables describing physical circum-
stances; 44 antecedent conditions; 25 drug categories
from toxicology studies; and 76 other autopsy find-
ings, including International Classification of Disease
(ICD) codes. Two authors independently coded the
information from each medical examiner file using a
manual of operational definitions; they compared re-
sults, and in cases where a discrepancy existed, a
consensus was determined.
in the two domains (marital status and underlying
disease) in which multiple comparisons were made.
Demographic characteristics of the Kevorkian eu-
thanasia cases were compared to U.S. mortality sta-
tistics for 1997, the most recent year for which data
are available (Hoyert et al., 1999). The rate of eutha-
nasia per 100,000 deaths was calculated by race, sex,
and marital status. Risk ratios were calculated, with
White, Male, and Married used as reference catego-
ries. Confidence intervals (CIs) were calculated for
each risk ratio, and p values were determined for
each CI.
Results
Description of Kevorkian Euthanasia Cases
Data Analysis
The characteristics of the euthanasia cases are pre-
sented in Table 1. Forty-nine (72%) of the 69
Kevorkian euthanasia cases were women, and most
were non-Hispanic Whites who lived at home at the
time of death. Male and female euthanasia cases
were similar except for marital status. Approximately
one third of women (31%) and 40% of men were
married when they died, but a significantly higher
Demographic characteristics, antecedent condi-
tions, and autopsy findings of the 69 Kevorkian cases
were analyzed using the Statistical Package for the
Social Sciences (SPSS). Chi-square analyses using Fisher’s
Exact Test were conducted on categorical variables,
and independent t tests were calculated for continu-
ous variables. Bonferroni corrections were calculated
Table 1. Characteristics of 69 Kevorkian Euthanasia Cases Who Died and Were Investigated by the Medical Examiner in Oakland
County, Michigan, 1990-1998
Women (n ꢀ 49)
Men (n ꢀ 20)
p Value
Demographic Data
Mean age (yrs)
59.9 (ꢁ13.6)
54.8 (ꢁ18.9)
—
Range (yrs)
34–86
21–89
Marital status
Married
Divorced
Widowed
Never married
31%
43%
16%
10%
40%
15%
5%
—
ꢂ2 ꢀ 4.9, p ꢀ .03
—
40%
ꢂ2 ꢀ 8.2, p ꢀ .004a
Antecedents
Physical health problems
Decline in health status
Depressive symptoms
Pain
96%
76%
14%
41%
4%
31%
8%
95%
65%
10%
20%
0%
15%
10%
—
—
—
—
—
—
—
Fear of being a burden
Prior talk of suicide
Prior suicide attempts
Autopsy Resultsb
Cancer (all types)
Neurological disease
Cardiovascular diseasec
Chronic obstructive pulmonary disease
Emphysema
27%
37%
33%
2%
27%
25%
35%
35%
35%
10%
35%
25%
—
—
—
—
—
—
Terminally illd
Toxicology Results
Analgesics
41%
6%
43%
45%
5%
45%
—
—
—
Antidepressants
Benzodiazepenes
aBonferroni correction to adjust for multiple marital status comparisons yielded p ꢀ .008 for individual comparisons to set the overall
probability of committing a type 1 error at .05.
bIn 7% of euthanasia cases (4 women and 1 man), medical examiners found no evidence of physical disease at autopsy. Autopsy and
post-mortem toxicology results were available for all female cases and 19 of 20 male cases. Determination of terminal illness was avail-
able for all 69 cases.
cIncludes moderate to severe atherosclerosis of arteries and/or aorta; fibrosis; calcification of mitral, aortic, or tricuspid valves; aneu-
rysmal dilation; or recent infarction.
dLife expectancy of less than 6 months as determined by the medical examiner at autopsy.
Vol. 41, No. 4, 2001
441

percentage of women were divorced (43% of women
compared to 15% of men). Men were significantly
more likely to have never married (40% of men com-
pared to 10% of women); the statistical significance
of this finding was upheld after correcting for multi-
ple comparisons.
firmed in 9 women and 5 men. Two individuals had
Parkinson’s disease, and two cases of dementia were
confirmed at autopsy. Cancer diagnoses accounted
for 27% of women and 35% of men. Lung, ovarian,
and breast cancer comprised 85% of cancers in
women; in men, cancers were evenly distributed
across a range of primary sites. Only 4% of women
and none of the men indicated that they wanted to
die to avoid being a burden to their families.
Toxicology studies revealed that 42% of all cases
were positive for analgesics at the time of death, and
one third (34%) were cancer patients. Nearly half
(43%) were positive for benzodiazepenes, and of
these 27% had either ALS or MS, 20% had terminal
cancer, and 10% were being treated for anxiety dis-
orders. Only 6% of women and 5% of men were
positive for antidepressants. Toxicity results were nega-
tive for alcohol, antibiotics, antihypertensive drugs or
other cardiovascular drugs, diuretics, and hypoglycemic
medications.
A total of 96% of all euthanasia cases had a his-
tory of physical illness confirmed at autopsy, and the
remaining 4% had a history of psychiatric problems.
However, only 25% of all cases were determined to
be terminally ill (i.e., expected to live less than 6
months) by the medical examiner at autopsy. A de-
cline in health status (operationally defined as a re-
cent event such as the onset of a new symptom, recom-
mendation to have surgery or other invasive procedure,
or metastasis of cancer) prior to the time of death
was reported for 76% of the women and 65% of the
men. In 5 (7%) of the 69 cases (4 women and 1 man)
the medical examiner found no anatomical evidence
of disease at autopsy. These individuals were re-
ported to suffer from conditions such as chronic dif-
fuse pain with no identifiable physical cause, fibro-
myalgia, chronic fatigue syndrome, and depression
or other psychiatric problems as documented in med-
ical records and investigative reports. Fewer than
15% of women and men were reported to have had
clinically significant depressive symptoms at the time
of death. Women were twice as likely as men to have
talked about suicide prior to dying, but fewer than
10% of both men and women had attempted suicide
in the past.
Comparison of PAS and Euthanasia Cases
A total of 43 persons died by PAS in Oregon in
1998 (Chin et al., 1999) and 1999 (Sullivan et al.,
2000). As shown in Table 2, their median age was 70
years and almost all were White. One third were
married when they died, 30% were divorced, 26%
were widowed, and 12% had never married. Most
patients had cancer, with lung cancer being the most
prevalent; the others had AIDS or end-stage heart or
lung disease. All had been certified by at least two
physicians as meeting the statutory definition for ter-
minal illness (i.e., expected to live less than 6 months).
The majority of patients (76%) were enrolled in hos-
Approximately one third of men and women had
a neurological disease confirmed at autopsy. Amyo-
trophic lateral sclerosis (ALS) was confirmed in 10
women and 2 men; multiple sclerosis (MS) was con-
Table 2. Comparison of the Characteristics of Oregon Physician-Assisted Suicide (PAS) Cases and Kevorkian Euthanasia Cases
Oregon PAS
Kevorkian Euthanasia
Casesa (n ꢀ 43)
Cases (n ꢀ 69)
p Value
Median age (yrs)
% Female
% Caucasian
Marital status
Married
70
44%
98%
58
71%
96%
—
ꢂ2 ꢀ 7.9, p ꢀ .004
—
33%
30%
26%
12%
100%
33%
35%
13%
19%
23%
—
—
—
—
—
Divorced
Widowed
Never married
Residents of state where death occurred
Underlying illnessesb
Cancer (all types)
ALS
72%
9%
0%
2%
100%
NA
29%
17%
20%
0%
25%
13%
1%
ꢂ2 ꢀ 19.8, p ꢃ .001c
—
—
—
—
—
MS
HIV/AIDS
Terminally illd
Depressive symptomse
Enrolled in hospice
76%
ꢂ2 ꢀ 67.2, p ꢃ .001
aAs reported in Sullivan, Hedberg, & Fleming (2000).
bALS ꢀ amyotrophic lateral sclerosis; MS ꢀ multiple sclerosis; HIV/AIDS ꢀ acquired immune deficiency syndrome.
cBonferroni correction to adjust for multiple underlying illness comparisons yielded p ꢀ .008 for individual comparisons to set the
overall probability of committing a type 1 error at .05.
dLife expectancy of less than 6 months.
eThe Oregon Death with Dignity statute requires physicians to certify that the judgment of patients requesting lethal medications to
end their lives is not impaired by mental disorders, including clinically significant depressive symptoms.
442
The Gerontologist

Table 3. Comparison of the Characteristics of 69 Kevorkian Oakland County Euthanasia Cases With U.S. All-Cause Mortality Data
U.S. Residents Who Died
Case Patients
(n ꢀ 69)
Rate of Euthanasia
(per 100,000 deaths)
Risk Ratio
(95% CI)b
Characteristic
in 1997 (n ꢀ 2,272,237)a
p Value
Race
White
Non-white
Sex
1,967,898
304,339
66
3
3.3
1.0
1.0c
0.3 (0.1–0.9)
ꢂ2 ꢀ 4.6, p ꢃ .05
Male
1,130,050
1,142,187
20
49
1.8
4.3
1.0c
2.4 (1.4–4.1)
Female
ꢂ2 ꢀ 11.4, p ꢃ .001
Marital Status at Deathd
Married
938,886
225,308
870,581
228,711
23
24
9
2.4
10.7
1.0
1.0c
4.3 (2.5–7.7)
0.4 (0.2-0.9)
2.3 (1.2–4.6)
Divorced
Widowed
Never married
ꢂ2 ꢀ 30.9, p ꢃ .001
ꢂ2 ꢀ 4.5, p ꢃ .025
ꢂ2 ꢀ 6.4, p ꢃ .01
13
5.7
aAge 15 years and older. Hoyert, Kochanek, and Murphy (1999).
bCI ꢀ confidence interval.
cThis was the reference category.
dMortality data on marital status were available for 2,263,486 U.S. residents.
pice at the time of death as compared to only 2 of the
69 Kevorkian cases. Oregon statute requires that in-
dividuals who request a lethal prescription be ad-
vised of alternatives to PAS, such as hospice.
Compared to persons who were married, those who
were divorced were 4.3 times more likely to choose
euthanasia (CI ꢀ 2.5–7.7, p ꢃ .001). Persons who
had never married were 2.3 times more likely to
choose euthanasia than married persons (CI ꢀ 1.2–
4.6, p ꢃ .01). Persons who were widowed at the time
of death were less likely to choose euthanasia (rela-
tive risk [RR] ꢀ 0.4, CI ꢀ 0.2–0.9, p ꢃ .025).
In the first year of legal assisted suicide in Oregon,
those who were divorced or never married were
more likely than married persons to choose PAS (di-
vorced persons, RR ꢀ 6.8, CI ꢀ 1.3–37.2, p ꢀ .03;
never married, RR ꢀ 23.7, CI ꢀ 4.4–128.9, p ꢃ
.001). Persons who died from ingesting lethal pre-
scriptions (PAS) did not differ by race or sex from
Oregon residents who died from similar diseases, pri-
marily cancer (Chin et al., 1999). Data from the sec-
ond year of legal PAS revealed that only those with
college educations were at increased risk for PAS rel-
ative to other Oregon residents (Sullivan et al., 2000).
The median age of the Kevorkian euthanasia cases
was 12 years younger than the Oregon PAS cases,
and they were significantly less likely to have cancer,
a finding whose significance held after Bonferroni
corrections for multiple comparisons of underlying
illnesses (Table 2). More than one third of the eu-
thanasia cases but only 9% of the Oregon cases had
a neurological disorder (ALS or MS). Depressive dis-
orders or depressive symptoms were reported in
13% of the euthanasia cases; Oregon statute requires
that individuals seeking PAS be certified by a physi-
cian as having no clinically significant depressive
symptoms that may influence decision making.
Risk Factors for Euthanasia and Legalized PAS
It is impossible to draw a random sample of eu-
thanasia cases from which to generalize, because
providing such direct assistance in dying is both ille-
gal and against physicians’ ethical codes of conduct.
Thus, in an attempt to estimate population parame-
ters from the convenience sample of Kevorkian eu-
thanasia cases, individuals who died with Kevorkian’s
assistance were compared with other U.S. residents
who died in 1997, the last year for which data were
available (Hoyert et al., 1999). Nationwide mortality
statistics were used because although those individu-
als who died with Kevorkian’s assistance all died in
Michigan, less than a quarter (23%) were Michigan
residents; they had lived in 24 different states.
Euthanasia cases differed by race, sex, and marital
status from the U.S. population (see Table 3). Eutha-
nasia cases were significantly more likely to be
White, female, divorced or never married, and they
were less likely to be widowed. The risk ratio for
non-White as compared to White persons was 0.3 CI ꢀ
0.1–0.9, p ꢃ .05). The risk ratio for women as com-
pared to men was 2.4 (CI ꢀ 1.4–4.1, p ꢃ .001).
Discussion
The results of our analyses revealed: (1) the vul-
nerability of persons who were not terminally ill to
seek Kevorkian for euthanasia, unchecked by clinical
safeguards; (2) the high representation of women
who chose euthanasia; and (3) the greater likelihood
of persons who were divorced or never married to
seek an assisted death, a pattern evident in both the
Kevorkian euthanasia and first-year (1998) PAS cases.
Terminal Illness
Discussions about PAS and euthanasia typically
assume that patients are near death, yet only one
quarter of persons who sought Kevorkian for eutha-
nasia were terminally ill when they died. Nearly all
of the Kevorkian euthanasia cases had serious physi-
cal illnesses that in some cases may have been com-
pounded by depressive symptoms or other psychiat-
ric illnesses. In addition, nearly three quarters had
Vol. 41, No. 4, 2001
443

experienced a recent decline in health status. The ac-
tual or perceived inability to cope with illness may
also have impacted the decision to seek assistance in
dying. When such patients run out of options for
treatment, yet fall outside the usual 6 months of life
requirement for hospice care, their desperation may
lead them to consider an assisted death instead of
other options, including palliative care and mental
health services.
The vulnerability of Kevorkian’s euthanasia cases
is in stark contrast to the PAS cases in Oregon. The
Oregon experience with an articulated standard for
legalized PAS assures that terminally ill, competent
individuals make the decision to obtain a lethal pre-
scription after being informed of available alterna-
tives such as palliative care and pain management.
Only two of the Kevorkian cases were under the care
of hospice at the time of death. Because the majority
of Kevorkian’s euthanasia cases had prognoses longer
than 6 months, which would usually exclude them
from hospice eligibility, it is even less likely that these
patients received adequate information about pallia-
tive care as an alternative to assistance in dying. In
particular, a sense of urgency about impending dis-
ability and narrowing future options may have moti-
vated the patients with neurodegenerative diseases to
seek help from Kevorkian before they were consid-
ered terminally ill by medical criteria (Ganzini et al.,
1998).
Patients in Oregon who seek a lethal prescription
have to be certified by two physicians as free from
depressive symptoms or other conditions that might
affect their ability to make health care decisions.
Kevorkian’s patients included individuals compro-
mised by depressive symptoms, undertreated pain,
and dementia. The small but troubling number of
cases in which no anatomical evidence of disease was
found at autopsy also highlights the significance of
pain and psychiatric issues in the desire to die and
the motivation to seek assistance in dying. The lack
of anatomical evidence of disease may underestimate
the suffering and desperation of these patients.
As legalizing PAS continues to be considered in
state legislatures, we need to know more about the
motivations and antecedent factors that precipitate a
decision to die. Alternatives such as aggressive pain
and symptom management and treatment for psy-
chological distress need to be more widely available
so that, if legal, PAS represents a choice, not the only
alternative to suffering. While patients near death de-
serve better options for end-of-life care that include
their preferences and values, opportunities are missed
to address the needs of patients with longer prog-
noses (and sometimes fewer options) in our efforts to
provide better care for the dying.
almost equally represented in the Oregon cases, but
women were 2.5 times more likely to seek Kevorkian
for euthanasia than men. The factors that made women,
particularly older women, more vulnerable to eutha-
nasia are difficult to discern from the available data.
Differing experiences with medical care may influ-
ence the ways in which women approach medical de-
cisions, including decisions to seek assistance in dy-
ing. Disparate treatment in cardiac care has been
demonstrated, (Ayanian & Epstein, 1991; Giles,
Anda, Casper, Escobedo, & Taylor, 1995; Schulman
et al., 1999; Steingart, et al., 1991) as well as the
greater risk for women to have inadequate pain con-
trol (Cleeland et al., 1994). Women are patients
more often than men, have more contacts with physi-
cians, and more frequently make decisions about
when others should seek medical care (Benson &
Marano, 1993; Horton, 1992; Thomas & Kelman,
1990). Recent research has begun to target the short-
fall in knowledge about women’s health, disability,
and help-seeking behavior that may also be helpful
for understanding gender differences in end-of-life
decision making (Hu et al., 1997, 1999; Legato,
1998; Legato, Padus, & Slaughter, 1997; Michels et
al., 1998; Rexrode et al., 1998; Willett et al., 1996).
The availability of a caregiver may also differen-
tially affect the end-of-life decisions made by men
and women. Women provide most of the care that is
given to dying patients, although women who need
care tend to receive less assistance from family mem-
bers than men, and are more likely to have to pay for
assistance even if married (Emanuel et al., 1999).
Wives are only one third as likely as husbands to re-
port their spouses as caregivers (Allen, Goldscheider,
& Ciambrone, 1999).
Marital Status
Marital status was a significant risk factor for PAS
cases in Oregon in the first year after the practice
was legalized, as well as for Kevorkian euthanasia
cases. Those who were divorced or had never been
married were significantly more likely to seek an as-
sisted death than those who were married. These re-
sults suggest the need to understand more about the
family and psychosocial context of medical care deci-
sion making in general, and end-of-life decision mak-
ing specifically. Medical decision making places con-
siderable demands on patients and families to assess
the risks and benefits of treatment as well as to make
decisions that may result in the death of the patient.
The decision-making process brings family dynamics
such as guilt, conflict, ambiguity, and uncertainty to
the surface, all of which must be dealt with in the
clinical context as family members act as surrogate
decision-makers or advisers to dying relatives.
Medical care decision making about end-stage or
terminal illness may differ for patients who are alone.
The primary vulnerability of women and certain
groups of men (i.e., those who are alone and coping
with the burden of serious illness) requires clinical at-
tention and should be the focus of additional re-
Gender
The high representation of women among eutha-
nasia cases is disturbing, given what is known about
the Oregon PAS experience, U.S. mortality data, and
the low suicide rate in women. Men and women were
444
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search. The adequacy of psychosocial support net-
works should be considered in persons with long-
standing chronic, end-stage, or terminal illnesses.
tive analysis of the Kevorkian euthanasia cases and
the emerging data from Oregon on PAS also present
an index of concern to researchers and clinicians
about the possible vulnerability of women and those
who are not married at the end of life. Continued re-
search on the role of gender and marital status in
end-of-life care is merited.
Limitations
This study has several limitations. Interpretation
of our results is limited by biases in the data sources
that were collected for other purposes (i.e., law en-
forcement investigations in Oakland County, Michi-
gan, and compliance with statutory regulations in
Oregon). Autopsy data are an excellent source for
detailed anatomical and toxicology information for
the Kevorkian euthanasia cases, but they do not al-
low for an evaluation of other relevant factors, such
as an evaluation of mental illness. Variables such as
psychiatric status, family structure, and other psy-
chosocial factors outside the autopsy examination
had to be constructed from medical examiner records.
As mentioned previously, autopsies are not required
of individuals who die from legalized PAS in Oregon;
published summary data based on mandatory physi-
cian reporting provided the data on these cases.
These infrequent and often concealed deaths due
to PAS and euthanasia yield a small sample of cases
that limits our ability to generalize. Both the Kevor-
kian euthanasia cases and the Oregon PAS cases may
not be representative of the majority of individuals
who may want assistance in ending their lives. Fur-
ther, the mortality comparisons used to estimate
population parameters must be interpreted carefully.
Although it would be more precise to select mortality
statistics that matched the underlying diseases of the
Kevorkian cases, the small samples that would result
precluded this approach. However, the broader mor-
tality comparisons did suggest some overall trends
and demographic patterns that suggest risk factors in
the population.
References
Allen, S. M., Goldscheider, F., & Ciambrone, D. A. (1999). Gender roles,
marital intimacy, and nomination of spouse as primary caregiver. The
Gerontologist, 39, 150–158.
Anstett, P., Cha, A. E., Cheyfitz, K., Christoff, C., Crumm, D., Dickerson,
B., James, S., Kovanis, G., Martin, A., McKee, K., Migoya, D., Mon-
togomery, L., Rubin, N., & Wendland, W. (1997). The suicide
machine: Understanding Jack Kevorkian, the people who came to him
and the issue of assisted suicide. Detroit, MI: Detroit Free Press.
Ayanian, J. Z., & Epstein, A. M. (1991). Differences in the use of proce-
dures between women and men hospitalized for coronary heart
disease. New England Journal of Medicine, 325, 133–143.
Bachman, J. G., Alcser, K. H., Doukas, D. J., Lichtenstein, R. L., Corning,
A. D., & Brody, H. (1996). Attitudes of Michigan physicians and the
public toward legalizing physician-assisted suicide and euthanasia.
New England Journal of Medicine, 334, 303–309.
Back, A. L., Wallace, J. I., Starks, H. E., & Pearlman, R. A. (1996). Phy-
sician-assisted suicide and euthanasia in Washington state: Patient
requests and physician responses. Journal of the American Medical As-
sociation, 275, 919–925.
Benson, V., & Marano, M. A. (1993). Current estimates from the Na-
tional Health Interview Survey, 1993. In Vital and Health Statistics
(Series 10, pp. 114–120). Washington, DC: U. S. Government Printing
Office.
Blendon, R. J., Szalay, U. S., & Knox, R. A. (1992). Should physicians aid
their patients in dying? The public perspective. Journal of the Ameri-
can Medical Association, 267, 2658–2662.
Breitbart, W., Rosenfeld, B. D., & Passik, S. D. (1996). Interest in phy-
sician-assisted suicide among ambulatory HIV-infected patients.
American Journal of Psychiatry, 153, 238–242.
Brown, J. H., Henteleff, P., Barakat, S., & Rowe, C. J. (1986). Is it normal
for terminally ill patients to desire death? American Journal of Psychi-
atry, 143, 208–211.
Caralis, P. V., Davis, B., Wright, K., & Marcial, E. (1993). The influence
of ethnicity and race on attitudes toward advance directives, life-pro-
longing treatments and euthanasia. Journal of Clinical Ethics, 4, 155–
165.
Chin, A. E., Hedberg, K., Higginson, G. K., & Fleming, D. W. (1999). Le-
galized physician-assisted suicide in Oregon—the first year’s experience.
New England Journal of Medicine, 40, 455–483.
From available data sources, assisted death ap-
pears to be an end-of-life choice almost exclusively
for White men and women. Studies of attitudes
about preferences for end-of-life care tend to show
that Whites are more likely to indicate that they
would forego life-sustaining treatment and more fa-
vorably inclined to advance directives than African
Americans (Caralis, Davis, Wright, & Marcial, 1993;
Garrett, Harris, Norburn, Patrick, & Danis, 1993).
The racial bias in the sample raises questions about
end-of-life choices in minority populations that could
not be addressed in this study.
The implications of our results for understanding
end-of-life decisions are important despite the small
numbers of persons available for study and the po-
tential biases in the data sets from Michigan and Or-
egon. While efforts to improve end-of-life care have
focused primarily on individuals who are in pain and
suffering from depression near the point of death, the
results of our analyses suggest that further improve-
ments may be realized by including better care op-
tions for patients with longer prognoses who are
struggling with the burdens of the chronic illnesses
that will eventually cause their deaths. The descrip-
Chochinov, H. M., Wilson, K. G., Enns, M., Mowchen, N., Lander, S.,
Levitt, M., & Clinch, J. J. (1995). Desire for death in the terminally ill.
American Journal of Psychiatry, 152, 1185–1191.
Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H.,
Steward, J. A., & Pandya, K. J. (1994). Pain and its treatment in out-
patients with metastatic cancer. New England Journal of Medicine,
330, 592–596.
Cohen, D., Llorente, M., & Eisdorfer, C. (1998). Homicide–suicide in
older persons. American Journal of Psychiatry, 155, 390–396.
Cohen, J. S., Fihn, S. D., Boyko, E. J., Jonsen, A. R., & Wood, R. W.
(1994). Attitudes toward assisted suicide and euthanasia among phy-
sicians in Washington state. New England Journal of Medicine, 331,
89–94.
Duberstein, P. R., Conwell, Y., Cox, C., Podgorski, C. A., Glazer, R. S., &
Caine, E. D. (1995). Attitudes toward self-determined death: A survey
of primary care physicians. Journal of the American Geriatrics Society,
43, 395–400.
Emanuel, E. J., Fairclough, D. L., Daniels, E. R., & Clarridge, B. R.
(1995). Euthanasia and physician-assisted suicide: Attitudes and expe-
riences of oncology patients, oncologists, and the public. Lancet, 347,
1805–1810.
Emanuel, E. J., Fairclough, D. L., Slutsman, J., Alpert, H., Baldwin, D., &
Emanuel, L. L. (1999). Assistance from family members, friends, paid
caregivers, and volunteers in the care of terminally ill patients. New
England Journal of Medicine, 341, 956–963.
Fried, T. R., Stein, M. D., O’Sullivan, P. S., Brock, D. W., & Novack,
D. H. (1993). The limits of patient autonomy: Physician attitudes and
practices regarding life-sustaining treatments and euthanasia. Archives
of Internal Medicine, 153, 722–728.
Ganzini, L., Johnston, W. S., McFarland, B. H., Tolle, S. W., & Lee, M.
A. (1998). Attitudes of patients with amyotrophic lateral sclerosis and
Vol. 41, No. 4, 2001
445

their care givers toward assisted suicide. New England Journal of
Medicine, 14, 967–973.
Garrett, J. M., Harris, R. P., Norburn, J. K., Patrick, D. L., & Danis, M.
(1993). Life-sustaining treatments during terminal illness. Journal of
General Internal Medicine, 8, 361–368.
Giles, W. H., Anda, R. F., Casper, M. L., Escobedo, L. G., & Taylor, J. A.
(1995). Race and sex differences in rates of invasive cardiac proce-
dures in U.S. hospitals: Data from the national hospice discharge
survey. Archives of Internal Medicine, 155, 318–324.
Horton, J. A. (1992). The women’s health data book: A profile of
women’s health in the United States. Washington, DC: Elsevier.
Hoyert, D. L., Kochanek, K. D., & Murphy, S. L. (1999, June 30).
Deaths: Final data for 1997 (National Vital Statistics Report No. 47
[19], pp. 77–78). Hyattsville, MD: National Center for Health
Statistics.
Hu, F. B., Grodstein, F., Hennekens, C. H., Colditz, G. A., Johnson, M.,
Manson, J. E., Rosner, B., & Stampfer, M. J. (1999). Age at natural
menopause and risk of cardiovascular disease. Archives of Internal
Medicine, 159, 1061–1066.
Hu, F. B., Stampfer, M. J., Manson, J. E., Rimm, E., Colditz, G. A., Ros-
ner, B. A., Hennekens, C. H., & Willett, W. C. (1997). Dietary fat
intake and the risk of coronary heart disease in women. New England
Journal of Medicine, 337, 1491–1499.
Lee, M. A., Nelson, H. D., Tilden, V. P., Ganzini, L., Schmidt, T. A., &
Tolle, S. W. (1996). Legalizing assisted suicide: Views of physicians in
Oregon. New England Journal of Medicine, 334, 310–315.
Legato, M. J. (1998). Cardiovascular disease in women: Gender specific
aspects of hypertension and the consequences of treatment. Journal of
Women’s Health, 7, 199–209.
Legato, M. J., Padus, E., & Slaughter, E. (1997). Women’s perceptions of
their general health, with special reference to their risk of coronary ar-
tery disease: Results of a national telephone survey. Journal of
Women’s Health, 6, 189–198.
Rexrode, K. M., Carey, V. J., Hennekens, C. H., Walters, E. E., Colditz,
G. A., Stampfer, M. J., Willett, W. C., & Manson, J. E. (1998). Ab-
dominal adiposity and coronary heart disease in women. Journal of
the American Medical Association, 280, 1843–1848.
Roscoe, L. A., Malphurs, J. E., Dragovic, L. J., & Cohen, D. (2000). Dr.
Jack Kevorkian and cases of euthanasia in Oakland County, Michi-
gan, 1990–1998. New England Journal of Medicine, 343, 1735–1736.
Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F., Sistruck, S.,
Gersh, B. J., Dube, R., Taleghani, C. K., Burke, J. E., Williamson, S.,
Eisenberg, J. M., & Escarce, J. J. (1999). The effect of race and sex on
physicians’ recommendations for cardiac catheterization. New En-
gland Journal of Medicine, 340, 618–626.
Seidlitz, L., Duberstein, P. R., Cox, C., & Conwell, Y. (1995). Attitudes of
older people toward suicide and assisted suicide: An analysis of Gallup
poll findings. Journal of the American Geriatrics Society, 43, 993–998.
Shapiro, R. S., Derse, A. R., Gottlieb, M., Schiedermayer, D., & Olson,
M. (1994). Willingness to perform euthanasia. A survey of physician
attitudes. Archives of Internal Medicine, 154, 575–584.
Steingart, R. M., Packer, M., Hamm, P., Coglianese, M. E., Gersh, B.,
Geltman, E. M., Sollano, J., Katz, S., Moye, L., Basta, L. L., Lewis,
S. J., Gottlieb, S. S., Bernstein, V., McEwan, P., Jacobson, K., Brown,
E. J., Kukin, M. L., Kantrowitz, N. E., & Pfeffer, M. A. (1991). Sex
differences in the management of coronary artery disease. New En-
gland Journal of Medicine, 325, 226–230.
Sullivan, A. D., Hedberg, K., & Fleming, D. W. (2000). Legalized physi-
cian-assisted suicide in Oregon—the second year. New England
Journal of Medicine, 342, 598–604.
Thomas, C., & Kelman, H. R. (1990). Gender and the use of health ser-
vices among elderly persons. In M. G. Ory, & J. R. Warner (Eds.),
Gender, health and longevity. New York: Springer.
Willett, W. C., Stampfer, M. J., Manson, J. E., Colditz, G. A., Rosner, B.
A., Speizer, F. E., & Hennekens, C. H. (1996). Coffee consumption
and coronary heart disease in women. A ten-year follow-up. Journal of
the American Medical Association, 275, 458–462.
Meier, D. E., Emmons, C. A., Wallenstein, S., Quill, T., Morrison, R. S.,
& Cassel, C. K. (1998). A national survey of physician-assisted suicide
and euthanasia in the United States. New England Journal of Medi-
cine, 338, 1193–1201.
Michels, K. B., Rosner, B. A., Walker, A. M., Stampfer, M. J., Manson, J.
E., Colditz, G. A., Hennekens, C. H., & Willett, W. C. (1998). Calcium
channel blockers, cancer incidence, and cancer mortality in a cohort of
U. S. women: The nurse’s health study. Cancer, 83, 2003–2007.
Received November 17, 2000
Accepted April 17, 2001
Decision Editor: Laurence G. Branch, PhD.
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