Euthanasia and physician-assisted suicide

Euthanasia and physician-assisted suicide

Euthanasia and physician-assisted suicide

Permalink: ‎

Euthanasia and physician-assisted suicide (PAS) are controversial issues worldwide. Euthanasia is defined as ‘the administration of drugs with the explicit intention of ending a patient’s life at the patient’s explicit request’ (Willems et al. 2000), whereas PAS is defined as ‘the prescription or supplying of drugs with the explicit intention of enabling the patient to end his or her life by an overdose’ (Willems et al. 2000). Euthanasia was legalized in Australia’s Northern Territory with the passage of the Rights of the Terminally Ill Act in 1995, but the government tried to hinder euthanasia with the passing of the Criminal Code Amendment (Suicide-Related Material Offences) Bill in 2004. The Netherlands and Belgium legalized euthanasia in 2002, whereas the state of Oregon legalized only PAS in 1997, becoming the sole jurisdiction in the United States to allow PAS. Most other states have voted to prohibit euthanasia and PAS (Doerflinger 1999). In Michigan, for example,

*Email: siuwanda@cuhk.edu.hk

ISSN 0958–1596 print/ISSN 1469–3682 online

� 2010 Taylor & Francis DOI: 10.1080/09581590902897386

http://www.informaworld.com

a referendum to legalize PAS was defeated by 70% of voters in 1998 (Ayers 1998). Similarly, voters in Maine rejected the legalization of PAS in 2000 (New York Times 12 February 1998).

The euthanasia/PAS movement has received widespread public attention and popular media coverage. As a case in point, Jack Kevorkian’s assisted suicide practices triggered intensive public debate in 1998 about euthanasia and PAS, when he showed a videotape of his administration of a lethal injection to Thomas Youk, who suffered from Lou Gehrig’s disease. With such dramatic news events, euthanasia and PAS activities have attained social visibility in developed countries. This study examines how Kevorkian, previously a pathologist, was portrayed in medical journals (core general medical journals from the United Kingdom [UK] and the United States [US]), publications of social movement organizations (anti- and pro-PAS/euthanasia), and the print media (local and national newspapers) through discourse analysis. These publications represent three distinct interpretive communities in society: the medical community, social movement organizations, and the print media. This study assesses Said’s (1997) notion that interpretive communities create different realities and are sustained by different social movement groups through a case study of the euthanasia and assisted suicide debate.

Social movements and the discourses of interpretive communities

Euthanasia and PAS are broadly conceived to be part of the ‘new public health movement’. New public health values support the notion that individuals should be able to control final illness outcomes (Kellehear 1998).

Some health workers and their patients are keen to bring the principles of the New Public Health to bear on the experience of dying and to help themselves control that element of outcome important to them both – the how and when of dying. (Kellehear 1998, p. 296)

The Northern Territories Euthanasia Bill in Australia allowed Janet Mills, who suffered from advanced skin cancer, to request PAS. Kellehear (1998) portrays Mills as a rational and sensible person who exercised her right to choose PAS.

Janet Mills was rather a public example of a growing number of people who endorse and support the view that she should be able to control the outcomes of what some people call ‘‘the final illness’’. Janet Mills represented a new type of dying person, and a fine individual example of attitudes and actions which, in principle, are perfectly aligned with the values of the New Public Health. (Kellehear 1998, p. 294)

Proponents of the new public health movement, euthanasia, and PAS are concerned with redefining the role of patients and the doctor–patient relationship. Oregon’s Death with Dignity Act stipulates that physicians are limited to providing a prescription for lethal drugs, rather than administering a lethal injection. This shift in the doctor–patient relationship in the final illness has rendered more direct and active control to patients (MacDonald 1998), and sparked a new social movement to legalize euthanasia and PAS. Euthanasia activists in Oregon are considered to be the leaders of this new social movement (MacDonald 1998) with their success in their legislative activity regarding PAS. However, euthanasia activists in other states have not yet achieved their goal of legalizing euthanasia or PAS.

Social movement actors rely on the media to get their message across to the populace, whereas journalists need information provided by social movement actors

170 W. Siu

(Molotch 1979). Media personnel are selective about the stories they cover, and are also selective about sponsoring social movement actors (Bozell and Baker 1990). More powerful social movement actors obtain better media access, whereas smaller social movement organizations and actors lack money and power to gain free media exposure. The smaller social movement actor, whom Lofland (1996) identifies as a ‘lone proponent, who perhaps has a loose band of supporters and sympathizers’, shares the ideological position of a particular social movement, such as the pro- euthanasia and PAS faction (p. 11). The lone proponent sometimes works alongside a social movement organization to further its goal. In return, the lone proponent receives support from the organization. For example, the Hemlock Society has referred patients to Kevorkian for assisted suicide and provided financial support in Kevorkian’s lawsuit (Kastenbaum 1995).

Hunt et al. (1994) state that social movement actors and organizations ‘provide vocabularies and stories for participants and sympathizers to construct their personal identity in ways that link or further commit them to the movement or social movement organization’ (p. 190). Social movement participants see discursive practices such as ‘cultural expressions, slogans, and patterns of rhetoric’ as vital resources to win the support of the community (Fine 1995, pp. 127–132). ‘Frame alignment processes’ resonate with ‘the stories, myths, and folk tales that are part and parcel of one’s cultural heritage and that thus function to inform events and experiences in the immediate present’ (Snow and Benford 1988, p. 210). In essence, these processes are ‘rhetorical strategies to affect the alignment of collective and personal identities’ (Hunt et al. 1994, p. 191). Hence, social movement frames become ‘a bundle of narratives, which when expressed within an interactional arena by participants strengthens the commitment of members to shared organizational goals and status-based identities’ (Nakagawa 1990, p. 25). In addition, the discursive practices of social movement actors articulate the notion that the dominant situation is unjust and must be changed (Hunt et al. 1994). Plotke (1995) notes that social movement actors are political and aim at shaping social relations: ‘They politicize previously uncontested relations, or repoliticize previously settled relations’ (p. 134).

Jasper (1997) observes that ‘moral protestors are often sensitive to moral dilemmas the rest of us ignore; they sometimes generate new ways of understanding the complexities of the human condition’ (p. 13). Social movement actors attempt to use symbols, frames, and themes to garner support, and sometimes succeed in capturing media attention and recruiting members by evoking outrage (Jasper and Poulsen 1995).

Condensing symbols are verbal or visual images that neatly capture – both cognitively and emotionally – a range of meanings and convey a frame, master frame, or theme. Organizers use such symbols to recruit members, especially strangers. A powerful symbol lends credibility to an explicit argument by connoting the implicit assumptions embedded in worldviews and common sense. . . .A moral shock . . . an event or situation raises such a sense of outrage in people that they become inclined towards political action, even in the absence of a network of contacts. Moral shocks can serve as the functional equivalent of a social network, drawing people into activism by building on their existing beliefs. (Jasper and Poulsen 1995, p. 498)

Moral shock appeals are not unknown to the euthanasia and PAS movement. The ‘most effective shocks are those embodied in, or translatable into, powerful condensing symbols’ (Japser and Poulsen 1995, p. 498). In 1988, for example, the Journal of the American Medical Association (JAMA) published an account of a

Critical Public Health 171

mercy killing that sparked great public controversy. Nelkin (1998) notes that some medical journals publish provocative editorials and articles to capture media attention, and that some editors in the medical community try to influence public opinion on certain issues. A prominent example of the latter is the executive editor of the New England Journal of Medicine (NEJM), Dr Marcia Angell, who has been outspoken in her support of doctor-assisted suicide.

The first legal debate over Kevorkian’s assisted suicide practices took place in 1990, when he helped to end the life of Janet Adkins, a 54-year-old woman suffering from Alzheimer’s disease. His acquittal sparked discussion in the medical and legal communities and in the public arena over the role of physicians in PAS. Kevorkian’s PAS campaign started on 4 June 1990, when he helped Janet Adkins to end her life, and came to an end in 1999, when he was convicted of second-degree murder for euthanizing Thomas Youk in 1998. The acquittal of Kevorkian in 1990 exemplifies his adroitness in manipulating political opportunities to further the cause of PAS (Taylor 1989). However, the court was effectively prepared to pardon Kevorkian for performing PAS, but not active euthanasia. The records of Kevorkian in helping patients to end their lives have been publicized by the mass media, which ‘makes alternative modes of behavior accessible to wide audiences’ (Gusfield 1994, p. 74). Kevorkian’s conviction in 1999 highlights the fine distinction between PAS and euthanasia, and in light of the intensity of public controversy around Kevorkian and its wider implications for end-of-life decisions (ELDs) in the media and public arena, it is of great importance to examine how this ex-pathologist has been portrayed in core general medical journals (both British and American), the publications of social movement organizations (anti- and pro-PAS/euthanasia), and the print media (local and national newspapers). Van Dijk (2001) states that a complete account of the linguistic features of even a short text ‘might take months and fill hundreds of pages’ (p. 99), so an account of a larger body of texts is an impossible task. Hence, this study examines the use of discourses to shed light on the power dimensions of interpretive communities, and whether and how the discourses on Kevorkian differ across interpretive communities over time.

Discourse analysis and framing

Discursive practices constitute ‘a particular way of dividing up some aspect of reality which is built upon a particular ideological representation of that reality’ (Fairclough 2001, p. 96). ‘By the very fact of selecting certain elements and presenting them to the audience, their importance and pertinence to the discussion are implied. Indeed, such a choice endows these elements with presence’ (Perelman and Olbrechts-Tyteca 1969, p. 116). The act of selecting and enhancing certain media texts and presenting them to the audience is framing (Entman 1993). There are at least two levels of a news frame: (1) mentally stored principles for information processing and (2) character- istics of the news text. For example, news frames of Kevorkian’s performance of euthanasia and PAS may act as information-processing schemata. Entman (1993) defines framing as follows:

To frame is to select some aspects of a perceived reality and make them more salient in a communicating text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described. (p. 52)

172 W. Siu

Pan and Kosicki (1993) note that a number of structures are employed to frame news stories to establish objectivity. First, certain conventions are used, which include quoting numbers and official sources as well as ‘marginalizing certain points of view by attributing them to a social deviant’ (p. 58). People, places, and things can be organized in a variety of ways. How people or sources are selected and organized in news stories is important because these selections carry with them content and meaning reflecting a message consistent with the beliefs of the writer (Jalbert 1983, p. 284). Second, script structures define the ‘who, what, when, where, why, and how’ that construct the news story as ‘a relatively independent unit’ (Pan and Kosicki 1993, p. 60). Third, different thematic structures are used, such as presenting a hypothesis in the leading paragraph of a news story that is supported by evidence in the subsequent paragraphs of the story (pp. 60–61). Voloshinov (1986) notes that the theme captures the significance of the whole utterance: ‘Theme is the upper, actual limit of linguistic significance; in essence, only theme means something definite’ (p. 102). Whereas people may not recall the specific details of a news text, the semantic superstructure, the theme, usually can be remembered as time goes by (Van Dijk 1988). Competing themes in news coverage reflect the way that reality is negotiated and constructed among different communities in the social movement of euthanasia and PAS (Plotke 1995). In this way, the competing stories about Kevorkian reflect the underlying power dimensions of different interpretive communities. Taken together, script structure and thematic structure depict a particular ideological representation of reality. Language choice is ‘a clear and sometimes powerful cue signifying an underlying frame’ (p. 63). The analytical structure of Pan and Kosicki (1993) draws our attention to the analysis of discourse at the micro-level to unveil the social construction of Kevorkian in the euthanasia and PAS movement. Five research questions are addressed in this study.

(I) (Core general medical journal [British and American] communities) How do The Lancet and the British Medical Journal differ from the New England Journal of Medicine and Journal of the American Medical Association in their coverage of Kevorkian in the PAS and euthanasia debate?

(II) (Social movement communities: pro- and anti-PAS and euthanasia groups) How does Timelines, the quarterly publication of the Hemlock Society, differ from the IAETF Update, the International Anti-Euthanasia Task Force’s bi-monthly newsletter, in its coverage of Kevorkian in the PAS and euthanasia debate?

(III) (Print media community: local and national newspapers) How does the Detroit News differ from the New York Times in its coverage of Kevorkian in the PAS and euthanasia debate?

(IV) (Comparison between the core general medical journal and print media communities) How do the British and American medical journals differ from the American newspapers in their coverage of Kevorkian in the PAS and euthanasia debate?

(V) (Comparison between the social movement and print media communities) How do the newsletters of social movement organizations differ from the American newspapers in their coverage of Kevorkian in the PAS and euthanasia debate?

Critical Public Health 173

Method

This study employed discourse analysis to investigate the coverage of Kevorkian in different interpretive communities. To examine the views of the medical

community, four core general medical journals published in the UK and US were chosen for analysis. The (NEJM), published by the Massachusetts Medical Society,

and the (JAMA), published by the American Medical Association (AMA), were chosen to obtain the perspectives of American medical doctors. The Lancet,

published by Joseph Onwhyn, and the British Medical Journal (BMJ), published

by the BMJ Group, a wholly owned subsidiary of the British Medical Association (BMA), were chosen to obtain the perspectives of British medical doctors. The BMA

is a physicians’ professional organization and has ‘over two thirds of practicing UK doctors in membership and an independent trade union dedicated to protecting

individual members and the collective interests of doctors. . . . We are the voice for doctors and medical students – in constant contact with ministers, government

departments, members of the UK, Scottish, Welsh and northern Ireland adminis- trations and many other influential bodies’ (BMA 2008a). Taken together, the four

medical journals reflect the views of the core general medical journal communities

in the UK and US (Thomson Reuters, 2009, Suber 2008). As such, these publications depict a mosaic of perspectives rather than the one-dimensional stance of either

country. To gauge the views of social movement organizations, the IAETF newsletter,

IAETF Update and publication of the Hemlock Society USA, Timelines, were chosen

to represent the opinions of anti-PAS/euthanasia and pro-PAS/euthanasia groups, respectively. The IAETF is a major taskforce against PAS and euthanasia, whereas

the Hemlock Society is a popular group that advocates the legalization of assisted suicide in the US. The Detroit News and New York Times were selected to represent

the local and national newspaper communities, respectively, in the US. The Detroit News was selected to represent the views of the people of Michigan because

Kevorkian performed his first PAS on Janet Adkins and euthanized Thomas Youk in this state. The New York Times (Times) was chosen because it is ranked third

in national circulation and is the largest metropolitan newspaper. It is owned by

the Sulzberger family (Audit Bureau of Circulation 2006). Arthur O. Sulzherger, Jr., the current publisher of the Times, calls the newspaper ‘a tower of liberalism [that]

carries the urban viewpoint, reflects a value system that recognizes the power of flexibility’ (Okrent 2004). Therefore, the Times was expected to reflect the public

perception of reality. Purposive sampling was employed for the newspapers. With regard to the Janet

Adkins case, the first week after her death (4–10 June 1990) and the first week

after Kevorkian’s acquittal on murder charges (14–20 December 1990) were sampled. All of the news articles from the Detroit News and New York Times

concerning Kevorkian during these periods were collected, with 14 news articles from the former and six from the latter. With regard to the Thomas Youk case, the first

week after CBS’s ‘60 Minutes’ broadcast about the euthanization of Youk (23–29 November 1998) and the first week after Kevorkian’s conviction for second-degree

murder (27 March–2 April 1999) were sampled. This generated 23 news articles from

the former publication and 16 news articles from the latter. For the sampling of the medical journals, the author downloaded articles

concerning Kevorkian from OvidWeb for the 1990–2001 period. Articles that

174 W. Siu

mentioned Kevorkian in the title, abstract, full text, or caption text were selected, which resulted in 23 articles from the BMJ, five articles from The Lancet, 10 articles from the JAMA, and 21 articles from the NEJM for the sampling period, giving a total of 59 articles for analysis. The sampling of the newsletters of the public advocacy groups was constrained by the availability of material. The sampling period ran from 1995 to 2001, with any articles that mentioned Kevorkian in the headline, sub-heading, or body text being selected for analysis. A total of 40 articles were collected from the IAETF newsletter and 20 articles from the Hemlock Society’s Timelines.

This case study employed discourse and framing analysis to examine the coverage of euthanasia and PAS in selected publications. This choice is partly in response to Rogers’ (1997) calls for more qualitative research into public health to explore the ‘social distribution of the context and processes with which health related actions are shaped’ (p. 31). Studies of social problems have employed ethnographic content analysis to examine the media coverage of the drug problem (Jernigan and Dorfman 1996). Framing analysis is similar to ethnographic content analysis, and is used to understand the meanings that are embedded in news coverage. Whereas ethno- graphic content analysis emphasizes the role of investigators in uncovering the themes of news stories and allows qualitative categories to emerge from the data (Altheide 1987), qualitative analysis uncovers the manifest and latent meanings of news coverage (Entman 1993). The coverage of the issue in the medical journals, publications of the social movement groups, and local and national newspapers was analyzed in the following three dimensions. The first is the themes that emerged from the coverage of Kevorkian. The second is the condensing symbols that were used to characterize Kevorkian. Here, a condensing symbol is defined as a device that captures a range of meanings and conveys a frame (Jasper and Poulsen 1995), such as the moniker ‘Dr. Death’ that was applied to Kevorkian, which evoked a sinister frame. The third dimension is the linking of the coverage of Kevorkian with that of other issues, and more specifically, investigation of whether the coverage of Kevorkian’s performance of PAS and euthanasia included other issues, such as the boundaries of medical intervention in ending life. This analytical approach is similar to Cohen and Wolfsfeld’s (1993) analysis of the Arab–Israeli conflict.

Each story was read at least three times by the author to identify the themes, condensing symbols, and links with other issues. First, each sentence was read to determine the presence or absence of framing devices, with each device identified being marked. Second, each paragraph was read to identify the presence or absence of the devices, and again each device was marked. Third, the whole news story was reviewed. This process ensured that the coding of the themes, symbols, and links was as thorough as possible.

Qualitative research emphasizes the role of the researcher to be critically reflective. The critical reflection is important to ensure the validity of qualitative analysis because the investigator’s underlying assumptions are challenged and examined (Burgoyne and Reynolds 1998). The author collected multiple sources of data: Detroit News, New York Times, BMJ, The Lancet, JAMA, IAETF Update, and Timelines. Within each data source, there was an emphasis on depth and quality. Purposive sampling was employed for Detroit News and New York Times on the Janet Adkins case in 1990 and the Thomas Youk case in 1998–1999. Purposive sampling is an appropriate sampling method in case studies (Babbie 2007). Saturated samples were collected from the BMJ, The Lancet, JAMA, NEJM, IAETF Update,

Critical Public Health 175

and Timelines. Taken together, multiple sources of data provide ample evidence to the study of Jack Kevorkian in PAS and euthanasia debate so that the investigator can go beyond the limited depth of explanation of the PAS and euthanasia debate. This approach ensured that valid and reliable interpretations were being made, which was consistent with the goal of ethnographic case studies. Meaningful insights can be obtained from this qualitative analysis of Jack Kevorkian.

Findings

The following tables explained the different frames and themes that were employed by the New York Times, Detroit News, JAMA, NEJM, BMJ, The Lancet, IAETF Update, and Timelines in framing Kevorkian in the PAS and euthanasia debate. The findings commentary was structured according to various interpretive communities: (1) print media community (see Table 1); (2) core general medical journal communities (see Table 2); (3) social movement communities (see Table 3); (4) print media community, core general medical communities, and social movement communities (see Table 4). The sub-headings captured the gist of the discourses on ELDs in each of the interpretive communities. Themes, symbols, and links were discussed accordingly.

Print media community: the Detroit News and the New York Times

A mosaic of discourses on ELDs: slippery slope and self-determination

As Table 1 shows, the main themes to emerge from the coverage of the Detroit News of Kevorkian were slippery slope and self-determination, but the paper also raised the questions of whether patients have the right to request assisted suicides, whether a doctor should grant the suicidal wishes of terminally ill patients, and whether physicians step beyond the legal and moral boundaries if they perform PAS. The Detroit News characterized the physician’s dilemma as a slippery slope: ‘A doctor who withholds or withdraws treatment where a person is terminally ill is acting within the standards of the medical community. When you take the next step and administer drugs . . . you’ve moved outside that umbrella’ (Detroit News 8 June 1990). The first PAS patient of Kevorkian, Janet Adkins, was characterized in the newspapers as an independent-minded, strong-willed woman who believed in the right to control her life and ‘in a dignified death. . . . It was just a matter of finding the means’ (Detroit News 6 June 1990).

Although personal liberty is a cherished value in the US, opinions were split on the issue of self-determination in assisted suicide and euthanasia. The Detroit News linked two issues in its coverage of Kevorkian: the interface between law and medicine and eugenics. In 1990, assisted suicide was not a crime in Michigan, although Kevorkian was later charged there with assisting the suicide of Janet Adkins. Previously, the state court had said, ‘Suicide is not a crime in the state of Michigan and we don’t normally conduct this kind of investigation on the basis of a suicide’ (Detroit News 25 November 1998). Nine years later, in 1999, however, Kevorkian was convicted of the second-degree murder of Thomas Youk based on a law banning assisted suicide that had been enacted in Michigan in late 1998. The coverage of Kevorkian’s euthanasia trial in 1998–1999 was linked to the issue of eugenics, with Michigan representing ‘ground zero’ in the battle between