Suicide -- it has always been a word spoken in hushed whispers with averted eyes. Not something respectable people talked about. Certainly not anything the medical profession would become involved with.
Then came Michigan physician Jack Kevorkian, his suicide machine, and the well-publicized death he abetted last year for an Alzheimer's patient. And then came Marjorie Wantz and Sherry Miller, two women with painful but non-terminal diseases who last week took their own lives in his presence.
These suicides -- following on the heels of the recent and surprising best-sellerdom of "Final Exit," a guide to suicide written by Derek Humphry, founder of the right-to-die Hemlock Society -- has thrust suicide front and center as an issue of public debate, medical ethics and political action.
Since "Final Exit" was published, the Hemlock Society, which has 81 chapters throughout the United States, has been growing. "It's been increasing all along," said Cheryl K. Smith, staff attorney and deputy director, in a telephone interview from the organization's headquarters in Eugene, Ore. "But we had a ** big increase in September, with 900 new members."
And yesterday Dr. Kevorkian urged in a statement read by his attorney, Geoffrey Feiger, that a commission be formed "to establish appropriate guidelines to regulate the right of people to decide their own destinies."
His statement comes a week before Washington state voters cast ballots on an initiative that could allow physicians to assist terminally ill patients in ending their lives.
"There's increased willingness to talk about [suicide], and increased focus by health care professionals," said psychologist David Clark, director of the center for suicide research and prevention at Rush Presbyterian St. Luke's Medical Center in Chicago.
"There is a small but growing number of physicians who are leaning toward the idea of physician-assisted suicide," said Dr. Louis Breschi, chairman of the professional ethics committee for the Medical and Chirurgical Faculty of Maryland.
With right-to-life and right-to-death now openly debated, with the technology of life support systems bringing into question the very nature of death itself, with people living longer and therefore facing increasing risks of slow death from degenerative diseases -- with all these factors omnipresent in modern society, it's no wonder that talk of suicide seems to be on many tongues.
Nonetheless, point out doctors and counselors, talking isn't doing, and while epidemiological data is not definitive, there does not seem to have been a dramatic upswing in suicides recently.
Rates of suicide have remained nearly level for close to 50 years, Dr. Clark said. And even though a Centers for Disease Control study released last month showed a 21 percent increase in suicide by the elderly between 1980 and 1986, the increase follows a long decline from an even higher peak in the 1930s and 1940s and is balanced by a falling suicide rate among younger people.
Whether the current attention to suicide among the old or ailing has any impact on what people actually do is also debatable. Neither "Final Exit" nor Dr. Kevorkian's suicide assists could have influenced the people who took their own lives during the period of the CDC study, said Dr. Richard Sattin, co-author of the report.
Nor is the popularity of "Final Exit," which has been on the New York Times best seller list for 11 weeks, in the "Advice, How-to and Miscellaneous" category, necessarily an approval rating, noted Dr. Clark, who is also president of the American Association of Suicidology.
Rather, he said, it is part normal curiosity, and part the kind of morbid fascination that leads people to buy Stephen King's scary novels. "It's something you only half believe, but it's communicated so successfully that it scares the wits out of you," he said.
In addition, Dr. Sattin and Dr. Clark agree that in more than 90 percent of suicides, depression or other mental illness is involved. "It is a necessary part of the equation," Dr. Clark said.
"I think there are a lot of people who are depressed about their living conditions, and a number of people with chronic illnesses that lead them to feel they are no longer wanted," said Dr. Sattin. "I think this is a public health problem that needs further investigation."
Dr. Clark added that there are also some people who have, indeed, watched others linger in the kind of painful deaths that Mr. Humphry wrote about.
"I think there is a very negative stereotype about getting old and sick and dying, and a romantic notion is circulating about bailing out of the airplane before the crash," Dr. Clark said. "It's as if your life is the plane, and when you hear a ping in the engine, there's a lot of encouragement to think it's better to jump out than to crash in a fireball."