Decisions to die for.

Courts, legislatures, medical groups and religious leaders are struggling with the complex question of death by choice.

March 6, 1996 - The U.S. Ninth Circuit Court of Appeals finds Washington state's ban on assisted suicide unconstitutional. The ruling affects nine states.

* March 8, 1996 - Dr. Jack Kevorkian, prosecuted under a now-expired Michigan law, is acquitted of criminal activity for assisting in the suicides of two patients.

* April 2, 1996 - The U.S. Second Circuit Court of Appeals rules New York's assisted suicide ban unconstitutional. Three states are affected.

* May 14, 1996 - Kevorkian is again acquitted of any crime for assisting in two patient suicides, this time under Michigan common law.

Two major court rulings in less than a month and a second and third acquittal for Kevorkian in two years represent unprecedented activity on the issue of assisted suicide. March also marked the 20th anniversary of the Karen Ann Quinlan case that first raised the national consciousness about the right to die. In a landmark ruling, the New Jersey Supreme Court found that the right to privacy included the right to refuse life-sustaining treatment. Twenty years later, the quickening debate over the right to die - whether by active intervention or treatment withheld - has developed a notable shift.

With a rapidly aging population and shrinking health care funds, the economics of end-of-life medical care come up as often as the issue of bioethics. The statistics are staggering. The 1995 White House Conference on Aging reports that the nation's elderly population, now 33 million, is expected to reach 77 million by 2030; one in five U.S. citizens will then be over 65. The fastest growing segment of the population is over age 85 and will number nearly 9 million by 2030, according to the U.S. Census Bureau. The federal government currently spends nearly 10 times as much on every person over 65 as it spends on those under age 18.

"I'm scared of the whole medical system in terms of economics," says Rashi Fein, who teaches the economics of medicine at Harvard Medical School. "This is an area where there is tremendous economic advantage to not getting involved with keeping people going. But I come down grudgingly on the side that regulation can come much closer to keeping us honest than the unregulated, underground system we have now." Fein says he is "increasingly troubled" about doctors participating in assisted suicide and that this role may in the long run damage both physicians and patients, through a loss of trust. But, he says, "What is needed is a way to minimize the risk of errors that are not correctable."

The National Right to Life Committee, religious leaders and many medical groups express grave concern that given sufficient economic pressure, the right to die will become the obligation to die. Some fear it could lead to euthanasia. They urge increased focus on pain management and interventions for depression.

Despite long-term activity on assisted suicide, to date only Oregon has passed a law (through voter initiative) to allow it, and a court injunction has kept the law from taking effect.

In the only major enactment so far this year, Iowa became the 34th state to explicitly prohibit assisted suicide. "The bill was more of a preemptive strike than a response to any specific problem," says Senator Andy McKean, one of the bill's sponsors. "Iowa is No. 1 in the country in per capita population of people over 85, and this was a show of concern and support for our elderly."

Nebraska Senator Ernie Chambers introduced a physician aid-in-dying measure that had numerous safeguards and stipulated the patient had to be diagnosed with less than six months to live, but the bill failed. "What the state does allow is a person to starve to death," he says, referring to current law that allows respirators and feeding tubes to be disconnected.

Michigan has measures pending both to prohibit and to allow assisted suicide. Senate Judiciary Chairman William Van Regenmorter has sponsored a bill to prohibit the practice. "Any time we permit any segment of society to have less value than another, it is a dangerous precedent," he says. "The potential to expand to other groups or classes is created." His bill specifically allows administration of medication if the intent is to relieve pain and not to cause death, even if it might increase the risk of death in a seriously ill person. But, he adds, the medication must be clearly defined. "Carbon monoxide is not considered medication by any standard," he says.

Senator Jim Berryman has sponsored a death-with-dignity bill patterned after Oregon's law. It would allow physician-assisted suicide under certain conditions. "Polls indicate 70 percent to 80 percent of Michigan citizens believe the state should stay out of these decisions, but right-to-life interests are dictating this issue in the Legislature," he says. "Since Kevorkian continues to be acquitted in these cases, Right to Life should welcome some guidelines."

Berryman says that attention needs to be refocused on the best interests of the terminal patient and adds: "I am not an advocate for assisted suicide; I am an advocate for personal choice." If the bill passes, the proposed regulations would face voter approval in the November general election.

LEAVING INSTRUCTIONS

The highly charged assisted suicide issue tends to eclipse other end-of-life options. Even the infamous Kevorkian cases have involved only 28 patients over a period of several years. Meanwhile thousands are affected each year by states' "advance directives" laws.

Advance directive is the umbrella term for an array of end-of-life medical instructions. The most common forms are living wills and health care or durable powers of attorney. A living will details the kind of medical care the patient will or will not accept (e.g., refusal of artificial nutrition or hydration). In a health care or durable power of attorney, the patient authorizes another person to make medical decisions on his behalf. The federal Patient Self-Determination Act of 1990 requires Medicaid- and Medicare-certified facilities to inform patients about advance directives.

At age 85, Estelle Browning prepared for her medical future by drawing up a living will. It stated that, in the event of incapacity, she did not want to receive artificial nutrition or hydration. When a stroke later left the Florida woman paralyzed and unable to communicate, she was nonetheless put on a feeding tube. It took more than two years and a ruling by the state Supreme Court before the patient's original directive was carried out. What went wrong?

Although most states have some type of advance directives law, lawsuits like the Browning case can occur because many doctors resist any action that is not life-sustaining. And vagueness in statute language can make liability a cause for concern. To date, no doctor has been held liable for withdrawing life support. Earlier this year, however, a jury levied a judgment of $16 million against a Michigan hospital for maintaining a severely brain-damaged woman on life support against her stated wishes.

In Connecticut, Representative Richard Tulisano sponsored a successful 1995 bill to undergird the state's advance directives laws and ensure that people "who are terminally ill and do not wish to be resuscitated will have their wishes complied with." But he admits that do-not-resuscitate orders bother him. "The protocols are not so simple. If resuscitation means something as simple as administering an intravenous medication, withholding such treatment is not an easy call to make."

Colorado Senator Dottie Wham, who chairs the Senate Judiciary Committee, sponsored a resolution this year setting up a task force to study the issues surrounding intractable pain. "If we are going to deal with end-of-life issues," she says, "we have to address intractable pain." The state's advance directives laws were also sponsored by Wham, who serves on the board of the Colorado Collective for Medical Decisions, a group formed in 1993 to "establish guidelines for use of appropriate care for persons nearing the end of their lives."

End-of-life medical issues command increasing attention as baby boomers become grandparents. "We are becoming a nation of 50 Floridas," says Richard D. Lamm, former Colorado governor and now director of the Center for Public Policy and Contemporary Issues at the University of Denver. Lamm has been widely misquoted - owing to a distortion of his remarks by a Denver newspaper - as having said that the elderly have a duty to die. The actual quote was: "We have a duty to die." It was a philosophical statement, he says, that "God made us all mortal."

When life begins has no universally accepted definition, and determining when life has ended is no less a conundrum. But there is increasing agreement that public policy needs to catch up with a medical technology able to sustain life almost indefinitely. John Paris, a Jesuit priest and professor of bioethics at Boston College, has testified in several landmark biomedical cases. The former consultant to the President's Commission for the Study of Ethics in Medicine summarizes the challenge: "There is a great deal of division on how we deal with death. But we are forced to ask ourselves how much is enough and when do we stop?"

Denise Griffin tracks end-of-life issues for NCSL.