21st-century way of death?

'Backstreet' euthanasia is on the rise. The establishment must face the debate, argues Ann Treneman

At the age of 39, Rebecca Badger believed that life was not worth living. Every day was filled with constant pain, the hours stretching out like a medieval rack before her as she lay on her couch in Goleta, California. She was a single mother with multiple sclerosis, a history of depression, and no health insurance. Now she feared she was becoming a burden to her daughter.

Rebecca Badger wanted to die with dignity. "I know there is a man out there with a heart of gold who will help me and I will go to him at the right time," she told the local television station KEYT one Sunday in July. The very next day she and her daughters flew half-way across America to Detroit. By Tuesday she was dead. Jack Kevorkian - or Dr Death as he is known in America - himself wheeled her body in to Pontiac Osteopathic Hospital at 11.47pm before disappearing back into the night.

"She had been suffering for years. She had a malignant case," said Kevorkian's spokesman and lawyer, Geoffrey Fieger. Her daughters said nothing. Like all relatives in Kevorkian's 40 assisted suicides, they had vowed to support their mother's decision.

The autopsy was less obliging. It said that Rebecca Badger was a 165lb, 5ft 9in female who died of a lethal injection of potassium chloride. There was no trace of disease, MS or otherwise. The medical examiner says he is keeping the entire spinal chord, just in case anyone doubts his word.

Was Dr Kevorkian's action murderous or merciful? Does it matter that Ms Badger was treated for 11 years by two doctors? Would the answer be different if her body had been riddled with disease but in no pain? Or if she was 59 and not 39? What if she had a confirmed diagnosis of Alzheimer's? These are the real questions in the euthanasia debate and these are the questions that no one wants to face because the answer will tell us who among us can choose to die.

Last week saw the world's first legal death by euthanasia and it was not a pretty sight. At 66, Bob Dent had suffered from prostate cancer for five years and the past few months have been "a roller coaster of pain". He planned to kill himself using Dr Philip Nitschke's "Deliverance" computer program but, early this month, he ran into a problem. The law in Australia's Northern Territory said he needed three signatures. He had one from a specialist and another from Dr Nitschke. Now he needed a psychiatrist to say that he was not suffering from treatable clinical depression.

Five psychiatrists in Darwin refused to sign. Things did not look good. A previous Nitschke patient had failed because he could not get the proper number of signatures. Mr Dent decided to look further afield. In the end Dr John Ellard, a Sydney psychiatrist, flew to Darwin to sign on the dotted line. A strange mission indeed for a Flying Doctor. Whatever this is, it is not death with dignity.

The politics of death are becoming impossible to avoid in our ageing world. In America, the right to die is expected to replace abortion as the next big moral battleground. Last year some 42 books were published in the US on the subject. Suicide has even gone "on line" with 170,000 people visiting the Deathnet Internet site since it was set up in January 1995. A powerful anti-euthanasia coalition made up of Right to Life, the Catholic church and some disabled rights groups is forming. Around the world the medical and political establishments are doing their best to avoid dealing with the issue. In the Netherlands euthanasia is widely practised but technically against the law.

Both the American Medical Association and the British Medical Association remain opposed to changing the status quo. But the truth is that many of their members do practise euthanasia and doctor-assisted suicide (the difference lies in the level of the doctor's participation). Just about any action that is taken makes us feel uncomfortable. Nowhere is this more obvious than in Detroit, where Kevorkian lives and works. There the debate is carried out at fever pitch; euthanasia is frequently compared to Nazi attempts to create a super-race. "Kevorkian bringing this out of the closet is about as useful as bringing masturbation out of the closet," a prosecutor sneers. Kevorkian's lawyer is equally forthright. "The only difference between Kevorkian and all the other doctors is that Kevorkian doesn't need testicular transplant," exclaims Geoffrey Fieger. "Write that down! Most doctors need testicular transplants! That means they've got no goddammed balls!"

The BMA says liberalisation would "herald a serious and incalculable change in the ethos of medicine". However, in the British Medical Journal this summer, the North America editor, John Roberts, wrote of Kevorkian as a medical hero: "We need the hero to make us feel uncomfortable. Medicine needs heroes today. Patients who suffer need their pain to be heard and felt. Those who are dying need our commitment to stay with them throughout their journey."

If only it were that simple. After all, technically, we are all dying and not all of Kevorkian's cases were even deemed terminally ill. Nor is Rebecca Badger's the first autopsy to show no sign of disease. Who knows who will follow Bob Dent in Australia (supposedly there is a queue of five already). In the Netherlands - where it is believed thousands of euthanasia cases go unreported every year - a grieving and depressed women was helped by a doctor to commit suicide.

Last week showed again how powerful the desire to die can be. People will search continents for signatures and fly half-way across a land to meet a strange doctor in a strange hotel room. In Australia, the federal government talks of overruling the Northern Territory law but does not understand yet that a Pandora's box has been opened and that it may be impossible to close.

Michigan has tried desperately to stop Kevorkian. Three times they have tried to put him in jail. On the face of it, this should not be difficult. To put it kindly, Kevorkian is an oddball. A pathologist, his obsession with death can be clearly seen in his paintings: they are ghastly canvases filled with body parts, blood and mayhem. One preoccupation used to be photographing people's eyes to determine time of death. His dream is to establish a suicide clinic and he advocates organ transplants and experiments on willing humans.

The juries in each of his trials seem unconcerned by such things. Instead they have concentrated on his patients. Kevorkian makes videotapes of all of them and the faces are unforgettable. One belonged to Merian Frederick, a 72-year-old woman rendered mute by Lou Gehrig's disease. Her neck and arm muscles were failing her and she would soon be unable to communicate. She had raised five children and was a grandmother to seven. She loved to canoe, hike and have a rollicking good discussion. Now she wanted to die before she became trapped inside her own body.

It is impossible to watch this video and not be moved (her daughter says that most people cry) and it is crystal-clear why Kevorkian has not been convicted. The men and women of the jury look at the screen and see themselves: when they are old, sick and tired of life they, too, want a choice. Like Rebecca Badger, they want a doctor with a heart of gold.

But last week has brought home two lessons. The first is that death with dignity remains a slogan and not a reality. The second is that choice is not always what it seems. Who decided that Bob Dent could die - a computer programmer, a doctor named Nitschke or a psychiatrist named Ellard? Did Merian Frederick die because she decided to or because Jack Kevorkian agreed to help her?

Janet Good knows all about such things: she is the conduit through which many people seek to reach Jack Kevorkian. A long-time supporter of euthanasia, she is one of Kevorkian's best friends. Last year, in what she calls "an extreme irony", she was diagnosed with terminal cancer. Her friend has agreed to help her die when the time is right: "I know it is easy, quite gentle and happens in seconds. Of course it is sad. I don't want to die. But I'm going to have a choice."

I would disagree with Janet Good. It is not her choice, but Kevorkian's. He has chosen to help her. The power lies with the doctor. We do not know why he chooses some patients and not others. The power also lies with the doctor in the Northern Territory. In Britain, too, it is the doctor who decides whether or not to help.

Some of these decisions are bound to be mistakes - fatal ones. It is time that the medical establishment grasped this nettle that euthanasia is already taking place on an ad hoc basis. In this, it is like backstreet abortions used to be years ago. Like abortion, it needs to be brought out into the open and looked at sensibly. Our lives - and deaths - are too important to leave to undignified chance.