In the winter of 1996, while I was studying the record of Jack Kevorkian’s first forty-seven physician-assisted suicides, I received a letter from a woman I did not know named Martha Wichorek. This letter was to be the first of many. Dated December 2, 1996, it read:

Prof. Kaplan, Dear Friend

In matters pertaining to the euthanasia–assisted suicide issue, we have heard and read a thousand times that “Only God gives life and only He should take it away.” True, God does give life and also takes it away gradually, by way of old age, disease, drugs, etc.

When “life” (being able to do things for yourself and others) is taken away, unless a heart attack or accident strikes first, every human being usually descends into the “miserable existence” stage (cannot do anything for yourself or others—totally helpless). This stage of that life-death cycle can last weeks, months or years and is the most dreaded of human experiences.

We also hear and read “the sanctity of life,” “concern for human life,” “we must protect life,” etc. Everyone agrees that it is right, moral and proper to sanctify, protect and value “life.” However, when “life” is taken away and we Elderly, terminally ill, Alzheimer’s, etc. descend into the “miserable existence” stage, very few officials and medical personnel acknowledge that this stage is a special stage and should receive special treatment. In fact, many just say “if the heart is beating, then the patient is alive.”

This refusal to divide the “life”–“miserable existence”–“death cycle” into distinct categories is causing most of the animosity in euthanasia discussions. Many deliberately use the word “life” when they know very well that they mean “miserable existence.”

This went on for three full pages. Among the indignities suffered, she included nursing home or hospital tests and procedures, hospice care, in-home and visiting-nurse arrangements, living wills, living with children, and committing suicide without the help of a doctor. She signed the letter, “a still clear thinking 81 year old human being.”

Concerned, I contacted Martha by telephone. During our conversation, I learned that she had lost her husband to cancer three years earlier and had three grown daughters. She lived alone and, aside from some normal ailments associated with aging, was in reasonably good health. She was not seriously ill, nor was she in any kind of acute physical pain. In fact, she had written three books, seemed to be active in her community, and possessed a very sharp mind. Yet she was forcefully advocating that there be a state-sanctioned clinic for “we Elderly, terminally ill, Alzheimer’s,” and insisted that she herself wanted to die before she became incapacitated or terminally ill.

After this call, I discussed Martha’s state of mind with a colleague, and though neither of us thought her acutely suicidal at the time, we were concerned that her perception of her situation would lead to a more concrete plan for her death in the future. I invited her to meet with me. She politely refused.

In March 1997, I received another letter. This time, Martha’s tone had changed. She wrote about her own death and about how she would take the money she would save by dying and use it to buy her grandson a car for his college graduation. Again, I called her. This time I pointed out the implicit hostility of such a gift, explaining that her grandson would prefer a living grandmother to a car made possible for him as a result of her suicide. She then talked about her husband’s death. I suggested that she get involved in some activities or even that she go for therapy. When she said no to both, I tried to stress her many capabilities and how much she had to offer in the fight for better health care for the elderly.

I next invited her to come and present her views to a class on suicide that I was teaching at Wayne State University. She declined but told me she enjoyed our calls. I offered to come visit her. Again she declined, and she gave me the phone number of a speakers’ bureau that specialized in “problems of the elderly.” Curious, I called the number—and discovered that the “speakers’ bureau” was the law firm of Geoffrey Fieger, the lead attorney for Jack Kevorkian. Martha’s legal knowledge and interests then began to make some sense, and my colleague and I, our concern mounting, resolved to keep in regular contact with her.

In April, Martha wrote again, now from a hospital where, after bouts of vaginal bleeding, she had undergone a hysterectomy. She was recovering well and acknowledged that she was “getting stronger,” but she described the “torture” she was enduring. She specified: “IVs with anesthetics, nutrients, etc.,” “tight rubber stockings that stretched from my toes to the crotch, and expanding and contracting legging attached to a motor for better blood circulation,” “tubes in my nose, for oxygen,” “breathing tubes to exercise my lungs,” “blood pressure and temperature checks every hour, an EKG, blood drawn for lab tests, etc.,” and being “expected to walk alone from the bathroom, one day after surgery, holding onto the IV pole.”

Martha spent three days in the hospital. Her surgery was successful, and she returned home. Again we both tried to see her. Again we were rebuffed.

Anyone who has undergone surgery will recognize Martha’s “tortures” as unpleasant but also as temporary and necessary to facilitate a quick recovery. Martha’s comments indicated that she did recognize why these measures were taken, and yet she seemed to regard them as an assault on her dignity, one that made “life not worth living.” Oddly, she claimed that in the absence of legalized euthanasia, she had chosen surgery “because the alternatives . . . such as living with children, in a nursing home, or with hospice or home-care arrangements were worse.”

After that, I called her several times but got no answer. When I returned from my summer vacation in September, I still could not reach her. And I received no more letters. On December 3, 1997, the media reported that Jack Kevorkian had assisted yet another person to commit suicide in Oakland County, Michigan. The name released was Martha Wichorek. She was the seventieth person to die with the help of Jack Kevorkian.

Martha had not actually been my patient, but when I heard her name in that news report, it felt to me as if I had lost her. That very afternoon, I received a note from her insisting that she was rational and competent at the time of her death. “I am not stressed, oppressed, or depressed,” she said. “I don’t have Alzheimer’s and am not terminally ill, but I am 82 years old and I want to die.”

Her autopsy revealed that the late Martha Wichorek had no anatomical evidence of disease. Nor, it turned out, had she been in any pain, other than that connected with some mild age-related arthritis. People who knew her said that up to the end she had been very active, even participating in her church’s fall cleanup. She had raked leaves, helped in painting a basement, and seemed to be generally cheerful. Why, then, had she availed herself of the services of Dr. Kevorkian?

Although I never saw or treated Martha, I think that her communications with me indicate an answer, or at least a partial explanation for her decision. It lay in her ideas about the stages of human existence spelled out in her very first letter. First, life is defined in terms of independence, self-sufficiency, and productivity. Next, the loss of independence does not just make one feel miserable but places one in another category, morally and legally unprotected: “the stage of miserable existence.” The difference between “being a living person who feels miserable” and “being no longer a living person, but one who has entered a ‘miserable existence’ category,” is monumental. For the first, there is compassion, but the second requires “special treatment” (a term to send chills down the spine of anyone familiar with euthanasia programs in the past).

Martha’s case raises broader issues: the availability of assisted suicide to physically sound but depressed individuals; the “quick” solution of death for the elderly when they feel useless; thinking of death as a “right” rather than a fact; and too much social concern with the legal rather than the psychological condition of those contemplating suicide.

Other themes stood out in Martha’s letters, many of which are common among those contemplating “rational” suicide. There were her black-and-white negative thoughts, her rejection of help, her insistence on a definition of life as being able to take care of oneself, her use of objectified terms (such as the new life stage of “miserable existence” to replace merely “feeling miserable”), her unsolicited speaking for others, her legalistic analysis of the problem of euthanasia and doctor-assisted suicide, her exaggeration of minor and temporary discomforts, her refusal to accept family support—cumulatively resulting in her choice to be “in control” and die.

One thing more: Martha Wichorek saw her death as a heroic martyrdom for the cause of euthanasia. Kevorkian, as we know, not only encouraged this kind of thinking but served as its most sanctified prophet. He preached to the very first woman he assisted to her death that the world would thank her for her heroic gesture. Martha had been seeking to give some new kind of meaning to her life. Thanks to Jack Kevorkian and his minions, she succeeded in standing directly on its head the very thing she had ?hoped for.

Kalman J. Kaplan is professor of psychiatry at the University of Illinois College of Medicine in Chicago.