The Doctor Decided on Death

By Denise Grady

The patient's name was Debbie, and she was dying of ovarian cancer. After two sleepless days, she was struggling to breathe, vomiting repeatedly from a drug meant to sedate her. The resident physician on call was roused from sleep and summoned to her bedside in the night. The doctor had never seen the emaciated, dark-haired figure before. "It was a gallows scene, a cruel mockery of her youth and unfulfilled potential," the doctor wrote later. "Her only words to me were, 'Let's get this over with.' " The resident took her exhausted plea literally and instructed a nurse to prepare an injection of morphine, "enough, I thought, to do the job." Then, as a woman visitor held Debbie's hand, "I injected the morphine intravenously and watched to see if my calculations on its effects would be correct." Within minutes the 20-year- old woman was dead.

The doctor's unflinching account, published anonymously in the Jan. 8 Journal of the American Medical Association, was the first such confession ever to appear in a U.S. medical journal. With stark candor and dramatic detail, it spotlighted one of U.S. medicine's most controversial issues: the extent to which American doctors commit mercy killings. The report has prompted a storm of protest and a flurry of letters to J.A.M.A., most of which were from physicians who condemned the resident's behavior as both illegal and unethical. New York City Mayor Edward Koch was so horrified by the J.A.M.A. account that he asked the Justice Department to investigate. Last week the Illinois state's attorney's office in Cook County, where J.A.M.A. is published, informally asked the magazine's editors for the author-physician's name, which so far they have refused to reveal.

Across the country, physicians upset by the story criticized the unnamed resident's action. "Euthanasia is practiced," says Washington Internist Jon Wiseman. "But usually it's done in a more passive kind of way, by withholding treatment -- not by putting someone to sleep like a dog." Do doctors commonly make that kind of decision alone? "No one talks about that kind of stuff," he says. Manhattan Internist Eric Cassell, who prefers not to pass moral judgment on mercy killing, believes that if it does occur, it should be only because the "circumstances are impossible to change or bear -- not merely because the patient is depressed."

Few dispute that the story raised troubling questions about a practice that may occur in hospitals more often than most patients realize -- or most doctors are willing to admit. J.A.M.A. Editor George Lundberg says his own staff split over whether or not to publish the piece. But two medical peer- review panels urged him to publish it. Lundberg, who believes the anonymous account is genuine (though J.A.M.A. has made no attempt to verify it), decided to go ahead. "My intent was to produce vigorous debate on a timely topic," he says. "We are technologically capable of prolonging dying at great cost with little apparent benefit."

Lundberg's own position reflects the A.M.A.'s posture on euthanasia: physicians may withhold life-sustaining treatment under certain circumstances, but should never intentionally cause death. Most physicians concur, though some acknowledge that the line is often hard to draw. Perhaps the harshest indictment of Debbie's treatment comes from doctors who maintain that morphine, used properly, could have kept her comfortable. Her regular physicians, not the hapless resident, believes Minneapolis Neurologist Ronald Cranford, are the "real criminals" for having failed to prescribe adequate medication for her pain. But if the dose required to bring relief also happened to hasten the end of her life, that is something a physician could live with. Pediatrician Kathleen Nolan, an ethicist at New York's Hastings Center, reports that several of her young patients, suffering terribly from cancer, died in this way. Says Nolan: "There is no dishonor."

The J.A.M.A. account of Debbie's death also underscores a fact of medical life: terminally ill cancer patients often suffer unnecessarily because doctors hold back narcotics for fear their patients will become addicted -- even when they have only weeks or months to live. This casts doubt over the profession's reassurances that pain will be controlled. And the dread of unrelenting pain is one factor that may encourage patients and doctors alike to blur the line between letting death occur and causing it.

Some doctors are wary of outside intrusions into an area that has so long been their province. Says Lundberg: "There are many physicians, myself included, who believe that the place where life and death decisions should be made is at the bedside, between the patient, family, doctor and, if appropriate, a religious representative, and that there's no place for the courts in this decision." Even so, if Debbie's bleak saga yields any lesson, it is that some physicians may need more help and guidance in navigating the murky area between unending pain and death.

With reporting by Lisa Kartus/Chicago and Raji Samghabadi/New York