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Book Excerpt: “Modern Death”

How Medicine Changed the End of Life By Haider Warraich, M.D.

Several hours into our meeting, Rafael started to read the piece aloud.

I was handed a Xeroxed copy of a single-page essay from the Journal of the American Medical Association, published in 1988. A poet and physician, Rafael Campo, had invited myself and several other medical residents to his home for a writing workshop. We were interested in writing powerful, moving essays, and Rafael picked out what he thought was a particularly strong piece. The essay was titled “It’s Over, Debbie,” and it seemed to us that the most intriguingly unusual thing about it was that the author’s name had been “withheld by request.” But that was before we read the piece itself.

The essay started like many other personal anecdotes penned by physicians and routinely published in medical journals: a sleep-deprived resident was paged in the middle of the night. The author, a gynecologist in training, was informed on a call night that a patient was having difficulty “getting rest.” As he proceeded to check what was going on, contrary to his expectation of finding an elderly female, he found a twenty-year-old girl named Debbie. Experiencing “unrelenting vomiting” and “labored breathing,” the young patient had terminal ovarian cancer. A dark-haired nurse was standing next to her, holding her hand and comforting her till the doctor on call arrived. “Hmmm, I thought,” wrote the author, “very sad.”

moderndeath-insideHe then went on to describe scenes that anyone on a cancer ward has seen innumerable times. “The room seemed filled with the patient’s desperate effort to survive … it was a gallows scene, a cruel mockery of her youth and unfulfilled potential.” However, it was what happened next in the essay that sent the first shiver down my spine, all the way to my toes.

“Her only words to me were ‘Let’s get this over with.’” The author returned to the nursing station with thoughts circling his head. “I could not give her health, but I could give her rest,” he wrote. He then drew up twenty milligrams of morphine in a syringe, walked back to her room, and injected the morphine into her vein. “With clocklike certainty, within four minutes, the breathing rate slowed even more, then became irregular, then ceased,” wrote the author. The article was not a long read, only a word over five hundred. It must have been difficult for Rafael to read the piece, but nothing would have been harder to write or say than the three very last words: “It’s over, Debbie.”

Few things have left me feeling as soulless as those last three words. I would learn later that I was far from the only one shaken to my being. The essay generated a firestorm at JAMA (Journal of the American Medical Association). They received more letters in response to this one piece than to any other article published in the journal’s more-than-a-century-long history. Overwhelmingly, physicians opposed the piece and what it purportedly represented far and wide. A comment published in the JAMA in the aftermath of “It’s Over, Debbie” was perhaps the most scathing:

By publishing this report, he [the JAMA editor] knowingly publicizes a felony and shields the felon. He deliberately publicizes the grossest medical malfeasance and shields the malefactor from professional scrutiny and judgment, presumably allowing him to continue his practices without possibility of rebuke and remonstrance, not even from the physician whose private patient he privately dispatched .… Decent folk do not deliberately stir discussion of outrageous practices, like slavery, incest, or killing those in our care.… The very soul of medicine is on trial.

The firestorm didn’t remain buried in the back pages of the JAMA. Ed Koch, the irascible mayor of New York, was incensed, calling the article “a confession.” He went on to demand that Attorney General Edwin Meese III force the journal into releasing information pertaining to the submission. “This is not a case of an informant. This is a case of a confessed murderer.” The Illinois State attorney general Richard Daley took action and issued a subpoena to the American Medical Association, which is based in Chicago and oversees the journal, requesting that all documents related to the article, including the name of the author, be released. A Cook County grand jury ordered that all records be turned over to the state for further prosecution.

Conspiracy theories swirled, with many not even believing the account to be true. Forensics experts doubted that twenty milligrams of morphine could in fact end someone’s life — least of all within the reported four minutes. Clinicians found the scenario implausible. Some doubted that any physician would make such a decision about a patient they didn’t know too well. Pressure was piled on George Lundberg, who was the editor of the journal at the time, and who had gone ahead with publishing the piece even after some of his editorial staff objected to it. Some even suggested that Lundberg’s wife, an English professor, had penned the piece.

After the firestorm that “It’s Over, Debbie” ignited, pressure kept piling on the American Medical Association from all directions to out the author and rescind the article. Yet the piece also generated a second wave, one that came from perhaps the most important stakeholders in this debate: patients and the public. A young woman whose mother had lost her mother to lung cancer wrote, “I feel very strongly that if such a patient wants to end her life by being injected with morphine or any other drug that will end her pain, then she should have the right. No one should have the right to make them suffer.” Others said that they “applaud that physician as one caring more about a patient’s pain than about cruel, outdated professional ethics and laws.” Alex Hardy, a patient who had been diagnosed with terminal metastasized cancer, wrote the most moving account:

I have traveled down a road filled with evasion, equivocation and moral hypocrisy. Most physicians don’t want to face the fact that one of their patients is going to die. Very few will even discuss death. It is often claimed by physicians that they can’t “play God” and remove life support. Aren’t they “playing God” when the life support is ordered?… My only concern is that some misguided physician will try to keep me alive against my wishes. Being alive is not merely existing on a machine or with massive drug doses. A person must have the ability to think, function, and participate (even in a small way) in the everyday flow of human events.

Alex Hardy died less than a month after writing this commentary. What the author of “It’s Over, Debbie” described has been called many things, ranging from physician-assisted suicide, euthanasia, and mercy killing to flat-out cold-blooded murder. In many ways it crystallized what is one of the most passionately debated issues in modern culture.