Alex spoke like a conspirator, out of earshot of the emergency room nurses, his thick Swiss accent cloaking his whispered words. "Help me to die quickly. Please, Jerry. Your word you gave me." I purposely ignored his plea and continued with his examination. Alex's blue eyes were puffy and inflamed, his skin blistered and lobster red, his joints swollen and tender. His temperature was charted at 105 degrees. The nurses had just bathed his burning flesh with rubbing alcohol, which rose in a halo of intoxicating vapors. I felt slightly faint, partly from the fumes, partly from the hour, awakened at 2 A.M. at home by the emergency call and arriving at the hospital shortly thereafter. I steadied myself by gripping the sidepost of his bed.
"I want to die. When I am still myself. I do not want to wait until I am sickly wasted. I have seen too many friends like that. Das ist kein Leben."
I translated in my mind: "That is no life." He was right: for many, AIDS in its advanced stages was hardly living. But the pneumocystis pneumonia diagnosed four days before had been Alex's first clinical manifestation of the disease after carrying the virus without symptoms for many years. I had prescribed Bactrim, a sulfa antibiotic, and his pneumonia had begun to improve. Tonight he had returned to the hospital with what appeared to be a severe allergic reaction to that treatment. The imflamed eyes, blistered skin, swollen joints, and elevated temperature were all consistent with that diagnosis. His electrocardiogram and blood tests showed no toxic effects of the allergic reaction on the heart, kidneys, or bone marrow. The partly treated pneumonia could be readily cured with alternative antibiotics. The allergy would quickly subside with steroids. How could I help make this the end when I understood it as just the beginning?
"Der Alex," I said softly, using his diminutive, "This is only an allergy to the antibiotic I gave you. You'll be better in a few days. It makes no sense to die now."
His face immediately registered the pained anger of betrayal. I had long been counted on as a friend and ally, and now, at a moment of need, I was abandoning him.
"We had an understanding," Alex said, seething through clenched teeth. "You do not have the sickness. You do not have to watch yourself decay, as I do, at the age of forty-three. I wish to end my existence. You have no right to deny me that!"
"You cannot make clear decisions at this moment," I shot back. "You are fevered and frightened. You want to throw your life away. I won't let you. It's wrong."
Alex grabbed the rails of his stretcher, poised as if to leap from the litter and attack. I moved my hands over his wrists, locking them under my powerful grip.
"Are you some god who decides who lives and who dies?" Alex spat in fury.
"At this moment yes."
It was close to 4 A.M. as I drove along Longwood Avenue back home to Brookline. I doubted I would be able to go back to sleep. My nerves were on edge, my heart in turmoil from the confrentation. It had ended in bitter silence, Alex turning away from me, burying himself in thoughts
The last ivory rays of a full moon illuminated the facade of the Harvard Medical School facing Longwood Avenue. The school was built at the turn of the century, modeled on a Greek temple, its five massive columns rising nearly four stories, its broad steps elevating the entrance some twenty feet above the ground. The intent of the founders was clear: this was a place of great importance, where the powerful gods of natural science and human healing were to be worshiped.
Were the school's columns Doric, Ionic, or Corinthian? I could never keep the differences straight. Alex, an accomplished architect, of course would know. But he would not so simply answer my question. He would want me to understand the building as he did, as a creation, virtually animate. He would explain how the neoclassical style reflected the aspirations of an emerging industrial America, its vision of itself as heir to the grandeur and intellect of the ancient Greeks. He would touch the marble pillars and gauge the physical composition of the stone, its resilience and range of coloration, and explain why it had been selected for a building of this type, in this climate and location.
I felt a searing pain penetrate my core. Here was a vibrant, sensitive, engaging person--pleading to be put to death.
The medical profession has its codes for easing the dying person's passage: "Expedite the process"; "Help nature take its course"; "Palitate maximally." Each aims to mask the stark of reality of the act.
The "understanding" Alex had referred to was established early in our relationship, as it is with most patients. Great comfort is gained from knowing there could be hymane limits to the seemingless endless dimensions of suffering. When we reach these limits, my charge is described in stylized euphemisms: "no further measures will be taken" and "you will be made comfortable."
Such scenarios are rarely as simple or neat as they might sound. Becuase, as Alex had said, it is an act of God performed by mortals.
When the decision is made, I order the intensive life support withdrawn, and, if there is pain, an infusion of morphine begun. As I watch the breathing quiet, the flesh slowly cool, I am invariably seized by a sharp moment of doubt. Had everything been done that could habe been done? Was there really no longer any reason to live? My fallibility is never more apparent to me at that moment.
The reality is very different from its portrayal by Dr. Kevorkian with his "death machine" and "assisted suicides." I read the reports of his exploits carefully in the press, particularly the profiles of his subjects. While he deserves credit for drawing attention to an important hidden issue, I mistrust his sangfroid dramatics. What for me is an agonizing process is made to appear glib and uncomplicated. What is a patient is simply depressed, or if the diagnosis is mistaken, or if some further therapy might improve the condition?
Alex had specified clearly what he saw as incompatible with continued life. If he were to become permanently and completely neurologically impaired, paralyzed, blind, demented, he wanted no intervention other than narcotics to lessen the pain and allow him to die. This had been our agreement it concluded that I had not breached it. What had changed to make Alex to ready to die?
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