On an unrevealed day in an unrevealed hospital, a doctor whose name we do not know gave a young woman whose name we do not know a lethal injection.

The doctor sent an article asserting this to the Journal of the American Medical Association. On Jan. 8 the journal, published in Chicago, printed it.

The Cook County state's attorney, considering the act a possible murder, asked a grand jury to subpoena the journal's file, including the doctor's identity. The journal refused to hand it over except by court order -- an issue still unresolved -- and the case last week leaped into headlines.

What news stories have discussed in large part is the AMA journal editor's right, as a journalist, to protect his source of information -- or even if the account is true.

But what many people have been wondering as they read of this case are more elemental questions:

Should society condone mercy killing when a suffering patient wants to die?

Should there be safeguards -- perhaps mandatory procedures -- for this, or should it be a private matter between patient and physician?

Or should these questions not even be raised? Should a so-called "mercy" killing remain, like any killing, murder legally and murder morally and always impermissible?

These events do happen. How often, no one knows. Doctors are reluctant to talk about any such cases in public.

Several interviewed last week for this story were asked if they had ever done such a thing or seen it done. All said no to both questions. A few, however, said they had "heard of it."

In a recent mail survey, the pro-euthanasia Hemlock Society asked 5,000 California doctors if they had taken the lives of terminal patients who asked to die. Of 588 who replied, 79 said they had.

An outstanding and conscientious physician, the late Dr. Edward Rynearson of the Mayo Clinic, was quoted in 1982 as saying: "I spent an active practice in trying to help people live, but there were very rare occasions when I helped them die. Never once was this questioned. The reason is simple: Never once did another physician, a nurse, a supervisor or anyone else know about it."

And more than one physician said last week: Some dying patients suffer unbearable pain. To suppress that pain may require an injection that in at least some cases could also suppress their breathing and hasten their death. It is not legitimate to give that injection to cause their death. It is legitimate to give it primarily to ease pain, knowing that it may also hasten death.

That is not what that unnamed physician reported doing. His or her article is reproduced on the cover of this section. The account was no scientific report, but a personal column in the AMA journal.

Briefly, this doctor -- a presumably young gynecology resident or doctor in specialized training -- was abruptly and unhappily awakened in the middle of the night to see a shockingly emaciated woman of 20 with ovarian cancer, vomiting relentlessly. The doctor identified the patient only as "Debbie." She was obviously at death's door.

A middle-aged woman was holding her hand. The young woman's only words were, "Let's get this over with."

According to the report, the doctor injected "Debbie" with 20 milligrams of morphine, and within four minutes her breathing ceased.

Humane or horrific? ::

Medical advances have produced forests of monitors, machines and supports that save many lives and fruitlessly prolong many lives.

They do the latter at human cost in patients' suffering and in families' suffering. And at a dollar cost.

Twenty-one percent of all Medicare funds are spent on patients in the last six months of life. A $200,000 bill for treating a final illness that ends with the patient's death after mere weeks is no longer uncommon.

"There's also an ethical question," a hospital administrator in Richmond said. "Do you jeopardize the care of other patients to take care of one patient? We have only so many dollars. Do we give everyone else less nursing care to take care of Charlie?"

In hospitals today there are "Code Blue" carts, packed with emergency equipment to revive dying patients. On a "Code Blue" signal, doctors and nurses rush the cart to the bedside. The first thought is to keep the patient alive, not debate whether or not the patient should be kept alive.

Sometimes a patient's chart may be marked "No Code" -- do not resuscitate. But in reality, most patients are revived. Doctors think hard before writing this order. Dr. Richard Bates of Lansing, Mich., once said, "If a man did to a dog some of the things we do to humans to prolong their existence, he'd be prosecuted for cruelty to animals."

Dr. Leon Morgenstern, director of surgery at Cedars-Sinai Medical Center in Los Angeles, has asked: "How far do we go in the surgical treatment of the aged, the terminally ill, the near brain-dead, the multiple organ-system failures? . . . We need some direction in these ethical dilemmas." ::

The unidentified doctor who dispatched "Debbie" decided the question unilaterally.

But the account leaves many unanswered questions. For one, did the injection truly cause the death?

Authorities say it would normally take a far larger dose to do so, although, some said, a small dose might be lethal in a patient who had not been given narcotics before or one in acute respiratory distress.

In any case, this doctor's intent was clear -- to bring about death.

However humane the intention may have been, the way it was done has horrified many physicians. While there sometimes has to be an end to useless suffering, the end, they believe, has to be one they can live with and one the law allows.

There is wide agreement that withdrawal of artificial life supports, including all medications except drugs to halt pain, is an acceptable way to let death occur in appropriate cases. One of mercy killing's severe foes, the Catholic Church, has said that this is not only acceptable but may be desirable when technology's only product is the extension of meaningless life.

The American Medical Association's Council on Ethical and Judicial Affairs in 1986 made an important, to some a startling addition for the person in "a permanent vegetative state." It said it is not unethical to withdraw even food and water from patients in irreversible comas, so long as the previous wishes of the patient, if known, or, alternately, of the family are respected.

Not all physicians or ethicists agree with this. But AMA council members said the rule was advisory, not binding; physicians who disagree may follow their consciences, and the AMA remains opposed to mercy killing.

"We're not talking about going into Granny's room and taking away the water pitcher," said Dr. Nancy Dickey, a Texas family physician who chaired the council, but about ending hydration and nutrition artificially administered through tubes into a patient who "derives no comfort, no improvement, no hope of improvement."

To the unidentified doctor who sought to help "Debbie" die, she was not a comatose patient but she was still one who had derived no comfort from her medical care, no improvement, no hope of improvement.

Yet the "unilateral decision to administer a lethal agent was wrong," said Dr. Kathleen Nolan, pediatrician and bioethicist at the Hastings Center in Briarcliff Manor, N.Y.

"It was the worst possible case, where a tired, overworked resident who had never before met the patient injects a lethal dose of medication without any discussion with the patient or anyone else."

What might have been done?

"If this doctor had wanted to relieve pain," she said, "the dose of morphine could have been drawn up in a syringe. Administration could have begun slowly to the point where the patient was comfortable, at which point whatever medication was unnecessary would have been discarded.

"This would have required more time. Ideally, a physician would have sat down and while administering the morphine" -- just enough to ease pain, not cause death -- "talked to the patient and found out what that person was like. And if the situation was out of the range of the physician's competence, a more experienced person should have been called in."

Dr. Ronald Cranford, a Minneapolis neurosurgeon, was an adviser to two groups that drew up guidelines on care of the dying: a 1983 president's commission and a 1987 Hastings Center panel.

"I think it unfortunate that {the AMA journal} printed this article, because the physician handled it so poorly," he said. "What he should have done and didn't do is prescribe adequate medication to keep her comfortable, not kill her, then talked with the physicians who were taking care of her and said, 'Why let this lady suffer unnecessarily?' "

In addition, Cranford said, "He didn't know her that well, he hadn't established a physician-patient relationship," and the account makes it appear that there are a lot of physicians who handle a situation like this so cavalierly. "I don't believe that."

At the same time, Cranford is among physicians who say -- with the president's commission and the Hastings panel -- that it can be ethical, and at times the only ethical course, for a physician to give enough morphine to end pain even if that dose may help end a life.

He explained: "In a situation like Debbie's, the doctor should have been concerned with one thing, minimizing suffering, and he should have used whatever dose was necessary, which could have been done without killing her." It is "very rare" that morphine suppresses breathing sufficiently to cause death. Even "50 or 200 milligrams or more usually doesn't cause significant respiratory depression."But if a legitimate dose "causes death, so be it. That is the well-known ethical principle of secondary effect. Even though there are gray zones, there is an important moral and legal distinction" between giving a possibly lethal dose to minimize suffering and one to cause death.

Unfortunately, he added, "There are a lot of physicians who fail to give adequate medication to minimize pain for many reasons."

Among their reasons: fear of killing a patient; fear of causing addiction, though addiction is hardly important in a patient close to death; plain habit or lack of adequate training in easing pain.

There is also the fact that doctors are trained from their first day in medical school to prolong life, not shorten it. And there is the worry of being accused of murder. "The specter of legal accusation looms behind every hand that reaches for the plug," Morgenstern says.

"I am afraid the Debbie case is going to make many physicians more fearful," said Cranford, "because here is a county attorney trying to find out the name of a physician to possibly charge him with murder."

The issue is critical for a significant number of people like "Debbie" -- patients with untreatable cancers causing suffering, repeated heart stoppages, irreparable injuries, the last stages of many diseases.

"I think there are thousands of Debbies out there, Cranford said, "and it's really unfortunate." ::

Dr. George Lundberg, the editor of the AMA journal, the doctor who decided to print the unnamed doctor's story, agrees.

Lundberg is a keen editor who has gone a long way toward converting a timid journal into one that has begun probing the painful social and economic impact of medicine's advances.

His own staff was split over running the story, but he was backed by two peer review panels. There was -- and is -- the possibility that the account is false. The journal did not verify it. Lundberg believed it.

"My intent in printing it was to promote vigorous debate in our pages on this timely and controversial topic," he said in an interview last week.

"Euthanasia is being practiced widely in the Netherlands, and people here are beginning to find out about it. Some people in California are gathering signatures to get a measure on the state ballot next fall to legalize euthanasia.

"There is the recent change in AMA policy to permit the withholding of life supports, including nourishment and hydration, under some circumstances. And the question of prolonging dying is getting a great deal of attention because of our profound technological capabilities to maintain life long past the time when nature would normally have caused death.

"For all these reasons, I think this interface -- the prolongation of dying and how society and physicians will deal with it, this issue with profoundly conflicting, high-powered ethics -- will be one of the main debates of the rest of this century.

"That is why it is timely."

As of last week, the AMA journal had received two waves of letters. The first, from physicians, mostly opposed both the anonymous doctor's act and the AMA journal's publication of the article. The second wave, from physicians and the public after the story hit the headlines, has mostly supported both the doctor and the journal. ::

Doctors in the Netherlands now commit active euthanasia -- true mercy killing -- on at least 6,000 patients a year, by one estimate. They are permitted to do so by court rulings that allow this when a terminally ill patient whose death is imminent makes an informed request.

According to Medical Economics, an American publication, some 2,500 of that nation's 31,000 doctors are willing to perform these acts. One Dutch doctor said that at the last moment he leans over the patient and asks: "Do you really want to leave this life now?"

The patient usually says yes "in the strongest terms," the doctor reported.

In the United States in 1988, Cranford asked, "Do patients really have control of their lives in dying?"


If the patient has made his or her wishes clearly known about how he or she wants to be treated or not treated, Cranford said. If the patient has a loving, caring family to make sure the patient's wishes are carried out. If there is a physician experienced in treating pain and sympathetic to the patient's goals. If there are caring nurses willing to honor the wishes of doctor, patient and family.

"Then the patient can be assured of having control of the dying process, and dying in her or his life style," Cranford said.

"But what does that say about the other 99 percent of the population?"