Philadelphia was stunned earlier this month by the murder-suicide of a prominent cancer specialist who killed his wife, his two children and himself. The crimes had a peculiarly medical cast: The four bodies were found connected to intravenous bags containing a lethal dose of sedatives that hung from picture hooks on the walls.
No one may know the details in those dark corners of Anthony R. Paul's life that pushed a seemingly calm and successful physician to such personal mayhem. But the facts of his family tell a familiar story -- a story of the well vs. the sick. His wife, Malanie, 47, a child psychiatrist, suffered severe arthritis and had become addicted to painkillers. His daughter, 17, brain-damaged and retarded, was also a severe asthmatic. Only the 12-year-old son was normal, "a gifted child," Paul wrote in his suicide note.
The stress mounted. The housekeeper suffered a heart attack. The wife attempted suicide. The daughter couldn't get into a summer camp.
"This has to stop!" the doctor wrote. And so he stopped it. The entire family was wiped out.
There are millions of Americans in families overwhelmed by illness. While they would never take this shocking route to familial destruction, they, too, often want to stand up and shriek: 'This has to stop!'
The problem ironically is fueled by advances in treating disease and saving lives. When it cannot cure, medicine can often patch patients up well enough to survive the acute phase of the disease and go home -- still sick -- to their families. In the process, family roles are redefined as the burden of caring for the sick shifts from the hospital to the home.
The "points of light" in each family who serve as caretakers have little preparation for the job. Suddenly their spouse, child or aging parent is the cancer patient who needs timed medication, the kidney dialysis patient who waits for a transplant, the schizophrenic in remission.
Until recently, all the medical attention has been focused on the patient, on the sick one. But the well ones in the family need care, too.
"The family gets more and more responsibility. They can't handle it," says Irene S. Pollin, social worker and founder of the medical crisis counseling center at the Washington Hospital Center.
The well ones in a sick family tend to be silent about their own burdens. They are oppressed by feelings of guilt -- after all, they're not sick -- fatigue and the practical worries about money and health insurance.
"They can't talk about it, but if you get them alone in a room, they'll tell you they need help," says Pollin. "Sometimes, the family needs more help than the patient does."
In many instances, illness determines the destiny of each person in the family. In the sad, provocative novel "Family Pictures," author Sue Miller shows how a middle-class Chicago family is tragically misshapen because the younger boy, one of six children, is retarded and autistic. Even death loses its sting. As the mother, weeping, explains after the son dies in an accident in his twenties: "Sad! That's not it, not at all. It's terrible. It's terrible, I know. But what I feel . . . I'm free . . . I'm free as a bird!"
Usually it is the not the child who gets sick but the spouse or parent who has a heart attack or develops multiple sclerosis, Alzheimer's disease or cancer. Two years ago, in the landmark book "Mainstay: For the Well Spouse of the Chronically Ill," writer Maggie Strong chronicled the anxiety, isolation and general havoc that can occur for the well one when illness strikes. Her husband was diagnosed with multiple sclerosis, a slow and incapacitating neurological disorder. Then her mother contracted kidney disease.
"Oh, Mom," her daughter says to her one day, "how can you stand it? Your mother is dying, and your husband is falling apart and you try . . . you try every day. I love you."
Taking care of sick family members has been largely women's work. According to a 1988 congressional study, the average American woman will spend 17 years rearing children and 18 years helping take care of aged parents. But now women have become an integral part of the work force. How can both men and women remain productive in the workplace and take care of the growing number of dependent relatives?
As First Lady Barbara Bush eloquently described to the graduates of Wellesley College in June, the country is "in a transitional period right now . . . learning to adjust to the changes and choices men and women are facing."
For most people, being a breadwinner and caring for the sick ones in the family is not an either/or choice. What's more, most men and women want to spend time with their families. As the First Lady said: "At the end of your life, you will never regret . . . not closing one more deal. You will regret time not spent with a husband, a friend, a child or a parent."
Which is why the failure last week of Congress to override the President's veto of the family and medical leave legislation sends such a mixed signal to many Americans. The bill may have been flawed in the administration's view by inviting too large a government role in private industry. But the lack of action reinforces the perception that the gap is getting wider between the rhetoric in Washington about helping families and the real needs of those trying to cope with the changes in this transitional age.