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Perfect Ending

An extraordinarily passionate doctor's career-long struggle with the issue of death and dying.

By Nathanael Johnson

Thursday, June 05, 2008

* For obvious reasons we are not using the doctor's real name. The Dr. Francis pseudonym is a reference to Francis Bacon, who observed that physicians who are experts in a disease but unfamiliar with the patient may "cure the disease and kill the patient."

The first time Dr. Francis killed it was easy. It's often said that for a soldier, the first kill is the hardest. Then it gets easier, until you don't even see a human at the end of your barrel: The optic nerve hands the image of an attacker directly to trigger finger, bypassing the portion of the brain that considers pros and cons. But Francis was a doctor, not a soldier. And for him, it was just the opposite: The first few times it seemed so simple. The patients were comatose and dying anyway. He just turned up the morphine drip and sped them along. Then the postmaster came along, and mercy killing got complicated.

The post office she ran in that little town was no more than a trailer on the side of the road, lined with fake wood paneling and a few rows of brass boxes. She kept an electric heater by her desk. Every day she would wheel her oxygen tank out to her Oldsmobile, lower herself into the seat and drive to work. It was only a few hundred yards, but she was too short of breath to walk that distance anymore.

Dr. Francis knew all this when he stopped in to check the mail that day. They were all neighbors in that town, and it was hard not to know each other's business. He waved hello, took the letters from his box, and asked if she had anything else for him.

"Actually," he remembers her saying in her smoker's voice, "There is something."

She was dying, she explained. It was getting harder and harder to breathe. Her emphysema was only getting worse. And the lung cancer, well, the cancer had won. There would be no more chemotherapy. Her doctors had told her there was nothing else they could do for her. With the doctors gone, that left her alone. As she saw it, there was only one more thing she could do about her labored breathing. That's why she was asking Dr. Francis if he would get her enough barbiturates to put her gently to sleep and stop the wheezing permanently.

Looking back years later, Dr. Francis shrugs. "I thought her request was reasonable. She was saying, ‘Hey I can't take it now, and it's going to get worse. Let me get out of here.' And it—it just seemed intellectually reasonable. And, I think, emotionally reasonable." Then he stops, struck by the strangeness of the moment in retrospect: "Funny that that conversation would happen in a post office."

Post office transactions are constrained to the most trivial of exchanges. A few cents for a stamp. A few words about the weather. The color of the curb outside limits the length of conversations. Yet there they were, making arrangements to determine the question of existence for this woman. A week or so later he gave her the pills.

Although she was circumspect, word got around. Before long, others approached Dr. Francis, and he gave them what they wanted. The way things were going, he could have become an undercover Jack Kevorkian—helping people die without the media spectacle. But Dr. Francis bristles when I compare him to the doctor who has assisted in at least 45 deaths. "He's a pervert," Dr. Francis protests. "He's insane. No, I was just interested in helping this woman end her suffering. If I could have found another way to end it without ..." he pauses, then settles on the bluntest way of putting it, "without killing her, I would have."

Kevorkian is a polarizing figure. Many in the Death with Dignity movement regard him as a hero, while those who believe in the inalienable sanctity of life see him as a monster. Dr. Francis has far more in common with the former group than the latter; he believes in personal liberties and likes to poke fun at religious dogma. But on this issue, Dr. Francis has a weight of experience that keeps him from being polarized.

The doctor's hair and beard are white these days and neatly cropped. He wears rimless glasses which magnify his eyes, giving him a vaguely owlish look. We sit in his living room, holding cups of herbal tea. It has grown dark in the room as the light fades outside. He chuckles. "If I was somewhat [like] Kevorkian, it was in my ignorance."

It came as no surprise to him when he heard the postmaster died—but the way she died was surprising. She never took the pills. Intrigued, Dr. Francis inquired after the other people to whom he'd prescribed barbiturates. Not a single one had hastened their death.

And so began a small mystery: What had made every single one of these people choose the long decline they had once so desperately wanted to avoid? What had changed to make the end of their lives more fulfilling? Another doctor might have puzzled over this a while, then shrugged it off. But for Dr. Francis, this mystery took on a special significance. At that point in his life he had begun to question his role as a physician and was looking for lessons.

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