AMA Journal Death Essay Triggers Flood of Controversy

An anonymous first-person essay in a medical journal in which a doctor describes killing a dying cancer patient with a shot of morphine has touched off a growing controversy over questions of medical ethics and freedom of the press, a controversy complicated by doubt about whether the episode ever occurred.

The unusual situation first took shape in early January when the Journal of the American Medical Assn. published the four-paragraph essay under the headline, “It’s Over, Debbie.”

In it, the unidentified doctor ostensibly in the third year of a residency in obstetrics and gynecology recounts a middle-of-the-night episode in which he or she rushed to the hospital room of a young woman dying of ovarian cancer and ended her life after she said, “Let’s get this over with.”

While the essay has triggered another round in the international debate over euthanasia--the AMA now faces a subpoena from a Chicago prosecutor demanding the name of the physician author--even more basic questions have arisen about whether the essay is to be believed and why it was published.

Kirk Johnson, general counsel at the AMA’s Chicago headquarters, said Thursday that even the journal’s editors were uncertain whether the article was based on fact or fiction. He acknowledged, however, that the journal knew the author’s identity, had communicated with him or her before the essay appeared and had confirmed that it was a specific physician.

Johnson and other top AMA officials have repeatedly emphasized that the association continues to vigorously oppose legalization of euthanasia and that the article--true or untrue--was published to stimulate discussion.

Fact or Fiction?

Dr. George Lundberg, the journal’s editor, decided to publish the essay even though “there are differing opinions about whether or not it is a piece of fiction, whether it has some basis in fact and has some fiction or is completely factual,” Johnson said. Lundberg, who had previously defended his decision to publish the essay, was instructed to stop commenting publicly on the controversy, Johnson said, after the subpoena was served on the AMA Tuesday.

In a prepared statement, the AMA said it “strongly condemns the conduct described in the essay. Indeed our ethical opinions specifically state that a physician should not intentionally cause death.”

However, experts ranging from the national head of the Hemlock Society, the Santa Monica-based organization that advocates the right to strictly regulated euthanasia, to Alexander Capron, a USC medical ethicist who was executive director of a presidential commission on moral issues in care of the dying, question whether the essay may have been bogus, planted in the journal by advocates or opponents of euthanasia to sway public opinion. Their doubts focus on questions of hospital procedure described in the essay and on whether the amount of narcotic used could have been fatal.

The controversy has taken on further significance in the unrelated field of press law with the subpoena served by Richard M. Daley, the Cook County prosecutor who is the son of the late mayor Richard J. Daley. Johnson said the AMA will demand a formal court hearing on the subpoena early next week in which the association will argue that an Illinois state statute that allows reporters to keep their information sources secret also permits the AMA to refuse to identify the essay’s author.

Lawyers nationally prominent in press freedom and source-protection issues agreed Thursday that the AMA is in a strong position. “While the case is exceptional in its drama,” said James C. Goodale, a New York-based press law expert, “it is unexceptional in the principle that it raises. It really isn’t any different than a garden variety source-protection case.”

Floyd Abrams, another New York press law expert, noted that the first major American press freedom case ever litigated--over the right of John Peter Zenger, a New York printer, to publish a journal in the 1730s--dealt indirectly with the right of a publisher to keep secret the identities of authors. “The purpose (of the right of source confidentiality) is to allow editors and reporters to keep their promises,” Abrams said. “I think the AMA journal is entitled to protection.”

Unquestionably, the essay made a dramatic point almost immediately after its initial Jan. 8 publication. “The call came in the middle of the night,” the essay began, relating how the doctor was roused from a sound sleep by a nurse to attend to “a 20-year-old girl named Debbie (who) was dying of ovarian cancer.”

In a room on unit 3-North, the account continues, the doctor finds Debbie--in great pain and struggling to breathe--pitifully wasted in her bed, an 80-pound terminal victim dying an agonizing death. A woman friend allegedly stood next to Debbie, “holding her hand.” “It was a gallows scene,” the essay continues, “a cruel mockery of her youth and unfulfilled potential.

“Her only words to me were, ‘Let’s get this over with.’ ”

Waited for Her to Die

After leaving the room and walking to a nearby nurses’ station, the doctor recalls, he or she asked a nurse for a syringe containing 20 milligrams of morphine. Syringe in hand, the doctor returned to the room, injected the morphine into Debbie’s body intravenously and waited for her to die.

“With clocklike certainty, within four minutes the breathing rate slowed even more, then became irregular, then ceased,” the doctor wrote. The essay ended with the poignant conclusion: “It’s over, Debbie.”

No sooner had the journal been received in physicians’ offices, however, than questions began to be raised about whether such a patient execution could have occurred in the way it was described. Simultaneously, euthanasia opponents demanded that the physician be publicly identified so he or she could be prosecuted. New York Mayor Edward Koch first called on Atty. Gen. Edwin Meese III to investigate, then wrote to Daley demanding a local prosecution. Right-to-life organizations quickly joined the battle.

Thursday, Koch’s office released a statement by the mayor contending that the medical journal essay is “a confession.”

“If the Illinois shield law (extends protection to the AMA journal), they ought to change that law. I do believe in protecting the press to protect its informants. This is not a case of an informant. This is a case of a confessed murderer.”

Koch said he was not opposed to euthanasia but that he felt the circumstances described in the essay departed so significantly from standards proposed even by euthanasia advocates that the case had assumed an entirely different character.

Truth as an Absolute Defense

Taking account of the questions about the veracity of the essay, Koch also noted that the Zenger case, decided in 1735, focused primarily on establishing truth as an absolute defense in libel cases. Koch’s office said he had sent a letter Thursday to Dr. James Sammons, the AMA’s executive vice president, saying “I believe a trial (in the AMA’s attempt to quash the Illinois subpoena) is vital to air this matter of vital public concern. A murder may well have been committed.”

Experts on drug overdose reactions and hospital procedure, however, focused with increasing skepticism on two key elements of the essay. For one thing, a still-growing number of observers has questioned whether the physician could have obtained the morphine from the nurse without generating potentially incriminating written records that would almost certainly have led to detection of the killing within hours.

“It seems unlikely that narcotics would be that readily available,” said Mary Babich, a spokeswoman for the American Hospital Assn., where, she said, a variety of hospital-procedure experts had reviewed the essay and doubted its veracity. “People here said they don’t believe it. That drug would have to be listed someplace. That much of a narcotic can’t just disappear. Somewhere down the line, it would have been noticed.”

A Los Angeles expert on emergency medical care and ways its procedures can be abused, interviewed on the condition he would not be identified, agreed. He characterized the scenario depicted in the essay as “impossible.” “It would be found on the next nursing shift,” he said. “The nurse who gave him the syringe would record it. The nurse would have put a note into the (patient record.)”

Still other experts questioned whether the 20-milligram dose of morphine could have been lethal, even in a badly deteriorated cancer patient. David Friedman, acting deputy director of the federal government’s National Institute on Drug Abuse, said the amount of morphine in question seems “on the low side,” though he said it was not possible to determine the cause of death in a patient as vaguely described as the young woman in the essay.

Friedman also cast doubt on the speed with which the morphine took the young woman’s life, noting that the dose in question is only slightly greater than what doctors universally consider to be a normal therapeutic amount for pain relief. He said morphine-related respiratory arrest deaths generally do not occur as quickly as within a matter of minutes.

‘The Best Bet’

“This may be a story in that it’s a plant . . . that it’s apocryphal,” Friedman said. “The issue that it’s dealing with is very important, very current. If (whoever wrote it) decided to make it up, they did it to make a point. I think that’s the best bet.”

“I think it (would be) possible that this happened except that the 20-milligram dose doesn’t sound high enough,” said Gene Haislit, Washington-based deputy administrator of the U.S. Drug Enforcement Administration, the police agency that also monitors hospital narcotics practices nationwide.

Some physicians, however, said it was conceivable that the dose in question could have killed--but only under circumstances so narrowly defined and comparatively unusual that it could not be determined from the essay whether death could have been possible in Debbie’s case.

The pervasive skepticism even colored the perception of Capron, the USC ethicist, who said he was so suspicious of the circumstances under which the morphine was obtained and the amount given to the patient that he had difficulty going beyond those doubts to a serious consideration of the ethical issues involved.

“If I were convinced this was a real (situation)--and for clinical reasons I’m not--then I guess I would believe that there would be grounds for prosecution for inappropriate behavior by a physician, potentially a homicide,” Capron said. “There are two things that are very regrettable and should be criticized (in the essay). The first is the condition of the patient. Why is a patient in such a situation that she has to call out in the middle of the night to get a doctor to come see her? This contributes to my skepticism.

“But what I think the letter should stand for, instead, is a realization that this is a concern not (because the essay is factual) but because physicians generally recognize there is a distinction between a dose of morphine aimed at relieving pain and a quote overdose of morphine to kill. There’s a lot of trouble around that issue.

“Even if it were apocryphal, I think we ought to take the occasion of this letter to talk about these issues.”

But the specifics of the case make Capron so suspicious, he said, that other more nefarious questions inevitably arise. “It (the essay) could be a piece of propaganda from either side (of the public policy debate over euthanasia),” Capron said. “Someone had a reason to write it. It didn’t write itself.

A Piece of Propaganda?

“It could be a piece of anti-euthanasia propaganda: ‘Look what happens when you give doctors these powers. They abuse it and take any request for pain relieve for a request to be killed.’ ” But Capron said the opposite could also be true, with the essay intended to focus attention on a dramatized and fictionalized case in which a horribly suffering patient was granted a legitimate wish to avoid further agony.

The circumstances of the killing--in which, specifically, the doctor made the decision to take the patient’s life alone, without consulting other doctors and without pursuing the matter with the patient or her family--conflict with euthanasia standards proposed by even the practice’s advocates.

A controversial California ballot initiative that would legalize physician-assisted suicide here, for instance, would specifically require that two doctors agree the patient should be helped to die, that the patient execute a written authorization when he or she was certifiably rational and that such decisions could not be made precipitously.

A Clear Violation

Derek Humphry, director of the Hemlock Society, noted that the case as described in the medical journal would clearly violate even legalized standards for euthanasia in California if the initiative was approved. The initiative, which has not yet qualified for the November ballot, is vehemently opposed by Capron, the California Medical Assn., the AMA and other individuals and organizations. Humphry noted that in the Netherlands, where euthanasia is legally tolerated by not formally legalized, the Debbie case would have attracted the attention of prosecutors because the doctor hadn’t known the patient long enough to participate in euthanasia.

Humphry, who took a leadership role in the euthanasia movement because of his own wife’s suffering before her death, said he found the circumstances of the killing of Debbie puzzling.

“ ‘Let’s get this over with.’ What does that mean? It’s not a request for death in clear terms,” Humphry said. “That’s a terrible way to die.”