The Debate Over Death : Euthanasia Issue Divides Physicians

Lunching at a desert resort, Dr. George Lundberg doesn’t look like someone who would provoke a national debate over whether a doctor’s killing of a dying cancer patient is an isolated episode or something that, as he said quietly, could occur “in almost any hospital, in almost any community, in the United States.”

Lundberg, a bearded medical journal editor and former California pathologist given to quoting Bob Dylan and the Rolling Stones in his lectures on the science of disease, has done just that. In the process, he has begun to motivate doctors to talk openly about whether death pleas from terminal patients should be heeded and whether doctors may already be complying with such wishes.

Active euthanasia, or the intentional killing of a patient, is considered murder in every state, though the legal system has long tolerated so-called passive euthanasia, which can involve switching off machines and administering drug doses that straddle the fine line between pain relief and overdose.

Protecting Doctor’s Identity

Lundberg himself faces a tentative March 18 Chicago court date in which he stands a slight but real chance of having to go to jail to protect the identity of the physician whose anonymous essay recounting a mercy killing episode was published in the Journal of the American Medical Assn., the magazine he edits. The county prosecutor in Chicago has demanded Lundberg provide details about the essay to a grand jury, a move Lundberg and the AMA are resisting under provisions of an Illinois law that permits reporters to keep their sources confidential.

Against this perhaps unlikely backdrop, the debate among doctors over active mercy killing has evolved into a discussion about such issues as the comparative risks of being caught if a lethal dose of narcotics is carried from the doctor’s office into the hospital in a coat pocket. Drug enforcement agencies, doctors say, are far less attentive to the security and record-keeping of office supplies than hospital pharmacies.

The doctors are reluctant to speculate about the precise frequency of euthanasia episodes. Yet the conversations are occuring increasingly, even in settings such as last week’s annual convention of the California Medical Assn.

Sitting at the end of a conference table of an opulent meeting room at a Reno, Nev., hotel casino, Dr. Laurens White, president of the CMA, and Dr. Richard Corlin, a member of the board of trustees of the Los Angeles County Medical Assn., compared notes on what they both said was a wrenching issue, even for prominent doctors accustomed to speaking out in public.

“I have once been asked to do something active,” recalled Corlin, a Santa Monica gastroenterologist. “A woman with a (severe) stroke, who had been cared for at home for 18 months. It destroyed the whole rest of the family. She was also a close friend.

“The one son who was the most functional (member of the remaining family) pleaded with me. I went over there and, I have to be honest with you, I was seriously considering it. Fortunately, she died that night on her own.”

Lundberg and Corlin both emphasized that the AMA and the CMA have long adamantly opposed the formal legalization of euthanasia. But that, Corlin said, is probably too rigid a position for the practical reality. “I think a tough, rigid, ‘no’ position is not the proper position,” he said. “I think we have to be in a soft ‘no.’ The problem is: Where do you stop?”

Today’s means of ending a life are far more sophisticated than administering a narcotics overdose. Physicians grappling with such issues also discuss techniques like injecting 20 or 30 milligrams of potassium into the blood stream to stop the heart, an overdose that, according to White and Corlin, usually will not be detected.

After all, the physicians noted, it is a combination of potassium, the muscle relaxant Pavulon and the narcotic Demerol that is at the heart of formulas for death by injection in several capital punishment states.

If the patient in question is already receiving large doses of narcotic pain killers, they added, a doctor complying with a death wish could switch to a tranquilizer like Versed--a lesser-known chemical cousin of Valium.

But to discuss such things in realistic detail, many doctors say, is to venture into what might almost be called a twilight zone of medicine.

In this case, it is a place that does exist, according to Lundberg, and doctors and the health care system must be forced to openly come to grips with it.

“I suspect this kind of thing is done,” said White, a San Francisco tumor specialist. “I doubt it is done very often. My own problem is I can’t be the executioner myself. I can’t do it emotionally.”

The essay that forced the issue into the open, a four-paragraph alleged recounting of the death of a 20-year-old terminal ovarian cancer patient, published in the Jan. 8 issue of Lundberg’s medical journal, has been widely attacked for its credibility, both because it describes medical techniques such as the use of intravenous alcohol to relieve pain and induce sleep that have not been widely relied on in the United States in more than a decade, and because its account of the fatal shot of morphine involves a dose that probably wouldn’t have been fatal.

Questions have also been raised about whether the way the doctor resident got the 20 milligrams of morphine--by simply demanding it from a nurse who meekly complied--could possibly have occurred without creation of written records that would have detected the killing.

It was published, moreover, in the context of the beginnings of the public debate in California over a proposed ballot initiative that would legalize “physician-assisted suicide” statewide. The pro-euthanasia Hemlock Society recently released results of a survey of doctors in which 79 California physicians claimed they had actively euthanatized patients--29 of them on more than three occasions.

Lundberg said he believes the article describes at least the rough details of an event that occurred sometime, somewhere. But, he contended, the essay’s true importance is not in its factual fastidiousness but as a tool to fuel discussion.

Slim Chance of Autopsy

“The review of deaths in hospitals in America today, not just in the past,” Lundberg said, “is inconsistent. A person dying in a hospital in the United States today has an 85% chance of not having an autopsy. A person dying in a nursing home has far over a 90% chance. Maybe over a 98% chance. Maybe even a 100% chance.

“So, you tell me what would have happened to an investigation of a terminal cancer patient’s death in the middle of the night. I will tell you I think this kind of thing could happen in almost any hospital, in almost any community, in the United States.”

Lundberg, White and Corlin agree that any notion of how common active euthanasia is--as opposed to the belief that the practice is carried out by American doctors and is easier to conceal than most people think--is entirely speculative because a doctor who admitted to the practice could face murder charges.

“I don’t have any way to know how common this really is,” Lundberg said.

Dr. C. John Tupper, former dean of the medical school at UC Davis and a member of the AMA’s board of trustees, remembered a telephone call he made to the chairperson of the pathology department at USC one day in the 1970s. He was calling to get a reference for George Lundberg, who was a candidate for chairman of the pathology unit at Davis.

It was several years before Lundberg’s elevation, in 1982, to the position of editor of the AMA’s flagship journal and director of the association’s internationally acclaimed scientific publication division. Ironically, former colleagues in Los Angeles recalled, Lundberg had established himself as one of the nation’s top experts in the toxic effects of street drugs and the phenomenon of overdose death.

Lundberg got the Davis job, Tupper recalled with a chuckle, after Lundberg’s boss at USC thought about the questions Tupper asked, paused for a moment and then told him: “ ‘I really don’t know how I could run this department without him. He is an absolutely fantastic, productive person with absolute intellectual honesty. He’s a fantastic man and I thank God I don’t have two of him.’ ”

Tupper hastened to explain the oxymoron. “What she meant,” Tupper said, “was that Dr. Lundberg sets extremely high standards for himself but he expects everybody else to live up to those same high standards.”

Background in Pathology

Lundberg, who turns 55 on March 21, was born in Pensacola, Fla., and went to the Medical College of Alabama, graduating in 1957. He is married and has five grown children and three grandchildren. Before taking the AMA’s top scientific publication job, Lundberg spent his entire medical career in pathology--the scientific study of the process of disease and the laboratory means to evaluate illness.

From 1967 to 1970, Lundberg was on the USC faculty. He chaired the pathology department at UC Davis from 1977 to 1982. He still teaches as a visiting professor at Rush Medical College in Chicago and Georgetown University in Washington.

Another former colleague, UCLA’s Dr. J. T. Ungerleider, agreed with Tupper’s reading of Lundberg, with whom Ungerleider collaborated on several politically controversial medical journal studies that successfully questioned the effectiveness of federal government drug abuse information-gathering systems established by former President Richard Nixon in the 1970s.

Lundberg, said Ungerleider, “is (the last of) that vanishing breed of very ethical people who won’t sell out. They won’t give up what they believe in.”

In that context, Ungerleider and Tupper agreed, the prospect that Lundberg may go to jail to protect the identity of the author of the euthanasia essay is not surprising. Lundberg himself is reluctant to divulge the AMA’s precise legal strategy or to say whether he considers a jail term a realistic possibility.

While the state’s attorney’s office has declined to comment on the case officially, AMA lawyers say the source-protection case may drag on for several weeks before Lundberg faces a judge who may order him to identify the author.

Journalists Back Lundberg

Within the last two weeks, the Chicago Headline Club--the local chapter of the Society of Professional Journalists--has filed a friend-of-the-court brief holding that Lundberg falls under the protection of the Illinois Reporter’s Privilege Act, the state shield law that allows journalists to resist court orders to identify their sources. Two other media groups--the Washington-based Media Institute and Reporters Committee for Freedom of the Press--said they intend to also file briefs. Media attorneys generally believe the AMA will prevail.

Lundberg will say little about the precise extent to which the subpoena and the possibility of a jail sentence were anticipated by the AMA before “It’s Over, Debbie” was published.

Separate Conferences

The essay, he said, was sent to outside reviewers twice and became the subject of three separate in-house editorial conferences as the journal’s top editors grappled with what he conceded was a division of opinion about whether it ought to be published. In the end, without taking a vote, Lundberg said he made the decision to run the essay.

“I think all the questions that have come up since the publication came up in our consideration,” he recalled. “The only things I’ve been surprised by is the length and vehemence of the discussion about the publishing decision and the misunderstanding, or deliberate misrepresentation, that if something appears (in the journal) as an essay, it somehow is automatically AMA policy. That is patently absurd.

“We knew what exposure this might cause . . . since the author (describes) performing what many would think of as a confession to having deliberately euthanatized a patient,” Lundberg said. “We expect criticism from all sorts of people and then there is the question whether this would be an appropriate vehicle for launching or accelerating the debate on mercy killing, which was already going on.

“I expect a serious debate to last a long time and that the way in which life and death are now handled in the modern world, where there are 3.5 billion people, will be quite different from the way it was handled when Hippocrates was alive.”

To Dr. Michael Baden, an internationally known overdose expert and director of forensic science for the New York State Police and the state’s criminal justice division, the controversy over “It’s Over, Debbie” underscores the existence of what he calls an “easy” reality in medicine--the ease with which patients can be put to death by doctors who escape, undetected.

Baden, who as a former medical examiner in New York City and Suffolk County, N.Y., has been deeply involved in controversies over overdose and the role of physicians in taking life, said Lundberg’s decision to publish the essay in the first place brings into the limelight something that has long existed in the shadows of medicine.

“When you’re dealing with a situation where a person is terminal for other causes and dies, not many are going to be investigated,” Baden said. “Everybody who dies in a hospital is given injections. A concern we have in general with euthanasia is the ability to give injections in a hospital for sinister or allegedly humanitarian reasons is very great and (the chances are) very great that it will go undetected.”

Autopsy Unlikely

The situation is made even murkier, Baden said, by the structure of medical practice. For a terminal cancer patient to undergo an autopsy or intensive, skeptical review, Baden contended, the treating doctor would probably have to initiate the review--a situation unlikely to occur if the doctor had complied with a death wish or decided to end the patient’s life unilaterally.

Too, he said, some hospital legal departments may wish to limit the scope of death review because records of an autopsy, once they come into existence, may be brought out in subsequent malpractice suits. “The hospital is put in conflict of interest,” Baden said. “They’re more interested in the well-being of the hospital than necessarily in getting a conviction.

“It would be very hard to find out how often these things occur. They tend not to be discovered and they tend not to be made public.”

The CMA’s White disagrees about the effectiveness of hospital death review, calling it far more effective in many institutions than Baden believes, but he agrees that social evolution and changing times are pushing the question farther than it has ever before been pushed.

“You have a situation where (the euthanasia advocate) is asking doctors to do what he is not willing to do and get him off the hook,” White said. “ ‘Instead of me killing my dying wife, you kill my dying wife and help me feel better.’ I don’t like that. I understand it. I sympathize with it.

“It’s not a paradigm of it’s this or it’s that. It’s a question of are you going to do this with a pistol or with a nice quiet, genteel injection? If you do it with one and not the other, you haven’t resolved the issue.

“The question is: Are you ready to do it? BAM!”