By a Doctor’s Hand : The baby was dying. Dr. Eva Carrizales says she only tried to ease the parents’ pain, but a grand jury calls her actions murder, forcing an anguished community to re-examine the way it treats life and death.

In retrospect, Clayton County Medical Examiner Joe Burton says now, they should have recognized the first call from Southern Regional Medical Center as a red flag.

Hospitals, after all, normally don’t contact the medical examiner when a fragile, terminally ill 39-day-old baby dies. In neonatology units, medical staffs regularly walk fine lines, judging whether and when to give up on such doomed, premature infants, but theirs is a tortuous ethical exercise practiced largely in private, shared only with the infants’ families. It is not the custom of medical staffs to invite county authorities to second-guess them. Yet that was precisely what nurses at Southern Regional appeared to be doing.

The first call, at 11:17 on Saturday morning, Oct. 16, went to Clayton County Coroner Abb Dickson. He relayed it to the forensic pathologists in Joe Burton’s office. Whatever nurse Gwen Pierce told Burton’s staffers, it didn’t arouse their concerns. Under Georgia law, if a death can reasonably be explained by natural causes, it’s not for the medical examiner. Investigator Don Wiegand declined jurisdiction.

The hospital persisted, though. At 5:45 p.m. that same day, Nancy Goodrum, Southern Regional’s vice president for patient services, called the coroner again. This time the hospital put the matter more explicitly.

Several nurses in the neonatal care unit, Goodrum reported, believed that Dr. Eva Carrizales, the attending neonatologist, had “hastened” a baby’s death. The baby, who had never left the neo intensive-care unit, was undeniably terminal. But at least two nurses, and possibly a third, said they’d seen Carrizales “holding the baby’s mouth shut.”

Finally, the medical examiner’s office spotted the red flag.

Whether the report was true or not, he had to investigate this case, Burton realized. What did they have here?

What they had, Burton in time would reluctantly conclude, was a caring, compassionate doctor so affected by her patients’ suffering that she’d crossed a forbidden line. What they had, Burton ruled on Nov. 4, was a homicide.

“ ‘Homicide’ is a term that medical examiners use in order to classify a death,” an obviously troubled and ambivalent Burton cautioned in his written report. “It does not imply that there was ‘murder.’ ”

Yes it does, a Clayton County grand jury decided six days later. Indicting Carrizales on a murder charge, the grand jurors concluded that the doctor “with malice aforethought did cause the death of Omar Jiminez . . . by asphyxia due to smothering and neck compression.”

The murder indictment of Carrizales has fueled an anguished uproar in this suburban region south of Atlanta. The medical examiner has cried over his decision; the district attorney has prayed. Carrizales has resigned her medical posts, and doctors of all sorts have flinched, thinking of the difficult, ambiguous situations they face daily. Carrizales’ supporters--among them parents of her tiny patients, fellow church congregants, colleagues and neighbors--have marched in rallies, organized fund-raising campaigns, called television stations, written letters to the editor. In statements to police detectives, communications through her lawyers and--before turning silent--interviews with journalists, Carrizales herself has insisted she didn’t cause the baby’s death.

Statements, medical nuances, hidden agendas--all have been the subject of agitated speculation. So, too, have matters beyond the immediate particulars of Carrizales’ case. How we let people die--that’s what this is all about, some of Carrizales’ supporters eventually began to suggest. Isn’t a dignified, peaceful death better than prolonged, gasping agony?

In the end, the hospital chief who turned her in, the medical examiner who judged her and the prosecutor who charged her all sound as reluctant to punish Carrizales as do her supporters. But punish her they very well might, for her murder trial looms, and no one feels able to back down.

“I don’t have a choice,” says Robert Keller, the Clayton County district attorney. “I would seek another charge if the facts allowed. But the facts don’t allow.”

TWO HOURS AFTER OMAR JIMINEZ’S DEATH, THE PHONE RANG IN THE home of Southern Regional executive Nancy Goodrum. There’s a problem here at the hospital, nurse Linda Emerson began. A problem with a baby’s death.

The baby, born by emergency C-section at 27 weeks gestation, weighing under two pounds, had been severely ill with lung and kidney problems. For days, the baby had been judged pre-terminal. But he had kept hanging on.

According to the nurses who were there, Emerson said, sometime early that morning the doctor turned down the ventilator, then later--apparently without the usual consultation with other doctors or explicit agreement of the family--took the baby off the ventilator and all support lines. But the baby wouldn’t stop breathing; for more than an hour, he kept gasping.

In that hour, the nurses believe they saw Carrizales put her hand over the baby’s mouth and squeeze the carotid arteries in his neck. The doctor even told them what she was doing, the nurses claimed. She said she was shutting off the blood flow to the baby’s brain. The nurses were very upset, Emerson said. They’d already placed a standard call to the coroner, reporting a child’s death. But they thought more should be done.

After digesting this report, Goodrum left messages at the hospital’s law firm, then drove to the hospital to review the baby’s chart. By early afternoon, she and a hospital attorney were speaking on a conference call with Dr. Donald Lackey, the hospital’s vice president for medical affairs. Lackey should call Carrizales, the lawyer advised, and point blank ask her three questions: Did she turn the ventilator down? Did she hold the baby’s mouth closed? Did she cut off the blood flow through the baby’s carotids?

It was a task Lackey approached with considerable dread. A doctor he knew and cared about might be in trouble, he realized. So might the hospital, and no hospital needs negative publicity.

Lackey hoped to hear a different perspective on this story from Carrizales--an explanation and a denial. Lackey admired Carrizales. Because his own specialty was newborns, the two occasionally chatted over coffee about the state of the art in their field. The 41-year-old mother of four had been at Southern Regional three years, and he thought her a nice, sensitive person with a good reputation as a doctor.

Those more familiar with Carrizales held even stronger feelings of admiration.

She’d come out of Mission, Tex., with her high school sweetheart, Enrique, she a Mission High cheerleader, he the football team’s wide receiver. Mexican Americans from poor families, they’d married young; she worked while he earned his architectural degree, then she, in 1982, earned her medical degree at what is now the University of North Texas Health Science Center in Ft. Worth. After completing a pediatric residency in Texas and, in 1990, a neonatology fellowship in Michigan, she’d joined a small practice that provided neonatal services to three Atlanta-area hospitals, including Southern Regional. She’d just taken her boards and was about to become certified.

Their two older daughters were attending the University of Texas, and their two younger children were still at home. Religious faith formed a central pillar of the Carrizales family’s life. Every Sunday morning, between the regular services at North Fayette United Methodist Church, Eva and her husband attended a church discussion group on how to apply their faith to daily life. “I have to pray every hour to be good,” she’d tell other church members. “If I can’t hold on to God, I’d lose it.”

She was, by most accounts, a compassionate doctor who loved babies. Appreciative mothers would call her at home, and later, when their babies had grown, drop by to show off how they were doing. Carrizales kept photos of her patients and their families on her refrigerator door. In fact, on the Saturday afternoon when Lackey called her, one of those photos pictured Omar Jiminez’s family--Omar Jiminez, who’d died in her arms just hours before.

The lawyers had told Lackey he needed to hurry, to get an answer quickly, so he steeled himself. “I need to ask you some questions,” he began. “I need to get some answers, then I need to get off the phone.”

To his hospital colleagues, to the police in oral statements and a signed letter, to the grand jury and to a journalist, Lackey’s account of what followed has not varied. Carrizales, he says, “basically affirmed all three points.” Yes, she had turned down the ventilator. Yes, she had held the baby’s mouth closed, out of sensitivity to the parents because his features were so distorted by gross swelling. Yes, she had placed her hand on the baby’s neck to limit the blood supply to the brain.

Listening to her, Lackey’s heart sank. This was not what he’d wanted to hear. It seemed to him she didn’t really understand the seriousness of the situation. He sensed she didn’t see anything wrong.

Over the next 24 hours, Lackey would call Carrizales back five times. He would advise her to get a lawyer, and he would refer her to one. He would also, at least as Carrizales recalls it, say, “You should have lied to me.”

At this moment, though, Lackey had no time for advice or comfort. “I told her I had to get off the phone,” he explained. “I said I would call her back.”

As both doctor and administrator, Lackey felt torn in several directions. He had good reason. Decisions to take infants off respirators because they are basically dead, because their systems are shutting down, are made almost daily in neonatal units across the country. But if it is a common business, it is also a tricky business, the subject of continual debate within the medical community.

Technology in recent years has enabled doctors to resuscitate ever smaller and more premature infants. As a result, it has also obliged doctors to withdraw treatment from a growing number of babies who eventually just can’t survive. Here is where the doctors risk trouble, since the criteria for judging when to give up remain uncertain, varying widely from hospital to hospital, doctor to doctor. The type of statistical certainty needed for more uniform guidelines just isn’t attainable.

The doctors, in other words, are always facing hard choices and the prospect of censure. More than a few neonatologists, discussing decisions they’ve made, privately say that beyond lawsuits, they fear losing their licenses--and even more. “What we constantly fear is being charged with murder,” one says.

Against this backdrop, the notion of handing Eva Carrizales to the legal authorities felt chilling indeed to Lackey. At the same time, though, Lackey understood why three nurses had come in tears to their supervisors. What they’d seen was not in synch with the norm.

Southern Regional has procedures to follow before withdrawing support. You don’t just take babies off ventilators and heart monitors on your own; you consult with two other doctors, who must see the patient and sign off. You also consult with the parents and document some sort of agreement, be it oral or written. Carrizales was insisting the prognosis and treatment had been explained to these parents, but at best this point remained unclear, for the parents, from Guadalajara, Mexico, were young, uneducated, bewildered, frightened. The mother had no immigration papers and neither spoke English.

Hospital procedures aside, it appeared, at least from the nurses’ statements, that Carrizales might have actively intervened to hasten a death. Doctors don’t knowingly do that--especially in front of other people, especially in a hospital neonatal intensive-care unit.

Lackey wondered--had stress caught up with Carrizales? He imagined her frustration over seeing another baby struggling slowly toward an inevitable death. The baby wasn’t ready to have physiology take over, the parents were present, and she lost it. Eva Carrizales was sensitive, caring, nice--what else could it be? In the end, he didn’t know what she was thinking. He only knew--or thought he knew--what she did.

In a series of conference calls that Saturday afternoon, the hospital administrators and lawyers considered their options. They could not, they soon decided, keep this to themselves. In 1989, they’d tried just that, to a disastrous end. A man who’d come into the emergency room, a stabbing victim, had died in surgery. The hospital administrator had actually hung up on reporters raising quality-of-care issues, generating a lot of bad publicity.

Many of the doctors wouldn’t like it; many would prefer review by peers rather than by cops and lawyers. But Lackey felt Nancy Goodrum had to call the coroner back. “Peer review wouldn’t come for days after,” Lackey explained later. “What were we going to do with the baby? Just hold it until then? Once Dr. Carrizales says yes, she did it, then we’re legally obligated to call the authorities.”

Just as Lackey expected, many doctors at Southern Regional vigorously objected. The nurses were confused, they argued, the nurses misunderstood the situation. “Where was due process, where was peer review?” demanded one doctor, pounding the table at a staff meeting the following week.

Two days after Goodrum contacted the coroner and medical examiner, Carrizales’ colleagues in fact did conduct a peer review. Focusing on the medical rather than legal dimension of Carrizales’ actions, they concluded that the care of this baby had not been “below standards.”

By then, however, it no longer mattered what a hospital peer review board thought about Eva Carrizales’ conduct. By then, Clayton County police detectives had spent the weekend at Southern Regional combing through files and interviewing nurses. By then, the death of a frail baby in a neonatal unit was a matter to be judged not in the medical community, but in a court of law--and in the court of public opinion.

An autopsy of baby Jiminez conducted a day after his death revealed just how ill the infant had been in his last hours. Among other ailments, he suffered from masses of inflamed and infected tissue in the brain, severe and late-stage broncho-pulmonary abnormalities, extensive fungal infection of the kidneys, liver congestion and spleen congestion.

What the autopsy did not reveal was any physical evidence of suffocation. There were no bruises on the neck or other proof that Carrizales had smothered the baby.

So Joe Burton, a 49-year-old forensic pathologist who provides medical-examiner services to five counties in the greater Atlanta area, turned to what evidence he did have. For days, he studied the police reports, medical reports and statements provided to investigators at the hospital. Drawing mainly from the nurses’ accounts, he pieced together something of a chronology.

The severely ill newborn, Burton saw, entered the Southern Regional neonatal intensive-care unit on Sept. 13. Within days, the baby developed a septic infection, then kidney problems. Doctors vainly tried to wean him off a respirator. At 1 month, his kidneys began failing, his heart rate soaring.

Through interpreters, the parents, Guadalupe Jiminez, 22, and Jesus Covarubias, 24, were made aware of their baby’s poor prognosis. Precisely what they were told, though, and how they responded, remained somewhat unclear. One early press report had the mother, through an interpreter, quoting the father as saying the baby’s death was inevitable, and that if the doctor did end the baby’s life, she was “doing them a favor.” A later press report had the mother telling an interpreter she felt “the doctor did something wrong” and the father declaring “she’s not God. . . . It’s not good because no one can do God’s job.”

All Burton finally could rely on were the parents’ statements to the police. Those statements indicated that neither parent knew “for sure” that the doctor was going to disconnect life support. No one, they said, directly discussed this with them, nor did they sign any documents. They did assume Carrizales knew what was best for their child, and they did know the baby was not expected to live.

On Oct. 15, the baby’s kidneys virtually stopped functioning. After midnight, his respiratory function began to deteriorate. By early morning, his blood gases showed high carbon dioxide and low oxygen levels.

It was “after the 4:30 a.m. time” on Oct. 16, Burton would later write, “that the complicated clinical scenario begins to develop with this infant.” That was when nurse Maritza Vias began pumping 100% oxygen to the baby through a face mask and notified Carrizales about the poor blood-gas readings. By then, nurses were using suction to clean large amounts of thick, white secretions from the baby and the ventilator tube.

According to Vias’ statement, when Carrizales entered the room minutes later, she ordered the nurse to stop the suctioning. Then, at 4:45 a.m., Carrizales ordered Versed, a narcotic sedative, be given intravenously. She also, according to Vias, turned down the ventilator pressure rate to a setting of 3.

Mulling over that ventilator setting and sedative, Burton couldn’t help but wonder whether Carrizales had in fact precipitated this baby’s decline. Some neonatologists, after all, would suggest that setting the ventilator to 3 and giving Versed was tantamount to saying, “You’re on your own, but this won’t hurt.”

The baby’s parents, Burton saw from the nurse’s notes, were called to the hospital shortly before 5 a.m. At 5:15, the mother said she wanted to hold her baby. Carrizales responded by disconnecting the ventilator as well as the various lines that deliver nutrients and monitor blood gases, then handed the baby to his mother as nurses again gave him oxygen through a mask.

Moments later, the baby’s heart rate plummeted; the alarm rang on the heart monitor. According to the nurses’ statements and notes, Carrizales turned off the monitor and ordered Epinephrine, a heart and nerve stimulant.

Eight to 10 minutes later, Carrizales took the baby from the mother and placed him in a radiant warmer as she directed the parents to the family room. For several minutes, she tried chest compressions. Then she stopped and told Vias to take away the oxygen mask.

Cradling the baby in her arms, Carrizales sat down in a wooden rocking chair in one corner of the neonatal intensive-care unit. The baby, according to the nurses, was gasping and still had an apparent heart rate. Carrizales rocked and cradled the baby, checking his heart rate every five or six minutes.

According to two nurses, Carrizales during this time “was holding the baby’s mouth closed.” According to Vias, Carrizales at one point said she was glad she was on duty and not her partner, because he would have kept the baby on the ventilator until Monday.

At 6:15, Carrizales gave the baby to Vias and went to talk to the parents. Detecting a breath and heart rate, Vias told Carrizales upon her return: “This baby is breathing.”

Carrizales took the baby back and--as Burton put it in his written report--”is alleged to have said something to the effect, ‘Don’t let the baby breathe.’ ”

Breathe he did, though; the minutes stretched on. At 6:45, when nurse Rebekah Martin replaced Vias, they noted that Carrizales was still cradling and rocking the gasping baby as she sat in the rocking chair. They saw no ventilators, no oxygen tubes, no monitors, no invasive support lines. “He still has a faint heart sound,” Carrizales murmured.

At 7:15, nurses again took the baby to the parents; they or the doctor apparently believed him dead. As the parents were holding him in a private family room, the baby apparently moved and gasped. Rosaura Martens, a family friend and translator, came running to the nurses, yelling, “The baby’s alive, it’s a miracle.” According to Martens, Carrizales responded by saying this was why she didn’t want the parents to hold the baby--”because they would think it would live.”

According to nurse Martin, Carrizales took the baby back and once more began cradling and rocking him, saying she was “holding the baby in such a way as to cut off the blood flow to the brain so that this won’t drag on. . . . The parents have been through enough, and this could last for days. . . .”

This comment, Martin told the police, so horrified and distressed her, she changed the subject. She could not, she told the police, actually see where the doctor’s hands were.

At 7:50, a priest came to be with the parents.

At 8, the baby was very “dusky,” with only a minimal heart rate and an occasional gasp.

At 8:10, he was still gasping occasionally, but had no audible heartbeat.

At 8:13, Carrizales pronounced Omar dead. She was at the end still cradling and rocking the tiny, doomed infant.

That, at least, was the sequence of events suggested by Burton’s reading of the nurses’ statements and notes. When Burton turned to Clayton County Police Detective Mark McGann’s interview with Carrizales, he found an alternative version.

McGann had reached the hospital at 9:30 that first night, some 13 hours after the baby’s death. First he’d heard a summary of the nurses’ accounts from a hospital administrator. Then, nearing midnight, Carrizales had passed word to him: If you want to talk to me, let’s do it now. She wanted to get home.

The doctor’s manner, McGann would later say, was flat and unemotional. She was direct, unguarded, sure of herself--and, in a way, utterly unsophisticated. McGann had read her the Miranda rights, but near the end of a one-hour interview, sitting in the presence of three police officers, she’d still asked, “Is this a police matter?”

McGann had been surprised that she was willing to talk, that she had actually initiated the interview. Other doctors in this situation would have seen danger, he felt. Other doctors would have said--whoa, need a lawyer. Instead, Carrizales had said, over and over: “This baby was terminal. . . . This baby was going to die.”

In his written report, Burton later summarized Detective McGann’s account of his interview with Carrizales:

“Dr. Carrizales states that the infant was dying and she did not institute a no-code order because she felt the infant was going to die on its own and would not have to require a withdrawal of life support. . . . Dr. Carrizales states that she was holding the mouth closed in order to keep the family from seeing the distorted features, that the baby was markedly swollen, oozing fluids, and she was doing it out of sensitivity to the parents. Her notes do also reflect that she placed her hand over both sides of the neck. She states that she did this in order to see if the heart was pumping blood up the carotids. She states that she may have made some statement to the nurses about something like this procedure could cut off the flow of blood to the brain but she states that there really wasn’t any flow to cut off at that time.

“Dr. Carrizales states further that many dying infants . . . have episodes in which their heart rate increases, decreases, and that they have spontaneous respiration and that this is primarily reflex and not consistent with the infant actually being alive. Such activity can go on for hours. She states that the heart rate that she was obtaining during the time she was rocking the infant was approximately five beats per minute and sometimes even slower. Dr. Carrizales admits that she did not follow hospital procedure in removing life support but states that this was the custom where she was trained in order to facilitate the sensitivity of a dying infant and his bonding with the family into the procedure more smoothly. Dr. Carrizales says that the infant had polycystic kidneys and was markedly bloated with fluid and had no chance to live.”

What to make of all this? Burton wondered when he’d finished reviewing the file.

The medical examiner couldn’t help but wonder whether any of the nurses held a grudge against Carrizales. There’s a high stress level in neonatal units, after all, with lots of emotions, lots of decisions, lots of medical ups and downs.

There are also lots of cases like this one, Burton believed; he just didn’t usually hear about them. Why this one?

One of the three nurses, according to the police report, had in fact complained about Carrizales once before. Nurse Terry Marin thought the doctor hadn’t properly consulted others before disconnecting the respirator to a very premature, hours-old newborn. So perhaps there was some ill feeling between them. Still, the nurses seemed to Burton genuinely upset with what they’d seen. They were shocked, particularly by the doctor’s comments. That’s what set this case apart. We couldn’t believe she was doing it, the nurses kept saying to McGann. We couldn’t believe she was telling us she was doing it.

Burton could see it both ways. Part of him sort of agreed with what he thought Carrizales had done. This baby, born 10 years ago, would not have lived at all. But part of him could not go along with it, especially the way she did it. Of course, it was not up to Burton to make value judgments. He had a role. His task was to determine how this baby died.

So he tried to look at the facts: This infant had multi-system organ problems, was septic, had kidney failure and significant pathology of the brain. It was almost certain that even with maintenance of life support, this infant would have died.

When, though?

Medical records and nurses’ statements suggested that once the ventilator had been turned down and later disconnected, and once fluids had been discontinued, the infant deteriorated markedly from his already critical condition. Had these measures been continued, it was virtually certain the infant still would have died. But removing them accelerated the process.

That was the issue for him, Burton felt: whether or not the infant died on its own or whether the death was facilitated by another. Carrizales insisted that for all practical purposes the infant was dead, so anything she may have done in no way affected the outcome. Burton saw it differently. To him, an infant with gasping respirations and a detectable heart rate can’t technically be declared dead, not unless you can show he had no brain waves.

It was obvious to Burton that Carrizales had shown humanitarian care, concern and love for this dying infant. Possibly it was because of her deep concern for the infant that she did her best to facilitate its death. Facilitate she had, though, Burton believed. To him, at least, the evidence clearly demonstrated that by holding the infant’s mouth closed and pressing the carotids, she had hastened the end of cerebral activity, even if that activity had been merely reflexive. She had, in essence, entered into the physiological happenings that resulted in this infant’s death.

On more than one night, Burton would later say, he lay awake over this case. He also conferred with the prosecutors, the police detectives, other doctors and half a dozen forensic investigators. One morning, when he and his colleagues staged their own mock grand jury, Burton was the only person who said he might not vote to indict her. But in the end, as he put it later, he decided “I had to speak for the truth.” If he was going to do his job honestly, he couldn’t back down. What would that mean for the next hard case? Where would it stop?

Yes, his judgment was based almost entirely on witnesses, not on hard medical evidence, not on anything from the autopsy. But bottom line, he just could not misbelieve so many witnesses.

“A homicide means that an action of another individual contributed to or caused the death of another,” he wrote in his report. “It does not imply that there was ‘murder.’ Murder is more of a legal term. I do not feel that we can classify this death as a natural death. . . . Had Dr. Carrizales not held the mouth shut, not held her hands in any way around the neck, and only had the infant off of life support, it is probable that death would have ensued, possibly within minutes of when it actually occurred. (But) I have no way of knowing for sure, nor does anyone else on this Earth have any way of knowing for sure exactly how long this infant may have continued to have gasping respirations and a slow or agonal (death agony) heartbeat. . . . In trying to be fair . . . I have no choice . . . other than to sign the case out as I have done. I have listed the cause of death as asphyxia, due to smothering and neck compression. . . .”

In the days following Joe Burton’s ruling, a small army of Carrizales’ shocked supporters rose to her defense. A dozen parents called the Atlanta Journal-Constitution within the first 24 hours alone to tell how she had saved their babies’ lives. Others marched in demonstrations outside Southern Regional, wrote letters to the editor, phoned the television stations. Members of Carrizales’ church organized a fund-raising campaign directed at the Georgia medical community.

A good number thought it important to document Carrizales’ record as a heroic and compassionate doctor. “The first month of our grandson’s life, we didn’t think he would live,” Judith Evans of Fayetteville wrote in a letter to the editor. “But Dr. Eva Carrizales gave him the same care and attention as the other babies. . . . When Thomas went home, Carrizales gave us her phone number and told us to call anytime we needed her. We need more doctors like Eva Carrizales.”

Others thought it relevant to ask why Carrizales had been singled out and turned in by her nurses and hospital. This whole thing began, they suggested, because of “personality conflicts” between Carrizales and the nurses. Carrizales was a “serious doctor” and “not gregarious.” In fact, she was “abrasive” and “assertive” and “distant” at times. She wasn’t “touchy-feely.” She didn’t ask nurses, she told nurses. She was not the nurses’ buddy. Men like that, her supporters observed, are called “aggressive”; women like that are called “bitches.”

“Usually a male doctor is in charge,” said Dr. Beth Killebrew, an obstetrician who belongs to Carrizales’ church. “That’s what this is about. A female doctor has to be different than a male. Women don’t like being bossed by another woman. She has to get nurses to be partners. She can’t just give orders.”

At least a few, among them members of the medical community in the greater Atlanta area, felt inclined to question the medical examiner’s methods and conclusions.

Burton was no stranger to such controversy. Well before the Carrizales case, he’d aroused animosity among other doctors. Part of the bad feeling derived from Burton’s perceived willingness to testify about what highly trained specialists should or should not do; part derived from his perceived willingness to “follow the money” and testify for the defense as well as the prosecution; part derived from the fact that Burton hadn’t passed all the exams required to be a board-certified forensic pathologist.

None of these matters, however, agitated the medical community as much as his report on Carrizales.

Burton’s conclusions are based on possibly unreliable witnesses’ statements, not hard scientific evidence, complained experts such as Kris Sperry, the deputy medical examiner in Fulton County (Atlanta). The autopsy yielded no evidence of suffocation, no bruises on the neck, nothing. Even if Carrizales had applied pressure to the carotid arteries, you couldn’t say for sure this had hastened death; babies’ brains were much more resilient to blood-flow interruptions than adults’. Nor could you make much of the gasps and lingering heartbeat; newborns, being very primitive organisms, have a propensity for involuntary brain-stem reflexes.

“It looks like, oh my God, the baby is trying to breathe,” Sperry said. “But no, it’s just muscles firing. I think Dr. Carrizales, because involuntary muscle reflex is so disturbing, wanted to hold the baby until it stopped, so she then could hand him to the mother still, without this twitching. This is not unreasonable. I’ve seen it myself, and it’s not pleasant to see. It can be devastating.”

Whatever the merits or flaws of these various arguments and objections, it eventually became clear that there was something else, as well, driving many of those who’d risen to defend Carrizales. The doctor’s indictment had aroused, in all sorts of people, certain instinctive and heartfelt attitudes toward death. Over and over, discussions here in Georgia about the Carrizales case have ended up focusing mainly on questions of how to let go of the dying.

“Eva is real big on dignity in dying, on holding and rocking rather than hooking to machines and reading gauges,” said Heidi Cornutt, a mother of four and a member of Carrizales’ church discussion group, when asked about the murder charge. “I didn’t realize she was a doctor when she told me how she’d held a dying baby. I thought she was a nurse, because I didn’t think of doctors doing that.”

“How we play out death is related to how we understand the idea of life,” said Cheryl Maxfield, the associate pastor at Carrizales’ church, who also wrote a letter to the Journal-Constitution’s editor. “An understanding of an afterlife, which for Eva is very real, means death is not a failure. . . . There are many debates raging about the proper way to deal with death in our culture and society. . . . What is really on trial here is a society and a theology trying to decide how we deal with the art of healing and the reality of death.”

One Saturday morning, 16 members of Carrizales’ Sunday discussion group gathered at their church to discuss these matters and the doctor’s situation. Eva Carrizales’ journey from an impoverished Texas background has brought her deep into the affluent baby boomer culture. There were, among this church gathering of her supporters, an insurance agent, an attorney, an accountant, two doctors, a mechanical engineer, a metallurgist, an airline pilot, a funeral director and several who called themselves stay-at-home moms.

At first, they mainly expressed disbelief about the charge. “What she’s accused of is anathema to her, to what she is,” said Killebrew. “That she’d be accused of this doesn’t fit. She would lay down her life for babies.”

As the morning stretched on, though, the church group gradually, hesitantly, began saying that even if Carrizales had hastened a dying baby’s death, they felt comfortable about it and supported her.

“I wouldn’t hold it against her.”

“What is death? Maybe that baby was dead, just gasping. Maybe Eva just stopped a reflexive involuntary reflex.”

“What Eva did is what a committee’s do-not-resuscitate order would do. Knowing Eva, I have confidence in what she decided.”

“Eva would never do anything to harm a baby if maybe it would live.”

“It would be different if it were a 5-year-old.”

“It would be different if there’d been a 50-50 chance. But the baby was going to die within five minutes.”

In time, the group began directing its fire at those who’d turned on Carrizales.

“Nobody disagrees the baby was terminal,” said Killebrew. “Why spend all this money and time over a fine line? It drives me up a tree.”

“I feel she’s being thrown to the wolves,” said Donald Harper, a Delta Airlines pilot. “The big thing is, you need to support your doctors. Why did the hospital turn her in?”

“Who is qualified to determine death in our society?” asked Associate Pastor Maxfield. “Is the legal community? Or is the doctor? That’s the question. Are we going to let policemen decide who is dead, and when? Who is to decide?”

Not until the meeting was drawing to an end did it emerge that no one there, despite their passionate sincerity, had actually read the medical examiner’s report.

“I only briefly looked at it,” said Killebrew. “It was too much, too emotional for me. It was all a blur. I know this woman, know her character, know who she is. Whatever happened, it was right. I don’t believe Eva smothered this baby, that she put a hand over his mouth. She just wouldn’t do that. She wouldn’t do that.”

Killebrew paused, looked down, considered. “It’s all based on Eva’s character,” she finally said. “Most people don’t know the details of the story.”

s much as he might have liked to, Clayton County Dist. Atty. Robert Keller could not so readily avoid the medical examiner’s report. By calling the baby’s death a homicide, Joe Burton more or less had backed the prosecutor into a corner. “I didn’t have a choice,” Keller said. “Joe had a harder choice. The key for me was Burton and what he decided. If he says homicide, I have to act.”

Additional impetus came soon after, when Keller learned of the questionable death of another baby under Carrizales’ care. In this incident, in June, 1993, at nearby Henry General Hospital, Carrizales reportedly gave a severely premature baby girl with a failing heart rate a potentially dangerous straight shot of potassium chloride, rather than drip it in slowly, as is standard. This episode hadn’t been reported at the time; only in the wake of the Southern Regional case were authorities hearing about it and investigating. Joe Burton wasn’t saying Carrizales had deliberately done anything to cause this death, but in witnesses’ accounts of Carrizales’ comments and conduct at Henry General, Burton did think he saw a “pattern of response” that gave him “considerable concern.”

All the same, Keller approached the Southern General case with much reluctance. Here was one of the most treacherous issues he’d faced in his 16 years as district attorney, and here also was something of a personal issue. His brother was a doctor--and a close friend of Eva Carrizales. Keller himself knew Carrizales well enough to have greeted her, at times in the past, with a hug. Inevitably, he found himself discussing this doctor’s case with his family.

“I prayed over what to do,” Keller said. “I felt I represented Dr. Carrizales as much as anyone. How should we respond?”

Keller eventually fixed on a highly unusual plan. Instead of issuing an arrest warrant, he would hand the matter to a grand jury--and he would let this grand jury hear witnesses for the defense as well as the prosecution. Keller had never done this before; grand juries usually hear only the prosecution’s case. But Keller wanted this one to hear everything available, including Carrizales and her neonatology experts. They could all say whatever they wanted.

If someone was going to put a murder tag on this one, Keller reasoned, it had to be the grand jury, not him. But maybe they wouldn’t. If he allowed the defense witnesses, the doctor just might not be indicted.

That plainly was the hope of the dozen mothers marching outside the Clayton County Courthouse in Jonesboro on the morning of Nov. 10, carrying placards with messages such as “Dr. Carrizales Saves Babies Lives . . . Doesn’t Kill Them” and “Thank You for My Little Miracle.” Some held up their children, all onetime patients of Carrizales. As she passed by them and a gaggle of journalists on her way to testify before the grand jury, Carrizales flashed a “V” for victory sign.

An hour later, having told her story without a defense attorney present--Keller wouldn’t violate that grand jury custom--Carrizales left the courthouse smiling. “It was great,” she told reporters. “I love the baby. I have no problems with any of the nurses. I know that they had some concerns, some misconceptions. But it’s all understandable. I just want to let baby Jiminez rest in peace. God bless us.”

Following her to the stand were six respected neonatologists and pathologists called for the defense, among them the Fulton County deputy medical examiner, Kris Sperry. None of the experts endorsed the notion of mercy killing or “facilitating” a death. Instead, despite some differences, they basically focused on the lack of hard scientific evidence.

From his standpoint as a board-certified forensic pathologist, Sperry told the grand jurors, all he could say reliably was that the manner of death was “undetermined.” To say more, he’d have to depend on the nurses’ observations and interpretations, which would require making “a personal value judgment” that didn’t fit with a scientific report. “I can’t sew moonbeams together to get an answer,” Sperry observed.

It is hard to say why none of this had much effect on the grand jurors. Perhaps Keller’s question--”Then why did she do it, and say she did it?”--had an impact. Perhaps it was Burton’s response--”I bet he wouldn’t let me occlude his baby’s carotids”--when a pathologist suggested Carrizales’ actions didn’t kill the baby. Perhaps it was the unexpected revelation from a nurse at Henry General Hospital, who testified that Carrizales, while working with her there one evening, talked openly about baby Jiminez living for 20 minutes after she’d blocked the flow of blood to his brain.

Whatever the mix of reasons, the grand jurors, after listening to 18 witnesses over a stretch of 12 hours, needed only 20 minutes to deliberate. Shortly after 10 p.m., apparently free from the tortured ambivalence surrounding them, the grand jurors voted to indict Carrizales on the charge of murder “with malice aforethought.”

This was not the outcome anticipated by Keller and Burton. They thought the defense witnesses had persuaded the grand jurors. “The district attorney gave the grand jury every option he could to not indict,” Burton said later. “I was surprised when the grand jury indicted her. I did not expect it.”

The next afternoon, Carrizales turned herself in at the Clayton County Detention Facility. After she posted a $10,000 bond, authorities let her go home.

A VAGUE UNEASE NOW COLORS the conversations of those who have brought Carrizales to account. Few appear comfortable with what has happened. Phone calls of inquiry are answered cautiously and only after much prodding.

“We had to do our jobs,” says Maj. Frank Horgan of the Clayton County Police.

“We normally have a feeling of accomplishment,” says Capt. Joe Reynolds, shaking his head. “Maybe it’s a little less so in this case. There are no bad guys here.”

The Southern Regional medical director, Donald Lackey, feels a particular regret. “I wish I didn’t have to be a witness at the trial,” he says. “My testimony helped form the grand jury’s decision. Dr. Carrizales could lose her license and go to jail for an act that doesn’t deserve this kind of penalty. But I don’t know what else to do. I have to give a truthful answer. If the district attorney asks me on the stand, I’d tell them I wish we didn’t have to punish her.”

Punish her they already have, however, a circumstance hard for them to ignore.

In the days following her indictment, Carrizales rather publicly struggled with a self-destructive fit of depression. She told her husband to kill her in order to cash in a life insurance policy and put her out of her misery. She visited a psychiatrist. And she, with her husband, spoke unguardedly about all this to an Atlanta Journal-Constitution reporter who visited her home. “This is what I did,” she said while holding her forefinger and middle finger to the neck of the reporter, pressing firmly. “I love babies. . . . It’s been a tremendous tragedy for my family.”

The Carrizales family’s financial ruin has been equally apparent. The doctor lost her reported annual income of $250,000 when she resigned her positions days after baby Jiminez’s death. Later, her husband, saying he was too distracted to continue as a self-employed architect, began pumping gas evenings at a convenience store. With legal fees already reaching $100,000--in January, Carrizales retained Georgia’s most renowned criminal defense attorney, Bobby Lee Cook--the Carrizales’ two older daughters had to leave the University of Texas. In February, the lender foreclosed on their Fayette County home, forcing them to move out.

If these signs of the Carrizales’ downfall were not discomfiting enough, there were also the reports of the doctor’s present activities to consider. Her church friends report she spends much time in downtown Atlanta, caring for the homeless and hungry, visiting prisoners, helping AIDs patients. Often she can be found at the Indian Health Service, where she plans to work “when this is over,” and at the Trinity Soup Kitchen. “She walks the streets and goes places where we won’t go,” says Beth Killebrew. “She does what we all say we will or should do.”

Monitoring these recurring reports of Carrizales’ fate and her supporters’ moods, Keller and Burton grapple still for a just response. Guilt and discomfort linger--but so, too, does an unwillingness to ignore precisely what happened at Southern General--and, for that matter, at Henry General.

Bob Keller wishes everyone involved could at least address openly the fundamental issues raised by Carrizales’ apparent conduct and, particularly, her comments. If such cases do happen all the time, if doctors always walk these fine lines, if doctors regularly make subjective judgments, if doctors do often prolong the death process pointlessly, if doctors should treat death differently--let’s talk about it.

“Why not just say, yes, I did it?” Keller asked. “Why not say yes, the baby can’t consent, the parents are incapable, so yes, I did it. I did it then, I’d do it tomorrow, I’d do it again and again and again.”

As Keller offered that thought one morning, he half rose from his chair, his fist pounding the desk in frustration. Some 13 weeks had passed since Carrizales’ indictment, and the district attorney had not yet gotten around to arranging the doctor’s arraignment (and would not for four more months). He appeared in even less of a rush to schedule a trial.

Keller spoke almost wistfully about the unlikely prospect of a plea bargain, something Carrizales’ lawyers flatly reject. “Why won’t they consider a voluntary manslaughter charge?” he asked, standing now and leaning forward over his desk. “You could say it was an emotional moment; you could offer probation. I’m not offering, but I wonder. Ask her lawyers. Ask her lawyers why they won’t consider that.”

Keller kept talking as he began to pace his office. “I’m convinced her motive was to end suffering,” he said. “But the family was not consulted. Does she have a right to do that? How do you translate that into a verdict? Into a sentence? You could argue the motive was compassionate. If so, what does it mean? Does mercy killing equal murder?”

Thinking of the coming trial, the unscheduled but unavoidable trial, Keller answered his own question.

“That,” he said, “is what we’re going to find out.”