How We Die_ Reflections On Life's Final Chapter Part 5

No matter the degree to which a man thinks he has convinced himself that the process of dying is not to be dreaded, he will yet approach his final illness with dread. A realistic sense of what is to be expected serves as a defense against the unrestrained conjurings of warrantless fear and the terror that one is somehow not doing things right. Each disease is a distinctive process-it carries its own particular kind of destructive work within a framework of highly specific patterns. When we are familiar with the patterns of the illness that afflicts us, we disarm our imaginings. Accurate knowledge of how a disease kills serves to free us from unnecessary terrors of what we might be fated to endure when we die. We may thus be better prepared to recognize the stations at which it is appropriate to ask for relief, or perhaps to begin contemplating whether to end the journey altogether.

There is a kind of dying for which very little or no preparation is possible, and perhaps not advisable. Death by violence is by and large the province of the young. Even when forewarned, youth does not heed the counsel that advises an acquaintance with the avenues leading toward the grave. Neither is youth influenced by statistics-trauma, defined as a physical injury or wound, is the leading cause of death for all persons below the age of forty-four in the United States. It kills approximately 150,000 Americans each year, of all ages; an additional 400,000 are permanently disabled. Sixty percent of the mortality occurs within the first twenty-four hours after injury.

Not surprisingly, our nation's leading source of trauma is automotive. Some 35 percent of major injuries are sustained by automobile occupants and another 7 percent by motorcyclists. The vehicular injuries have at least the virtue of being unintentional in the vast majority of cases. Not so with gunshot wounds (which account for 10 percent of all major trauma) and stabbings (which add almost an equal number). Pedestrian accidents make up 7 to 8 percent, and an additional 17 percent result from falls, which so often involve the very old and the very young. The remaining 15 percent of major traumas arise from a variety of sources, including industrial accidents, bicycle crashes, and an a.s.sortment of suicide injuries.

On a late summer day in 1899, a sixty-eight-year-old real estate broker, ironically bearing the name Henry Bliss, stepped off a trolley car in New York City and was killed by a pa.s.sing automobile, thereby acquiring the dubious distinction of becoming our country's first automotive traffic fatality. Since then, almost 3 million people have died of motor vehicle injuries. The most important contributing cause in those deaths (their traveling companion, so to speak) has been alcohol. Alcohol is a factor in approximately 50 percent of motor vehicle deaths in the United States. One-third of those who have died were victims of someone else's drinking.

Having argued that individual death is of necessity an integral component in the pattern of biological continuity, I add here the self-evident wisdom that nature requires no help. Her own cellular manipulations render unnecessary and ultimately counterproductive our killing of vast numbers of each other, and of ourselves. Trauma robs the species of its progeny and violates the orderly cycle of renewal and improvement. The traumatic death of a human being serves no useful purpose. It is as tragic to the species as to the family left behind.

How ironic it is, then, that so little of our society's biomedical effort is focused on the prevention and treatment of injuries. Only recently has violence been recognized as a major public health problem in the United States-that the number of deaths due to firearms in our country is, per capita, seven times the figure for the United Kingdom; that the frequency of suicide, the most grievous face of violence, has doubled among children and adolescents in the past thirty years, an increase due almost completely to firearms. Suicide is now the third-leading cause of death in those young age groups.

There are those who argue persuasively that the figures for suicide are much too low; they do not include that insidious form of gradually self-destructive behavior some call "chronic habitual suicide": drugs, alcohol, unsafe driving, dangerous s.e.xual habits, gang members.h.i.+p, and the other ways youth may defy the norms of society. Chronic habitual suicide limits not only the quant.i.ty of life but its quality as well. It deprives the rest of us of the talents, the pa.s.sion, and therefore the societal contributions that might have been made by the unfulfilled lives we are losing, often long before we have lost them. Such losses are immeasurable, and they slowly eat away at the edges of our civilization's fabric.

The term trimodal trimodal has been applied to the time sequence of traumatic dying: immediate, early, and late deaths. An "immediate death" takes place within minutes of the injury. It includes more than half of all traumatic fatalities and is always the result of injury to the brain, the spinal cord, the heart, or a major blood vessel. The physiological process is either ma.s.sive brain damage or exsanguination. has been applied to the time sequence of traumatic dying: immediate, early, and late deaths. An "immediate death" takes place within minutes of the injury. It includes more than half of all traumatic fatalities and is always the result of injury to the brain, the spinal cord, the heart, or a major blood vessel. The physiological process is either ma.s.sive brain damage or exsanguination.

"Early death" takes place within the first few hours. The usual cause is injury to the head, the lungs, or the abdominal organs, with bleeding in those regions. Death may be due to brain injury, blood loss, or interference with breathing. Regardless of interval, in fact, about a third of all trauma deaths are due to brain damage and another third to bleeding. Although "immediate deaths" are beyond medical intervention, the lives of many patients who fall into the "early" category can be saved by prompt treatment. It is here that rapid transportation, well-trained trauma teams, and battle-ready emergency rooms make the critical difference. It has been estimated that 25,000 Americans die each year because such resources are not universally available. An example of the effectiveness of a quick delivery system is to be found in the lessons of this nation's armed conflicts. In each of our last four major wars, an incremental change in medical know-how was accompanied by a decremental change in evacuation time. The result was a pattern of vastly improving mortality statistics from one war to the next.

"Late death" refers to those people who die days or weeks after the injury. Approximately 80 percent of those mortalities are caused by the complications of infection and failure of the lungs, kidneys, and liver. These people survive the initial blood loss or head trauma but often have sustained injuries to other organs, such as a perforated intestine, a ruptured spleen or liver, or perhaps a blunt injury to the lung. Not infrequently, surgery is required to stop bleeding, prevent peritonitis, or repair a damaged organ, perhaps removing it in the process. Many of these people, instead of recovering uneventfully, begin within a few days to develop fever, high white blood cell counts, and a tendency for some of their circulating blood volume to pool in inappropriate parts of the body, such as the blood vessels of the intestine, and thus be lost to the general circulation. All of these developments are characteristic of widespread infection, or sepsis, which becomes increasingly resistant to antibiotic and other drug treatment.

If the origin of the sepsis is an abscess or infected postoperative incision, surgical drainage will usually reverse the damage and allow the patient to recover. In many people, however, no drainable abscess can be found, so the symptoms progress. By the end of the first postinjury week, respiratory failure begins to appear in the form of pulmonary edema and pneumonialike processes, resulting in decreased oxygenation of the blood. The lung is one of the first targets of sepsis, but it is soon followed by the liver and the kidney. The entire evolving syndrome is thought to represent an inflammatory response to the presence in the blood of a variety of microbial and other invaders that generate toxic substances. These invaders may be bacteria, viruses, fungi, or even microscopic bits of dead tissue. The microbes, if they can be identified, are often found to originate in the urinary system, with the respiratory and gastrointestinal tracts following in frequency. In many cases, surgical wounds and skin are the sites of origin. In response to the presence of the circulating toxins, the lung and other organs seem to create and release certain chemical substances that have a deleterious effect on blood vessels, organs, and even cells, including the elements of the blood. The tissue cells become incapable of extracting sufficient oxygen from hemoglobin at about the same time that less hemoglobin is being brought to them by the reduced circulation. These events so much resemble the cla.s.sical picture of cardiogenic or hypovolemic shock that their total effect is called septic shock. If septic shock does not respond to treatment, the vital organs fail one after the other.

The occurrence of septic shock is not restricted to subjects of trauma. It is seen in a variety of illnesses in which a patient's defense mechanisms have become impaired. Not infrequently, in fact, it is the terminal event in such a spectrum of conditions as diabetes, cancer, pancreat.i.tis, cirrhosis, and extensive burns, overwhelming its victims with a mortality rate in the range of 40 to 60 percent. Septic shock is the leading immediate cause of death in intensive care units in the United States, accounting for 100,000 to 200,000 deaths each year.

Once the lung has lost some of its ability to oxygenate the blood and the circulation is impaired by a generally depressed myocardium and pooling in the vessels of the gut, several organs begin to demonstrate the effects of the decreased nourishment. Cerebral function dwindles. The liver loses part of its ability to make some of the compounds the body needs and destroy those it does not. The liver failure compounds a concomitant depression of the immune system and the lessened production of infection-fighting substances. At the same time, the decreased blood flow to the kidney prevents proper filtering and results in an inadequate urinary output and gradually worsening uremia, which is a backup of poisonous products in the blood.

All of this may be complicated by the destruction of cells lining the stomach and intestine, with resulting ulcerations and bleeding. Shock, kidney failure, and gastrointestinal bleeding are often the final events in people who die from the syndrome of posttraumatic failure of multiple organs. Stated another way, multiple organ failure is the end point of sepsis, and therefore the common end point for many patients whose primary process may be trauma or one of the more "natural" diseases of mankind. All the syndrome's characteristics seem to be caused by the effects of the toxins on various organ systems of the body. The ultimate outcome for any individual patient is related to the number of organs that cannot withstand the a.s.sault. If three are involved, the mortality is close to 100 percent.

The playing out of the entire process usually takes two to three weeks, and sometimes longer. One of my patients, whose sepsis was the result of pancreat.i.tis, lingered for months as all of us-surgeon, consulting physicians, anesthesiologists, resident staff, nurses, and technicians-called upon every diagnostic and therapeutic technique available in our university medical center to hold back the oncoming tidal wave of multiple organ failure, all to no avail.

The ordeal of patients who die of septic shock is indescribably difficult to watch. The unfolding of the ultimately lethal events follows a predictable pattern. First, there are the fever, rapid pulse, and respiratory distress, or at least some evidence of inadequate oxygenation found when the blood is a.n.a.lyzed. An endotracheal tube will be placed to aid the compromised respiration, but it soon becomes evident that no substantial benefit results. If the patient is not already sedated, his level of consciousness is beginning to fluctuate on its own. CT scans, ultrasounds, numerous blood a.n.a.lyses, and multiple cultures are done, all in an effort to find some remediable source of infection, often in vain. Consultants in groups converge around the cubicle, tapping and talking, and in general contributing to the increasing air of uncertainty. The patient is shuttled back and forth between the intensive care unit and the X-ray department as one or another imaging technique is called upon to seek out a pocket of pus or a locus of inflammation. Every transfer from bed to gurney and back becomes a logistical exercise in disentanglement of lines and wires. The spirits and plans of family and medical team change with each new set of laboratory reports, but only the good ones are shared with the anxious person in the bed, providing that individual can still fully comprehend their meaning. Antibiotics are started, changed, stopped in the hope of some treatable germ appearing in the bloodstream, and then restarted; in only about 50 percent of victims of multiple organ failure will a study of the blood yield microbes that will grow in a laboratory culture.

Various alterations in the blood elements appear, and the clotting mechanism may be inhibited, even to the point of spontaneous bleeding. The liver failure sometimes produces jaundice just as the kidney is showing its first serious evidence of progressive deterioration. Dialysis may be tried as a delaying action if there is still some hope of turning things around. By now, if not before, the anguished patient, providing he can still organize his thoughts, has begun to wonder whether enough can be done for for him to justify what is being done him to justify what is being done to to him. Although he cannot know it, his doctors are starting to wonder the same thing. him. Although he cannot know it, his doctors are starting to wonder the same thing.

And yet everyone continues on, because the battle is not yet lost. But all this time, something unnoticed has been happening-despite the best of intentions, the staff members have begun to separate themselves from the man whose life they are fighting to save. A process of depersonalization has set in. The patient is every day less a human being and more a complicated challenge in intensive care, testing the genius of some of the most brilliantly aggressive of the hospital's clinical warriors. To most of the nurses and a few of the doctors who knew him before his slide into sepsis, there remains some of the person he was (or may have been), but to the consulting superspecialists who t.i.trate the remaining molecular evidences of his dwindled vitality, he is a case, and a fascinating one at that. Doctors thirty years his junior call him by his first name. Better that, than to be called by the name of a disease or the number of a bed.

If the dying man has some luck left to him, he is by this time no longer aware of the drama in which he is the princ.i.p.al actor. He has gone from obtundation to minimal responsiveness or even coma, sometimes spontaneously as his organs fail and sometimes aided by narcotics and other medications. His family has gone from worry, to despair, and finally to hopelessness.

Not only the family but also the nurses and those doctors who have been with the dying man from the beginning gradually become affected by the heat of the crucible at the center of their losing campaign. They begin to question the very process by which they and the swarming consultants make treatment decisions or choose to pursue, with increasing desperation, yet another unpromising diagnostic clue. They torment themselves with the increasingly unavoidable perception that they are magnifying the suffering of a fellow human being in order to keep alive the slim hope of recovery; the most self-scrutinizing of the physicians confront that part of their motivation which is the excitement of solving the riddle and s.n.a.t.c.hing up a glorious last-minute victory when the game seems all but unwinnable.

Their separation from the patient brings some of the members of the treatment team gradually closer to the family, as though a transfer of empathy takes place over the long weeks of the vigil. Especially near the end, the comfort that can no longer be perceived by the dying is bestowed upon those who have already begun to mourn. Rarely are there last words in intensive care units-whatever consolation is to be found must come from the warm embrace of a nurse, or the solace of a doctor's words.

Finally, even those who have been unable to let go-even they-feel the relief that comes with the end of the long suffering. I have seen veteran nurses weep openly when an ICU patient dies; I have seen middle-aged surgeons turn their faces away so that young colleagues might not notice the tears. More than once, my voice, and my spirit, too, have cracked before I could utter the words that had to be said.

Of course, such scenes are not restricted to ICUs-they occur also in the general wards and in emergency rooms. Premature death by disease or unprovoked violence can be viewed dispa.s.sionately by only very few in the legions of those who care for the sick. But when the premature death is the result of self-destruction, it evokes a mood quite different from the aftermath of ordinary dying-that mood is not dispa.s.sion. In a book about the ways of death, the very word suicide suicide appears as a discomfiting tangent. We seem to separate ourselves from the subject of self-murder in the same way that the suicide feels himself separated from the rest of us when he contemplates the fate he is about to choose. Alienated and alone, he is drawn to the grave because there seems no other place to go. For those left out and left behind, it is impossible to make sense of the thing. appears as a discomfiting tangent. We seem to separate ourselves from the subject of self-murder in the same way that the suicide feels himself separated from the rest of us when he contemplates the fate he is about to choose. Alienated and alone, he is drawn to the grave because there seems no other place to go. For those left out and left behind, it is impossible to make sense of the thing.

I have seen my own att.i.tude toward self-destruction reflected in the response of my eldest child. My wife and I had driven one hundred miles to the city where she was a college senior, because we both agreed that we should be with her when she heard the shocking news that one of her most admired friends had killed herself. As gently as we could, and at first without any of the few details available to us, we told our daughter what had happened. It was I who spoke, and I said it all in two or three short sentences. When I was finished, she stared at us unbelievingly for a moment as the tears began overflowing onto her suddenly flushed cheeks. And then, in an uncontrolled paroxysm of rage and loss, she burst out, "That stupid kid! How could she do such a thing?" And that was, after all, the point. How could she do it to her friends and to her family and to the rest of those who needed her? How could such a smart kid commit such a dumb act and be lost to us? There is no place for this kind of thing in an ordered world-it should never happen. Why, without asking any of us, would this beloved young woman just go ahead and take herself away?

Such things seem inexplicable to those who have known the suicide. But for the uninvolved medical personnel who first view the corpse, there is another factor to consider, which hinders compa.s.sion. Something about acute self-destruction is so puzzling to the vibrant mind of a man or woman whose life is devoted to fighting disease that it tends to diminish or even obliterate empathy. Medical bystanders, whether bewildered and frustrated by such an act, or angered by its futility, seem not to be much grieved at the corpse of a suicide. It has been my experience to see exceptions, but they are few. There may be emotional shock, even pity, but rarely the distress that comes with an unchosen death.

Taking one's own life is almost always the wrong thing to do. There are two circ.u.mstances, however, in which that may not be so. Those two are the unendurable infirmities of a crippling old age and the final devastations of terminal disease. The nouns are not important in that last sentence-it is the adjectives that cry out for attention, for they are the very crux of the issue and will tolerate no compromise or "well, almosts": unendurable, crippling, final unendurable, crippling, final, and terminal terminal.

During his long lifetime, the great Roman orator Seneca gave much thought to old age: I will not relinquish old age if it leaves my better part intact. But if it begins to shake my mind, if it destroys its faculties one by one, if it leaves me not life but breath, I will depart from the putrid or tottering edifice. I will not escape by death from disease so long as it may be healed, and leaves my mind unimpaired. I will not raise my hand against myself on account of pain, for so to die is to be conquered. But I know that if I must suffer without hope of relief, I will depart, not through fear of the pain itself, but because it prevents all for which I would live.

These words are so eminently sensible that few would disagree that suicide would appear to be among the options that the frail elderly should consider as the days grow more difficult, at least those among them who are not barred from doing so by their personal convictions. Perhaps the philosophy expressed by Seneca explains the fact that elderly white males take their own lives at a rate five times the national average. Is theirs not the "rational suicide" so strongly defended in journals of ethics and the op-ed pages of our daily newspapers?

Hardly so. The flaw in Seneca's proposition is a striking example of the error that permeates virtually every one of the publicized discussions of modern-day att.i.tudes toward suicide-a very large proportion of the elderly men and women who kill themselves do it because they suffer from quite remediable depression. With proper medication and therapy, most of them would be relieved of the cloud of oppressive despair that colors all reason gray, would then realize that the edifice topples not quite so much as thought, and that hope of relief is less hopeless than it seemed. I have more than once seen a suicidal old person emerge from depression, and rediscovered thereby a vibrant friend. When such men or women return to a less despondent vision of reality, their loneliness seems to them less stark and their pain more bearable because life has become interesting again and they realize that there are people who need them.

All of this is not to say that there are no situations in which Seneca's words deserve heeding. But should this be so, the Roman's doctrine would then deserve consultation, counsel, and the leavening influence of a long period of mature thought. A decision to end life must be as defensible to those whose respect we seek as it is to ourselves. Only when that criterion has been satisfied should anyone consider the finality of death.

Against such a standard, the suicide of Percy Bridgman was close to being irreproachable. Bridgman was a Harvard professor whose studies in high-pressure physics won him a n.o.bel Prize in 1946. At the age of seventy-nine and in the final stages of cancer, he continued to work until he could no longer do so. Living at his summer home in Randolph, New Hamps.h.i.+re, he completed the index to a seven-volume collection of his scientific works, sent it off to the Harvard University Press, and then shot himself on August 20, 1961, leaving a suicide note in which he summed up a controversy that has since embroiled an entire world of medical ethics: "It is not decent for Society to make a man do this to himself. Probably, this is the last day I will be able to do it myself."

When he died, Bridgman seemed absolutely clear in his mind that he was making the right choice. He worked right up to the final day, tied up loose ends, and carried out his plan. I'm not certain how much consideration he gave to consulting others, but his decision had certainly not been kept a secret from friends and colleagues, because there is ample evidence of his having at least informed some of them in advance. He had become so sick that he felt it doubtful that he would much longer be capable of mustering up the strength to carry out his ironclad resolve.

In his final message, Bridgman deplored the necessity of performing his deed unaided. A colleague reported a conversation in which Bridgman said, "I would like to take advantage of the situation in which I find myself to establish a general principle; namely, that when the ultimate end is as inevitable as it now appears to be, the individual has a right to ask his doctor to end it for him." If a single sentence were needed to epitomize the battle in which we are all now joined, you have just read it.

No contemporary discussion of suicide, at least not one written by a physician, can skirt the issue of the doctor's role in a.s.sisting patients toward their mortality. The crucial word in this sentence is patients patients-not just people, but patients patients, specifically the patients of the doctor who contemplates the a.s.sisting. The guild of Hippocrates should not develop a new specialty of accoucheurs to the grave so that conscience-stricken oncologists, surgeons, and other physicians may refer to others those who wish to exit the planet. On the other hand, any degree of debate about physicians' partic.i.p.ation should be welcomed if it will bring out into the open a muted practice that has existed since Aesculapius was in swaddling clothes.

Suicide, especially this newly debated form, has become fas.h.i.+onable lately. In centuries long past, those who took their own lives were at best considered to have committed a felony against themselves; at worst, their crime was viewed as a mortal sin. Both att.i.tudes are implicit in the words of Immanuel Kant: "Suicide is not abominable because G.o.d forbids it; G.o.d forbids it because it is abominable."

But things are different today; we have a new wrinkle on suicide, aided and perhaps encouraged by self-styled consultants on the limits of human suffering. We read in our tabloids and glossy magazines that the actions of the deceased are, under certain sanctioned circ.u.mstances, celebrated with tributes such as are usually reserved for New Age heroes, which a few of them seem to have become. As for the pop cultural icons, medical and otherwise, who a.s.sist them-we are treated to the spectacle of those publicized peddlers of death willingly expounding their philosophies on TV talk shows. They extol their own selflessness even as the judicial system seeks to prosecute them.

In 1988, there appeared in the Journal of the American Medical a.s.sociation Journal of the American Medical a.s.sociation an account by a young gynecologist-in-training who, in the wee hours of one night, murdered- an account by a young gynecologist-in-training who, in the wee hours of one night, murdered-murder is the only word for it-a cancer-ridden twenty-year-old woman because it pleased him to interpret her plea for relief as a plea for death that only he could grant. His method was to inject a dose of intravenous morphine of at least twice the recommended strength and then to stand by until her breathing "became irregular, then ceased." The fact that the self-appointed deliverer had never seen his victim before did not deter him from not only carrying out but actually publis.h.i.+ng the details of his misconceived mission of mercy, saturated with the implicit fulsome certainty of his wisdom. Hippocrates winced, and his living heirs wept in spirit. is the only word for it-a cancer-ridden twenty-year-old woman because it pleased him to interpret her plea for relief as a plea for death that only he could grant. His method was to inject a dose of intravenous morphine of at least twice the recommended strength and then to stand by until her breathing "became irregular, then ceased." The fact that the self-appointed deliverer had never seen his victim before did not deter him from not only carrying out but actually publis.h.i.+ng the details of his misconceived mission of mercy, saturated with the implicit fulsome certainty of his wisdom. Hippocrates winced, and his living heirs wept in spirit.

Though American doctors quickly reached a condemning consensus about the behavior of the young gynecologist, they responded very differently three years later in a case of quite another sort. Writing in the New England Journal of Medicine New England Journal of Medicine, an internist from Rochester, New York, described a patient he identified only as Diane, whose suicide he knowingly facilitated by prescribing the barbiturates she requested. Diane, the mother of a college-age son, had been Dr. Timothy Quill's patient for a long time. Three and a half years earlier, he had diagnosed a particularly severe form of leukemia, and her disease had progressed to the point where "bone pain, weakness, fatigue, and fevers began to dominate her life."

Rather than agree to chemotherapy that stood little chance of arresting the lethal a.s.sault of her cancer, Diane early in her course had made it clear to Dr. Quill and his several consultants that she feared the debilitation of treatment and the loss of control of her body far more than she feared death. Slowly, patiently, with rare compa.s.sion and the help of his colleagues, Quill came to accept Diane's decision and the validity of her grounds for making it. The process by which he gradually recognized that he should help speed her death is exemplary of the humane bond that can exist and be enhanced between a doctor and a competent terminally ill patient who rationally chooses and with consultation confirms that it is the right way to make her quietus. For those whose worldview allows them this option, Dr. Quill's way of dealing with the th.o.r.n.y issue of a.s.sent (since then elaborated in a wise and outspoken book published in 1993) may prove to be a reference point on the compa.s.s of medical ethics. Physicians like the young gynecologist, and the inventors of suicide machines, too, have a great deal to learn from the Dianes and the Timothy Quills.

Quill and the gynecologist represent the diametrically opposed approaches which dominate discussions of the physician's role in helping patients to die-they are the ideal and the feared. Debates have raged, and I hope will continue to rage, over the stance that should be taken by the medical community and others, and there are many shades of opinion.

In the Netherlands, euthanasia guidelines have been drawn up by common consensus, allowing competent and fully informed patients to have death administered in carefully regulated circ.u.mstances. The usual method is for the physician to induce deep sleep with barbiturates and then to inject a muscle-paralyzing drug to cause cessation of breathing. The Dutch Reformed Church has adopted a policy, described in its publication Euthanasie en Pastoraat Euthanasie en Pastoraat-"Euthanasia and the Ministry"-that does not obstruct the voluntary ending of life when illness makes it intolerable. Their very choice of words signifies the churchmen's sensitivity to the difference between this and ordinary suicide, or zelfmoord zelfmoord, literally "self-murder." A new term has been introduced to refer to death under circ.u.mstances of euthanasia: zelfdoding zelfdoding, which might best be translated as "self-deathing."

Although the practice remains technically illegal in the Netherlands, it has not been prosecuted so long as the involved physician stays within the guidelines. These include repeated uncoerced requests to end the severe mental and physical suffering that is the result of incurable disease which has no other prospect for relief. It is required that all alternative options have been exhausted or refused. The number of patients undergoing euthanasia is approximately 2,300 per year in a nation of some 14.5 million people, representing about 1 percent of all deaths. Most frequently, the act is carried out in the patient's home. Interestingly, the great majority of requests are refused by doctors, because they do not meet the criteria.

Involvement is the essence of the thing. Family physicians who make house calls are the primary providers of medical care in the Netherlands. When a terminally ill person requests euthanasia or a.s.sistance with suicide, it is not a specialist to whom he is likely to go for counsel, or a death expert. The probability is that doctor and patient will have known each other for years, as did Timothy Quill and Diane, and even then consultation and verification by another physician is mandatory. The length and quality of Quill's relations.h.i.+p with Diane must have been major considerations in the decision of a Rochester grand jury in July 1991 not to indict him. is the essence of the thing. Family physicians who make house calls are the primary providers of medical care in the Netherlands. When a terminally ill person requests euthanasia or a.s.sistance with suicide, it is not a specialist to whom he is likely to go for counsel, or a death expert. The probability is that doctor and patient will have known each other for years, as did Timothy Quill and Diane, and even then consultation and verification by another physician is mandatory. The length and quality of Quill's relations.h.i.+p with Diane must have been major considerations in the decision of a Rochester grand jury in July 1991 not to indict him.

In the United States and democratic countries in general, the importance of airing differing viewpoints rests not in the probability that a stable consensus will ever be reached but in the recognition that it will not. It is by studying the shades of opinion expressed in such discussions that we become aware of considerations in decision-making that may never have weighed in our soul-searching. Unlike the debates, which certainly belong in the public arena, the decisions themselves will always properly be made in the tiny, impenetrable sphere of personal conscience. And that is exactly as it should be.

Into all of this, an organization called the Hemlock Society has intruded itself. These pages are not the forum in which to critique the problematic way in which this well-meaning self-help group of generally intelligent people has publicly validated the suicide decisions of those who may suffer from impaired judgment. Nor is it my intention to ventilate more than just a bit of my disdain for the misguided way in which the Hemlock Society's founder, Derek Humphry, has represented himself in the limelight of the media during promotion of his ill-advised cookbook of death, Final Exit Final Exit. But no one should make a final judgment on Final Exit Final Exit without being aware of a startling statistic: A 1991 survey conducted by the United States government's Centers for Disease Control found that 27 percent of 11,631 high school students had "thought seriously" about killing themselves in the previous year, and that one in twelve had actually attempted it. More than half a million young Americans are known to try suicide each year, plus an undiscoverable other huge group of those whose attempts are never disclosed. without being aware of a startling statistic: A 1991 survey conducted by the United States government's Centers for Disease Control found that 27 percent of 11,631 high school students had "thought seriously" about killing themselves in the previous year, and that one in twelve had actually attempted it. More than half a million young Americans are known to try suicide each year, plus an undiscoverable other huge group of those whose attempts are never disclosed.

In a June 1992 letter to the Journal of the American Medical a.s.sociation Journal of the American Medical a.s.sociation, two psychiatrists at the Yale Child Study Center advised: "With its lurid examples, explicit instructions, and vigorous advocacy for suicide, Final Exit Final Exit may have an especially pernicious effect on adolescents, who, with their high rate of attempted and completed suicide, appear susceptible to imitative influences and cultural factors that glorify or destigmatize suicide." may have an especially pernicious effect on adolescents, who, with their high rate of attempted and completed suicide, appear susceptible to imitative influences and cultural factors that glorify or destigmatize suicide."

Depression, the periodic despondency of the chronically ill, and the death fascination of some segments of our society are not strong enough justifications for teaching people how to murder themselves, to help them do it, or to bestow a blessing on it. No one with impaired powers of judgment is in a position to make a critical decision about ending his or her own life-on that point, there is no disagreement, even among the ethicists who argue most persuasively for the concept that has recently come to be known as "rational suicide." In no way, as Dr. Quill has pointed out, does Derek Humphry's death primer "resolve the profound moral, ethical and personal uncertainties it raises about the meaning of euthanasia and a.s.sisted suicide." As with all issues that deal with human life, there is no universal answer, but there should be a universal att.i.tude of tolerance and inquiry. It is perhaps too much to ask that there should also be a universal method of decision-making that is more specifically stated than the guidelines already described. Until a better one is available, Dr. Quill's way-of empathy, unhurried discussion, consultation, questioning, and challenged a.s.sumptions-will do just fine.

Though Humphry's philosophy can be condemned, his method cannot. The by-now-well-known technique of swallowing a quant.i.ty of sleeping pills just before enclosing one's head in a firmly secured airtight plastic bag does work quite as well as Humphry suggests, even if not by exactly the physiological mechanism he describes. Because the bag is so small, the oxygen is used up quickly, well before the rebreathed carbon dioxide has any significant effect. Rapid cerebral failure ensues, but what really causes death is is that a low blood-oxygen level slows the heart quickly to a complete standstill and the arrest of circulation. There may be some symptoms of acute heart failure as the rate of ventricular contraction decreases, but it hardly makes a difference, because dying is so efficiently accomplished. Although one would a.s.sume there might be terminal convulsions or vomiting inside the bag, this apparently rarely, if ever, occurs. Dr. Wayne Carver, the chief medical examiner of the state of Connecticut, has seen enough of such suicides to a.s.sure me that their faces are neither blue nor swollen. They look, in fact, quite ordinary-just dead. that a low blood-oxygen level slows the heart quickly to a complete standstill and the arrest of circulation. There may be some symptoms of acute heart failure as the rate of ventricular contraction decreases, but it hardly makes a difference, because dying is so efficiently accomplished. Although one would a.s.sume there might be terminal convulsions or vomiting inside the bag, this apparently rarely, if ever, occurs. Dr. Wayne Carver, the chief medical examiner of the state of Connecticut, has seen enough of such suicides to a.s.sure me that their faces are neither blue nor swollen. They look, in fact, quite ordinary-just dead.

Each year, some thirty thousand Americans commit suicide, and most of them are young adults. This figure refers, of course, only to those whose deaths can with some certainty be attributed to self-destruction. The stigma that still attaches to suicide is sufficient that families, and the subjects themselves, will often disguise the circ.u.mstances. Survivors sometimes appeal to a sympathetic physician to write something else on a death certificate. Elderly males, as indicated earlier, kill themselves at the highest rate per thousand, giving in to the stress of physical illness and loneliness, and being particularly p.r.o.ne to depression.

The great majority of suicides still use the old-fas.h.i.+oned methods of firearms, stabbing, hanging, pills, and gas, or a combination of several. Not infrequently, a poorly planned suicide is botched, especially when attempted by an emotionally distraught individual. In desperation, such people sometimes keep trying until they succeed, resulting in a body being discovered that has been lacerated, shot, and finally poisoned or hanged. When Seneca ultimately did take his own life, it was not by choice but on the order of the emperor Nero. Although one might think his many years of contemplation on the subject had made him something of an expert on its accomplishment, that was not the case-he was a renowned statesman, but he did not know much about the human body. In his determination to make an end of things, he plunged a dagger into the arteries of his arm; when the blood did not come fast enough to suit him, he cut the veins of his legs and knees. That not sufficing, poison was swallowed, also in vain. Finally, records Tacitus, "He was carried into a [heated] bath, with the steam of which he was suffocated."

Barbiturates, a more modern agent of suicide, kill in several ways. The coma they induce is so profound that the upper airway may become obstructed because the head droops into a dangerous position, cutting off the intake of air. That, or the aspiration of vomit, then results in asphyxia. Barbiturates in very high dosage also cause a relaxation of the muscle in arterial walls, allowing the vessels to dilate enough so that blood is lost to the circulation by pooling. In such large amounts, the drugs suppress the contractility of the myocardium and can thus cause cardiac arrest.

In addition to barbiturates, there are several other common pharmacologic agents of dispatch: Heroin, like some of the other intravenous narcotics, kills by causing rapid pulmonary edema, although the mechanism that makes it happen is not known; cyanide inhibits one of the biochemical processes by which cells use oxygen; a.r.s.enic damages several organs, but its ultimate way of killing is to produce irregularities of cardiac rhythm, sometimes with coma and convulsions.

When a would-be suicide hooks up one end of a hose to an automobile's exhaust pipe and inhales at the other, he is taking advantage of the affinity that hemoglobin has for carbon monoxide, which it prefers by a factor of 200 to 300 over its life-giving compet.i.tor, oxygen. The patient dies because his brain and heart are deprived of an adequate oxygen supply. The color imparted to the blood by the carboxyhemoglobin makes it significantly brighter and paradoxically even more vibrant than its normal state, with the result that the skin and mucous membranes of a person who dies by carbon monoxide have a remarkable cherry-red tinge. The absence of the typical bluish discoloration of asphyxia may deceive those who discover what appears to be a pink-cheeked body in the bloom of health, but dead nevertheless.

Hanging accomplishes much the same thing, but by a mechanism significantly less gentle. The weight of the victim's body provides enough force to tighten the noose and bring about mechanical obstruction of the upper airway. The obstruction is sometimes caused by compression or fracture of the windpipe, but it may also be the result of upward displacement of the base of the tongue, which blocks off the ingress of air. Because the constricting noose cuts off drainage through the jugular and other veins, deoxygenated blood is dammed back up into the tissues of the face and head. The discovery of a grotesquely hanging corpse whose swollen, sometimes bitten tongue protrudes from a bloated blue-gray face with hideously bulging eyes is a nightmarish sight upon which only the most hardened can gaze without revulsion.

In a legal, or judicial, hanging, the executioner attempts to avoid asphyxia, but sometimes he fails. When the knot of the noose is properly positioned just beneath the angle of the condemned man's jaw, the sudden drop of five to seven feet should fracture and dislocate the spinal column at the base of the skull. The spinal cord is thereby torn in two, causing immediate shock and paralysis of respiration. Death, if not instantaneous, is very quick, although the heart may continue to beat for a few minutes.

The sequence of events in suffocation by suicidal hanging is similar to that in all cases of mechanical asphyxia, intentional or not, such as smothering or choking. Nonsuicidal choking is exemplified by the well-known "cafe coronary," in which a bulky chunk of food suddenly obstructs the windpipe of a diner, often drunk. Made panicky by his inability to take in a breath, the agitated, hypercarbic victim, in a futile attempt to help himself, grabs at his throat and chest as though he is having a heart attack (hence the name cafe coronary). He will rush toward the bathroom, hoping to vomit up the suffocating plug in his windpipe, because even in his dying moments he remains too embarra.s.sed to do it in front of his gaping fellow diners, who may be sitting there aghast and unable to act. If he is at home and alone, he will probably die, but the Heimlich maneuver may save him if he is in a public place and a bystander can manage it.

If the food plug is not forced out, the process of suffocation continues unchecked. The pulse quickens, the blood pressure rises, and the level of carbon dioxide in the blood increases rapidly to a state called hypercarbia. Hypercarbia produces extreme anxiety, and the decreased oxygen makes the frightened victim appear blue, or cyanotic. He makes increasingly strenuous attempts to pull air past the obstruction, which only serve to wedge the plug even more firmly in place. Just as in a hanging, unconsciousness supervenes, and sometimes convulsions triggered by the unoxygenated and hypercarbic brain. In a short time, the efforts to breathe become weaker and more shallow. The heartbeat becomes irregular, and finally stops.

Drowning is, in essence, a form of asphyxia in which the mouth and nostrils are occluded by water. If the drowning is suicidal, the victim will not resist the inhalation of water, but if accidental, as is usually the case, he will fight it by holding his breath until becoming too exhausted and hypercarbic to continue. At this point, the air pa.s.sages all the way down into the lung become obstructed by water. If the struggle takes place while the drowning person is thras.h.i.+ng about near the surface, enough air may be sucked in to create a barrier of foam. The foam and water in the airway can set off the vomiting reflex, which adds to the problem by forcing the acid stomach contents up to the mouth, from where they can be aspirated into the windpipe.

If the drowning takes place in fresh water, the water is absorbed into the circulation through the lungs, diluting the blood and upsetting its delicate equilibrium of chemical and physical elements. Red blood cells are destroyed by the imbalance, resulting in the release of large amounts of pota.s.sium into the circulation, an element that functions as a cardiac poison by inducing the heart to fibrillate. Should the drowning occur in seawater, the process is virtually the reverse. Water leaves the circulation and enters the alveoli of the lung-the picture produced is that of pulmonary edema. Pulmonary edema may also occur during drowning in a swimming pool, because chlorine acts as a chemical irritant on the lung tissue.

In the struggles of a drowning victim, the aspiration of water is at first delayed and then abetted by one of the body's inherent survival mechanisms. When the first bit of water enters the airway, the larynx reflexly goes into spasm and closes off in an effort to prevent further intake. But within two or three minutes, the decreasing blood oxygen relaxes the spasm and water rushes in. It is this so-called terminal gasp phase that allows the aspiration of so much water that its absorption in a freshwater drowning may account for as much as 50 percent of the blood volume.

A lifeless human body is heavier than water, and the head is its densest part. Accordingly, the corpse of a drowning victim will always sink headfirst to the bottom and remain floating in that position until putrefaction produces enough gas in the tissues to create a buoyancy that makes it rise to the surface. This process takes anywhere from a few days to a few weeks, depending on the temperature and condition of the water. When the body returns, it is difficult for its appalled discoverer to believe that this rotted thing once contained a human spirit and shared nature's life-giving air with the rest of healthy humanity.

Drowning kills almost five thousand people in the United States each year, and alcohol is involved 40 percent of the time. Except in cases of suicide or murder, it almost always occurs under conditions of suddenness, and usually without warning. Nevertheless, the great majority of drowning victims do at least have some sense of its possibility, since it ordinarily takes place when they are in proximity to deep water. The approximately one thousand Americans who yearly suffer lethal electrocution, however, almost never suspect they are about to die, even when they are working around high-tension equipment. By far the most common cause of death following electric shock is ventricular fibrillation caused by the pa.s.sage of current through the heart. Fibrillation or arrest may also be caused by high-voltage electricity reaching the cardiac center of the brain. If the brain's breathing center is injured, respiratory cessation is the cause of death. Although most lethal electrocutions occur among men who work around high-voltage cables, electrical accidents in the home kill many children and adults each year.

In these various ways, the victims of homicide, suicide, and accidents are deprived of the oxygen supply that maintains existence. This recital of cause and physiological effect hardly exhausts the roll call of soldiers in the squadrons of violent death. Nor does a brief discussion of terminal equanimity, near-death experiences, or a.s.sisted suicide more than begin to address the many new issues that have lately been added to the already-lengthy catalog of concern that merits the attention-more than the attention, the scrutiny-not only of philosophers and scientists but of all of us. In matters touching on death, the clinical and the moral are never so far apart that we can look at one without seeing the other.

VIII.

A Story of AIDS CALL ME I ISHMAEL." She smiled at the recollection of that irony, and looked beyond me with wistful eyes into the room where the father of a young family lay dying.

"It was only four months ago, but it's a lifetime, really. I walked into the clinic that day, and there he was, sitting in a cubicle waiting for the great miracle-doctor who was coming to help him. The doctor was me. 'Good morning, Mr. Garcia,' I said, just as bright and breezy as a new interne is supposed to be. And he jumped up, this little Hispanic guy with a great big smile on his face. 'Call me Ishmael' was what he said-imagine it! I guess he never read the book. Melville's Ishmael survived, and mine never had a chance. He'll be dead in a few days, but I'll remember him the rest of my life." She paused; I could tell that the next words were caught on some jagged thing in her throat, because they sounded lacerated when she was finally able to force them out. "He was my first patient with this f.u.c.king G.o.dd.a.m.n disease!"

One crisis after another had taken place since that summertime afternoon when Ishmael*1 Garcia leaped up from the chair and stuck out his open palm to shake hands with Dr. Mary Defoe, and both of them had vastly changed from what they had been. Though she had seen plenty of AIDS patients while in medical school, Mary never quite realized the full magnitude of individual catastrophe until she actually took on the intimidating responsibilities of a newly graduated doctor. Garcia leaped up from the chair and stuck out his open palm to shake hands with Dr. Mary Defoe, and both of them had vastly changed from what they had been. Though she had seen plenty of AIDS patients while in medical school, Mary never quite realized the full magnitude of individual catastrophe until she actually took on the intimidating responsibilities of a newly graduated doctor.

From the sunny July afternoon when he first presented himself to the AIDS clinic until the chilly gray November morning when she was destined to p.r.o.nounce him dead, Mary Defoe and Ishmael Garcia would be doctor and patient. Whether hospitalized or being followed in the outpatient clinic, he thought of her as his personal physician. From time to time, other internes a.s.sumed his care for brief periods when Mary rotated to a different service, but they always found each other again and resumed their journey toward the grim conclusion they both knew lay ahead.

Early in training, most doctors develop relations.h.i.+ps with patients that become models on which they will base their responses to sickness and death for the rest of their careers. For Mary Defoe, Ishmael Garcia will surely represent a reawakening of an old image long lost to modern generations of healers-impotence in the face of a plague of death upon the young.

In the calculus of death, no one before 1981 could have factored in HIV, the human immunodeficiency virus. The first hints of its gathering fury struck just at the instant when biomedical science was beginning to offer cautious congratulations to itself on having achieved a state of advancement where the final conquest of infectious disease seemed at last within sight. AIDS not only confounded the microbe hunters; it shook the confidence held by all of us that technology and science can keep humanity safe from the whims of nature. In a very few explosive years, virtually every young doctor in training was treating his or her share of those dying who were meant to live.

Dr. Defoe and I stepped into Ishmael's room-noiselessly, though he was far beyond hearing any sound we might have made. It was more out of respect than necessity that we were so quiet. When a man is dying, the walls of his room enclose a chapel, and it is right to enter it in hushed reverence.

How different this scene from the frenzied drama so often played out during a patient's last moments, as desperate attempts are made to revive him to yet another few weeks or months of waiting for death-and sometimes only hours or days. After the incalculable miseries of Ishmael Garcia's descent into the valley of fever and incoherence, this oblivion was earned; it was fitting that the end, at least, should be undisturbed.

The room's overhead illumination had been turned off and the blinds were closed against the glare of midday autumn suns.h.i.+ne, bathing the entire s.p.a.ce in a uniformity of subdued daylight. The unconscious man in the bed had a high fever-the yellowish skin of his forehead glistened against the stark whiteness of his freshly changed pillowcase. Ravaged as he was by the wasting effects of his disease, it could be seen that he had once been very handsome.

I had read Ishmael's chart, and I knew that with his very last breath, the tranquillity would be shattered by a full-scale attempt at resuscitation. In a moment of terror months earlier, he had begged his wife to see to it that the doctors did everything possible to preserve his life-that she not allow them to give up. And now, Carmen could not make herself believe what the AIDS team was telling her: that the possible had become impossible. She clung to that part of her pledge which would destroy the easy exit of an essence in which she devoutly believed-the immortal soul of her husband.

Though Ishmael had been separated from his wife for three years prior to his illness, she was nevertheless his legal next-of-kin, and she spoke for his family. In reality, she spoke only for herself, because Carmen and her husband had together made the unyielding decision to keep the diagnosis to themselves. Neither Ishmael's parents nor his two sisters knew the name of his disease. If they did, they never spoke of it.

When she realized just how sick Ishmael was, Carmen had let him return home. Somehow, she found the strength to put aside his years of unfaithfulness and drug dependence, and even the near-poverty into which his irresponsibility had thrown her and their three daughters. He came back so that she could be his nurse and the only one of his family or friends to share his knowledge of the ultimate end. In spite of everything, he had been a good father, she said, and she owed him this much. For the sake of their three girls and for the recollections of a life that once had been, she permitted her dying husband to return.

In refusing to let him die when his time came, Carmen insisted that she was doing one last kindness for Ishmael-it was, after all, what she believed she had promised him. She refused to discuss with the doctors why she would not listen to their reasoned arguments, and none of them had the heart to press her. They supposed, they told me, that somewhere in the depths of her awareness, Ishmael's obvious devotion to their girls made Carmen feel some unjustified element of guilt about her rejection of her prodigal husband and her obdurate refusal to respond to his sputtering intervals of good behavior and promises of reform. The staff had gone so far as to seek a consultation with the chairman of our hospital's Bioethics Committee, but when they told him that a successful resuscitation might be possible, he would not overrule the dictates of Carmen's heart. In circ.u.mstances like this, who knows where wisdom lies?

Ishmael was never alone in that room. The three girls were always with him, a constant presence watching over their adored father through the plastic facing of a three-by-two-foot blown-up photograph standing on the wide windowsill. There they were, three beautiful curly-haired kids in party dresses, smiling out at the world and their father on a day much happier than this. I gestured toward the picture, wordlessly asking Mary a question.

"Yes," she replied, "the two older ones come here almost every day, but Carmen doesn't bring the littlest one. The six-year-old just plays by herself around the foot of the bed-she doesn't really understand. The ten-year-old cries; she stands by her father's bedside every minute she's here, wiping his face and stroking it, and she can't stop crying. I try not to come into the room when they're here-it's more than I can bear."

A Spanish Bible lay at the base of the children's photograph. It was open to chapters 27 through 31 in the Book of Psalms, and several of the verses were marked in various colors of a Hi-Liter. I wrote down the verse numbers on an index card and looked them up when I got home: 27:9Hide not Thy face from me, put not Thy servant away in anger. Thou art my help; reject me not, neither forsake me, O G.o.d of my salvation.

27:10For though my father and my mother forsake me, the Lord will take care of me.

28:6Blessed be the Lord, because He has heard the voice of my supplication.

It struck me that Ishmael is Hebrew for "G.o.d has heard." The name derives from the words spoken by the Lord when He found Sarah's maidservant Hagar in the wilderness after she fled from the wrath of her mistress: "Behold, thou art with child, and shalt bear a son, and shalt call his name Ishmael, because the Lord hath heard thy affliction." G.o.d had found the mother and child by a well, to which He then gave a name bespeaking his recognition of their plight, Be'er-la-hai-roi Be'er-la-hai-roi, "The well where the One Who lives has seen."

When the biblical Ishmael was fourteen, G.o.d again heard and saw, and this time it was the voice of the lad himself to which He responded, saving him from imminent death in the wilderness and promising to make him a great nation.

To the Ishmael lying in that bed, G.o.d seemed not to listen. Neither did He listen, nor did He seem to see. Certainly He did not act, in spite of the torment He observed. In this, Ishmael Garcia was like Job, in the face of whose suffering G.o.d was not only at first inactive but silent, too, as though having chosen to be without sight or hearing. If G.o.d heard Garcia's entreaties or saw his anguish, He did not change His mind. He never does, in this f.u.c.king G.o.dd.a.m.n disease.

I prefer to believe that G.o.d has nothing to do with it. We are witnessing in our time one of those cataclysms of nature that have no meaning, no precedent, and, in spite of many claims to the contrary, no useful metaphor. Many churchmen, too, agree that G.o.d plays no role in such things. In their Euthanasie en Pastoraat Euthanasie en Pastoraat quoted in the previous chapter, the bishops of the Dutch Reformed Church have not hesitated to deal quite specifically with the age-old question of divine involvement in unexplained human suffering: "The natural order of things is not necessarily to be equated with the will of G.o.d." Their position is shared by a vast number of Christian and Jewish clergy of various denominations; any less forbearing stance is callous and a further indecency heaped upon people already too sorely tried. Although there is a great deal to be learned from the plague of AIDS, the lessons it teaches lie in the realms of science and society, and certainly not within the purview of religious elucidation. We are dealing not with a punishment but with a crime-one of those random crimes that nature now and then perpetrates on its own creatures. And nature, as Anatole France reminds us, is indifferent; it makes no distinction between good and evil. quoted in the previous chapter, the bishops of the Dutch Reformed Church have not hesitated to deal quite specifically with the age-old question of divine involvement in unexplained human suffering: "The natural order of things is not necessarily to be equated with the will of G.o.d." Their position is shared by a vast number of Christian and Jewish clergy of various denominations; any less forbearing stance is callous and a further indecency heaped upon people already too sorely tried. Although there is a great deal to be learned from the plague of AIDS, the lessons it teaches lie in the realms of science and society, and certainly not within the purview of religious elucidation. We are dealing not with a punishment but with a crime-one of those random crimes that nature now and then perpetrates on its own creatures. And nature, as Anatole France reminds us, is indifferent; it makes no distinction between good and evil.

There is a good deal more to AIDS than its bare clinical facts disclose. Although such a statement may be made about any disease, how much more so may it be said of this specific plague. But no matter the cultural and societal implications of AIDS, certain of its clinical and scientific manifestations must be understood before the full tragedy unfolds of how it kills its victims. The case of Ishmael Garcia is archetypical.

In February 1990, Garcia had his first positive blood test for HIV. The test was done as part of the evaluation of a nonhealing open sore on his left forearm, which brought him to the medical clinic of the YaleNew Haven Hospital. The infection was almost certainly caused by his intravenous drug habit. Because he felt quite well otherwise, especially when the sore cleared rapidly with a short outpatient course of antibiotics, he never kept any follow-up appointment beyond the one at which he was told his diagnosis. In January 1991, he developed a dry cough that gradually worsened over a period of several weeks. As the cough progressed, a feeling of tightness appeared in Ishmael's chest, aggravated by coughing or a deep inspiration. After more than a month during which things gradually worsened, he began to be frightened by the appearance of two new symptoms: a fever, and shortness of breath brought on by even minor activity. When his breathing difficulty reached the point where it increased with no greater movement than walking around his small furnished room in New Hav