The Journal of the American Medical Association is not a sensationalist rag. The gore that dots its pages is of the clinical sort found in operating rooms. The passions it evokes are relatively arcane debates between people who do double-blind crossover studies for a living.
Nevertheless, this year the very same journal presented the country with something new in the annals of horror stories.It was the tale of an exhausted young doctor stalking the hospital halls and rather casually injecting a terminally ill patient with lethal drugs.
The editors published an anonymous piece written by a self-described mercy killer who had been confronted with a young woman dying painfully of cancer.
The author wrote: "Her only words to me were, `Let's get this over with."' And after several seconds of deep moral dilemma, this doctor killed her.
The horror story was entitled, "It's Over, Debbie." But the Debbie story has had one of the longest postmortems in JAMA history.
First the editors had to go to court to defend the author's anonymity from outraged law enforcers. Next they had to defend the publication of the piece from those who doubted its truth and/or the wisdom of printing it.
Finally they had to sort through 150 letters on the subject the equivalent of 1,500 for Dear Abby and choose 18 to print in the current issue along with two commentaries and an editorial.
For a time, this story produced a good deal of heat about needle-wielding free-lancers. There was almost no professional support for this resident's off-the-cuff decision to "end it all" without talking to Debbie, her real doctor or her family. Not even the Hemlock Society approved.
But in some perverse way, the horror story may finally be provoking a more level-headed and much needed discussion about a humane way of dying.
From the debate raging in and out of the "Letters" column, it seems that there is a very real split between the medical profession and the public. Most doctors were anxious to defend themselves from charges that they might be hastening death.
The public, on the other hand, seemed most concerned with a painful and prolonged dying.
As Dr. George Lundberg, the editor of JAMA, who has been fully immersed in this debate, says: "The argument ranged from the doctors' concern with preserving life to the public's rather profound desire not to suffer."
In the letter from one non-physician: "What is more unethical, to let this young woman live in misery or to relieve her suffering?"
To many of us, the choices seem just that stark: a prolonged miserable dying or a doctor-assisted death. Increasingly the public is reacting to its fear of pain and suffering by trying to get control over medical treatment.
Consider the initiative that may end up on the California ballot this year. It would allow a terminally ill patient to write a directive saying that a physician could help the patient die by an injection.
This is not being pushed by injection-happy physicians. It's being advocated by people fearful of the alternative. It comes from the other assumption (also based on what we've witnessed) that too few terminally ill people, especially those with cancer, experience a humane dying, one in which the patient's comfort is a priority.
Dr. Ronald Cranford of Minneapolis has written about the treatment of his mother-in-law in the final stages of lung cancer. Her priorities became his treatment. He replaced life-prolonging drugs with painkilling drugs.
Most doctors, he says, believe in making their patients comfortable, but don't "have the courage of their convictions in terms of the humane care of the dying."
This is the debate that should be taking place. What are the appropriate humane roles of doctors in care of the dying? When should doctors remain passive through the simple non-treatment of a patient?
When is it appropriate to administer painkillers even if those shorten a life? How involved should a doctor become in active euthanasia? Providing lethal drugs? Administering them on request?
Debbie's doctor, a stranger to her, acted on one ambiguous remark: "Let's get this over with." But from the extraordinary response to this case, most of us want a much more intense conversation with the medical community about suffering as well as death.