Home Remedies for Cold and Flu Symptoms

Causes And Effects Of The Black Death

There are various estimates of how many people died during the 1348-49 outbreak. Most historians believe between a third and half of the population were killed by the Black Death. The population of England at the time of the Black Death is estimated to have been around 6 million, so that means approximately 2 to 3 million people died.

Despite the scale of the fatalities, there is evidence that there was some sort of organised response from local government. Mass graves of victims have been found from the Middle Ages. The way the bodies are carefully laid in side by side suggests bodies were treated respectfully and in a dignified way.

A result of the high mortality rateclosemortality rateThe percentage of people who would normally die from a disease. So a disease with a mortality rate of 50% would mean an average of 50 people would die out of every 100 infected. Was a shortage of workers. This led to rapid wage rises as landowners had to compete for workers by paying more. In 1351 a law was introduced to force wages to go back to the levels they had been at before the Black Death. This was one of the causes of the Peasants' Revolt in 1381.

As no one knew exactly what caused the Black Death, they could do little to stop future outbreaks. There were further Black Death cases throughout the Middle Ages and beyond. There was another significant outbreak in 1665, particularly affecting London. This outbreak shows there had been no real increase in understanding about what was really causing the disease or how to prevent it.

It wasn't until the work of Louis Pasteur and Robert Koch in the 1800s that it was discovered germs are the cause of disease. The plague bacteria was finally discovered by Alexandre Yersin in 1894. The bacteria was named after him; 'Yersinia pestis.'

Why More Black Doctors Won't Solve The Black Maternal Mortality Crisis

There must be conversations about how deeply engrained anti-blackness is in healthcare systems and ... [+] how even those who are Black have internalized these negative stereotypes.

getty

Recently, resurfaced comments from Bravo's hit reality show "Married to Medicine" star Dr. Jackie Walters, have reignited critical conversations about Black maternal health and medical racism. In a resurfaced video from 2020, while Dr. Jackie was having a conversation with another star from the show Dr. Heavenly Kimes, Dr. Jackie stated, "Sometimes, as African-American women, we're a bit more dramatic and that you go to the doctor and you complain and you complain and you complain and you're not taken seriously because you cry wolf the entire pregnancy." The video came as a shock to many, as Dr. Jackie recently had a conversation with Vice President Kamala Harris about the dire Black maternal mortality crisis in the United States. Dr. Jackie did issue an apology on her Instagram page but the situation provides an important opportunity for conversations about why diversity alone will not close the Black maternal mortality gap. Black women are, according to the Centers for Disease Control and Prevention (CDC), three times more likely to die because of a pregnancy-related cause compared to their white counterparts.

Often times, when discussing medical racism within healthcare, the solution proposed is more diversity. People will say things like "we need more Black doctors," which is absolutely true, but isn't the cure-all for the inequities that are so pervasive within healthcare and medicine. There must also be conversations about how deeply engrained anti-blackness is in healthcare systems and how even those who are Black have internalized these negative stereotypes. Research indicates that Black people are not immune to perpetuating harmful and anti-black stereotypes that are learned within society and this can lead to discrimination against fellow Blacks.

Often times, when discussing medical racism within healthcare, the solution proposed is more ... [+] diversity.

getty

There are several examples of the prevalent nature of anti-black bias within society. In early January 2023, the brutal beating of a 29-year-old Black man named Tyre Nichols after a traffic stop dominated headlines. The story was particularly shocking to some because all five of the officers involved were Black. Internalized racism and anti-blackness may have played a role in Nichol's untimely death.

Anti-black bias also shows up in healthcare in a number of ways and may contribute to the abysmal Black maternal mortality rates. In early July 2023, Jessica Ross, a Black 20-year-old mother in Georgia, went into labor. An NBC News report indicates that according to a lawsuit filed by Ross and her partner Treveon Isaiah Taylor Sr., obstetrician Dr. Tracey St. Julian applied "ridiculously excessive force" during the delivery resulting in the baby's decapitation. The story may have been particularly surprising to some because the obstetrician, Dr. Tracey St. Julian, was a Black woman.

Addressing the Black maternal mortality crisis and other racial disparities within our systems and structures requires a nuanced and multi-pronged approach. For one, Black doulas can play an instrumental role in closing the Black maternal care gap. Second, in medical and healthcare education and curriculum, there needs to be more conversations about how harmful stereotypes can be internalized, especially by those who are part of oppressed communities, and research must continue to examine the persistent nature of anti-blackness within these structures. Representation is not enough—diversity alone can lull us into a false sense of security. We must be committed to ensuring that equity, inclusion and justice are the north star of our efforts to address Black maternal health and close racial health gaps.

Dr. Jackie Walters was contacted for this story but did not immediately respond for comment.

Doctors, Patients, And The Dutch Cure

WashingtonPost.Com: Seduced by Death: Doctors, Patients, and the Dutch Cure

Seduced by Death Doctors, Patients, and the Dutch CureBy Herbert Hendin, M.D.

Chapter One: Selling Suicide

A few years ago, a young professional in his early thirties who had acute myelocytic leukemia was referred to me for consultation. With medical treatment, Tim was given a 25 percent chance of survival; without it, he was told, he would die in a few months. Tim, an ambitious executive whose focus on career success had led him to neglect his relationships with his wife and family, was stunned. His immediate reaction was a desperate, angry preoccupation with suicide and a request for support in carrying it out. He was worried about becoming dependent and feared both the symptoms of his disease and the side effects of treatment.

Tim's request speaks directly to the question at the heart of assisted suicide and euthanasia. Does our need to care for people who are terminally ill and to reduce their suffering require us to give physicians the right to end patients' lives? The question is one that may well tear our society apart.

Asking this question, however, helps make us aware that neither legalizing nor forbidding euthanasia addresses the much larger problem of providing humane care for those who are terminally ill. To some degree the call for legalization is a symptom of our failure to develop a better response to the problems of dying and the fear of unbearable pain or artificial prolongation of life in intolerable circumstances. The absence of such a policy permits doctors like Jack Kevorkian to be seen as champions of people who are terminally ill, and legalization of assisted suicide and euthanasia to be seen as the best cure for fear.

The uninitiated are apt to assume that seriously or terminally ill people who wish to end their lives are different from those who are otherwise suicidal. Yet the first reaction of many patients to the knowledge of serious illness and possible death is anxiety, depression, and a wish to die. Such patients are not significantly different from patients who react to other crises with the desire to end the crisis by ending their lives.

Many patients and physicians displace anxieties about death onto the circumstances of dying: pain, dependence, loss of dignity, and the unpleasant side effects of medical treatments. Focusing on or becoming enraged at the process distracts from the fear of death itself. Tim's anxieties about the painful circumstances that would surround his death were not irrational, but all his fears about dying amplified them. Once Tim and I could talk about the possibility or likelihood of his dying--what separation from his family and the destruction of his body meant to him--his desperation subsided. He accepted medical treatment and used the remaining months of his life to become closer to his wife and parents. Two days before he died, Tim talked about what he would have missed without the opportunity for a loving parting.(1)

If assisted suicide were legal, as an Oregon law now being contested in the courts would make it, Tim--who was mentally competent--probably would have qualified for assisted suicide and would surely have found a doctor who would have agreed to his request.

Since the Oregon law, and similar laws being considered in other states, does not require an independently referred doctor for a second opinion, Tim would likely have been referred by a physician supportive of assisted suicide to a colleague who was equally supportive; the evaluation would have been pro forma. He could have been put to death in an unrecognized state of terror, unable to give himself the chance of getting well or of dying in the dignified way he did. The Oregon law is the latest example of how public frustration can lead to action that only compounds the problem; in the rush to legislate, advocates have failed to understand the problem they are claiming to solve.

The experience of the Dutch people makes it clear that legalization of assisted suicide and euthanasia is not the answer to the problems of people who are terminally ill. The Netherlands has moved from assisted suicide to euthanasia, from euthanasia for people who are terminally ill to euthanasia for those who are chronically ill, from euthanasia for physical illness to euthanasia for psychological distress, and from voluntary euthanasia to involuntary euthanasia (called "termination of the patient without explicit request").(2) The Dutch government's own commissioned research has documented that in more than one thousand cases a year, doctors actively cause or hasten death without the patient's request.(3)

Virtually every guideline established by the Dutch to regulate euthanasia has been modified or violated with impunity. A healthy but grief-stricken social worker mourning the death of her son two months earlier is assisted in suicide. A man in his early forties who is HIV-positive but who has no symptoms and may not develop them for years is also helped to die, without any effort to address the terror behind his desire to end his life.

In this country people are being asked to vote on matters about which they are uninformed. They are being asked the wrong questions. Can a suicide be rational? Or morally justifiable? As we shall see, yes or no answers to these questions are not sufficient to address the more complex question of whether the country should formally legalize assisted suicide and euthanasia.

Today, proponents of what is called "rational suicide" draw on the concept of bilanz Selbstmord or "balanced suicide," promoted by German philosophers in the early part of this century.(4) Individuals assumed to be mentally unimpaired dispassionately took stock of their life situation, found it unacceptable, and, foreseeing no significant change for the better, decided to end their lives.

Contemporary advocates see a close analogy between a rational decision for suicide and the decision of the directors of a firm to declare bankruptcy and go out of business. Yet the idea that life can be measured on a balance scale is itself a characteristic of suicidal people. Some of the most depressed suicidal patients spend years making elaborate lists of reasons why they should go on living to counter the many reasons they can think of for dying.

Suicidal individuals are also prone to make conditions on life: I won't live "without my husband," "if I lose my looks, power, prestige or health," or "if I am to die soon."(5) They are afflicted by the need to make demands on life that cannot be fulfilled. Determining the time, place, and circumstances of their death is the most dramatic expression of their need for control.

Depression, often precipitated by discovering one has a serious illness, exaggerates the tendency toward seeing problems in black or white terms. Solutions or even alternative possibilities are not considered. When a patient finds a doctor who shares the view that life is worth living only if certain conditions are met, the patient's rigidity is reinforced.

Strikingly, the overwhelming majority of those who are terminally ill fight for life to the end. Some may voice suicidal thoughts in response to transient depression or severe pain, but these patients usually respond well to treatment for depressive illness and pain medication and are then grateful to be alive.(6) Those whose terror of illness, however, persuades them that quick death is the best solution may be willing victims of physicians who advocate assisted suicide.

Patients are not alone in their inability to tolerate situations they cannot control. From the physician's viewpoint, Lewis Thomas has written insightfully about the sense of failure and helplessness that doctors may experience in the face of death; such feelings might explain why doctors have such difficulty discussing terminal illness with patients.(7) A majority of doctors avoid such discussions, while most patients would prefer frank talk.(8) These feelings might also explain both doctors' tendency to use excessive measures to maintain life and their need to make death a physician's decision. By deciding when patients die, by making death a medical decision, the physician preserves the illusion of mastery over the disease and the accompanying feelings of helplessness. The physician, not the illness, is responsible for the death. Assisting suicide and providing euthanasia become ways of dealing with the frustration of being unable to cure the disease.

The role of physicians and lay advocates of euthanasia in determining the outcome when patients approach them with what is often an ambivalent request to die is one of the least understood aspects of the problem. That role is hidden when cases of euthanasia are virtually marketed to the American public in an attempt to persuade them that legalization of euthanasia is necessary. In this context it will be useful to look at such cases and to examine the role of the three people in this country who have done most to popularize euthanasia: Timothy Quill, Jack Kevorkian, and Derek Humphry.

Quill and DianeThe doctor assisting a suicide is not simply a dispassionate observer responding to the patient's needs and wishes. This is illustrated by the best-known case of assisted suicide in this country--Dr. Timothy Quill and Diane, his patient of eight years. Quill, an associate professor at the University of Rochester School of Medicine, presented a seemingly reasonable case in the New England Journal of Medicine(9) and in a subsequent book, Death and Dignity: Making Choices and Taking Charge.(10)

Quill, Diane's internist, tells us that she came from an alcoholic family and suffered from depression and alcoholism through much of her adult life. At the time of her death, she was a recovered alcoholic who had recently been diagnosed with acute leukemia, the same condition suffered by Tim, the patient mentioned earlier. Like Tim, she was given a one-in-four chance of surviving painful chemotherapy and radiation. Diane told Quill that "she talked to a psychologist she had seen in the past"(11) and implied that the psychologist supported her decision to end her life. After Quill helped implement her decision, he published his account to persuade the medical community to approve such actions.

Quill's account aroused considerable controversy among physicians, many of whom responded with letters to the New England Journal of Medicine for or against ending the life of a terminally ill patient. It was left to psychiatrists, most notably Dr. Patricia Wesley of Yale, to challenge both Quill's role in Diane's decision and his self-portrait as a compassionate figure responding in a disinterested way to a patient's needs.(12)

Quill tells us that once the suspicion of leukemia was confirmed by bone-marrow biopsy, the hospital oncologist, believing that delay was dangerous, "broke the news to Diane" and began plans for chemotherapy. When Quill saw her shortly thereafter "she was enraged at hthe oncologist'sesumption that she would want treatment, and devastated by the finality of the diagnosis."(13) She informed Quill that she wanted no treatment and wished to go home to be with her family. Instead of exploring with her what had occurred with the oncologist or the wisdom of making a hasty decision in anger, Quill tells us, "together we lamented her tragedy and the unfairness of life."(14)

Diane justifies her refusal of treatment and her demand for suicide by her need to be in control and by her conviction that she would die during the treatment for leukemia. Quill never questions Diane's insistence on total control--an impossible demand in the face of serious illness--nor does he see this insistence as a sign of depression. That Diane appeared composed after deciding to end her life is not surprising. Those who are suicidal (with or without physical illness) often appear less depressed after deciding to end their lives; coping with the uncertainties of life and death is what agitates and depresses them.

Quill also did not challenge Diane's certainty that treatment would fail, which she had no way of knowing. It is not surprising, given Quill's responses, that Diane went one step further than refusing treatment to ask for his help in dying. Although he initially told her he could not take part in her suicide, he tells us--and appears to have conveyed to her--that her request "made perfect sense."(15) Patricia Wesley points out that "it is frighteningly naive to assume that when our guide to medical practice is `doing what the patient wants,' we will escape the imposition of the physician's values on the clinical encounter. Personal values can be sequestered in the questions not asked, or the gentle challenge not posed, when both should have been."(16)

Quill responded to Diane's wish for assisted suicide by referring her to the Hemlock Society, describing it as "helpful" and implicitly confirming her attitude that "if you cannot be fully independent, you are better off dead." Wesley adds: "In making this referral and describing it as `helpful,' Quill once again powerfully shaped the clinical interaction between himself and his patient. It is not a neutral act to refer a patient contemplating suicide to the Hemlock Society.... It renders utterly incoherent to us, as possibly it did to Diane, Dr. Quill's claim that he had left the door open for her to change her mind."(17) Wesley questions whether the result would have been different if Dr. Quill had recommended a support group for cancer patients.(18)

Diane returned to Quill requesting barbiturates, which were the Hemlock Society's recommended method of suicide, and he prescribed them while assuring himself that she knew the lethal amount. He explains that he decided to help her because he feared "the effects of a violent death on her family" or "the consequences of an ineffective suicide."(19) He does not tell us whether these are his own fantasies or whether he was succumbing to the emotional blackmail of an explicit suicide threat.

Diane came to say goodbye to Quill shortly before her death and promised a reunion at her favorite spot on the edge of Lake Geneva, with dragons shining in the sunset. Quill concludes his account by regretting that legal obstacles prevented his presence at her deathbed and wondering whether he "will see Diane again, on the shore of Lake Geneva at sunset, with dragons swimming on the horizon."(20)

Quill's account, with its shared fantasy of reunion on Lake Geneva, arouses a sense that Quill's overidentification with Diane permitted his own needs and attitudes to intrude into the decision to assist her suicide. Death as a metaphor for reunion in a magical netherworld is a common fantasy among suicidal people. That both doctor and patient shared it suggests that neither really came to grips with the fact of death.

Although Diane's case is not a persuasive argument for assisted suicide or euthanasia, one might expect to find more convincing cases in Quill's book, Death and Dignity. Yet one does not. Quill makes the strongest argument for euthanasia with a patient who killed himself because he did not want to involve his family and friends in the illegal act of assisting in his suicide. This is not Quill's case, though; the story was related to him by a member of the Hemlock Society who was prepared to assist in the suicide before the patient decided to act alone.

Most of the book is a convincing demonstration of the wisdom of withholding or withdrawing treatments that prolong agony for dying patients. The effectiveness of the illustrations is marred by Quill's need to keep reinvoking Diane to continue justifying having assisted in her suicide. Diane reappears in virtually every chapter. Apart from defending his decision to assist her, Quill laments the fact that the need to avoid prosecution made it impossible for him to be with her when she took the pills he prescribed. But, with or without legalized assisted suicide, most people would want to die in the company of their families, not their family doctors; it would seem to be one of the advantages of assisted suicide over euthanasia. Quill's lament seems to bespeak an emotional involvement with Diane that clouded his judgment.(21)

Kevorkian and HumphryIf Timothy Quill raised the issue of assisted suicide primarily for physicians, the general public has encountered assisted suicide and euthanasia largely through the publicity campaigns of Jack Kevorkian, Michigan's "suicide doctor," and Derek Humphry, founder of the Hemlock Society. Many of the patients drawn to Kevorkian have been, like Diane, people whose terror of illness has persuaded them that quick death is the best solution: Janet Adkins, for example, was a woman in the early stages of Alzheimer's disease who feared the later progress of the disease. Ms. Adkins consulted Kevorkian, a retired Michigan pathologist passionately committed to promoting assisted suicide and the use of his "suicide machine." After a brief conversation, Kevorkian decided she was a suitable candidate and used the machine to help Ms. Adkins kill herself.(22) Clearly Kevorkian's lack of knowledge of her and his investment in promoting assisted suicide disqualified him from making such a determination. At the time, no Michigan law prohibited assisted suicide (most states have such laws), but Kevorkian was admonished by the Oakland County Circuit Court not to repeat the practice.(23) Disregarding the admonition, Kevorkian subsequently helped to end the lives of many others, some of whom were seriously ill but not near death.(24) One such patient, Marjorie Wantz, had a history of suicide attempts; she complained of pelvic pain, but an autopsy done after Kevorkian assisted in her suicide showed no evidence of physical disease.

Kevorkian's license to practice medicine has since been "summarily suspended,"(25) but a Michigan judge ruled that he could not be prosecuted for murder in the absence of a state law prohibiting assisting a suicide.(26) In 1993, Michigan passed such a law on a temporary basis, which Kevorkian violated with the avowed intention of testing whether the law was constitutional;(27) that law was upheld by the Michigan Supreme Court. Moreover, the court ruled that even in the absence of such a law--and the temporary statute eventually expired--assisting in a suicide could still be prosecuted as a felony.

Kevorkian goes beyond simply arguing for assisted suicide, however. He advocates creating a board-certified medical specialty, "obitiatry," based on a four-year medical residency that would train physicians in the practice of "medicide." A grandfather clause would permit pioneers like himself to be certified to develop the program. Kevorkian presents a detailed model plan for the state of Michigan, dividing it into eleven geographic zones, each with its own obitiatry headquarters and death clinic. He talks us through the process by which Wanda Endittal, a hypothetical patient with multiple sclerosis, seeks help to end her life. Her physician, Dr. Frieda Blame, refers her to an obitiatrist, Dr. Will B. Reddy. After an elaborate consultation process with other obitiatrists, including psychiatrist Dr. Lotte Goode, Wanda's case is referred to the "action obitiatrists." One of them, Dr. Dewey Ledder, makes a last review of her file, and the other, Dr. Shelby Donne, performs the medicide. The account reads much like a Swiftian satire on the world we would create if Kevorkian's vision were to be followed, and indeed Kevorkian recognizes that his plan "may sound overblown, overly grandiose or impractical."(28)

Kevorkian's fascination with death has a long and strange history. He was first called "Dr. Death" during his medical residency in 1956 because of his interest in photographing the retinal blood vessels of patients at the moment of their death in the hope of using the information to distinguish between death and coma, shock, or fainting.(29) He achieved notoriety a few years later with papers suggesting that death row inmates be anesthetized at execution time so that their living bodies could be used for experiments lasting hours or even months, after which they would be given a lethal dose of the anesthetic.(30) He noted that human experiments on criminals would save the lives of innocent animals killed in the name of science. He first used the word "obitiatry" in connection with these experiments.

His persistent interest in such experimentation led him to be a pariah among physicians and caused the loss of an academic appointment at the University of Michigan. "The medical profession made a mistake when they ostracized me," he told U.S. News & World Report in 1990. "I have no career anymore. This is the substitute."(31)

Derek Humphry, another prominent euthanasia proponent, assisted in the suicide of his first wife, wrote a book about it (Jean's Way),(32) and with his second wife, Ann Wickett, formed the Hemlock Society to support the right to assisted suicide. Humphry, like Kevorkian and Quill, tapped into deeply felt anxieties concerning dying in intolerable circumstances, anxieties that led some to support his efforts without regard for the consequences. Initially he claimed he would never send through the mail instructions on how to commit suicide because the information might get into the wrong hands.(33) Then he published Final Exit, a how-to-kill-yourself manual, and promoted its sales to the general public.(34) When asked about the contradiction between his original statement and his how-to-do-it book, he replied, "I simply changed my mind." Since the publication of Final Exit there has been a significant rise in the number of people--some of them young people found dead with the book nearby--who asphyxiated themselves with a plastic bag, a method recommended by Humphry.(35)

Humphry's participation in the suicide pact of his second wife's parents also raised questions. In her book, Double Exit,(36) her letters, conversations with friends, and her own taped suicide "note," Humphry's second wife, Ann Wickett, made clear that she was tormented by having actively participated with Humphry in the suicide pact of her parents.(37) Although her ninety-two-year-old father may have been ready to die, she knew that her seventy-eight-year-old mother was not. Such pacts have been romanticized and considered rational suicides, but published case reports confirm my own clinical experience that in most such pacts a man who wishes to end his life coerces a woman into joining him.

Even after death, euthanasia and assisted suicide can be a tool serving the idiosyncratic needs for power and control of its practitioners. Ann Wickett blamed Humphry for her death, accusing him of first abandoning and then divorcing her when she developed breast cancer.(38) At one point he left a message on her answering machine threatening to reveal her involvement in the death of her mother if she did not stop attacking him and the Hemlock Society. She had found it necessary to physically restrain her mother during the process of assisting in her death, which made her legally vulnerable in a way that Humphry, who had no such difficulty with her father, was not. Confronted during a national television interview with the taped threat to Ann Wickett, Humphry responded, "I did it in the heat of anger and I have my flaws and errors, just like everybody else."(39)

Selling Death and DignityDying is hard to market. Voters, many repelled by the image of doctors giving their patients lethal injections, rejected euthanasia initiatives in Washington and California. Learning from those defeats, Oregon sponsors of a similar measure limited it to assisted suicide, which requires the doctor to supply the means but not directly kill the patient. The patient assumes a role now familiar in euthanasia advertising: the noble individualist fighting to exercise the right to die.

Both assisted suicide and euthanasia have been presented as empowering patients by giving them control over their death; assisted suicide has been seen as less problematic, however, in that it offers protection against potential medical abuse, since the final act is in the patient's hands. Neither advocates nor opponents believe that it is possible morally or legally to permit assisted suicide and to deny its "benefits" to those too enfeebled to induce their own death.(40) Most advocates admit that assisted suicide is but a first step toward euthanasia, a step for which it is easier to win public acceptance.(41) Opponents see little protection in assisted suicide: people who are helpless or seriously ill are vulnerable to influence or coercion by physicians or relatives who can achieve the same results whether or not they participate in the patient's death.

Supporters of assisted suicide and euthanasia have found the ultimate marketing technique to promote the normalization of assisted suicide and euthanasia: the presentation of a case history designed to show the rightness of assisted suicide or euthanasia. Such cases may rely on nightmarish images of unnecessarily prolonged dying or predictions of severe disability. The extraordinary case where most would agree it was desirable to end life is represented as typical. Those who participate in the death (the relatives, the euthanasia advocates, and the physician) are celebrated as enhancing the dignity of the patient, who is usually presented as a heroic, fully independent figure.

How much truth is there in this advertising? Does this accurately describe what happens? Even in cases advocates believe best illustrate the desirability of legalizing assisted suicide, there is ample room to question whether the death administered in fact expresses the patient's wishes and meets his or her needs. To dramatize these model cases, advocates present them in some detail--and this creates the opportunity to see the discrepancy between the theory and the practice of assisted suicide and euthanasia.

How a death can be orchestrated and publicized to prove the value of assisted suicide was illustrated by an article featured on the cover of the New York Times Magazine in the fall of 1993.(42) The article described the assisted suicide of Louise, a Seattle woman whose death was arranged by her doctor and the Reverend Ralph Mero, head of Compassion in Dying, a group that champions assisted suicide. Members of the group counsel people who are terminally ill, advise on lethal doses, convince cautious doctors to become involved, and remain present during the death. Mero and his followers do not provide the means for suicide (the patients obtain such help from their doctors) and claim not to encourage the patients to seeks suicide.

Mero arranged for a Times reporter to interview Louise in the last weeks of her life, offering Louise's death as an illustration of the beneficial effects of the organization's work. Yet the account rather serves to illustrate how assisted suicide made both life and death miserable for Louise.

Louise, who was referred to Mero by her doctor, had been ill with an unnamed degenerative neurological disease. The reporter tells us, "Louise had mentioned suicide periodically during her six years of illness, but the subject came into sudden focus in May during a somber visit to her doctor's office." As Louise recounted it, "I really wasn't having any different symptoms, I just knew something had changed. I looked the doctor right in the eye and said, `I'm starting to die.' And she said, `I've had the same impression for a couple of days.' " A magnetic resonance image (MRI) confirmed early deterioration of the frontal lobes of Louise's brain, which led her doctor to warn her that she had at most a few months to live. Louise said her doctor explained that "she didn't want to scare me.... She just wanted to be honest. She told me that once the disease becomes active, it progresses very fast, that I would become mentally incapacitated and wouldn't be myself, couldn't care for myself anymore. She would have to look into hospice care, or the hospital, or some other facility where I would stay until I died."

We are told that Louise did not hesitate with her answer. "I can't do that ... I don't want that." The reporter continues, "Her doctor, Louise thought, looked both sad and relieved. `I know, I know,' the doctor said. 'But it has to come from you.'" Louise made sure that they were both talking about suicide and then said, "That's what I'd like to do, go for as long as I can and then end it."

What happened between Louise and her doctor? The doctor's quick affirmation even before the MRI scan had confirmed Louise's decline is somewhat disturbing. She prefaced a grim description of Louise's prognosis with assurance that she did not want to scare her. The doctor's relief when Louise chose suicide betrays the doctor's attitude toward a patient in Louise's condition.

As the account continues, the doctor indicated that she would be willing to help, had recently helped another patient whom Louise knew, and would prescribe enough barbiturates to kill Louise. To avoid legal trouble, she would not be there when Louise committed suicide. They exchanged several hugs and Louise went home.

The doctor was concerned that a friend and patient whom she had advised about assisted suicide had not died from medication he had taken; his friends had had to suffocate him with a plastic bag. The doctor called Compassion in Dying for advice. The reporter quotes the doctor as saying about contacting Mero, "I was ecstatic to find someone who's doing what he's doing.... I loved the fact that there were guidelines."

On the phone, Mero advised the doctor on the medication to prescribe and then visited Louise, suggesting that he was prepared to help Louise die before knowing her, meeting her, or in any way determining for himself whether she met any guidelines. When he did meet Louise, she asked him at once if he would help with her suicide and be there when she did it, and she was almost tearfully grateful when he said yes. He repeated many times that it had to be her choice. Louise affirmed that it was, saying that all she wanted "these next few weeks is to live as peacefully as possible." Louise seemed concerned with being close to others during her final time and with transforming her remaining days into a loving leave-taking.

The doctor was concerned that Louise's judgment might soon become impaired: "The question is, at what point is her will going to be affected, and, if suicide is what she wants, does she have the right to do it when she still has the will?" The doctor, like Mero, said she did not want to influence the patient, but was worried that Louise might not act in time. "If she loses her mind and doesn't do this, she's going into the hospital. But the last thing I want to do is pressure her to do this."

The closeness before dying that Louise seemed to want was lost in the flurry of activity and planning for her death as each of those involved with her dying pursued his or her own requirements. At a subsequent meeting of Mero and Louise, with Louise's mother and her doctor also present, Mero gave Louise a checklist of the steps to be taken during the suicide, from the food to be eaten to how the doctor would call the medical examiner.

The doctor indicated that she would be out of town for the next week, but that she had told her partner of Louise's plans. "You don't have to wait for me to get back," she told Louise, hinting, the reporter tells us, that it might be a good idea not to wait. The doctor was more direct when alone with Louise's mother, telling her that she was afraid that Louise might not be coherent enough to act if she waited past the coming weekend.

The doctor and Mero discussed how blunt they could be with Louise, wanting her to make an informed decision without frightening her into acting sooner than she was ready. They hoped "she would read between the lines." Mero assured the reporter that he always wanted to err on the side of caution. Mero is described by the reporter as "a cautious, deliberate man who is not necessarily joking when he says: `I was spontaneous. Once. When I was nine years old.'" When discussing Compassion in Dying, Mero "talks so slowly that a listener sometimes wonders if the next word will ever come."

A few days after the meeting, Mero called the reporter in New York and asked her to come to Seattle as soon as possible. He knew she was planning to come the following week, but he warned her not to wait that long.

The reporter left immediately for Seattle and found Louise in a debilitated condition. She was in pain, getting weaker, and spoke of wanting to end her life while she could still be in control. She said she was almost ready, but not quite. She needed about a week, mainly to relax and be with her mother.

The reporter "blurted out" to Louise, "Your doctor feels that if you don't act by this weekend you may not be able to." Her words were met with a "wrenching silence," and Louise, looking sharply at her mother, indicated that she hadn't been told that. Her mother said gently that this is what the doctor had told her. Louise looked terrified, and her mother told her that it was okay to be afraid. "I'm not afraid. I just feel as if everyone is ganging up on me, pressuring me," Louise said. "I just want some time."

Louise's mother was growing less certain that Louise would actually take her own life. When she tried to ask her directly, Louise replied. "I feel like it's all we ever talk about." A friend who had agreed to be with Louise during the suicide was also uncomfortable with Louise's ambivalence but was inclined to attribute her irritability and uncertainty to her mental decline. When Louise indicated that she would wait for Mero to return from a trip and ask his opinion on her holding on for a few days, the friend suggested that this was a bad idea since Mero did not know her well and might not understand the change in her mood.

Like many people in extreme situations, Louise expressed two conflicting wishes--to live and to die--but only for death did she find support. The anxiety of her doctor, Mero, her mother, and her friend that Louise might change her mind or lose her "will" may have originated in their desire to honor Louise's wishes, or even in their own view of what kind of life is worth living, but eventually their anxiety overrode the emotions Louise was clearly feeling and drove the pace of events more than Louise's will. Although those around her acted in the name of supporting Louise's autonomy, Louise began to lose her own death.

Confounding predictions, Louise made it through the weekend. Over the next days she was in touch with Mero by phone, but, he told the reporter, he kept the conversations short because he was uncomfortable with her growing dependence on his opinion. Nevertheless, after a few such conversations, the contents of which are not revealed, Louise indicated she was ready, and that evening Mero came and the assisted suicide was performed. A detailed description of the death scene provides the beginning, the end, and the drama of the published story. When, six and one-half hours after taking the sleeping pills, Louise did not die, her friend considered calling the doctor for advice, but Mero advised waiting. Had she not died from the pills, Mero subsequently implied to the reporter, he would have used a plastic bag to suffocate her.

After seven hours the end came. The doctor was called; the death was not listed as a suicide.

Everyone--Mero, the friend, the mother, the doctor, and the reporter--became part of a network pressuring Louise to stick to her decision and to carry it out in a timely manner. The death seems to have been virtually clocked by their anxiety that she might want to live. Mero and the doctor influenced the feelings of the mother and the friend so that the issue was not their warm leave-taking and the affection they had for Louise, but whether they could get her to die according to the time requirements of Mero, the doctor (who probably could not stay away indefinitely), the reporter (who was working with Mero to construct a story on an actual assisted suicide), and the disease, which obeyed a more flexible schedule than previously thought. Louise was explicit that all of them had become instruments of pressure in moving her along. Mero appeared to act more subtly and indirectly through his effect on the others involved with Louise.

Lisa Belkin, the Times reporter, describes in detail what happened, including her own role. Her account shows Compassion in Dying and Mero violating the limits they themselves set. The organization's guidelines state that its representatives evaluate the patient prior to making the decision to assist suicide, do not encourage patients to choose assisted suicide, and are never actively the agent for suicide. Ms. Belkin indicates that Mero agreed to help assist in the suicide even before meeting Louise. He advised her to act quickly, and he was prepared to be the agent for death if the pills did not work. The failure is not simply of adherence to Mero's own guidelines, but of the illusion that such guidelines truly operate to protect patients. Ms. Belkin's misgivings, evident throughout the piece, are perhaps even suggested by her title, "There's No Simple Suicide."

Without a death there would be, of course, no story, and Mero and Ms. Belkin had a stake in the story, although Mero had criticized Kevorkian to the reporter for wanting publicity. The doctor developed a time frame for Louise to act, conveniently coinciding with her own absence, although it would be medically impossible to predict with such precision when Louise would be unable to make a decision and, in fact, the doctor's prediction was wrong. Her own past troubled experience with a patient who was a friend seems to have colored the doctor's need to have Louise's suicide over with quickly and in her absence if possible. Louise was clearly frustrated by not having someone to talk to who had no stake in persuading her.

Individually and collectively, those involved engendered a terror that Louise bore alone while they reassured each other that they were gratifying her last wishes. The end of her life does not seem like death with dignity; nor is there much compassion conveyed in the way Louise was helped to die. Compassion is not an easy emotion to express in the context of an imminent loss. It requires that we look beyond our own pain to convey the power and meaning of all that has gone before in our life with another. Although the mother, friend, Mero, and the physician may have acted out of good intentions in assisting the suicide, none appears to have honored Louise's need for a "peaceful" parting. None seems to have been able to accept the difficult emotions involved in loving someone who is dying and knowing there is little one can do but convey love and respect for the life that has been lived. The effort to deal with the discomfort of Louise's situation seems to have driven the others to "do something" to eliminate the situation.

Watching someone die can be intolerably painful for those who care for the patient. Their wish to have it over with quickly can become a form of pressure on the patient that must be separated from what the patient actually wants. The patient who wants to live until the end but senses his family cannot tolerate watching him die is familiar to those who care for people who are terminally ill. Once those close to the patient decide to assist in the suicide, their desire to have it over with can make the pressure put on the patient many times greater. The mood of those assisting is reflected in Macbeth's famous line "If it were done when 'tis done, then 'twere well it were done quickly."(43)

Certainly assisted suicide--the fact that she took the lethal medication herself--offered no protection to Louise. It is hard to see how her doctor, Mero, her mother, her friend, and the reporter could have done more to rush her toward death.(44)

Euthanasia advocates like Mero reassure themselves and try to reassure others that they are behaving responsibly because they repeatedly ask patients, "Are you sure you want to kill yourself?" or they say, "You don't have to go through with this." This is repeated like a mantra designed for the protection of the practitioner; the patient is expected to respond with the obligatory "Yes, I want to" answer. The patient's interests would be better served by a willingness to hear what the patient is really feeling about her situation and how illness has affected her view of her own past and of her present relationships.

Unlike the detailed account presented by Ms. Belkin, most case reports are vignettes limited to one or two paragraphs describing the patient's medical symptoms; they usually leave out the social context in which euthanasia is being considered, obscuring the complex and often subtle pressures on patients' "autonomous" decisions to seek death. The opening chapter of Choosing Death, a book of essays about euthanasia, describes four cases in which euthanasia is presented as indicated or warranted.(45) Although the authors do not point it out, in every case the detailed narrative makes clear that the motives and personality of another person who could not stand to see the condition of the patient intruded upon what was happening. In one case a patient's homosexual lover cannot bear to watch him suffering; in another a doctor is considering strangling his father, also a doctor, because he cannot endure his father's growing dementia; in a third case a husband whose wife is a stroke victim who will die in a few days cannot wait because the situation recalls his mother's attending for years to his father, who was also a stroke victim; and in another, nurses who cannot stand the suffering of a patient contemplate ending her life, although she has given no indication of wanting assistance in dying.

In the selling of assisted suicide and euthanasia, words like "empowerment" and "dignity" are associated only with the choice for dying. But who is being empowered? The more one knows about individual cases, the more apparent it becomes that needs other than those of