SAN FRANCISCO -- It's an insurance policy of sorts, and Richard Goldman stores it in his refrigerator vegetable bin: "Want to see?" he asks, unwrapping dozens of brown vials of morphine.
He has guarded the lethal drugs for years -- a do-it-yourself suicide stash willed to him by a dying friend, for use if Goldman, 47, decides he cannot face a lingering death from AIDS. But he'd rather not have to rely on these leftovers, with their expired use-by dates.
He'd rather have his doctors' help.
On Jan. 8, the Supreme Court will hear arguments on whether terminally ill patients have a constitutional right to end their lives with a doctor's help.
The question has special urgency in San Francisco. Here, acquired immune deficiency syndrome has created a large, young, assertive caseload of patients who have been forced to think about death.
Here, people from many segments of the community -- patients, doctors, nurses, ethicists, hospice workers, the disabled, people concerned with AIDS and people concerned with other illnesses -- have been pushed to consider whether they back legalizing assisted suicide.
There are people like Richard Goldman who stockpile drugs, planning to kill themselves alone if they have to. There are patients in support groups who routinely discuss suicide, trading formulas for fatal mixtures of medications. Some leave pills to friends, a legacy for suicide. Some share advice on approaching a skittish doctor obliquely, so as not to jeopardize the physician's license. ("I still can't sleep, Doctor. I need more of those pills you gave me last week.")
In the AIDS community, many people say they know physicians who occasionally, quietly help. Some San Francisco medical professionals have argued out a set of model guidelines for doctors, should the practice become legal. Even without legal sanction, one doctor estimates about 25 percent of AIDS deaths are assisted suicide.
"That kind of death is common and unreported," says Goldman, trained as a physician's assistant and now leader of an AIDS support group.
There's even a new vocabulary, for those who say the word "suicide" connotes desperation. They prefer the term "self-deliverance."
But for all the people arguing in favor of assisted suicide, there are many vocal opponents.
"What will happen to this society if we countenance the killing of sick and dying people?" asks Wesley J. Smith, an Oakland attorney whose book on assisted suicide will be published next year.
Instead of legalizing assisted suicide, Smith says, people should be fighting for more hospice care and better pain relief, to ease the last days of the dying. They should be guaranteeing counseling for clinically depressed patients, to help them cope with their illness.
"We're patting ourselves on the back about how sophisticated we are and how we stand up for individual rights. We look at [Dr. Jack] Kevorkian killing people, and we shrug our shoulders: If they want to die, they want to die. Don't we care about each other?"
The questions prompted by the issue are endless: Is every life worth living? Whose pleas for suicide help should doctors heed? Only people who are terminally ill? Patients in unrelenting pain? The disabled? Children? The profoundly depressed?
An issue of personal rights
For some people who have had to consider death, the issue is not complicated. It is one of personal rights.
Richard Goldman believes he should be able, without fear, to ask a doctor for help in dying.
"AIDS has changed the face of health care as we know it," he says. "People with AIDS have demanded to be a partner in their health care. We're no longer pawns doctors can write prescriptions for. We want to be partners in how we live and how we die."
Goldman directly sought his doctors' promises of help should he one day choose suicide. "It was such a relief to hear them say, 'I'll be there. We've done it. We'll continue to do it.' "
If they had refused, Goldman says, he would have sought "new doctors." But raising the issue was not easy. "It's like asking a physician to commit a crime."
Now on protease inhibitors, a new AIDS treatment, Goldman feels better than he has in years. His deep fatigue has eased. The AIDS-related cancer that nearly killed him in 1989 has not returned. It's unknown how long the new drugs will be effective.
He's not sure if he will ever use the morphine he has stored away. But he wants to know it's there. "It's just another option that's available to me."
Need to bring it into open
In San Francisco, doctors and patients say that many physicians will help when confronted with patients begging for aid with suicide. But few doctors will talk about it -- even to each other.
Dr. Fred Marcus, a Redwood City, Calif., oncologist, is one of the rare physicians who bluntly says that patients need to be able to ask for legal help with suicide.
Assisted suicides occur now, Marcus says, "more frequently than the public is aware. It's clandestine. It's underground. That's why it needs to be legislated and controlled."
Marcus supports the practice because he has seen people facing death in torment.
And they are pleading for the doctor they trust to help them kill themselves.
It has happened rarely, maybe 10 to 15 times in his 15 years as an oncologist, says Marcus. But there are patients for whom he can do nothing more and and whose pain cannot be eased.
In those rare cases, he says, laws against assisted suicide "get in the way of my being compassionate." To say no to these patients is "abandonment," Marcus says. "It is cruelty.
"I'm saying to them, 'You've been my patient all these years and now that you're on your deathbed, I'm turning my back on you.' No. I can't do that."
He picks his words carefully as he tells these patients' stories, mindful that assisting in suicide is illegal. Marcus will not say exactly what happened in these cases.
"I was asked," he says. "When the time came, appropriate things were done. Suffering was relieved."
When patients raise the issue of suicide -- and many do, though only a very few actually take their lives -- he pushes them to think hard. "Do you really believe that at the end of your life you want to participate in this, or do you want this to end naturally?" he asks.
If they insist they want to kill themselves, he first tells them it is illegal for him to participate. Then he might advise them to read "Final Exit," the suicide primer by Derek Humphry, founder of the Hemlock Society.
"I might say, 'If you took the whole prescription I gave you last week, with a little wine and something for nausea. ' Anyone can read that in 'Final Exit.' " Then, in very rare cases, he might say, "There are ways you and I could work out."
He is angry with what he sees as the smugness of the most rigid opponents of physician-assisted suicide. Many of them, he says, are administrators -- the doctors, nurses and hospice directors who aren't facing desperate patients every day.
Better care, not death
The opponents of assisted suicide say the dying won't be helped by making suicide easier. What will help, they believe, is better care -- stronger pain relief and more hospice programs to be sure no one dies alone and afraid.
Wesley Smith says proponents of assisted suicide have been beguiled by some dreamy notion of a gentle exit, propaganda he attributes to groups such as the Hemlock Society.
The suicide supporters are largely upper-middle class, he says, who can afford good medical care and are confident that no one will rush them toward death.
"They believe they will end their lives with their friends surrounding them." They're not impoverished people living in squalid rooms, Smith says. "There's nothing romantic about a single-room-occupancy hotel, and those are the people who can be most easily pushed into this."
The debate, he warns, comes as the economics of the American health system is changing. Care of the dying and disabled is costly. "There's tremendous money to be made in the premature deaths of people," Smith says.
If the practice becomes legal, "you're creating a social climate in which it's OK to say, 'This life isn't worth living.' What's lost in the euthanasia movement is the greater good of protecting the inherent value in every human life."
A Harris poll last year found that two-thirds of Americans favor allowing doctors to help a patient commit suicide. Smith describes his opposition as "politically incorrect" but says he believes the surveys will change if people are educated about the issue.
Like many opponents of assisted suicide, he talks of "the slippery slope" society stands on if it legalizes the practice.
People presume, Smith says, that only the terminally ill would have the right to assisted suicide. But more than half of Kevorkian's patients were not facing death within six months. And federal appeals court rulings did not limit the right to the terminally ill.
That puts the poor, the elderly, the depressed and the disabled at risk of being pressured to get out of the way, he says. "Our attitudes toward them will change," Smith says.
"A lot of people with disabilities are scared," says Paul Longmore, a history professor at San Francisco State University, who was partly paralyzed by polio when he was 7.
Opponents include powerful organizations. The White House disapproves, as does the American Medical Association.
"Although for some patients it might appear compassionate to hasten death, institutionalizing physician-assisted suicide as a medical treatment would put many more patients at serious risk for unwanted and unnecessary death," the AMA's court brief says.
Two federal court rulings last year, holding that the Constitution contains a right to assisted suicide, prompted lawyers, ethicists, doctors and hospice directors in greater San Francisco to plan for the possibility that the practice might become legal.
"Doctors aren't trained how to do this and what to consider," says Steve Heilig, of the San Francisco Medical Society, a University of California ethics professor.
During the past few months, the Bay Area Network of Ethics Committees, based at the San Francisco Medical Society, has ** produced model guidelines for care of the terminally ill -- for use should the Supreme Court find a right to assisted suicide.
The guidelines begin by urging that patients be referred to hospice programs, which specialize in making a patient's last days comfortable, or to a doctor trained in pain control.
The patient must be a competent adult with six months or less to live. (No teen-agers. No one in a coma. No one in unrelievable pain who isn't close to death.) He or she must be offered counseling for depression; must be urged to discuss death with family members; must not appear to be giving in to pressure from anyone.
The patient must be informed about how pills and injections work in killing the patient and must sign two witnessed requests for suicide, with at least 48 hours between the documents.
"Some people say this is too many requirements and it will drive it underground again," Heilig says. "But I have a lot of concerns about the slippery slope people talk about all the time. We've got to have some guidelines in place. And the point of all this is to make it rare."
'I'm the one with AIDS'
Jeffrey Fenston began to think about his death several years ago -- when he was diagnosed with AIDS the night before he was to run a marathon.
Today, he drives a car bearing a Hemlock Society bumper sticker: "Good Life/Good Death."
Like Richard Goldman, Fenston, 43, wasn't shy in asking doctors for assistance: "When the time comes, will you help me kill myself?"
For a moment, Fenston said, he feared he had made his doctors uncomfortable by asking them to break the law. "Then I thought: I'm the one with AIDS."
Both his physicians eventually agreed. But like Goldman, Fenston has been hoarding pills, just in case he's left on his own.
His cache includes foil packets of ice-blue Xanax and Halcion pills, hundreds of them -- an impressive collection of anti-anxiety and sleeping tablets that still doesn't amount to enough to kill him. A safe-deposit box holds more pills, some bought in Mexico.
What he really wants to make his inventory complete is Seconal, a powerful, dangerous barbiturate that's rarely prescribed.
But Fenston, who used to be a corporate travel manager, is sure that if he wants Seconal, he'll get it. If a doctor won't help, he will find the pills through the "underground pharmacies," AIDS patients' networks for sharing suicide drugs.
Sometime in the future, if AIDS overwhelms him, Fenston plans to ask his doctors for advice on which drugs to select for his death. He presumes he will take an anti-nausea medication, swallow hundreds of crushed pills and wash everything down with a shot of booze. He will be alone, careful "not to leave a mess for my friends to clean up." He will be the one who says when and how -- and he believes his doctors will help.
"The most esteemed quality in our society seems to be suffering," Fenston says. "Suffering is highly, highly revered. I want to say: Suffering is optional."
Pub Date: 12/29/96