*TC The Johns Hopkins neurologist was nearing the end of a busy, routine day at the hospital. He had finished seeing patients and was phoning in his last prescription, a refill for an anti-seizure medication. But the most important medical decision would make that day, one he had sweated over for weeks, weighed heavily on his mind. And now was the moment of decision.
He lifted the receiver and dialed 503-342-5748, the Oregon-based national headquarters of the Hemlock Society, a group that promotes the right of a terminally ill person to choose how and when he will end his own life.
With this phone call, the doctor was divorcing himself from what medical practice officially allows. This would not be a case he would discuss at grand rounds. The resolution of this case would be a well-kept secret. The doctor asked to speak to Derek Humphrey, founder and director of the Hemlock Society and author of the suicide manual, ''Final Exit,'' that topped the New York Times best-seller list last August.
He identified himself to Mr. Humphrey and explained that he had a patient in the final stage of a progressive, fatal neurological illness who wanted to prevent further agony by killing himself. The doctor had agreed to help.
''I frankly don't know how to go about it,'' the Hopkins neurologist told the suicide guru. ''I didn't learn this in medical school.''
For all his other patients, the doctor had done the things a doctor is trained to do. Diagnose the illness, treat them, teach them how to prevent certain types of medical problems and, in cases of fatal illness for which there is no known treatment, tell them honestly what to expect and give supportive care.
This case was different. The doctor was asked to assist in a mercy killing. It was that painful, challenging edge where the law, professional training and ethics banged against his human compassion and will to bring mercy and comfort to his patient. There was no known therapy that could halt the relentless ravages of this disease. For weeks his conscience had been a battleground of clashing values. The doctor's human side overcame his professional training.
This article is being written with the understanding that neither the doctor nor the patient will be identified. No facts have been changed, but both the patient and the patient's spouse are given a generic ''he'' or ''his'' pronoun that does not reveal whether the patient was a man or a woman. The doctor was willing to be interviewed because he thinks the issue of physician-assisted suicide needs to be discussed publicly and within the medical profession.
How to respond to a patient who wants to die was never touched on in his medical training. The only conversations he recalls about life and death were whether an individual patient should be resuscitated. The doctor said he did not feel he could discuss with other neurologists whether to participate in killing a patient. Doctors just ''don't talk to each other about this,'' the neurologist said. ''I can't think of anything else that's similarly guarded. I think it's uniquely secret.''
Mr. Humphrey sent the Hopkins physician his book by express mail and indicated one lethal potion that works particularly well -- a combination of a narcotic, a barbiturate and a muscle relaxer that also acts as a sedative.
After talking with Mr. Humphrey, the doctor called the spouse and relayed what he had learned. ''We talked about how to minimize suspicion on the part of the funeral home and coordinate it so that I would be in town when the act was done,'' the doctor said. The spouse called the funeral home and said his spouse was ill and expected to die soon and asked what the funeral home required at time of death regarding the death certificate.
With the full intention of writing a medical recipe for death, the neurologist wrote prescriptions for the three ingredients of the lethal potion and gave them to the patient's spouse. The doctor and the spouse shared the responsibility for helping to kill a patient who was not well enough to commit suicide alone.
The Hopkins physician said his decision did not come easily. While he did not consult his Hopkins peers about the case, he did talk with the patient's other doctors, a psychiatrist and an internist who practice outside Hopkins. ''They were both very supportive of this and promised confidentiality,'' the neurologist said. ''We had treated [the patient's] depression over a period of time. It was important to me to be confident that when [the patient] ultimately made this decision, it was being made in as clear an emotional and mental state as possible.''
He had also talked out his other concerns with the patient: ''that my action may come back to haunt me'' professionally or legally; that the spouse may be left with guilt feelings; that the potion ''might not work.''
''After discussing all these concerns, I told [the patient] I thought it was a reasonable thing for a person in [his] situation to decide to do,'' the doctor said.