When I first knew Simon Rhoner he was in his prime: vigorous, self-assured, successful. He came to my office on a number of occasions and I admired him for his scholarship, his affability and his well-expressed opinions. Our relationship was collegial, and we always came to an understanding about any clinical matter. The only time I disagreed with him outright was when he brought up a theoretical case for active euthanasia. He wasn't surprised when I rejected his arguments: "I understand your position," he simply said. When I asked why he had raised the subject he stood up, paused for a moment, and said, "I have thought a great deal about this. We must all die, but sometimes the process achieves no purpose and is very unpleasant."
At another visit he asked if I knew about Sigmund Freud's arrangement. I didn't. Simon then told me about the cancerous growth that had been removed from Freud's palate in 1922, when he was 66 years old. Aware of the probable outcome, Freud asked his doctor to help him "disappear from the world with decency."
"Was Freud's request for active, or for passive, euthanasia?" I asked.
Simon looked me in the eye and said, "Active." FIGURE
A short time later I found a biography of Freud and discovered that there was more to the story. Freud survived the initial operation and continued his work for another 16 years, despite 33 additional operations, considerable pain, and the discomfort of a large, ill-fitting dental prosthesis. In 1939 Freud lay dying in England; the cancer had eaten through his cheek. Tormented by pain and no longer able to eat, he reminded his physician, Dr. Schur, of their arrangement. Schur promised to give him adequate sedation, and the next morning he administered a third of a grain of morphine. Freud fell into a peaceful sleep and died just before midnight the next day - roughly 36 hours after receiving the morphine.
I had known the Rhoner family for a number of years. Simon's wife, Kate, was an accomplished musician and gardener; their two children were, like their father, pursuing academic careers. At one point Simon spent his sabbatical year in Australia, with Kate. I missed my contact with him, but he came to consult me soon after their return. He seemed well, but there was a troublesome finding on the physical exam: a hard nodule on the prostate gland. We agreed on some routine investigations and a referral to a urologist. Soon after, a pathology report brought unwelcome news: malignant changes that extended to the outer limits of the gland. Simon was composed and matter-of-fact when we discussed the diagnosis and its implications. We accepted the urologist's recommendations for treatment, and six months later Simon felt like his old self. He was excited about his family's various projects and the imminent publication of the book he had written when on sabbatical. He left me a chapter, in which he had written about the medicalization of life. He argued that fixing up bodies and keeping them going as long as possible served the system's material values, not the patient's needs. He deplored the fact that, to demonstrate its power over death, the medical profession didn't hesitate to overrule the patient's wishes.
The following summer my wife and I spent an afternoon with the Rhoners at their summer cottage, which was nestled into the side of a rocky peninsula overlooking a long stretch of beach. The water was alive with white caps and spume; above, seagulls flew stationary on the wind. The setting had a natural orderliness. Behind the cottage, trapping the last warm rays of the day, was a bedrock patio. The textured rock was bordered with lichens - pink, avocado and red. Beyond were dusky blueberries with a touch of autumn in their leaves, robust huckleberries and waxy bayberries, all ringed by salt-pruned spruce, the blue sky and the scudding white clouds.
From inside the cottage we could hear strains of classical music, and in the midst of the conversation, Prokofiev's Dance of the Knights surged out. Simon got slowly out of his chair, wincing as he went to close the French doors. He saw me watching him and explained, "I was wrestling with my son on the beach yesterday; I must have strained my back."
The next day he came to my office. The pain was worse. A bone scan confirmed what we already knew: the cancer had spread.
"I'm not interested in castration," Simon said bluntly.
I mentioned other options but suggested that the urologist would be the best one to advise.
Simon's eyes blazed. "Therapy to the end! A useless battle with death. Where is the healing function of medicine? Doctor, do we have an arrangement?"
I put my hand on his shoulder and said, "I'll be your Dr. Schur."
Simon saw the urologist and opted for a second opinion in a distant city. He started a new therapy there, and all winter long dutifully flew back and forth. He seemed to be holding his own, but in the spring the pain returned. By May he could no longer make the flights. I met with the family. Simon did not want any more treatment. He was experiencing a lot of pain and wanted to die at home. I started a program for pain control.
Two weeks later, toward the end of the afternoon, Simon phoned. "I'm in agony," he said. "It's time for an injection."
Simon looked gaunt and exasperated lying on his bed. I drew up the equivalent of the next increment of his oral morphine and injected it.
"Will it be enough?" he asked.
I took his hand and said, "I'll be here for you."
Simon closed his eyes, shook his head, and said, "I'm not going to say goodbye." Then he waved me out of the room.
Downstairs, his wife and children waited. They very much wanted to care for Simon at home and were keen on learning about skin care, lifts and transfers, and pain control. We made arrangements for nursing support, and I wrote out prescriptions for pain relief.
On my next visit Simon let me know he had been annoyed with me.
"Why?" I asked.
"You know why. I didn't say goodbye to you but after the morphine injection I half hoped not to wake up. Furthermore, you made arrangements with my family that were not discussed with me." He looked at me severely and then grabbed my hand. "I forgive you," he said. "Now I suppose you want to confirm that my heart's still pumping."
Over the next month Simon was remarkably free of pain. A daily routine emerged, one that clearly reflected Kate's aesthetic sense. Every morning after breakfast she would help him downstairs to a comfortable chair that looked toward an eastern exposure. Here he had his coffee and read the morning paper. Simon showed me the view plane. Leading to the window was a vase of freshly cut flowers, and through the window was a small forsythia bush that would soon break into bloom. Next to the forsythia was a young serviceberry tree that in turn brought forth delicate white-brown blossoms. Beneath and around the splashes of colour were lush evergreens - junipers, pines and yews - and beyond the aromatic bark mulch and winter grass grew a slanting row of linden trees.
Late in the morning Simon moved to an alcove facing south near the kitchen and listened to music: Buxtehude, Bach and Chopin. The bay window was alive with colour: hanging plants merging with ferns and palmettos, through the window a thick spruce hedge, and above, in the distance, the sweep of a cedar-shake roof.
During the afternoon, in the family room, Simon organized his papers and worked on his correspondence. In front of him was a picture window overlooking the garden. Birds swooped into the feeders close to the window and then darted away to the shrubbery. This garden, full of wonderful highlights that merged and produced a whole, was in the centre of the city, but it could have been in Bouchard, Belingrath or Kew.
After supper, Simon's daughter read him Chekhov, but as the days lengthened, his strength began to fade. One week he was actively discussing the points in the story; by the next he was falling asleep in mid-sentence. His daughter would finish the story, and then his son carried him upstairs to bed.
By the last week of June, Simon slept most of the time. The stories and music continued, and when I visited there was always a gentle smile on his face.
The evening of the first of July my wife and I walked down to the harbour to watch the fireworks. It was warm, with just a puff of wind langorously propelling the sailboats across the yellow and magenta water. The crowd stirred as the curtain of night fell and the first rocket sizzled high in the sky, exploding in reds and whites and blues. Beautiful variations of colour continued to build in the night sky into a profusion of sound and colour. Then came a pause ... and a single rocket arched high over the harbour, exploding in a magnificent, luminous blossom of bronze and silver and gold. In the awed hush that followed my pager summoned me.
Soli Deo Gloria.