John smoked—a lot. Mostly back when cigarettes and martinis were still fashionable and Ronald Reagan's face adorned Chesterfield posters. Early years on the farm that his immigrant father had dug out of the Pennsylvania countryside were filled with responsibility and love. Childhood dreams were born in a one-room, clapboard schoolhouse with eight grades huddled around a coal stove. The teacher, fresh from the Pennsylvania Normal School, gave John his first taste of books and cigarettes. Neither one seemed dangerous at the time.

Then came that special girl. But her matriarchal Southern mother did not approve of the damn Yankee. Although she banished him from her house and her daughter, she could not stop the letters and the secret meetings. Soon the two young lovers stole away to the church up the street, picking up the required witnesses along the way. There they etched their love into the county registrar's book and eventually into the old lady's family Bible.

With Pearl Harbor, life settled into a happy routine of marriage, postponed dreams, and ration books that doled out cigarettes and sugar. Postwar days saw a good job as a machinist, promotion to shop foreman, a new baby girl, and a sense that some dreams could come true. Then came the angel of sudden death for his beloved wife. Her progressive mitral stenosis from old rheumatic disease brought her to the University hospital for one of the first commissurotomies, but not soon enough. At 46, he was left with his daughter, his books, and his Camels.

His world now centered on this little girl, who was both the remnant of his love and his life. He moved next door to the big white-columned house of his mother-in-law. There she and two widowed daughters, who had returned to the only home they had left, carefully watched over the child. Yes, there were days the little girl missed the presence of a woman she barely knew. But most days she was far too busy growing up in the safety of a father's love to be disturbed by such things.

As she grew, she shared John's passion for books and listened with her heart as he taught her compassion and integrity. School passed quickly and easily. She basked in his paternal pride. Then she declared her intention to apply to medical school. The family told her that Marcus Welby was a figment of some television producer's vivid imagination. But her father's piercing blue eyes just smiled. He reassured her that sensitivity and science were not mutually exclusive. Armed with his confidence and the innocent courage of youth, she soon conquered medical school, residency, and fellowship, and returned home to the University. The relationship with her father changed. Although John could never quite relinquish his little-girl picture of her, they now talked as adults. During long hours over coffee, they shared ideas. With her support he had quit smoking during her medical school years. But this decision was to come too late.

Caring for him as a daughter and not a physician, she entrusted him to Dr. Mike, her favorite pulmonologist. This triangle worked well. John continued a restricted but independent life in his own home, enjoying frequent visits from his two young grandsons. During these years, her career matured uneventfully until she was asked to assume the position of Coursemaster for the ethics program in the medical school. Without hesitation, she said yes. She had always been interested in ethics and she eagerly greeted this challenge. Fearing some inadequacy that might hamper her students, she immediately enrolled in graduate coursework in bioethics and returned again to the books that she had always loved. To enrich the offerings, she brought in physicians and ethicists of different backgrounds to work with the courses. The students met her enthusiasm in kind, and as students always do if allowed, taught her. Soon her work expanded to include housestaff education and often faculty as well. The problems were rarely easy and often none of the alternatives were pleasing.

Then the tobacco years began to catch up with John. The baseball games with his grandsons were replaced by checkers. The pulmonary function test results and arterial blood gases began their slow downward spiral. Finally, Dr. Mike suggested gently that now was the time for home oxygen. John was skeptical and reluctant to encumber what little freedom he had left, but was soon persuaded by the relentless dyspnea that dogged his every step. He asked her, "What do you think?" She hedged, "That's what we have Dr. Mike for". The Gemini twins of doctor and daughter battled to an uneasy truce. She arranged to be at his home when they delivered the system—a compressor for the house and a large liquid tank to refill the portable canister. She listened closely as they educated father and daughter about how it all worked.

John adapted quickly to his new appendage, and it could be found trailing him up a ladder as he hung new curtains in his house or under his car as he changed the oil. None of her elegant persuasion could slow him down. "So what if I fall off the ladder and break a hip? Maybe I'll die quickly," he would say. Only his worsening dyspnea could slow him.

Then one Thanksgiving, John made his first of many journeys to the medical intensive care unit. The careful attention of Dr. Mike and the housestaff paid off and John slid home, bypassing any real consideration of a ventilator. Three months and three hospitalizations later, John and his daughter sat in his room talking when one of her favorite residents came in.

"You know, I think I would like to take a trip," John said.

Not sure where this was leading, the resident replied, "Oh?"

"Yes, to Holland," said John.

The resident shifted his weight on uncomfortable feet and said "That would be nice. I believe the tulips there are really beautiful".

"Maybe," said John. "But mostly I would like Holland because they let you put people to sleep there like we do animals when they're suffering".

The resident's eyes mirrored the apprehension that crept into his soul. He rambled on about how John was a long way from that. The older man just smiled. His daughter, the doctor, thought a long time about what he had said.

John went home, calm and stable again for a time. Then Dr. Mike called: "John has discussed suicide with me and has made specific plans. I think you'd better remove the guns in his house if you can without upsetting him". Her father had collected and rebuilt antique firearms for many years. His finest pieces were displayed in a gun case he had carved by hand. And so, when John was away playing with his grandsons, she arranged to have all the ammunition and firing pins removed and stored at her house. If John ever noticed, he never spoke of their absence.

Another month, another hospitalization. Again he cheated the ventilator and made it to the floor. Then early one morning, her phone rang. John appeared to be in respiratory failure and in imminent danger of arresting. The resident had already called Dr. Mike. Dutifully noting the do-not-resuscitate order on the chart, the resident wanted to verify its accuracy.

"Yes, that's correct," she said. "If he arrests, you are not to begin CPR. You may go with inhaled ß agonists and other meds, but no intubation. I'm on my way". Her calm voice masked the terror she felt in her heart at losing this special person. She drove slowly and deliberately; a selfish part of her wished he would be gone before she arrived, sparing her the inevitable. He was not. The medicines had worked their magic again.

Two more months and two more hospitalizations later, she continued to think. Home was no longer an option. After his last discharge, she had arranged around-the-clock sitters. John stayed at home less than 24 hours. Whether from hypoxia or the blessing of some unseen angel, John became more forgetful and understood fewer details around him. After thoughtful consideration, she chose a hospice program especially known for its respiratory care. It was a hard choice, one made with her memory of his previous wishes and not his mind now. Dr. David, the director, was both geriatrician and a treasured friend of many years. The staff were efficient, caring, and concerned beyond her expectations, but that could not stop the tears as she toured the facility. Her promise of professional detachment withered and died.

The days and weeks stretched into spring and early summer, and she almost believed John could get well and go home. Dr. David mercifully said no. She came daily. John enjoyed the garden where she often took him outside to sit. They talked, reminisced, and tried desperately to hold fast to the moment.

Then came the yellow sputum again. The well-balanced triangle was now without one of its points, so the two remaining decided to forego the hospital and parenteral antibiotics and a ventilator in favor of oral antibiotics and continued close attention to respiratory therapy. Without speaking it, they knew what this would mean. She telephoned her office to cancel outpatients and lectures for the next several days. Fortunately, she was not on service; her partners had already accommodated her father's illness many times and she was glad she would not have to ask yet another time. The students had just turned in their final exams from the introductory ethics course, and she carried those to his bedside as she sat and they talked and waited together.

As the hours passed, John talked less and she thought more. The questions she graded took on a haunting significance: define and give an example of microallocation and macroallocation of health care; should health care for the elderly be limited—why or why not; develop two arguments for or against physician-assisted suicide; is physician participation in active euthanasia compatible with the practice of medicine in today's world and justify your answer; contrast three differences between the traditional Hippocratic oath and any one of the modern versions studied in class. She thought of Quinlan and Brophy and Cruzan, of Debbie and her ovarian cancer, and especially of Diane and Dr. Quill and the covenants that bind parent to child or physician to patient.

Seventy-two hours was a very long time. In the papers she held, innocent young students argued the pros and cons of assisted suicide and euthanasia. Before her eyes, John struggled and fought for every breath. In her mind, she saw tulips and heard the echoes of his wish for a trip to Holland. In her heart, she cried and wished for the courage to act.

Would it be so wrong to use the skills he had encouraged her to gain? The battling forces she faced were not good and evil, but rather the little girl who loved her daddy and wanted to stop his suffering, and the trained physician who wondered if medicine has the right to assert absolute control over every process of life. The decision to withhold John's care was a definable act with both an intent and a soon-to-be-seen effect. A syringe of stolen morphine, easily obtained and used compassionately, would also have intent and effect. Could she truly say that between these two acts there existed a moral difference of such magnitude that the scene before her was justified? In the end, she was powerless against the person he had taught her to be. When the time came, she quietly held him in her arms and kissed him goodbye. Then she rang for the nurse: "My father just died. The time was 3:49 a.m.".