“Out, Out, Brief Candle!”

I grew up in a multigenerational two-family home in Queens, New York City, during the 1960s and Seventies. Every weekend, my grandparents prepared a feast for the whole family. Among them were my mother’s younger brother, Marvin, and his wife, Inge, an artist who’d immigrated from Germany.

They were childless, but Marvin delighted in his four nieces, including my sister and me. A professor of Shakespearean literature, he read Macbeth and King Lear to us when we were young, along with the more child-friendly works of Lewis Carroll.

Shakespeare, as interpreted through Marvin’s voice, became a kind of life coach for me. But back then, I didn’t grasp the full import of Macbeth’s desperate cry: “Out, out, brief candle!”

Marvin’s own poetry was brutally spare—dark, honest meditations on life and death. Deeply curious, he devoured thousands of books on subjects from cosmology to philosophy. When I decided to pursue a medical career, he was proud, but occasionally lamented that I was trading poetry for memorization.

Inge, a few years older than Marvin, was scarred by her traumatic experiences in Nazi Germany; she suffered from PTSD and severe agoraphobia (including a fear of hospitals and medical clinics) that limited their travels to Manhattan. When Marvin retired, at age seventy, he continued to write fiction and poetry; but Inge, by her late eighties, was wheelchair-bound—blind, frail, incontinent and in chronic pain, with little left that gave her joy. Wary of strangers, she refused hospice; a local physician provided her basic care through home visits.

One Sunday in 2017, while visiting my parents in New York, I received a frantic call from Marvin.

“Judy, Inge was suffering; she begged me to help her die. She could no longer bear this pain of living. I had to act.”

“Marvin, what happened?” I asked anxiously.

“I put her morphine into the blender and fed her the slurry, but she’s still breathing. I need help.”

I told Marvin to sit at her bedside and hold her hand. With my husband, Rob (also a physician), I raced to Marvin’s apartment.

Inge had a pulse, but her breathing was shallow and irregular; she was barely responsive, even when we rubbed her chest to try to rouse her. She moaned occasionally, grimacing and appearing to be in pain. We needed to relieve her suffering.

“Please don’t let them take her to the hospital,” Marvin said. “She wanted to die here, with me.”

I had to think quickly: We needed medical help for Inge to die peacefully, but we also needed to protect Marvin from the potential legal consequences of having prepared the morphine mixture.

I called hospice and explained that Inge was actively dying and in distress. A kind nurse arrived, asked a few questions, then gave Inge a high dose of morphine via intramuscular injection, which allowed her to pass quickly and peacefully. Marvin spent the night alone in their apartment to process her death.

Afterward, he permitted us to confide this experience only to close family. Although it was clear how dearly he’d loved Inge, I feared the potential legal repercussions of his actions. To my relief, though, no questions arose.

Through the early months of the COVID pandemic, Marvin continued his literary activities, but he was miserable without Inge. By age ninety-two, his vision and mobility were declining; he was losing weight and complaining of abdominal pain.

“I’ve had a good run, but I don’t want to be alive anymore,” he told me. “Why should I stay around, with nothing left to give my life meaning”?

We urged him to seek medical help, but he feared losing his independence and remained pessimistic.

During this same period, as fate would have it, I’d been diagnosed with acute leukemia and was gravely ill. After a year of chemotherapy and a subsequent relapse, I was preparing for a stem-cell transplant. Our entire family was feeling overwhelmed.

One morning, my mother received a letter:

Dear Ruth,

I am sorry to end things this way and leave everything behind. There is no reason for me to stay around any longer. “Tomorrow, and tomorrow, and tomorrow.”

Love, Marvin

He was found lying peacefully in bed, surrounded by his books, with an empty morphine bottle nearby. His final words were entirely in character: succinct, wry and honest.

Over the following weeks, Rob and I shared the story of Marvin and Inge with some of our colleagues.

We felt that, in attending to Inge’s needs at the time of her death, we’d acted consistently with our duty as physicians—but our colleagues’ responses were mixed.

“Were Marvin and Inge depressed?” one asked. “If so, would treatment have been possible?”

“It’s illegal to give a loved one medication with the intent to end a life,” said another.

Still another implied that, as a doctor, I’d concealed the events surrounding Inge’s demise and might possibly have been able to prevent Marvin’s death. Some questioned whether helping to end Inge’s life was truly merciful, and whether anyone should end the life of another.

On the other hand, many physicians and non-physician friends and family members expressed support for Marvin’s actions. They understood how he’d felt at ninety-two—alone, his body and senses failing, no longer able to lead a meaningful life.

End-of-life discussions have long been part of my work in neurology, and I’ve spent decades helping patients and families navigate these moments. I reassure them that even if we cannot cure, we can comfort. Yet, like most clinicians, I recognize that, despite our best efforts, hospice and palliative care have their limitations. My own perspective, based on clinical and personal experience, is that we must find ways to alleviate suffering while also respecting individual autonomy.

A recently completed master’s degree in bioethics has deepened my understanding of the profound questions surrounding end-of-life issues. I believe that Marvin’s actions, on Inge’s behalf and his own, did not deny the value of their lives and humanity. Marvin claimed his own agency, and I believe that his actions honored Inge’s and reflected a spirit of beneficence, not maleficence.

I believe that choosing to help to end a loved one’s life, or one’s own, in the face of unbearable pain can be a rational and moral act—and that, despite fears of a slippery slope, Medical Aid in Dying (MAID) deserves serious, continued debate. MAID is currently legal in Washington, DC, and in ten US states, with three others actively considering legalizing it. It is also legal in at least a dozen other countries.

I think about these questions both as a physician and as a patient with an uncertain future (although my leukemia is in remission). I have no clear answers, but if I were in Inge’s place, I know what I would want.

Like Marvin, I’ve often turned to Shakespeare in difficult times. Even if Macbeth was right that all human ways ultimately lead to “dusty death,” I believe that each of us is more than “a walking shadow, a poor player, that struts and frets his hour upon the stage and then is heard no more.”

We have moral agency. Exercising it responsibly is the greatest challenge any of us can confront—and the most human thing we can do.