* For obvious reasons we are not using the doctor's real name. The Dr. Francis pseudonym is a reference to Francis Bacon, who observed that physicians who are experts in a disease but unfamiliar with the patient may "cure the disease and kill the patient."

The first time Dr. Francis killed it was easy. It's often said that for a soldier, the first kill is the hardest. Then it gets easier, until you don't even see a human at the end of your barrel: The optic nerve hands the image of an attacker directly to trigger finger, bypassing the portion of the brain that considers pros and cons. But Francis was a doctor, not a soldier. And for him, it was just the opposite: The first few times it seemed so simple. The patients were comatose and dying anyway. He just turned up the morphine drip and sped them along. Then the postmaster came along, and mercy killing got complicated.

The post office she ran in that little town was no more than a trailer on the side of the road, lined with fake wood paneling and a few rows of brass boxes. She kept an electric heater by her desk. Every day she would wheel her oxygen tank out to her Oldsmobile, lower herself into the seat and drive to work. It was only a few hundred yards, but she was too short of breath to walk that distance anymore.

Dr. Francis knew all this when he stopped in to check the mail that day. They were all neighbors in that town, and it was hard not to know each other's business. He waved hello, took the letters from his box, and asked if she had anything else for him.

"Actually," he remembers her saying in her smoker's voice, "There is something."

She was dying, she explained. It was getting harder and harder to breathe. Her emphysema was only getting worse. And the lung cancer, well, the cancer had won. There would be no more chemotherapy. Her doctors had told her there was nothing else they could do for her. With the doctors gone, that left her alone. As she saw it, there was only one more thing she could do about her labored breathing. That's why she was asking Dr. Francis if he would get her enough barbiturates to put her gently to sleep and stop the wheezing permanently.

Looking back years later, Dr. Francis shrugs. "I thought her request was reasonable. She was saying, ‘Hey I can't take it now, and it's going to get worse. Let me get out of here.' And it—it just seemed intellectually reasonable. And, I think, emotionally reasonable." Then he stops, struck by the strangeness of the moment in retrospect: "Funny that that conversation would happen in a post office."

Post office transactions are constrained to the most trivial of exchanges. A few cents for a stamp. A few words about the weather. The color of the curb outside limits the length of conversations. Yet there they were, making arrangements to determine the question of existence for this woman. A week or so later he gave her the pills.

Although she was circumspect, word got around. Before long, others approached Dr. Francis, and he gave them what they wanted. The way things were going, he could have become an undercover Jack Kevorkian—helping people die without the media spectacle. But Dr. Francis bristles when I compare him to the doctor who has assisted in at least 45 deaths. "He's a pervert," Dr. Francis protests. "He's insane. No, I was just interested in helping this woman end her suffering. If I could have found another way to end it without ..." he pauses, then settles on the bluntest way of putting it, "without killing her, I would have."

Kevorkian is a polarizing figure. Many in the Death with Dignity movement regard him as a hero, while those who believe in the inalienable sanctity of life see him as a monster. Dr. Francis has far more in common with the former group than the latter; he believes in personal liberties and likes to poke fun at religious dogma. But on this issue, Dr. Francis has a weight of experience that keeps him from being polarized.

The doctor's hair and beard are white these days and neatly cropped. He wears rimless glasses which magnify his eyes, giving him a vaguely owlish look. We sit in his living room, holding cups of herbal tea. It has grown dark in the room as the light fades outside. He chuckles. "If I was somewhat [like] Kevorkian, it was in my ignorance."

It came as no surprise to him when he heard the postmaster died—but the way she died was surprising. She never took the pills. Intrigued, Dr. Francis inquired after the other people to whom he'd prescribed barbiturates. Not a single one had hastened their death.

And so began a small mystery: What had made every single one of these people choose the long decline they had once so desperately wanted to avoid? What had changed to make the end of their lives more fulfilling? Another doctor might have puzzled over this a while, then shrugged it off. But for Dr. Francis, this mystery took on a special significance. At that point in his life he had begun to question his role as a physician and was looking for lessons.

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"I was running an ER at the time, so I could see [all kinds of people]—people who drank, people who smoked a lot, people who ate too much, people who were accident prone, people who had trouble with relationships. I started seeing that their sicknesses or injuries didn't come out of a vacuum. And yet we had no handle on how they lived. We put Band-Aids on them and sent them back to the same crap. I began to see that I was mainly trained as a mechanic. Really what I was operating was a high-tech turnstile."

Perhaps it's obvious, Dr. Francis says, but at the time it was fascinating to discover that a person's culture, their values and priorities in life, the way they conducted their relationships, their fears and aspirations—that all these airy intangibles—could result in real, visible, bodily harm. And, he reasoned, this relationship should work in reverse as well: A patient's mind should be able to salve the afflictions of the flesh. After all, those people to whom he had prescribed pills had somehow found a way to cope with their own suffering after the tools of physical medicine had been exhausted.

This line of reasoning dovetailed with Dr. Francis' theory about what had happened with those people who'd asked him for suicide drugs: He'd made the wrong diagnosis. Dr. Francis had diagnosed life as the cause of their suffering and provided the appropriate prescription. But the real cause of their suffering, Dr. Francis thinks, was loss of control. Fortunately, his prescription provided a kind of off-label effect: "Those pills—having that parachute in hand—gave them a sense of control. And that sense of control—maybe it was just the illusion of control—but it was enough to evaporate that particular kind of suffering. The result is that people wanted to be around longer."

Hospice workers, doctors, and Death with Dignity advocates have told me that people die like they have lived. The people who make plans to hasten their death have often lived a life of exacting discipline. Terminal sickness often robs patients of control—control of their daily schedules, control of their bodies, control of their minds. Having this one last piece of power—power over of time of death—may ease the frustration that comes with loss of control. Numbers from Oregon, which legalized physician-assisted dying in 1997, support this idea. In the decade after the law passed, 459 people have received lethal medication and 292 used it.

Eventually Dr. Francis' doubts led him away from medical practice, but his interest kept him around the fringes. One day a group of cancer patients asked him to give some advice about pain control, and he stuck around afterward to watch. It was about what you'd expect: People would talk about what the doctors had told them, chat about the way they felt, make dark jokes about their common situation, and solicit advice. But there was something in this that interested Dr. Francis. So much so that he asked permission to come to the next meeting. He kept attending for the next five years.

In these meetings Dr. Francis watched as the cancer patients slowly unraveled the snarled threads of their fear, sadness, and self-pity. Often these strands led to the least expected places. The true source of suffering might have less to do with the indignities of dying than with fear of leaving a life unfinished, some loose end untied. But the most interesting thing Dr. Francis saw was that once people understood what was eating at them, they could act on it. There was almost always a way to end suffering.

Dr. Francis wasn't the only one to see this. While he was doing his soul searching, end-of-life care was evolving along parallel lines with the hospice movement. Back when Dr. Francis was young, end-of-life care was almost non-existent. The postmaster's doctors had said, "There's nothing more we can do for you." Today doctors tell their patients that, while they may not be able to make them live forever, hospice can almost guarantee a pain-free death.

Interestingly, the Death with Dignity movement followed a similar path. When Dr. Francis was handing out pills, the Hemlock Society was the leading organization in the Death with Dignity movement. The pages of its newsletters were filled with plans for suicide machines and detailed recipes for ending life. Since then it has morphed into Compassion and Choices, which places the focus on providing options and ending suffering, rather than simply providing the means for death.

Today, many people agree that suffering doesn't need to be the part of dying. But there's still plenty of room for disagreement. Dr. Francis thinks that those who advocate physician-assisted death may be too quick to dismiss the process of dying as an important part of life. And on the other side, he thinks the medical establishment still tends to focus on technical fixes with such blinkered obstinacy that it sometimes misses what the patient really wants.

"As soon as you put on the white coat you start thinking a little differently," he says. Dr. Francis remembers a meeting in which oncologists were consulting about a patient's breast cancer. The patient had said she didn't want surgery for any reason, yet as the doctors took in her information and began to reason out the possible treatments, that bit of data failed to penetrate.

"And they all said, ‘The only thing we can see here is surgery,'" says Dr. Francis. "They were thinking about how to fix the problem, not about what is good for the patient. And these are truly wonderful people. They care about their patients. They are personally warm. But you have to devote monastic time to keeping up with information in the field. The nature of our medical system is such that doctors must immediately come up with a solution, then move on. And that allows for our amazing technical expertise. But if you only see the problem, that obscures the real person."

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I ask Dr. Francis if this is what bothers him about Kevorkian—that he was so willing to provide a solution to the problem without taking the time to see the real person in front of him.

"Well, he doesn't know anything about the people. He just shows up in his van: ‘All right, who wants this?' It's like he's running a drive-thru, for christsake," Dr. Francis says.

Assisted dying, I suggest, fits perfectly into a medical system based on physical solutions. It's the last available technical fix. If you follow Western medicine to its logical conclusion, it only makes sense to find Kevorkian there.

Dr. Francis nods, "You could call him the living end."

Dr. Francis' work with cancer patients provides a glimpse into how a medical system that is not focused on physical solutions might work. He begins by asking his patient: What bothers you about having cancer?

"Of course I don't say it that way," he explains. "You can't ask straight on or people get pissed. You're supposed to understand that having cancer really bothers people. OK, cool, but what about it bothers you? After they talk about it a while they usually say, ‘What bothers me about it is I'm worried I'm gonna die.' All right, next question: What bothers you about dying?"

Figuring this out can take weeks. "It's not the kind of conversation you can have in a post office," Dr. Francis says. And the answers people give are often revelatory.

"Eventually you might come back and say, ‘I've thought about it for a while and what bothers me is I have unfinished business with my son,'" Dr. Francis says. "Well, vaya con dios, dude! Go do it."

Of course, things don't always come to such a tidy conclusion. Sometimes people would literally rather die than walk down the dark corridors of their souls to find some source of pain. Dr. Francis thinks that there's almost always a way to relieve suffering—but that's almost. There are always exceptions. He's humble enough to know that his philosophy won't work for everyone.

Dr. Francis has changed in the 40-plus years since he gave a prescription of barbiturates to the postmaster of that small town. He says he probably wouldn't do that today. While his thoughts on this dilemma are now much more nuanced than they were when he was young, one thing hasn't changed: He still thinks that the doctor he was all those years ago should have the right to prescribe those pills if that's what the patient requests.

"As far as what goes on in that little room, I don't think the law should be there. That's the closest thing we have to confessionals in secular society. The problem is doctors don't have priestly training," Dr. Francis says.

And the problem here, as he sees it, lies not with the doctors but with the society that cedes only that one small space for conversations about death.

"If we were truly a civilized society, we'd talk to each other long before we considered suicide. We'd have community networks. Part of the reason we talk about law and torts so much in the U.S. is we've lost so much of our community. In the old days if you were even out of sorts everyone knew about it and they'd drop off a lasagna for you. And now people are much more anonymous and less educated in speaking their feelings."

Medical technology continues to offer more options for extending life, which means that more people are going to have choices about how they die. To make this new technology a blessing rather than a burden, people will have to relearn a very old technology: The art of having a conversation about death that lasts longer than a 20-minute parking limit.