IN 1995, doctors in the Netherlands assisted some 3,200 people to die at their own request - one in 40 of all deaths. In one in eight of such cases the doctor assisted the patient to commit suicide, but usually actually administered the poison after the patient had been given a sleeping draught.
The law draws no distinction between the two acts. In theory euthanasia in either form is illegal and subject to up to 12 years in jail but a doctor will not be charged if the clear guidelines are followed. Formulated by the Royal Dutch Doctors Association (KNMG), they were enshrined in law with a notification procedure in 1994.
But the practice has been accepted in the Netherlands for nearly 20 years, and has the support, polls suggest, of over 80 per cent of the population.
The guidelines require that four conditions be met: that the patient must - 1) be a mentally competent adult; 2) must request euthanasia voluntarily, in a considered, documented way, repeatedly over time; 3) be suffering intolerably, with no prospect of relief, although not necessarily terminally; and that 4) the doctor has consulted with another independent physician.
Now, on the basis of two major 1996 government commissioned studies (Van der Maas and Van der Wal) of both the overt and covert practice of euthanasia, the government is proposing substantial changes to the system, due to lie debated in parliament before the summer.
The idea, is both to improve transparency - allaying fears of doctors acting unaccountably - and to reassure doctors they have nothing to fear from the law if they act in accordance with the procedures.
It is proposed to supplement the coroner's current review of each case for the prosecuting authorities with a report from new local ethical committees composed of a doctor, a lawyer, and an "ethicist" (probably a philospher, scientist or priest).
The purpose, officials and ministers insist, is not to make euthanasia more or less available - the guidelines remain unchanged but to increase the rate at which doctors are prepared to report performing it. Despite the broad social acceptance of the practice, doctors admitted confidentially to the studies that they only report some 40 per cent of cases to the authorities for scrutiny (up, however, from 18 per cent in 1990).
Yet, despite figures that may be startling to the rest of the world, the Dutch insist euthanasia is widely practised by doctors elsewhere.
A recent, less extensive, survey of doctors in Washington state found that some 12 per cent had been asked in the previous year to assist in a patient's suicide, and 4 per cent to perform euthanasia. About a quarter said they did so, mirroring almost precisely Dutch figures.
A survey of British GPs and hospital consultants found that 14 per cent admitted to having performed euthanasia.
Moreover, according to an American Hospital Association estimate, about 70 - per cent of hospital deaths in the US occur - after a decision has been made to forgo treatment. And some 17.5 per cent of US deaths (20 per cent in Holland) are preceded by the use, for pain relief, almost certainly life shortening quantities of opioids, usually morphine.
ALTHOUGH legally permissible and ethically less difficult, the figures suggest that in the age of high tech medicine doctors everywhere are increasingly going to be drawn into the dilemmas surrounding the euthanasia debate.
In the Netherlands, despite the low level of official reporting, the surveys found that in virtually all of the reported and unreported cases the guidelines had been followed.
Demand for euthanasia has also grown steadily in 1995 doctors received some 34,500 requests for euthanasia some time in the future, up a third since 1990. The number of requests for immediate or short term euthanasia was 9,700 (up 9 per cent), but of this total only 37 per cent, or 3,200, were granted.
Doctors estimate that the time by which life was shortened was no more than a week in 91 per cent of cases, although both sides of the argument admit such guesses are notoriously imprecise.
In only two to five cases a year do psychiatrists comply with a request for assistance with suicide on mental rather than physical grounds - polls show only half the population regard euthanasia on mental grounds as acceptable. The number of cases in which doctors acted without the express request of the patient - not classed as euthanasia - declined slightly from 0.8 per cent of total deaths to 0.7 per cent. In such cases, because doctors face prosecution, the reporting rate is virtually zero.
A new special national ethical council will be established for such cases, with far tougher standards.
Court records show that between 1990 and 1996 13 doctors were charged with causing death, under all the above categories. Only six were found guilty - three received no sentence, the others, suspended sentences of between a week and six months.