In homes across the Netherlands, family doctors are carrying out euthanasia at the request of patients seeking a dignified final release from incurable or terminal illness.
Dr. Herbert Cohen, one such practitioner, says he has been involved in "up to a dozen" mercy killings in the last three or four years and has always informed the police beforehand.
He has never been prosecuted.
"Before they die, they say the most marvelous things. Yes, I remember one old lady saying, 'I think I'm the only one who is not nervous in this room,' " Cohen said in an interview at his office in this small town near Rotterdam.
Lists of Patients
His files contain handwritten lists of patients to whom he has administered euthanasia, giving their age, sex and illness, but no names. He also has a simple "thank you" card designed by one man before he died.
Many of the patients who choose mercy killing are old and often suffering from terminal cancer. Some are young patients, suffering from acquired immune deficiency syndrome, doctors say, although they dismiss rumors of "euthanasia tourism" to their country by U.S. victims of the deadly virus.
Article 293 of the Dutch criminal code states that anyone who "takes another's life at his or her explicit and serious request" faces up to 12 years in jail.
But doctors usually avoid prosecution by following guidelines established as precedent since a landmark court case in 1973, when a doctor was acquitted after performing euthanasia on her terminally ill mother.
These guidelines dictate that a person must unwaveringly ask to die throughout a period of time. Other physicians must agree with a doctor's diagnosis and prognosis of the suffering as being unbearable and irreversible. The doctor then performs euthanasia if there is no other option.
The government is considering formalizing these rules.
The issue of euthanasia is divisive, but a 1985 poll in the Netherlands showed that 67% favored it. Opponents talk of barbarity.
"A man must not be allowed to take someone else's life," said Gerrit van den Berg, head of the Dutch Patients' Society.
No statistics exist, but Jeane Tromp Meesters of the Dutch Society for Voluntary Euthanasia estimates that there are 6,000 to 10,000 cases a year, an average of 20 a day at home and in hospitals.
'Prefer to Hush It Up'
"Doctors are not sure if and how they will be prosecuted, so they often prefer to hush it up," she said. "As patients are often very ill, it won't always arouse suspicion if they die."
Ger van der Werf, a family doctor, said that 51 of the 63 colleagues he surveyed had carried out euthanasia. He estimated that general practitioners perform about 5,000 mercy killings a year. His survey was published in a Dutch medical journal.
Many people are told they must leave the hospital and go home if they want euthanasia, Tromp Meesters said.
Cohen, 56, talks frankly about euthanasia and the ethics, giving poignant details about case histories.
Police File Cases
In the last few years, Cohen has warned police a day or two before he carries out a mercy killing and then contacts them afterward with details. Police formally file a case to the prosecutor's office, but it goes no further.
His most recent case was a 72-year-old man with cancer of the pancreas, a terminal condition. Cohen attended as the second doctor and visited the house several times.
"The other doctor and I rehearsed every move and even every phrase we would use," Cohen said. "It sounds sick, but if you don't, nothing happens." The doctors and patient agreed on a date.
"It went off smoothly, with only his wife present in the bedroom," Cohen said. "Barbiturates were administered intravenously to cause a coma in three to five seconds. The other drug was then injected, a curare drug which paralyzes all muscles, including respiratory muscles."
'Not Aware of Change'
Breathing stopped at once, the heart within 20 minutes.
"The person holding the patient's hand is not aware of any change," Cohen said. "There is no twitching or anything like that. I wouldn't know what is more dignified."
Nearly all of his euthanasia patients have terminal cancer, but he has also dealt with other diseases.
Cohen said he has good links with the police. Their attitude and relatives' comments were consolation for a task that has given him sleepless nights.
Cohen, who is Jewish, survived the Holocaust during World War II by hiding near Amsterdam.
"I'm a law-abiding citizen," he said. "It's a heritage of the war. You see hunger, illness, poverty. But the most important thing which scars you for life is the absence of rights."
The law has to be strict on euthanasia "because there is the slippery slope and not all doctors are angels," he said.
"I don't want to give the impression I'm proud of performing euthanasia," he said. "I'm much prouder if I can create the circumstances which make the patient change his mind."
60% Reject Euthanasia
About 60% of the cases he attends do not end in euthanasia, but with better drugs, care or counseling.
One patient who still saw no way out was a 33-year-old woman in a nursing home with rapidly progressing multiple sclerosis. She could speak only with difficulty, move one hand and was near the point where her respiration would fail, Cohen recalled.
He saw her every two weeks for six months and each time she asked to die. The woman, a divorcee with a 10-year-old child, was eventually transferred to a hospital for the euthanasia because her condition meant that she could not go home.
On the appointed day, a friend helped her put on make-up and choose what jewelry to wear.
Dutch health officials, including Dr. Bart Eyrond of the Dutch AIDS Policy Coordination Center, dismissed reports of "euthanasia tourism" by American AIDS patients, after disclosures that Dutch sufferers are requesting mercy killing and a few are getting it.
Tromp Meesters, who has received a handful of requests for advice from the United States, said she has counseled foreign AIDS patients not to come here, in part because it would be hard to find a doctor prepared to register them and then administer euthanasia.
One Amsterdam doctor, Sven Danner, said that about 10 Dutch AIDS victims have received euthanasia. He was personally involved in one such case, in 1985, he said.
Roy Buyze, spokesman for the Amsterdam Academic Medical Center, said that Dutch AIDS patients frequently ask for euthanasia because "their outlook is limited, to put it mildly," but doctors were reluctant to accede to the requests.