COLUMN ONE : Setting a Date for Death : By legally sanctioning mercy killing, the Netherlands has become an unwilling international model for the practice. But, as one family’s ordeal illustrates, euthanasia is never an easy way out.

Arjen Erich had been expecting the news, but the phone call at work one Wednesday afternoon last winter still left him feeling dazed.

“The hospital says it’s a go,” his youngest brother, Marcus, reported matter-of-factly. “It’s set for noon Friday.”

The family gathered around at the appointed hour. Marcus cracked jokes from his hospital bed. The doctor came in and handed him a glass filled with a dark liquid. Marcus took a sip and complained about the bitter taste, then swallowed the rest. Within minutes, Marcus was unconscious. For the next hour, his family sadly bade him farewell. Then, the doctor, visibly nervous and his hands shaking, administered an injection. Finally, the 31-year-old AIDS patient was dead.

It is a scene that has been quietly played out thousands of times over the last several years in the Netherlands, where laws forbidding euthanasia were on the books but tacitly ignored.

Now, however, the Dutch government is no longer merely looking the other way when doctors perform euthanasia; it is legally sanctioning the practice and prescribing a set of guidelines in a controversial step that makes this tiny country a somewhat unwilling international model for mercy killing.

“It’s been under discussion here for 20 years,” said Liesbeth Rensman, press officer at the Dutch Justice Ministry. “Society is changing. You can make a choice about letting people suffer a lot for what little time they have left. We’re mostly talking a matter of days, or maybe weeks, not months or years.

“It’s very humane and very careful.”

But a Feb. 9 vote by the lower house of Parliament approving the guidelines hardly ended the debate in this liberal nation of 15 million.

No definitive statistics are available, but as many as one in every 50 deaths is attributed to euthanasia or physician-assisted suicide. The number of euthanasia cases per year is thought to average 2,300, although critics argue that deaths falsely reported as natural could increase that number tenfold.

Religious groups and doctors who oppose euthanasia immediately raised alarms about coldblooded abuses, and a Vatican official publicly compared the Netherlands to the Nazis and their “final solution” program of genocide for Jews. There were unsubstantiated reports of elderly people refusing to enter nursing homes for fear of being put to sleep like an unwanted pet.

“In a civilized country, you kill the pain, not the patient,” said euthanasia opponent Karl Grunning, a retired general practitioner who heads the Rotterdam-based World Federation of Doctors Who Respect Human Life.

If the upper house of Parliament approves the new policy, as is expected, and it goes into effect, Grunning said that his organization plans to challenge it in the European Court of Justice on grounds that it violates the European Convention on Human Rights.

Worried that its international image of tulip fields and windmills might be replaced with sci-fi visions of murderous doctors or mass suicides, the Dutch government has launched a public relations campaign to counter what it describes as misunderstandings about its new policy. Fact sheets were translated into half a dozen languages and distributed to media organizations and Dutch embassies around the world.

But, as the case of Marcus Erich illustrates, there is behind the official press releases and public rhetoric a deeply human drama whose players insist that even under the most ideal circumstances, euthanasia is never an easy way out.

FRIDAY, JAN. 10, 1992: Marcus calls us on the phone. His health is deteriorating so much that he must be taken to the hospital. He does not eat, is nauseous and very tired. He has no strength. He has a fever. He takes many pills.

--From the journal of Arjen Erich

Marcus Erich had tested HIV-positive about seven years before he calmly set an appointment for his own death at the university hospital in Utrecht. Euthanasia had first come up at a family barbecue a few years earlier, his older brother Arjen would later recall, but nothing was resolved then.

“My own attitude was denial,” the 37-year-old employment counselor said while watching a videotape of Marcus’ last morning in the living room of his old farmhouse in this village near Utrecht. “I just wanted to talk about now and to keep hoping that somehow a cure would be found in time for Marcus.”

*

The September before he died, Marcus Erich attended an international conference on AIDS in London. A social worker and ardent activist on behalf of AIDS patients, he was deeply concerned about the lack of support and care for Third World victims of the deadly virus.

When he returned to the Netherlands, he was so weary that he couldn’t even make the half-hour trip from the Amsterdam airport to his Utrecht home. The AIDS organization he worked for booked him into a hotel for the night.

“He clearly said that he didn’t want to lose his mind,” Arjen recalled. “He had toxoplasmosis, which some AIDS patients get, and it causes dementia. In the last few months, he was starting to show symptoms, like paralysis in his arm and leg and memory loss.”

On Jan. 11, serious stomach problems landed Marcus in the hospital. Four days later, he began talking about euthanasia.

WEDNESDAY, JAN. 15: Marcus says that if he has to continue this way, only downhill, with short intervals of well-being, it has no use for him anymore. He doesn’t want to live any longer. When I ask him how he knows when the moment is there, he tells me that he will know when the time comes.

Dr. Hans Wessel never knew Marcus Erich, but he has killed patients in similar circumstances. The 44-year-old Amsterdam general practitioner does not hesitate to use the verb kill instead of euthanize . Of the dozens of his patients who might discuss or actually request euthanasia each year, he agrees to administer lethal drugs to three or four.

“Most of my euthanasia patients tend to be elderly, but the last one was 32,” Wessel said. “My patients have included those with AIDS, cancer and mental illness--schizophrenia.

“Doing euthanasia, I’m sick for a week afterward,” he added. “Is the patient manipulating me? Am I playing God? I’m quite ambivalent about it.

“It is awful to do it, to kill, to execute a life, but it is also a privilege to stand so close to a person, to be so intimate with their feelings and their way of life.”

Wessel says he decided to perform euthanasia during his first year of practice, 17 years ago. An old man with cancer begged to be put out of his misery. The young doctor refused.

“My medical training was entirely focused on keeping people alive,” Wessel said. “I didn’t see him as a whole, as an individual human being. When he finally died after many complications and much pain, I was really angry at myself for having been so disconnected and for not getting involved and in touch with his feelings.

“I believe my role in his life was bad,” he said. “I really felt guilty for not genuinely accepting him as a human being and respecting his way of life and his decisions. I still feel quite guilty when I think of him.”

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The government guidelines on euthanasia are essentially those that the Royal Dutch Medical Assn. established several years ago at the urging of physicians who wanted a way to test their judgment in cases where euthanasia was being considered.

The guidelines include a dozen “requirements of carefulness,” ranging from careful documentation of the patient’s case history to establishing that the patient’s suffering is “unbearable” and hopeless.

The patient must be lucid and request euthanasia repeatedly. The request also must be reiterated when the patient is alone with the physician, in an attempt to ensure that no one else is trying to pressure the patient into euthanasia. The doctor must seek a second opinion.

Under the new guidelines, if doctors follow the rules explicitly and report euthanasia to the proper authorities, they are virtually assured that charges will not be brought against them. The guidelines stipulate that anyone other than a physician is forbidden to perform euthanasia and will be punished.

*

“It is an oversimplification to state that euthanasia is accepted in the Netherlands,” Maurice A. M. de Wachter, director of the Institute for Bioethics in Maastricht, wrote in a recent report on the subject. “Certainly both debate and practice are more open and developed in the Netherlands than in any other Western countries, but Dutch society recognizes that many serious questions remain.”

An exhaustive government survey of euthanasia undertaken in 1990 found that the most common reasons for requesting euthanasia were loss of dignity, pain and being dependent on others. Pain alone was the reason behind only 10 of 187 cases.

THURSDAY, JAN. 16: The doctors want to call in a psychiatrist. It has to be clear that Marcus isn’t making this decision while in a depressed state. He dislikes it. They don’t take him seriously. But how can you not be depressed in a situation like this? He asks us to talk about it with the family.

The hospital spent three days reviewing Marcus’ request before deciding. Dutch doctors are quick to emphasize that euthanasia is not available simply on demand; two out of three patients are turned down.

When Marcus called Arjen to report the hospital’s approval, Arjen gathered his things, zombie-like, and took the rest of the day off.

“I had been expecting it, of course,” Arjen recalled, “but still it was a shock, to have it settled. To know the day your little brother was going to die.”

Whenever Arjen and his wife, Joke (pronounced YO-ka), visited Marcus in the hospital, he seemed always to be on the phone or just hanging up. How strange it must be, thought Arjen, to be telling your friends exactly when you are going to die.

*

The Erichs had collected information from the Dutch Society for Voluntary Euthanasia months earlier and were familiar with how the wheels of bureaucracy would turn. The society, founded 20 years ago by the patients of a doctor who was prosecuted for performing euthanasia on her own mother, has grown from 50 members back then to more than 60,000 dues-paying members today.

The Amsterdam-based organization serves as an information clearinghouse and patient advocacy group. Spokesmen say the new policy doesn’t go far enough, that euthanasia should be taken out of the criminal code altogether.

The group also advocates euthanasia in some cases in which the patient is unable to request it for himself or herself, such as when newborns are so severely deformed that there is no hope for survival.

Whether the severely mentally ill should be allowed to request and receive euthanasia is not clear in the guidelines, since “lucid” is not specifically defined, and the question is hotly debated.

“I know of a case where a woman had survived Auschwitz,” said Pit Bakker, a former chairwoman and current board member of the Society for Voluntary Euthanasia.

“She had outlived her family and she said: ‘Now I’m over 80. When I had my children and my husband, I could live with it. I can’t live anymore. Every night, I’m back in Auschwitz.’ ”

The woman’s request for euthanasia was granted, Bakker said.

*

“There’s always a subjective element,” said Dr. Ron Berghmans, a researcher at the Institute for Bioethics. “It’s up to the patient to evaluate their suffering. There’s no consensus on incompetent patients.”

Berghmans and other experts are reluctant to call the Dutch guidelines any kind of international model.

“Countries have different cultures, different values, different political systems,” Berghmans said in a telephone interview. “It’s not easy to take one solution and transfer it to another country.”

TUESDAY, JAN. 21: Joke buys forget-me-nots. Marcus writes his last will. Again we talk about the funeral, what should be on his grave. Forget-me-nots, lilies of the valley and crocuses, with a stone border and standing marker. He tells us which people from his address book do not have to be informed of his death. A good number of them are already deceased themselves. We want to be near him. We agree to come stay the night in the hospital the day before it happens. We are walking around with a stomachache. The closer we are to Marcus, the less it aches. It is very soothing to sit beside his bed and talk about everything with him.

Marcus’ doctor had told the Erichs that the euthanasia could be performed either by lethal injection or with a fatal “cocktail,” which Marcus would have to drink himself. Marcus said he didn’t want to be a hero if he didn’t have to; he preferred the shot.

But the Erichs’ trust in Marcus’ longtime physician was sorely tested the day before Marcus planned to die. Marcus had gained some strength and was eating again. This meant that he would be able to keep down a “death cocktail.” The doctor said he was sorry if there had been any misunderstanding, but he wouldn’t give Marcus a lethal injection as long as Marcus could administer the fatal drugs himself.

Marcus was angry at first, but when Joke began arguing his case, he just smiled at her and told her to let it be. He would drink the cocktail.

*

The memory still upsets Joke.

“He was probably going to die in two months anyway,” she said. “Why did they have to make it difficult?”

From his cluttered office where ceramic frogs compete for space with medical tomes and robust plants, Wessel has a perspective on that: “We’re trained to defeat death. I go through mourning and a bad depression even after a patient dies a natural death, but it’s a totally different feeling when I help them to die.”

He has had patients leave when they learned he practiced euthanasia, but Wessel is not aware of any seeking him out specifically so they could die. He cannot envision any type of “euthanasia tourism” in the Netherlands, such as there is for abortion, because there are no euthanasia clinics and because the guidelines and a doctor’s own conscience dictate that there be an established relationship of trust between the patient asking for death and the physician administering it.

THURSDAY, JAN. 23: We go to his home. We find his papers, and want to leave, when Joke says, ‘Doesn’t he need some clothes for Friday?’ Oh yeah, that’s true. ‘What kind of clothes?’ ‘Distinguished ones?’ We take his suit. . . . Joke takes a T-shirt with a pink triangle. At the hospital, he asks for the clothing. The distinguished ones are out; they no longer fit. ‘Didn’t you bring the T-shirt with the pink triangle?’ Dammit, we feel good chatting with each other. We make jokes, like we used to. Our brother Rogier makes a video. We take a last drink together. With his sedatives surely he will sleep now. We make jokes about the inheritance. He tells us to send the tape to “America’s Funniest Home Videos.” Then it is enough. We leave. When you are not with him, it is much more difficult. All kinds of thoughts continuously come to mind. This is the last evening together, this is the last time I walk through this corridor with him still being there. . . .

On Friday, Jan. 24, 1992, Marcus Erich’s three older brothers, their wives and his parents gathered in his hospital room for breakfast. Marcus was agitated when the meal was late. After eating, he ordered everyone out of the room, so “he could fix himself all up,” Arjen recalled. His family could smell the after-shave when they came back in. Marcus bid everyone a personal goodby.

There was a jigsaw puzzle there that Marcus had been working on. He loved the silly things. This one was of the Manhattan skyline. It was almost done, but not quite. Arjen and Joke felt sad when they looked at the pieces that would never find their places. A photograph of the unfinished puzzle would become Marcus’ death announcement.

“After we finish our coffee, I’ll ring,” Marcus said, and his family understood that he meant he would summon the doctor to help him die.

When the doctor arrived with the glass full of dark liquid, Marcus took a sip and grimaced.

“Yecch, it tastes bitter!” he complained. Then he swallowed it in a single gulp. “Couldn’t they have put some flavor in it?” he wondered. Arjen had a funny thought just then, but he didn’t speak it aloud: Who would sample a thing like that to test the flavor?

“What’s in this stuff, anyway?” Marcus asked. As the doctor began to explain, Marcus fell asleep, snoring deeply. The doctor had said death would come within half an hour. His family stood around the bed and murmured goodby. Have a safe journey, they kept telling him, sleep well.

“This went on for an hour,” said Joke, who, for reasons she still cannot fathom, felt compelled to rinse out the glass containing the vile potion, pausing to put just a drop on her own tongue.

Waiting for Marcus to die that afternoon, the family reacted in different ways. His father was stoical and characteristically silent, Arjen said.

“My mother had extreme difficulty. She has rheumatism and cannot cry. Mother spent the entire time talking nonstop to the doctor. He was telling her about Marcus, about how much he admired him, about their friendship. She can’t remember anything about it though. I can’t remember much either. It’s very strange.”

When it became clear that the potion had not worked, that Marcus was in a coma but not dead, the doctor kept his promise to intervene, bringing out the syringe from his pocket.

“His hands were shaking, and the head nurse had to whisper instructions to him,” Arjen recalled. Fifteen minutes later, Marcus Erich was pronounced dead.

FRIDAY, JAN. 24: Once alone with him, I speak out loud: “Goodby, buddy. I think you are utterly strong. I couldn’t have done it like this. Dammit, my little brother, have a safe trip.”

Having gone through this, Arjen Erich is at a loss to offer others advice. It is far too personal, he said. But of one thing he is certain: “People have to know that they are doing it for themselves. They need to know how difficult it is afterward for us. It was a tremendous blow.

“Both Joke and I fell ill with a bad lung infection. We were sick for three months. It doesn’t make it any easier for those you leave behind.”