"I WANT TO DRAW THE LINE MYSELF"

By JAY BRANEGAN/AMSTERDAM

Frans Swarttouw, former chairman of the Fokker aircraft company and one of the Netherlands' most colorful businessmen, bid an unusual farewell to his countrymen a few weeks ago. Stricken with throat cancer, the executive, 64, who once characterized an entrepreneur as "a guy who works hard, drinks himself into the ground and chases women," said he had stopped his painful therapy and opted out of a life-saving operation that would have left him an invalid. "I want to be able to draw the line myself," he said on TV. Three days later, he was put to death by a doctor. "His last evening at home was so cozy," his wife said. "Frans gave himself another quarter of an hour: 'One last gin and tonic and a cigarette, then we'll get down to work.'"

The touch of bravura was uniquely Swarttouw, but the candor about voluntary death was typically Dutch. While euthanasia and physician-assisted suicide remain taboo subjects in much of Europe and are contentious topics in the U.S., they have been openly debated and researched for more than 20 years in Holland, which has a record of pragmatism in dealing with thorny social issues like drugs and abortion. Euthanasia is still, under Dutch law, a crime punishable by up to 12 years in prison. But in fact, the Netherlands has tolerated the practice for more than a decade, and the number of cases has risen dramatically over the past five years. Have the Dutch found a sensible and humane way of dealing with the unbearable pain and suffering that often comes at the end of life? Or is this a policy run amuck?

The government has established official guidelines, and physicians who follow them are not prosecuted. "The euthanasia debate is far from over, but there is an acceptance of the phenomenon," says Gerrit van der Wal, professor of social medicine at Amsterdam's Free University. "There's less discussion of the pros and cons, and more about how to control it."

Van der Wal was co-director of a major independent study published late last year on assisted suicide (in which the doctor gives a patient the means to end life) and euthanasia (in which the doctor terminates life at the patient's request). It concluded that there were about 3,600 cases in 1995 in Holland (pop. 15.5 million), a jump from the 2,700 cases estimated in 1990. Another 900 deaths fell into the troublesome category of "termination of life without the request of the patient."

Euthanasia is far more prevalent than assisted suicide (the Dutch make little moral or legal distinction between the two). Most patients were ill from cancer, and the large majority had less than a month to live. While more patients sought euthanasia or help with suicide in 1995 than before, doctors remained hesitant, turning down two-thirds of the requests.

The euthanasia movement was launched by a celebrated 1973 case of a doctor who helped her mother die and was then acquitted of criminal charges. That year the Dutch Voluntary Euthanasia Society, NVVE, was founded, and today its 88,000 members carry "euthanasia passports" and lobby for more liberalization. The Dutch Royal Society of Medicine endorsed guidelines in 1984, and today's de facto decriminalization represents a compromise between euthanasia foes and advocates of full legalization. Periodic controversies roil the debate. In 1994, for instance, the Dutch TV station IKON's filming of the death by euthanasia of a man with Lou Gehrig's disease in a documentary, Death on Request, brought a denunciation from the Vatican.

Both supporters and critics of assisted suicide and euthanasia point to Holland to bolster their arguments. "It's terrible medicine," says psychiatrist Herbert Hendin, executive director of the American Foundation for Suicide Prevention in New York City, whose recent book, Seduced by Death, brands Dutch policy a failure. The Dutch establishment, however, was reassured by the latest study. To address the biggest problem it found--more than half the doctors didn't report euthanasia cases to the public prosecutor as required--the government proposes that instead, doctors would report to a panel of legal, medical and ethical experts to make sure these guidelines were followed: the patient must be suffering unbearably from an incurable disease; he or she must make repeated requests for euthanasia; the doctor should know the patient well enough to ensure the request is voluntary, and the doctor must consult with another physician.

The Dutch claim their system has built-in safeguards. For one, most people still rely on a family doctor,which reduces the risk of routinized euthanasia by an impersonal system. For another, Holland's welfare state is alive and well. Nursing care for the chronically ill is good, and everyone's medical expenses are covered, so finances are not a factor.

Inevitably, of course, there are abuses, and flagrant ones are prosecuted. Sippe Schat, a doctor from northern Friesland, goes on trial later this month for the alleged murder of a 72-year-old cancer patient who had seemed in good spirits just before she died in a nursing home. According to prosecutors, Schat simply gave her a lethal shot of insulin without consulting anyone and left her to die alone, allegedly telling a nurse as he left, "If she hasn't died by 7 a.m. tomorrow, give me a call."

What about the 900 people euthanized without asking for it? Admits Van der Wal, "We don't like these cases, but we don't deny them either." The study found that about half the patients had earlier discussed euthanasia. Many were in great pain in the last days of life and were given morphine, which eased their suffering but also hastened death. The government has proposed tighter controls of these nonrequest cases, but practitioners say Holland's candor has merely thrown light on a common, if little discussed, medical practice. "Doctors all over the world shorten the lives of patients under the cover of pain reduction, and only we are stupid enough to talk about it," says Bert Keizer, a nursing home physician in Amsterdam, whose memoir about his life among the dying, Dancing with Mister D, was a best seller.

Keizer says he grants only one of the five or so "serious" euthanasia requests he gets a year. "The process is so stressful that most physicians do whatever they can to avoid getting involved in euthanasia cases," he says. "It's still as emotional and difficult as ever, but the current climate makes it easier to discuss with the patient."

That's just the problem, insists Amsterdam psychiatrist Frank Koerselman, one of the few in Holland to buck the consensus. "Patients are scared by pain and the loss of their dignity, so they immediately start talking about active euthanasia," he said. "They are badly informed about alternatives." In particular, says oncologist Zbigniew Zylicz, who runs a hospice for dying cancer victims outside Arnhem, "the knowledge and practice are very low for palliative care," the art of easing pain in the final stage of a terminal illness. Zylicz estimates that a quarter of the 400 or so dying patients he has treated asked first for euthanasia. After counseling and skilled use of painkillers, all but two agreed to die naturally. "We could cut the number of euthanasia cases to 50," he says. Acknowledging such arguments, the government recently called for more emphasis on palliative care.

For many terminally ill patients and their families, it's having the option that counts. When Annemie Douwes Dekker's husband Hink was first told he had multiple sclerosis in 1978, his family doctor agreed to discuss the possibilities of euthanasia if and when the time came. "That was a great help to us," Annemie recalled. Five years later Hink, then 50, had been in a nursing home for a year and was deteriorating rapidly, losing his ability to communicate and control bodily functions. Yet, says his widow, now 62 and living in Haarlem, "he had a strong heart; he could have gone on living for years."

When Hink first asked to be put to death, the doctors refused, but after a few more months and more requests, Douwes Dekker remembers, "They said, 'Your husband is ready for it.'" That weekend he came home from the nursing home to be with the family, and the doctor administered the poison. "He just faded away," she says. "I'm convinced we did the right thing. He died a good death."

That's what euthanasia means in Greek, good death. For the Netherlands, it's also good policy. Other countries will have to decide for themselves, but surely the Dutch style of open debate about a painful and difficult topic is the best way to do so.

--With reporting by Barbara Smit/Amsterdam

With reporting by BARBARA SMIT/AMSTERDAM