Dutch euthanasia: Is it for export to U.S.?

By ELLEN GOODMAN

AMSTERDAM - Halfway through our conversation, Gerrit van der Wal gets up to consult his dictionary. Surely, he says, there must be an English equivalent for the Dutch word gedogen.

The medical school professor, who conducted the most recent research on doctor-assisted death in the Netherlands, flips through the pages until he comes to the right place. "Gedogen," he reads slowly, "tolerance." Then he shakes his head and says, "No, that isn't quite right."

If the word is not easily translated, perhaps it is because the concept is so Dutch, so not-American. Gedogen describes a formal condition somewhere between forbidden and permitted. It is part of the Dutch dance of principle and pragmatism.

Here, drugs are gedogen. They remain illegal, but soft drugs like marijuana and hash are available in duly licensed coffee shops that dot this city.

And here too, euthanasia is gedogen. The ending of a life by a doctor remains illegal, but doctors who follow careful guidelines may grant their patients' death wishes.

I am here in this northern country awash with tulips and controversy because our own Supreme Court has been asked to decide the question of doctor-assisted suicide. Holland has grappled longer and more publicly with the end-of-life issues that we are only now beginning to confront seriously.

As Ad Kerkhof, a puckish psychologist at the Free University, says, "Holland has become a Rorschach test for euthanasia." Indeed, opponents look to Holland and describe this flat country as a land of slippery slopes.

In a week of interviewing, people bristled at the notion that Americans think the Dutch are ridding themselves of the old and handicapped. In fact "euthanasia" is defined here as the termination of life by a doctor at the express wish of a patient. Under the guidelines, the patient's suffering must be unbearable and without the possibility of improvement. The requests must be persistent and confirmed by a second physician.

Dr. van der Wal, warily leading me through his most recent survey of doctors, points out that only 2.4 percent of deaths in Holland happen with a physician's assistance. Nine out of 10 requests are turned away. Most of those who had assisted suicide were not nursing home patients but cancer patients in their 60s or 70s. They died in the last days or weeks of their illness, at home, treated by a family doctor they knew for an average of seven years.

The Dutch system is not fail-safe or without its own ethical dilemmas. Most euthanasia deaths are still (and illegally) not reported to the government. The most troubling discovery is that between 900 and 1,000 patients a year die from what they call "nonvoluntary euthanasia."

As doctors here note, a bit defensively, this is not the result of Holland's euthanasia policies. It exists unseen and unreported in countries, even our own, where doctors deliver lethal painkilling doses of medicine without consent.

In practice, half of those who were no longer physically able to give consent had expressed the wish for euthanasia earlier. Most were in the last stages of disease. But Dr. van der Wal agrees, "It's a weak point in your system if you don't know what the patient really wants. There is always the danger that you are ending life against the will of the patient."

It's a weak point as well that the Dutch laws don't make a distinction between mental and physical suffering. Not long ago, a psychiatrist performed euthanasia on a physically healthy woman who had lost her children and was in deep despair. He was acquitted in a case that left public confidence rattled.

The policy of gedogen doesn't help the Dutch decide what to think of those who value independence so much they want to control their own death. Nor does it help a doctor who carries the burden and power of deciding when someone has suffered "enough."

What is notable is that 71 percent of the Dutch remain firm in their support of euthanasia policies. There is a palpable pride in doing things "the Dutch way." Pride in a system in which the law evolves with public consensus.

Yet time and again, even the strongest supporters of euthanasia told me, as did a retired family doctor, Herbert Cohen: "Euthanasia is not for export." The difference between Holland and America, they say, is universal health care. No one here chooses to die to protect their family finances.

Perhaps what is exportable, though, is the Dutch tolerance for ambiguity. For living in the ethical gray zone, grappling with complexity instead of denying it, keeping open to change.

If there is an American parallel to the Dutch way, it might be a state-by-state experiment, a testing of different rules and experiences with assisted suicide. The truth is that we too want to find a way of dying that is both merciful and careful.

Yet today, in the countryside of canals and gedogen, it's not always easy to find the right words in an American dictionary.