I never saw a dead body until my first anatomy class. Today those who have willed their bodies to science receive letters of gratitude, visit with our students, and have their names put up on memorial plaques; but 37 years ago our subjects were derelicts and anonymous old men found dead in flop house hotels. George C, his name written on a tag tied to one toe, lay stretched out on one of the six dissecting tables in the anatomy laboratory that autumn morning when 1 was 22 and beginning medical school. I remember hesitating at the door and then joining my four partners at Mr. C.'s side, trepidation giving way to curiosity, the moment imprinted forever in my memory by the smell of formalin.

Physician aid in dying is a broader topic than euthanasia in that the latter usually refers to active euthanasia, while physician assistance also encompasses the issue of assisted suicide. Volumes could be and have been written on physician-assisted death. But my purpose here is to address a specific aspect of the topic: the policy implications with regard to proposed legislation on physician-aided death.

Although the title's reference to physician assistance suggests a focus on the role of the professional, what people often take to be most important and at the heart of the topic is the issue of the patient's rights, usually seen as being manifested in four different ways. First is the right to a dignified death, as free from pain and suffering as possible. In crossing national boundaries and preceding the organization of the professions and the creation of societies, this right is viewed as one that ought to be recognized.

Assisted suicide is a tragic issue, one of those for which the tools of mere logic are inadequate and in which the power of the individual case is compelling and seductive but not necessarily clarifying. Meaningful dialogue is difficult. Persuasion is limited because the resolution of the issue, on a moral level, must be founded upon fundamental notions of what it means to be human, especially in the midst of suffering or disability or at the point of death.

“[A] murder prosecution is a poor way to design an ethical and moral code for doctors,” observed the California Court of Appeal in 1983. Yet, physicians who have chosen to help terminally ill patients to commit suicide have trespassed on illegal ground. When skilled medical care fails to relieve the pain of terminally ill patients, some people believe that physicians may assist in these suicides. Others reject any kind of physician involvement. The debate on assisted suiczide and active euthanasia has focused on whether these acts can ever be acceptable. We propose to shift the debate to a less divisive issue: whether a caring physician who provides a suffering and ill patient with a prescription for a lethal dose of medication should be prosecuted as a felon. Even assisted suicide's opponents may object to such criminal prosecution. We propose to modify existing criminal laws to give physicians who assist their terminally ill patients in suicide, under carefully defined circumstances, a legal defense against criminal charges.

Physician-assisted suicide is a novel idea having affinities with both suicide and euthanasia. It has affinities with suicide because it involves a self-inflicted death, and it has affinities with euthanasia because the physician is instrumental in the death. It is, however, not exactly either, making it the subject of an exciting debate.

There has been no informed or honest debate in North America over the issue of liberalized euthanasia. Despite thousands of newspaper stories, scores of learned academic articles, a handful of closely analyzed legal decisions, and hours of broadcast news and talk show imagery, a full discussion is yet to begin.

In advanced technological societies there is growing concern about the prospect of protracted deaths marked by incapacitation, intolerable pain and indignity, and invasion by machines and tubing. Life prolongation for critically ill cancer patients in the United States, for example, literally costs a fortune for very little benefit, typically from $82,845 to $189,339 for an additional year of life. Those who return home after major interventions live on average only 3 more months; the others live out their days in a hospital intensive care unit.

I graduated from medical school in 1957. I first went into hospital practice for 3½; years, and then went to Africa for 5 years before returning to Holland to resume practicing as a Family Physician. I have also participated in the postgraduate training and education for family doctors in Amsterdam, Currently, there are approximately 2,300 patients in my practice, about average for a Dutch physi- cian. Ten percent of those patients are over the age of 65.

Over the last two decades, Dutch courts have left room for euthanasia (i.e., the deliberate termination of the life of a person on his request by another person). Although a crime under the Penal Code, euthanasia will usually not result in prosecution and conviction if it is committed by a physician according to rules of careful medical practice (including consultation of another physician); if the patient's request is voluntary, well-considered, and enduring; and if there is unacceptable and hopeless suffering and there are no other solutions to the patient's situation.

Is it remarkable that the Royal Dutch Medical Association (RDMA) as a medical professional organization has the point of view that in particular circumstances euthanasia is an acceptable act for a physician. Seen from the viewpoints in the international (medical) community, we might say that it is highly remarkable. Frankly put: the RDMA has met strong international disapproval of its standpoint on euthanasia during the last 10 years or so. For instance, the World Medical Association still condemns physicians performing euthanasia as “unethical.” So far the RDMA is the only professional medical organization that holds the view that in particular cases euthanasia is morally acceptable. However, viewed within the context of Dutch society, the Dutch system of healthcare, and the sociocultural approach to moral questions in The Netherlands, the RDMA point of view ceases to be reprehensible.

The open practice of euthanasia in The Netherlands stood alone in the world until the government of the Northern Territories in Australia accepted the possibility of physician-assisted suicide. Even though the active ending of lives in The Netherlands is still a crime by law, the current practice allows it and acquits physicians if certain conditions have been met. Of the many facets of euthanasia, the teaching of this practice represents a further logical step. In this contribution, we intend to describe the comprehensive teaching program of euthanasia of the Free University of Amsterdam's Postgraduate Family Medicine Program. Here students receive university-based training for 1 day a week in a cohort of 12 and on the job training for 4 days with individual family physicians for 2 consecutive years. We especially intend to portray the integration of euthanasia into the wider teaching of the process of counseling and aid of the dying.

As a bioethical and social issue, euthanasia has become in the 1990s what abor- tion was in the 1960s. Around the world, a de facto taboo on open discussion of the practice is seemingly falling by the wayside, as recognition increases that “active” euthanasia is taking place in spite of social and legal prohibitions. Euthanasia, or more specifically physician-assisted suicide, has become the most visible bioethical issue of the present era; and in the United States the debate has taken on a prominence and urgency unprecedented in our nation's history.

In many countries the debate over the role that physicians may (or should) play in ending life has been limited to the judiciary and other law making institutions, professional medical organizations; and academics. Because of their multidisciplinary and diverse membership, ethics committees may be a particularly appropriate venue through which these discussions can be expanded to include a much larger community. In addition, ethics committees generally act in only advisory capacities because they do not actually make decisions, so they may provide a forum for open discussions in ways that the court and the medical boards (which make licensing determinations) cannot.

In The Netherlands, the close relationship between doctor and patient over time can be viewed as an advantage in protecting the patient. Is it possible to implement this aspect of euthanasia in the United States?

Hospital ethics committees in The Netherlands have had the unique responsibility of developing euthanasia policies for their institutions. Although each policy necessarily reflects a particular facility, family resemblances necessarily remain. In the interest of ethics committees outside The Netherlands that may soon face the same challenge, two such policies are presented here accompanied by commentary high-lighting their similarities and differences.

Over the past year the debate over physician-assisted death has been waged in several courts and legislatures, and before at least one electorate as well. Measure 16, the Oregon Death With Dignity initiative that would permit physician-assisted suicide in some circumstances, was approved by the electorate; but it remains on hold while a permanent injunction issued against it by a Federal judge is reviewed by the United States Court of Appeals. Another Federal court judge's decision that the Washington statute criminalizing physician-assisted suicide was unconstitutional when applied to the case of a competent terminally ill patient in intractable pain, was reversed by a three judge panel of that same United States Court of Appeals.