Although concern about potential abuse is legitimate, the real ethical question is whether people have the right to choose how to spend their final days. Terminally ill British cancer patients often retire to hospices and spend their final days there receiving pain relieving injections of heroin, but no heroic medical intervention. These and other options will become heated topics of debate in the United States, as increasing numbers of people assert that they, rather than health care bureaucracies, should make the final decisions.

Two 1996 federal appeals court rulings that some claim enhance the care of the terminally ill may actually worsen their condition, some physicians say. The Second and Ninth Circuit Court decisions grant terminally ill patients the right to obtain a lethal dose of medication, equating it with refusing life-sustaining interventions.

But pointing to the experience of the Netherlands, doctors from the University of California, San Francisco, say that abolishing "the distinction between refusing life-prolonging treatment and obtaining suicide assistance could lead to inappropriate care for terminally ill patients."

Policies adopted by the Dutch have served as a model for proposed statutes in the United States. But efforts at regulating assisted suicide have failed in the Netherlands, concludes a related commentary in JAMA.

Analyzing studies conducted in the Netherlands in 1990 and 1995, the authors say that:

• About 59 percent of Dutch physicians do not report cases of assisted suicide and euthanasia -- even though required to do so by regulations.

• More than 50 percent feel free to suggest euthanasia to their patients -- although such prompting may compromise the voluntariness of patient consent.

• About 25 percent admit to ending patients' lives without their consent.

The estimated total number of deaths caused by active physician intervention in the Netherlands increased from 4,813 or 3.7 percent of all deaths in 1990 to 6,368 or 4.7 percent of all deaths in 1995. Thus, "Given legal sanction, euthanasia, intended originally for the exceptional case, has become an accepted way of dealing with serious or terminal illness in the Netherlands."

Sources: Ann Alpers and Bernard Lo, "Does it Make Clinical Sense to Equate Terminally Ill Patients Who Require Life-Sustaining Interventions with Those Who Do Not?" and Herbert Hendin (American Foundation for Suicide Prevention) et al., "Physician-Assisted Suicide and Euthanasia in the Netherlands: Lessons from the Dutch," Journal of the American Medical Association, June 4, 1997.

The Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM), both highly-respected medical journals, have looked at the same evidence on doctor-assisted suicide in the Netherlands and come to entirely different conclusions.

Dr. Herbert Hendin, a psychiatrist in New York who opposes doctor-assisted suicide and co-authored of the JAMA report, doubted the results of the first Dutch report when the findings were published last fall in the NEJM.

The earlier NEJM report maintained that the Netherlands has not seen a wholesale increase in doctor-assisted deaths of terminally or chronically ill patients in recent years Hendin arranged for a review of the data and came up with startlingly different conclusions.

• Doctor-assisted suicide and euthanasia are still technically illegal in the Netherlands, but have been widely practiced for two decades, and six years ago the Dutch government set up a system designed to encourage doctors to report such practices -- promising to protect them from punishment if they followed certain guidelines.

• JAMA contends that doctor-assisted deaths in the Netherlands have increased 27 percent in five years, with physicians administering fatal doses of pain killers to "fully competent" patients without getting their approval in many cases.

• On the other hand, NEJM maintains that such deaths in the Netherlands have not appreciably increased, and -- according to the author of the original Dutch study -- a request to do whatever was necessary to ease pain had been made by the patient at some point.

The original researchers confirm an increase in "euthanasia" deaths overall but argue that, as a percentage of all deaths in the Netherlands, the rise isn't statistically alarming and is attributable to an aging population, cultural changes and a high incidence of cancer -- rather than doctors running amok.

• The NEJM study cites figures that show doctor-induced deaths accounted for 2.3 percent of all Netherlands' deaths in 1995, up from 1.9 in 1991.

• The JAMA study concludes the gap widened from 1.7 percent to 2.4 percent.

Hendin claims there were nearly 1,900 cases of doctors administering lethal doses of opiates to patients -- up more than 40 percent from 1,350 such cases in 1990. He charges that in the vast majority of cases "no request for death was made by the patient" and that substantial numbers of patients were mentally competent.

NEJM executive editor Marcia Angell counter-charged that much data in the JAMA article was "either misleading or irrelevant."

Source: Lucette Lagnado, "Top Journals Divide Over Assisted Suicide," Wall Street Journal, June 4, 1997.