LIVE AND LET DIE

March 2002

32’

Not a lot of note happens in Wyk aan Zee. It's just another windswept village on the North Sea coast of Holland that comes to life only for the brief summer season. So just under 10 years ago the municipal authorities were a bit perplexed about what to do when local GP, Arnold van Oudvorst, came and reported to them that he'd killed a patient.

DR ARNOLD VAN OUDVORST, GP: The prosecutor said, "Of course this is in legal way spoken, this is murder. So we'll look in your files and see if we prosecute you, yes or no."

It was Wyk aan Zee's first notified case of euthanasia, but it was dealt with without the sort of public outcry you'd expect in, say, an Australian seaside resort.

DR ARNOLD VAN OUDVORST: And a few weeks later - they were very horrible weeks - I got a letter that again thanks for admitting and everything was done as it should be done, and it was very...They told me it was done very well, so they won't prosecute me for murder.

REPORTER: No further action?

DR ARNOLD VAN OUDVORST: No further action.

REPORTER: Great relief?

DR ARNOLD VAN OUDVORST: Yah, but I have a record. A criminal record it's called? Yah, I have a criminal record.

This is George van Luijk. 56 years old and very recently a widower. Twelve weeks ago, he sat at his wife's bedside and watched her die when Dr Van Oudvorst gave her a lethal injection.

GEORGE VAN LUIJK: This is my first day on the water. I like it still. I can almost sail a little bit.

George has always wanted to learn to sail. Now it's a way of helping to cope with having lost his wife Henny after 30 happy years.

GEORGE VAN LUIJK: I can relax my mind, and that's good. That's good. Not that I forget, or I don't want to remember, but I can relax a little more, and that's good. That's good.

DR ARNOLD VAN OUDVORST: As a person, it's going - how to say? - It is like going through hell, I think. You know Henny will die, you know the patient will die. What you do, you do, she will die? But it is your hand which makes it quicker. But in your hand, it is your hand who helps the person die in a soft, nice way, not with suffering.

GEORGE VAN LUIJK (Translation): He used two things - a sedative and the lethal dose. But then she... she was still laughing then, she was laughing loudly. But when he gave the sedative she suddenly stopped laughing, all the colour left her face and her mouth fell open.

The stories of Dr Van Oudvorst and George van Luijk would provoke outrage and controversy in most societies. In the Netherlands, they no longer provoke even a raised eyebrow. On average, every day in Holland, at least 10 terminally ill people die by euthanasia with the assistance of a doctor, and it's legal.

REPORTER: You can imagine people looking at the Netherlands and reacting with horror saying, "Well, you have a society here where the society is actually helping people to commit suicide."

DR AYCKE SMOOK, ONCOLOGIST: That's in other countries it's the same, but they don't talk about it, and we talk about it, and that's the difference between other countries in my opinion, that we talk on every corner of the street about these issues.

The Dutch do talk these issues through, and manage to reach consensus on a remarkable range of topics that seem to elude so many other nations. So when some 25 years ago, doctors started to publicly admit they were helping their patients to die, rather than face unbearable suffering, there was no great demand to lock 'em up. There's a Dutch word - 'gedogen' - which broadly translated means tolerance of attitudes and ways of behaviour which are not necessarily condoned politically or legally. "Gedogen beleid" is a policy of tolerance, 'live and let live', and that's allowed euthanasia to gradually filter its way up through Dutch society until it's gained broad support amongst the community, until eventually the politicians have had the courage to legalise it. And it's 'gedogen' that seems to keep Holland at the cutting edge of liberal social reform. Take Amsterdam's coffee shops. At the Dampkring, you can openly buy a range of hashish and cannabis to smoke here or take away and yet it remains technically illegal to sell such drugs in Holland.

ERIC BORTSMAN, MANAGER 'DAMPKRING': It's not legal, it's not illegal, it's gedogen. There is a law that says you cannot sell drugs, but...

Eric Bortsman has been openly selling a big selection of dope at the Dampkring coffee shop for eight years and never been busted. Why? Because the community doesn't think it's damaging society, so the police don't see a need to act. And what's more, it's good business.

ERIC BORTSMAN: And when this became, let's say, bigger, then the police started thinking, "Well, we have to do something here." And I don't think it was because there was lots of trouble, but I think it was an economic thought. "People are making money and we're not. Let's get in there and bring the tax people and see how we can get some money, as well." And I think that's the reason why they started making rules in the 1980s.

As for the doomsayers, who predicted such tolerance would inevitably lead to a tidal wave of hard drug addiction, they've been proved wrong. Holland has the lowest heroin addiction rate of any developed nation. And as for why the Dutch seem so comfortable with 'gedogen' - this grey area between legal and illegal - there are almost as many opinions about its history as there are people in Holland.

ERIC BORTSMAN: In the 16th/17th century, when the Dutch, let's say, opened up the cities for refugees, political refugees or religious refugees - from these days on they wanted to have these people here because they wanted to make money and the Dutch are real merchants and I think that was the beginning of 'gedogen'. I mean, they wanted to have your business and they don't mind if you're from the Islam, or if you're Christian, or just bring your business to our country and we're happy with that.

The Dutch were amongst those who enthusiastically led the social and sexual revolutions of the 1950s and '60s, with early widespread acceptance of abortion, the contraceptive pill and legalisation of the sex industry. Today, it's not locals but tourists who frequent Amsterdam's red-light district, fascinated by such an open, crime-free and socially tolerated display of human sexuality. As with human sexuality, so with human mortality. The Dutch first confronted the issue of euthanasia 200 years ago.

DR AYCKE SMOOK: In Amsterdam, there was a person who killed his wife on her request and that was the first time that it came to court and the judge said it's not good what he did, but understandable. His wife was suffering so much, so he put a cushion on her head and she died.

It wasn't until the '60s that euthanasia again became part of the Dutch political agenda. It did so because of the efforts of people like Elly de Hullu, a convert to euthanasia, after watching her 6-year-old daughter lose a long and terrible battle with cancer.

ELLY DE HULLU, VOLUNTARY EUTHANASIA SOCIETY: When my eldest daughter was sick, we couldn't talk about euthanasia with our family doctor, that was not usual, it was not possible to get euthanasia, so she had to die in a natural way.

REPORTER: Which meant a long and a painful death?

ELLY DE HULLU: Yes, yes, it was terrible.

Today, Elly de Hullu spends a deal of time helping her surviving daughter in her work of making life more bearable for people confined to wheelchairs. And when she's not doing that, she's arguing the cause of euthanasia, as she has done now for 30 years.

REPORTER: Do you think that had euthanasia been available in the '60s that that's a route that you would have taken for your daughter?

ELLY DE HULLU: Yes, oh yes.

REPORTER: No doubt about it?

ELLY DE HULLU: No, no doubt about it, no.

REPORTER: And how could one make that decision on behalf of a 6-year-old child?

ELLY DE HULLU: Well, it is a little bit difficult. She didn't speak about her illness and we didn't speak with her, but I think it has to be possible that a child says, "Well, make an end to my life, it is so terrible I can't bear it any longer."

Almost three decades after their daughter died, Elly's merchant seaman husband was diagnosed with terminal cancer. When the pain became too much, they'd already decided together how he should die.

ELLY DE HULLU: Well, one morning he said, "Today it is enough for me, you'll have to call our doctor, and our doctor came and he gave two injections and after some moments, it was over.

REPORTER: And you'd had your chance to say goodbye?

ELLY DE HULLU: Yes, I said "Have a good trip," just as we said when we leaved the ship.

Back in the 1970s, there were, in fact, plenty of Dutch doctors quietly breaking the law. Cancer specialist Aycke Smook was amongst them. He could see no logical or ethical objection when terminally ill patients asked him to end their suffering.

DR AYCKE SMOOK: In my situation in hospital, also with the head nurse of the ward and then we went in sneaky in the rooms and we ended life - on request of the patient, of course. And afterwards, after have a coffee or something like that, we informed the family that their relative died, unfortunately we found him dead in bed.

Like many of his colleagues in the '70s Dr Smook tired of the hypocrisy of "sneaky" euthanasia. So they began to challenge the law by reporting their actions to the coroner and discovered that judges were prepared to accept that exceptional cases of great pain from terminal illness warranted euthanasia. Dr Smook's moment in court came when he pushed the boundaries by ending a patient's life at home rather than in hospital.

DR AYCKE SMOOK: In 1992, I was prosecuted after having helped a patient to die at home. And so I went three times to court, and in the final court they said, "The prosecutor is not accepted, the charge is not accepted, so he is free." It was the first time in a euthanasia case where there was no verdict of guilty.

Like our own politicians, confronted by growing public debate on such a huge ethical dilemma, Dutch lawmakers in The Hague were paralysed by indecision. For decades they did nothing, taking the easy option of allowing the courts to make decisions and lay down the law for them.

PROFESSOR EGBERT MYJER, AMSTERDAM CHIEF PROSECUTOR: What they did...said, was "Leave it to the judiciary," and what happened in this country was that in the final, it was the Supreme Court which made decisions, which laid down conditions in which euthanasia might be justified. Very strict conditions.

REPORTER: So in other words, it was an issue that was too hard for politicians to deal with and they left it to the courts to make the laws?

PROFESSOR EGBERT MYJER: Yes, they did the same with strikes of government officials, for instance. Also too hot a political issue, so leave it to the courts.

DR ARNOLD VAN OUDVORST (Speaking to Peter George): This is, we call "will". I believe you call it a "living will". In here are a few forms...

Despite the importance of the decision to legalise euthanasia, Dutch people will actually notice few changes under the new regime. And for doctors, the main difference is that a police investigator and prosecution is no longer a threat.

DR ARNOLD VAN OUDVORST: As a doctor you need this will. If you don't have this will, this will, or it's handwritten, people can write it themselves, but they have to sign it. If you don't have this will, euthanasia cannot go on.

Regional Ethics Committees now review each case to ensure procedures were followed and that a second, independent medical opinion confirmed that the illness was terminal and the patient was suffering unbearable pain and also voluntarily sought euthanasia.

PROFESSOR GERRIT VAN DER WAL, UNIVERSITY OF AMSTERDAM: I think in all Western countries there is a practice of euthanasia and assisted suicide.

REPORTER: Anyway, regardless of the law?

PROFESSOR GERRIT VAN DER WAL: Regardless of the law.

Professor Van der Wal spent years investigating euthanasia in Holland and around the world before helping draft the law that politicians finally accepted last year.

REPORTER: Do you think you're taking something of a step into the unknown?

PROFESSOR GERRIT VAN DER WAL: Oh yes, that's right.

REPORTER: And is that a risk?

PROFESSOR GERRIT VAN DER WAL: That's a risk, but a controlled risk, I think. But we have to realise that we sometimes are making steps in the dark, so I'm not afraid.

Yet, unease remains about what the Dutch have done, even amongst those who believe euthanasia should be an option. They're concerned that unless the society shows more compassion, the elderly and infirm may begin to feel forced towards euthanasia for lack of alternatives. At 88, Jantje has a few days left to live. Afflicted by a terminal cancer, she's chosen to die naturally at a hospice for the terminally ill in the provincial city of Alkmaar. Yet it is her good fortune to find one of only 84 hospice beds available in a country of 16 million people.

REPORTER: Is that enough?

ELLIS JONKER-HORTMAN, ALKMAAR HOSPICE: No, it's not enough. We need more, much more than 84 beds. I think about 1,000 would be a bit sufficient to fulfil the - what do you call it? The need. The need for hospice place.

Ellis believes euthanasia is only acceptable if the alternatives of hospices and palliative care are equally available to the terminally ill.

REPORTER: Do you think the government has failed in some ways, that whilst it's pushed ahead with euthanasia now, it's failed to push ahead with these alternatives?

ELLIS JONKER-HORSTMAN: I think so. When the only way out seems to be euthanasia, you have to inform people what choices they have. They want to have choices for other forms of care-taking, at home, or in hospice, or in a nursing home with special hospice places or in special units in the hospital.

CLEMENCE ROSS, CHRISTIAN DEMOCRATS MP: The elderly homes here, they're overfilled.

The Christian Democrats originally opposed euthanasia. Having lost that battle, they're trying to ensure the government puts money into the alternatives - palliative care and hospices.

CLEMENCE ROSS: We have a lack of personnel. People can only be showered or be washed once or twice in a week. So people don't feel very comfortable thinking that they will get old or perhaps die under such circumstances. So, I think, in these circumstances, it's very, well we should be very careful to talk about euthanasia as if it were a normal way to end your life. It's not a choice, it's something terrible that could happen and we don't want people to die like that.

And it is to these concerns that Holland's churches point in what appears to be a rearguard action against the widespread acceptance of euthanasia.

CARDINAL SIMONIS, CATHOLIC CHURCH: For me, the most terrible thing is the so-called "freedom" that you choose for death, but, in fact, it will be forced by my surrounding, because I am such a burden for my family and so on, and then the old mother says, "Doctor, I am such a burden for my children, make an end on it." So-called liberty.

REPORTER: Do you think, in the end, legal euthanasia is going to make it a lot cheaper for the state in terms of not having to have palliative care, hospices?

ELLY DE HULLU: No, no. No, and it's not a reason to legalise it.

REPORTER: No, but there's some people that argue that is the way this nation is going. Older people are no longer of any use. It's better to encourage euthanasia?

That's not true. No, no, no. In any case, patients - an old man or woman - has to take his own decision.

Already, the boundaries of who can die and under what circumstances are being pushed to the limit.

CLEMENCE ROSS: During the past few years we saw the practice developed into a direction that was not debated on. We saw that in the first place we were thinking of terminally ill people and after a couple of years, also mentally ill people, elderly and people who are tired of life came into the picture, and that doctors who committed euthanasia on these people were not being prosecuted.

Last year saw the case come to the highest appeals court in Amsterdam of a respected doctor who helped end the life of a controversial former Dutch senator who was suffering no physical illness at all. 86-year-old Edward Brongersma told the doctor his life had become a void and he longed for death. After months of discussion and obtaining a second opinion, the doctor, Phillip Sutorius, agreed to help the old man with a lethal cocktail of drugs.

PROFESSOR EGBERT MYJER: The Sutorius case is a case about an 86-year-old man, an academic, who was just tired of living. He was clear with his mind. He just said, "I am tired of living, please help me, let me do it the decent way instead of the indecent way by well, doing it the violent way."

Yet, even in the Sutorius case, the prosecutor sought a very Dutch solution.

PROFESSOR EGBERT MYJER: My legal opinion is that Dr Sutorius is a fantastic doctor and I ask the Court of Appeal, "Please declare him guilty, but don't impose him any penalty, because he's a brilliant man, apart from that he went one step too far."

And steps still further are being talked about in Holland today. Beyond today's limits of euthanasia for people suffering terminal illness and unbearable pain, may lie the suicide pill. It was first proposed by a retired Supreme Court judge called Drion. Many think it is an extreme proposition, but in a very Dutch way, they don't shy away from the debate.

ELLY DE HULLU: They are thinking about a pill that has to be taken at 2 or 3 moments. So you have the first pill and you can think, "OK, I will live longer, so the second pill, the third pill, I don't take them." When you jump from a train or from a roof, it is one moment and - you die.

REPORTER: The next step could be the suicide pill then, could it not?

PROFESSOR GERRIT VAN DER WAL: Oh yah, it could be.

REPORTER: And you'd accept that as well as a possibility at least?

PROFESSOR GERRIT VAN DER WAL: Yes, I accept that as a possibility, but I think that we are not far enough to regulate and attack the possible negative side effects.

CLEMENCE ROSS: I think it is a bit of a decadent discussion, as well. It seems as if we would live in a society where people make rational choices, where everybody is in the circumstances that he has seen all of the world, sits in his library and thinks, "Well I've had it and now I can choose to die, because we have the discussion on the pill of Drion."

DR AYCKE SMOOK: You can say when you are 60, you have seen enough of the world, but there are youngsters that have seen more than many elderly people in the world who can say, "This is not my way of life and I don't want to exist in this terrible world any longer."

REPORTER: Would you not expect to see a huge increase in the number of suicides, particularly amongst young people?

ELLY DE HULLU: No. OK and why not? What is wrong of it?

REPORTER: Because life has got to be a lot more valuable than that, hasn't it?

ELLY DE HULLU: Yes, but if you are in a situation that you don't find your life valuable to go on, and then at that moment, it is better to take a pill than to jump before a train.

No-one knows where the debate will take the Dutch people, and it remains a deep emotional, professional and ethical dilemma for young doctors setting out to make life better for their patients. With euthanasia now out in the open, young doctors at least have the chance to candidly discuss the dilemma that they are certain to face.

REPORTER: Have you any idea how you are likely to respond as a person the first time a patient says to you, "Doctor, please help me end my life?"

MEDICAL STUDENT: I don't know how I will respond. Of course you think about it and I have already made up my mind, so to speak. I think I would help a person.

REPORTER: Do you think in your medical career euthanasia is something that you would be able to deal with?

MEDICAL STUDENT NO. 2: No, it's very difficult for me. And I'm sure I will not do it in my career.

REPORTER: Why not?

MEDICAL STUDENT NO. 2: Because of a lot of reasons, religion and principle.

MEDICAL STUDENT NO.3: I think everybody should be able to end their life in the way they want it to and I also think it's especially a doctor's place to help in that situation.

REPORTER: Obviously you two are totally in disagreement with each other, can you respect each other's views?

MEDICAL STUDENT NO 2: Yes, of course.

MEDICAL STUDENT NO 3: Totally.

MEDICAL STUDENT NO.4: I think it will always stay difficult. It will never be easy, no matter how long you think about it.

DR ARNOLD VAN OUDVORST: In the beginning I don't think I can do that, so I won't, but then...

REPORTER: What changed your mind?

DR ARNOLD VAN OUDVORST: The suffering of the patient.

At Wyk aan Zee, the local GP, Dr Van Oudvorst, lives just a few doors away from George van Luijk. They became close as George's wife Henny confessed her desire to end her pain by ending her life. The doctor's now a regular visitor, as is Corien Zwietink, a grief counsellor. George first confronted the prospect of euthanasia when Henny crafted a figurine of herself after having had a cancerous breast removed.

GEORGE VAN LUIJK (Translation): Her head bowed, her hands like this...and her scar.

REPORTER: The scar for where the breast was removed?

GEORGE VAN LUIJK (Translation): Yes, yes. And this was the most painful part. That's how she felt. Her head bowed...She was terribly depressed at that time. After that, she was never really happy again. She was terribly down that time.

There were months of doubt, but when the time came, it came quickly.

GEORGE VAN LUIJK (Translation): So I called the doctor. I was crying. I said "Doctor, come at once." He was here in no time. And again he talked and talked to Henny. He kep asking "Are you sure, are you sure?" And she said "I'm sure, I'm really sure."

DR ARNOLD VAN OUDVORST: In the end you know the question, in the end you know what is going to happen, probably. And the second thing is if you know somebody well, you start to like persons, and that makes it very difficult, yah.

GEORGE VAN LUIJK (Translation): My daughter was home as well. She was in bed. So I fetched her and told her ...(breaks down)...

REPORTER: Would you like to stop, George?

GEORGE VAN LUIJK (Translation): No. And my daughter said, "I knew it. I felt that today it would happen."

DR ARNOLD VAN OUDVORST: At the moment, from doing, from giving the person the medication, I just tried to block out all emotions and just work like a machine.

GEORGE VAN LUIJK (Translation): Even if I live to be a hundred, I'll never forget that image. I'll always remember it. It was terrible.

REPORTER: You obviously miss Henny, but were you glad to have been able to see her on her way with dignity?

GEORGE VAN LUIJK: Yes. I'm glad, and I'm sad. I'm glad that I was there... I'm glad I was there, but it was terrible to watch. I don't know... yes, it's good I witnessed it. You can't go back. It's better I was present than if I hadn't been there. If I hadn't been there I might regret it later. It would be too late, so I'm glad I was there. I held her hand, and suddenly it went limp.

DR ARNOLD VAN OUDVORST: Yah, you're crying inside, outside also, but inside mostly. But especially with Henny, I can tell that also, she was so happy I came there. Everybody said she was happy and that is so strange. You come there, you feel like she would greet you like a good friend, she greets you like, yeah, almost Santa Claus or somebody like that.

There is an end for us all, of course. Illness, accidents and old age account for the vast majority of the 140,000 deaths each year in Holland. But already one person in 40 - 3,500 a year, chooses to die by euthanasia. In his mourning, George van Luijk is comforted by knowing that the woman he loved died at a moment of her choosing. Letting her go was George's final act of love.