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Physicians in The Netherlands largely determine amongst themselves how they treat patients, whereas statutory regulations mostly concern indirect matters, such as qualifications of the treating persons, quality of care and patients' rights. Special items of service are currently reserved for special institutions. When the new Special Medical Services Act is passed, the minister is empowered to prohibit items of service if he/she considers these undesirable for social, ethical or legal reasons. More discussion is needed before such sensitive matters are to be regulated by law.

Patients' rights in Europe are becoming more and more similar. International agreements influence this development. New are the 'Declaration on the promotion of patients' rights in Europe' drawn up by the Regional Office for Europe of the WHO and adopted by a special European Consultation in 1994, and the draft of a 'Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine' (Convention on Human Rights and Biomedicine of the Council of Europe). The WHO-declaration has also influenced the "Declaration of the rights of patients' of the World Medical Association in 1995.

An exploratory, descriptive, retrospective study was carried out concerning the use of means for euthanasia or assisted suicide, primarily regarding the period 1986-1989. Data were collected via an anonymous written inquiry among a random sample of family physicians in North Holland (n = 521) and family physicians in the rest of the Netherlands (n = 521). The inquiry contained among others questions about the last case they had encountered. In addition, police reports of euthanasia or assisted suicide administered by family physicians in North Holland (n = 263) were analysed. The response to the inquiry was 67%; (non-respondents did not differ from respondents): 388 cases could be analysed. The use of euthanatics by family physicians in North Holland and those in the rest of the Netherlands was identical. More than 40 different euthanatics were used, most of them incidentally. The most frequently used (combination of) means were a benzodiazepine with a neuromuscular relaxant (23%), a barbiturate with a neuromuscular relaxant (20%), barbiturates (15%) and opioids (12%). Most euthanatics were given intravenously (61%, of which 5% by infusion), orally 21%, intramuscularly 12%, rectally 3% and subcutaneously 2%. The quantities applied varied greatly. The average length of time from the start of the procedure till decrease was 3.8 hours (less than or equal to 1 minute-72 hours). In 12% of the cases complications or unintended effects were reported. Comparison of inquiry and police reports showed some differences.(ABSTRACT TRUNCATED AT 250 WORDS)

We conducted a survey among two random samples of Dutch doctors in order to determine whether they acted prudently with regard to euthanasia and assisted suicide. The doctors completed an anonymous questionnaire and those who at one time or another had applied euthanasia or assisted suicide (52%) were asked about several aspects of the requirements for prudent practice. 'Pointless suffering' was the most important and most common reason for requesting euthanasia or assisted suicide; 'pain' was rarely the most important reason. In 7% of the cases alternative forms of treatment were still available; these were hardly ever therapeutic. A total of 12% of the doctors had applied euthanasia or assisted suicide without having had any kind of consultation or discussion with a colleague, a nurse or any other health care professional; 26% had not issued a certificate testifying to death from natural causes. We conclude that some of the family doctors do not observe the procedural requirements, but that the majority satisfies the material requirements for prudent practice.

A survey was conducted among family doctors to determine the frequency with which they were requested to administer euthanasia or assist in suicide, and how often they actually applied these procedures. Two random samples (in each n = 521) were taken from the population of Dutch family doctors (n = 6300) and requested to complete an anonymous questionnaire. The response was 67%. The entire body of Dutch family doctors practices euthanasia or assisted suicide about 2000 times per annum; 48% have never engaged in these practices. An average of 40% of all requests are complied with. We conclude that far fewer family doctors are involved in euthanasia and assisted suicide than was previously supposed. Euthanasia or assisted suicide was administered to 1 in 25 persons who died in their own homes.

In order to assess the suffering of patients who died at home and with whom family doctors participated in euthanasia or assisted suicide, an exploratory, descriptive, retrospective study was carried out regarding primarily the period 1986-1989. Data were collected via anonymous written inquiry among an at random sample of family doctors in North Holland (n = 521), and family doctors in the rest of the Netherlands (n = 521). With reference to the last case of euthanasia or assisted suicide they had encountered questions were included about physical and emotional suffering, signs and symptoms and life expectation. Correlations and differences were analysed by means of the chi2-test. The response to the inquiry was 67% (non-responders did not otherwise differ from responders): 228 (North Holland), 160 (rest of the Netherlands) cases could be analysed. Most patients suffered physically as well as emotionally. The most frequently mentioned aspect was 'general weakness or tiredness'. Also 'dependence or being in need of help', loss of dignity, humiliation' and 'pain' were often present to a (very) large extent. At the time the procedure was carried out the life expectation in almost two-thirds of the cases was less than 2 weeks; in 10% of the cases it was more than 3 months. For several reasons, this investigation reduces the possibilities of extrapolation. Further investigation is necessary to determine whether this picture of suffering is specific of this category of patients.

In order to map out morbidity, age and sex of patients with whom family doctors participated in euthanasia or assisted suicide, an exploratory, descriptive, retrospective study was carried out primarily regarding the period 1986-1989. Data were collected via an anonymous written injury among an at random sample of family doctors in North Holland (n = 521), and family doctors in the rest of the Netherlands (n = 521). In addition, police reports of euthanasia/assisted suicide administered by family doctors in North Holland (n = 263) were analysed. The inquiry included among others questions about the last case doctors had encountered. Diagnoses were classified according to the ICD-9. The results were compared with compiled mortality data relating to persons who died in their own homes. Correlations and differences were analysed by means of the chi2-test. The response to the inquiry was 67% (non-responders did not otherwise differ from responders): 228 (North Holland), 160 (rest of the Netherlands) and 263 (police reports) cases could be analysed. Of the patients, 85% suffered from a malignant neoplasm. The average age at which euthanasia or assisted suicide was practised was 63.4 years (men) and 66.1 years (women). Under the age of 30 and above 85 euthanasia or assisted suicide was administered only rarely. Proportionally these procedures were applied to the same extent to men as to women. In about 20% of the cases an important secondary diagnosis was present. In conclusion, it is especially the malignant neoplasms that cause such suffering that euthanasia or assisted suicide are practised. The average age at which they are applied is considerably lower than that of the total of people who die in their own homes.(ABSTRACT TRUNCATED AT 250 WORDS)

The development of the debate on euthanasia in The Netherlands, the role of the courts and proposals for legislation are discussed. In foreign newspapers and other publications an erroneous picture of the Dutch situation on euthanasia is sometimes given. In Parliament two proposals for legislation are pending. The parliamentary debate is expected to be reopened in 1989.

Clinical autonomy has become a subject of discussion and revision because of a number of developments. In hospitals, doctors are ceasing to function as independent entrepreneurs and see their autonomy curtailed by organizational constraints and imperatives. More important however is the growing interference of public authorities who seek to promote equity and social justice within a framework of scarce resources. Professional standards are also a force which is limiting clinical freedom. Finally, the autonomy of physicians is revisited, because of the growing assertiveness of patients, who want to participate in the decisions regarding their own medical care.

In this article the developments in euthanasia in The Netherlands are discussed. To a large extent unanimity has been reached about the definition of euthanasia. Since 1973 the courts have become involved in euthanasia cases. The lower courts and the Supreme Court allowed for euthanasia on request under certain conditions. In 1982 a State Committee on Euthanasia was established. This Committee made a proposal of a law on euthanasia and assistance to suicide on request. The Committee delineated requirements to be followed for euthanasia not to be punishable. Although a majority of the Dutch population is in favour of a liberalizing legislation, the political situation delays its adoption.

On the national and international level, legal instruments for the protection of the patient are developing. From the WHO-Europe study 'Trends in Health Legislation' trends regarding patients' rights on the national level in Europe are discussed. Moreover, an overview of international activities for the promotion of patients' rights is given. It is concluded that the movement towards the elaboration of patients' rights is evolving slowly and that the interaction between international and national activities in this field is unclear. As a consequence there exists underregulation of the rights of patients in Europe.

During the past decades health legislation and regulation have been on the increase in most industrialized countries. The growing role of government in the provision and financing of health care, the need to correct given aspects of health care and the mandate to protect the underprivileged have been some of the many reasons for increased regulation. Different regulatory approaches and their respective advantages and disadvantages are reviewed in this paper. Particular attention is given to the crucial issue of how to regulate the access to scarce resources and how to cope within a legislative approach with the resulting patient selection.