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KEVIN: First, what I do here-- see, what I do is I water down the cap thoroughly, soaking it in the sink here.

JOHN BIEWEN: Kevin has devised a home remedy for his crushing headaches-- frozen hats.

KEVIN: And then-- I don't know why I didn't think of this before. In medical science, you'd use this. I mean, it's a cheap way of doing it. But then you stick the cap in.

SPEAKER 1: It's a basic--

KEVIN: It's a basic-- your basic cheap baseball cap. I don't use any of my real good ones. Chuck it in the freezer and take the other one out. See? It's hard as a rock. And what I do is I bring it to the dining room table and I set it down until it thaws a bit. And then I start cracking it apart so it fits my head. And then I put it on. Tight. And it works wonders with headaches and pressure on the head. I always keep two or three in the freezer.

JOHN BIEWEN: Kevin lives in a well-to-do Minneapolis neighborhood. He asked that we not use his real name. Kevin has a rare hereditary blood disorder for which there's no cure. He watched his father slowly deteriorate and die from the same disease. Kevin is 44. He's a big man with slightly graying dark hair. He walks stiffly and his eyes are tired.

KEVIN: I live in constant pain. Migraine headache since 1988 constantly with no let-up. Living with a constant toothache in most of the major joints in my body. It's the only way I can describe it to people, a toothache. If you think of a toothache and then just move it to all the joints in your bodies, that's what that feels like. A burning sensation on the outside of the skin, rather like having a grease burn the day after in large areas of my body. So that's basically the kind of pain I live with. All the time. Without end.

JOHN BIEWEN: Kevin's disease could kill him next week or it could take another 10 years. The quality of Kevin's life is decaying, to the point where he says it's barely worth living. He says he won't wait for nature or medicine to unfold their plans for him.

KEVIN: My current plans are very simple, really. I intend to eat, drink, smoke-- I do smoke. Watch as many good movies, listen to as much fine music as I can. And I'm also currently, and actively right at the moment, planning my own demise if things like my ability to walk washes away. My sight washes away. My hearing. My ability to recognize where I am washes away. I will not continue to live. I don't need to and I don't want to.

JOHN BIEWEN: For years, the Right to Die movement has tried to gain acceptance for Kevin's choice. Americans have traditionally been opposed to any kind of suicide. Many believe that only God should decide when to end a life. And most everyone agrees that suicide by people suffering from depression should be prevented.

But Right to Die activists insist that for terminally ill people who are in pain, suicide can be a reasonable, logical option. And they argue doctors should be able to help in such suicides. Some public opinion surveys indicate that a majority of Americans agree. Kevin says he began to think of suicide as a rational choice two years ago when he lost his ability to work.

KEVIN: And it would be OK if I could take my energies and my creative talents and say, all right, well, I can't do that, but I could probably do this, but I can't do that either. I can't do charity work. I can't-- I can't. That's when it first occurred to me that, well, I've got no purpose. I refuse to be just to suck-off on life. I just won't do it. I won't do it.

JOHN BIEWEN: A man is dying slowly at Riverside Medical Center in Minneapolis. He's a very thin man. Plastic tubes penetrate his nose. An intravenous line drips nutrients into his arm. The man looks around the room with wide open, but rather blank blue eyes. A technician works nearby looking not at the patient, but at one of the machines attached to him.

SPEAKER 2: Doing an echocardiogram, we're looking at his heart with ultrasound. Look at the valves as they open and close. Walls as they squeeze. And we listen to the blood flow.

ARTHUR CAPLAN: The overwhelming odds are that if you die in the United States, you're going to die surrounded by machines that are buzzing and tweeting and spitting out all kinds of data. You're going to die attended by professional people. And it's a pretty good chance you won't die with your family members around and they're not going to see death.

JOHN BIEWEN: Arthur Caplan, Director of the Center for Biomedical ethics at the University of Minnesota, says there is a growing impression that machines are taking over death. Modern medicine prolongs sick people's lives, but can also prolong their suffering. Margaret Battin, a Professor of Philosophy and Medical Ethics at the University of Utah, says increasingly, the quantity of life is being extended at the expense of quality. She argues it's time to recognize that the kindest, most merciful, most ethical treatment is sometimes death.

MARGARET BATTIN: Every single person dies. Many people die badly. I think it's probably fair to say that more people die badly in the modern medical world than was perhaps previously the case. And if we turn a blind eye to that, it seems to me that that's a symptom of losing hold of traditional moral principle.

JOHN BIEWEN: What if our society allowed ill, suffering people to get help in dying from their doctors? Would we be less humane or more?

[ACCORDIAN MUSIC]

Holland is known for picturesque cities, windmills, wooden shoes, and tulips, but it's also becoming known as the only place in the world where doctors directly end their patients' lives, where active euthanasia is done more or less openly.

SPEAKER 3: My name is Max Delanga. I live in a small Village of Son, which is near Eindhoven in the southern part of Holland. My wife died 16 months ago by euthanasia. I was a rather good marriage. We have four children who live outside the house, of course, now.

JOHN BIEWEN: Max Delanga is a retired engineer. With his blond hair and easy smile, he seems much younger than his 67 years. Max's wife had cancer.

SPEAKER 3: January of 1990, I went to the specialist in hospital, and he then already told me she will surely die. There is nothing we can do. We will do everything we can to make her sickbed as dignified as possible. And if you wish, or she wishes, also, we can care for a dignified ending of her life in due time.

SPEAKER 4: Did you know what he meant by that?

SPEAKER 3: I very well knew what he meant by that.

JOHN BIEWEN: The Dutch government says 3,300 people a year-- that's 2.6% of deaths in Holland-- die as a result of active euthanasia by doctors. Dr. Karl Gunning of Rotterdam is President of the World Federation of Doctors Who Respect Life, a group of physicians who oppose abortion and euthanasia.

KARL GUNNING: If human life is allowed to be ended, who will decide who should shall live and who shall not live? Is it not very clear that only those who are essential for the economy, which are useful for society, they are allowed to live? The beautiful women and the strong men and et cetera. And all the weaklings, all those who are a burden to society, they will all be disposed of.

JOHN BIEWEN: People on the streets don't express fear that they'll be disposed of polls show over 80% of the Dutch want the legal option of dying with a doctor's help.

SPEAKER 5: If you've done everything in your power to make your life as pleasant as possible, but there is no way to make it any more acceptable, it is your right to step out if you want to. Nobody can tell you. It's you who's living.

SPEAKER 6: If you have too much pain to live, why should you live?

SPEAKER 7: I think you have to be free to what is-- yeah, to decide when you want to make an end of your life, I think.

SPEAKER 8: It's the same for me. I know what I would do when I'm so old or sick or what, but there is the possibility to make the choice, to have the choice, it's such a good thing for me, yeah.

SPEAKER 3: We both realized that she was going to die. And curiously, this was a kind of relief because then, the uncertainty had disappeared, and this has brought us together. Later on, I realized this. Those two months may have been the best part of my marriage because when you go that way together, you are very close together, and this was a very good time.

JOHN BIEWEN: Though widely accepted, active euthanasia is illegal in Holland. Dutch courts have agreed not to prosecute doctors who end their patients' lives so long as the patient is suffering unbearably and makes a well-informed, repeated request for euthanasia. The doctor is also supposed to offer alternative treatments and consult with another professional.

Dr. Herbert Cohen, a general practitioner in a suburb of Rotterdam, says the last requirement for performing euthanasia is that it be done carefully.

HERBERT COHEN: Carefully means tender, with care. You might even say with love.

JOHN BIEWEN: Cohen contrasts the Dutch euthanasia practice with that of Michigan Dr. Jack Kevorkian who performed his first assisted suicide in the back of a van for an Alzheimer's patient he hardly knew and who still had years to live.

KARL GUNNING: If I did something like that here, I would be convicted. That-- there is such a lack of care, a lack of tenderness in that that I would certainly be convicted.

JOHN BIEWEN: A Dutch government report says only a third of patients who request euthanasia end up dying that way. Doctors more often find alternatives that satisfy patients until they die naturally. Critics of the Dutch system say it's dangerous to trust doctors with euthanasia. Dutch doctors sometimes end the lives of patients who've lost consciousness, but who never directly asked to die.

Defenders of the Dutch policy respond that their country's openness about euthanasia is the best way to prevent abuse. Max Delanga says his family doctor, a long-time friend, initially resisted his wife's request for euthanasia.

SPEAKER 3: He said, I understand what you say, but you say that to me because you have a lot of pain now. I'll give you a morphine injection that will relieve the pain and I'll come back tomorrow. Well, this is what happened, and the next day, he came back and then she said, indeed, pain is much less now. But still, you must help me. I don't want to go on.

Jeanne Tromp Meesters of the Dutch Society for Voluntary Euthanasia says most people who choose death do so not only to end their physical pain, but to escape a condition that they find intolerable and without dignity.

JEANNE TROMP MEESTERS: Itching, smelling, stinking. The stench of wounds that will not heal anymore. And being incontinent, and that makes you stink as well. The suffering of all that. Being nauseated all the time, nauseous, being short of breath, having to fight for each breath. All these things, and very often, people have several of these symptoms at the same time, make you beg to please end your life because you don't feel human anymore, then.

SPEAKER 3: I sat by her bedside, and then she said, I feel so very happy now because I've talked with everyone. With good friends, with the children, with my sister. I am completely at ease now, so let's start it. And then the morphine supply increased, and she more or less dozed off. Woke up every now and then. She said, give it a moment. Do you believe that I can see the cat again? Because our cat had died a year before. Or don't you believe that's possible?

Well, we both laughed about it, of course, but it demonstrates how relaxed-- or relaxed she felt and how satisfied. Well, and then within a couple of hours, she slept in my arms and she died.

[PIANO MUSIC]

JOHN BIEWEN: All sides in the Right to Die debate in the US look to Holland for evidence supporting their position, but many ethicists say the two societies can't be compared. Holland is a small, homogeneous country where doctors make house calls and know their patients well. Most Americans barely know their doctors.

Ronald Cranford, a Minneapolis physician and ethicist, says some American doctors do help their patients die, but they do so secretly and indirectly to avoid prosecution.

RONALD CRANFORD: And I know of physicians who will tell their patient, take this medication for sleep, but never take a hundred of these pills. Never take a hundred because if you take a hundred, something bad might happen. And it's very clear what the physicians are doing in a offhand way, is telling them exactly what the fatal dose is.

JOHN BIEWEN: Kevin says he would like a physician's help with his suicide plan. He's buying his lethal drugs on the black market.

KEVIN: I will go about the business on my own with no one else's help because I can't seem to find anybody who will help me, although they all concede, it's rational and that it's understandable and that I'm not crazy and all these other things, they don't want me to do it. It's really simple and very selfish on their part. And so I get no help from anyone. Therefore, I'm going to have to go and make these arrangements myself.

ALBERT JOHNSON: I think that I could tolerate morally the idea that one person might help another person to end their life.

JOHN BIEWEN: Dr. Albert Johnson teaches medical ethics at the University of Washington in Seattle.

ALBERT JOHNSON: It's the intimacy of friend that justifies the participation. When you come to physician-assisted suicide, you have another thing entirely.

JOHN BIEWEN: Many medical ethicists, including Albert Johnson, argue that doctors should never be put in the position of ending a life because it distorts the power and trust invested in the doctor-patient relationship. Voters in Washington State this fall rejected an initiative that would have legalized physician-assisted suicide for terminally ill patients. Initiative campaigns are now under way in California and Oregon.

Surveys show that the Right to Die movement in the US is growing, but Anne Sires of Everett, Washington is thankful that she never had the option of assisted suicide.

ANNE SIRES: I carry a lunch box because I have so many medications that I-- it's easier for me to just put them all into one little lunch box that I can carry with me.

JOHN BIEWEN: Anne Sires is 43 years old. She has cancer throughout her body and spends virtually all her time in her small apartment where she lives with her teenage son. The disease has left her thin and drawn. Anne's doctor told her in 1984 that the illness was terminal.

ANNE SIRES: When they tell you you're going to die and you go through, I mean, the emotions, you can't even imagine what you go through. It's incredible. And then you think, well, I better get to clean in my house. You know, I better give this to who I want to give this to and I better pack this away, and I won't be wearing these anymore. And, I mean, just tons of different things.

JOHN BIEWEN: On at least five different occasions, Anne's doctors told her death was near. Five times she gave away her clothes. Each time with more intensive medical treatments, she rallied, and then had to get another set of clothes.

ANNE SIRES: It got kind of funny because, I mean, I had nothing to wear. Literally, nothing to wear.

JOHN BIEWEN: Anne fought against Washington's initiative for physician-assisted suicide. She says no matter how tightly it's regulated, the practice would result in people dying before their time.

ANNE SIRES: In the very beginning, it was really hard, and there were a lot of times when I was pretty depressed and not knowing what to do. And I'm just thankful that Initiative 119 wasn't around then because I might have made the wrong decision, and seven years, I would have missed with my son all his growing up and getting into girls and playing football and things like that. I would have missed it all.

JOHN BIEWEN: Opponents of doctor-assisted suicide say people support the movement because they have a legitimate fear of the American way of death. Bioethicist Arthur Caplan says American doctors are trained to attack disease, but they're often stingy with the painkillers and sympathy that can comfort terminally ill people.

ARTHUR CAPLAN: What's wrong with the health care system as we confront how we manage dying? Oh, just about everything. The amount of time the average medical student spends learning about the management of the dying patient is probably only rivaled by the amount of time they spend studying information about diet and nutrition, which is to say somewhere between nothing and next to nothing.

JOHN BIEWEN: Caplan and others say more humane care for the dying would largely diffuse the movement toward doctor-assisted suicide. But there's another force in American health care that suggests this country may not be ready for legalized euthanasia-- money. Unlike Holland, the US does not offer universal health care coverage, and many families are financially devastated by the costs of keeping loved ones alive. Heleen Dupuis is a medical ethicist at the University of Leiden in Holland.

HELEEN DUPUIS: I think a society that places a financial burden on the family of dying people should not accept euthanasia that easily because patients may be forced by the financial situation of their families to request euthanasia, and in Holland, money never comes into it.

JOHN BIEWEN: Experts say there are gross inequities in the quality of health care available to Americans varying with race, economic status, and education level. Those who support doctor-assisted suicide say well-written laws would prevent potential abuses, but Dr. Carlos Gomez of the University of Virginia Hospital says those people who already get shortchanged by the system would be the ones most likely to be coerced into suicide.

CARLOS GOMEZ: The people that need to be kept foremost in our minds are not the ones that write articles about euthanasia, are not the ones that appear on talk shows. They're the ones that we rarely hear about, that walk the streets in this country at night, that wind up in emergency rooms, that live in nursing homes. They're the ones that we need to worry about if, in fact, euthanasia is legalized in this country.

JOHN BIEWEN: How you feel about physician-assisted suicide probably depends on your level of faith in American medicine and other institutions that care for the dying. It may also depend on your experience with death. Many Right to Die advocates watched loved ones endure agony. They demand the right to avoid such a fate. The right to choose death. But personal experience can also lead to the opposite conclusion.

ANNE SIRES: It's not for me. I couldn't do it.

JOHN BIEWEN: Ann sires has been fighting death for seven years. She appears close to losing.

ANNE SIRES: And I would say to other people, there's pain management, and if you work with your doctor, they're working with me and we're keeping it under control. I mean, there are some times when it gets pretty bad, but I just-- I don't want to miss out on a minute of my son's life or a minute of what I've got left to look out like in a sunny day like today, a fall crisp day. And I don't want to-- I don't want to miss that.

KEVIN: This is my garden. This is therapy. I created this garden for therapy. This keeps me sane in the warm seasons.

JOHN BIEWEN: On a warm fall day, Kevin walks in the small lush garden in front of his house in Minneapolis. Kevin has set a high standard for life. It's quality that matters to him, not duration. Kevin says he's not afraid of death. He's seen dozens of friends die before him, mostly of AIDS. His garden is scattered with symbols of them.

KEVIN: These canna lilies right here are from another friend of mine who died two years ago named Paul. As is this sculpture right here. I think those things are nice. I can walk around and say, well, that's Paul's, and that's Brian's over there. And it's really rather pleasant.

JOHN BIEWEN: Kevin says his desire to end his life with a doctor's help is simply a question of freedom, of self-determination. He resents the taboo on suicide. He says Americans are too quick to tell other people what they can and can't do. Kevin thinks many Americans also oppose doctor-assisted suicide because they want to believe that with a doctor's help, they can cheat death.

KEVIN: People want to control life, and you can't. They want guarantees that everything's going to be OK, and it's not going to be OK. They want to go to a doctor and they want to be guaranteed they're going to get better. That doesn't happen. Marcus Welby was a TV show, not reality. It's not that way.

Gardens keep you grounded that way. Some plants do better than other plants. A rose is not just another rose. They don't all bloom universally. Zinnias do not all grow to the same height. Delphiniums don't do that. There are good plants, there are bad plants. Some require certain care, some require other kind of care. It's the same with people.

The whole concept of a garden, the beginning to the end, is a wonderful thing to live with when you're ill. It really gives you the idea of the cycle of life, and part of the cycle of life is death.

[PIANO MUSIC]

JOHN BIEWEN: Choosing Death was produced by John Biewen and Stephen Smith. The narrator was John Biewen. Technical director, John Scherf. Support for this program was provided by the Northwest Area Foundation. This program was a production of Minnesota Public Radio.

[THEME MUSIC]