At present, physician-assistance in dying is known to be provided in several countries in varying frequencies [1
]. In the Netherlands, euthanasia is defined as deliberately ending a person's life at the person's request. In physician-assisted suicide, the person self-administers medication that is prescribed by a physician. Euthanasia and physician-assisted suicide are allowed provided that a physician performs the act while adhering to specific requirements. Euthanasia and/or physician-assisted suicide is also legally allowed in Belgium, Luxembourg and the US states of Oregon and Washington [5
] and discussions about the legalization of physician-assisted dying are going on in other countries, such as the UK, Spain, France, Columbia and Australia [9
]. Debates about legalization often relate to concerns about whether it is possible to keep the practice of physician-assisted dying within agreed borders [14
]. Concerns relate to the risk that vulnerable people may be or feel coerced to request assistance in dying, that alternatives to assistance in dying are lost out of sight, or that deciding to provide assistance in dying becomes too 'easy' an option without careful consideration of alternatives.
In the Netherlands, physicians have to report euthanasia and physician-assisted suicide to enable review by one of five regional multidisciplinary review committees. They should comply with criteria of due care that have been developed by the courts during the preceding decades and are generally considered to be a summary of case law [16
]. These criteria require a physician to assess that (1) the patient's request is voluntary and well-considered, (2) the patient's suffering is unbearable and hopeless, (3) the patient is informed about his situation and prospects and (4) there are no reasonable alternatives. Further, (5) another, independent physician should be consulted and (6) the termination of life should be performed with due medical care and attention [17
]. To demonstrate their compliance with these criteria, physicians have to submit a detailed report, which describes their way of acting and its circumstances. This report is usually based on a standard form that contains both open and closed questions regarding the criteria of due care. Review committees have to assess whether the physician acted in accordance with the criteria. They do so by scrutinizing the physician's report, and, if necessary, by asking the physician to supplement this report either orally or in writing, or by obtaining information from other persons involved. The Belgian Euthanasia Act, that legalizes euthanasia since 2002, is largely similar to the Dutch Euthanasia Act [18
]: the Belgian Act includes similar criteria of due care but review is done by one multidisciplinary committee. Luxembourg legislation (2008), draws heavily on the Belgian experience [5
These Acts differ from the Oregon Death with Dignity Act, that legalizes physician-assisted suicide since 1997 [8
]. To request a prescription for lethal medication, the Oregon Act requires that the patient is an adult resident of Oregon who is capable and who has an illness that is expected to lead to death within six months. To obtain the lethal medication the patient should make one written and two oral requests (separated by at least 15 days) to his or her physician. The patient's primary physician and a consultant are required to confirm the diagnosis of a terminal condition and the prognosis, determine that the patient is capable, and refer the patient to a psychiatrist or clinical psychologist for further evaluation, if either believes that the patient's judgment is impaired by depression or other psychiatric/psychological disorder. The primary physician should also inform the patient of all feasible alternatives [19
]. If the patient meets the eligibility criteria and the physician writes a prescription, physicians have to report to the Oregon Health Division which lethal medications were prescribed. They further have to indicate that they fulfilled the requirements by checking the boxes in the attending physician's compliance form [20
]. After receiving the report of the death of the patient, the Health Division asks the reporting physician whether the patient indeed had died from the medication. The law and requirements for the Washington Death with Dignity Act are virtually identical to the Oregon Act [21
The purpose of reporting and reviewing practices of euthanasia and physician-assisted suicide is to evaluate how the norms laid out in the laws and regulations are being handled in actual practice. External review enables countries to evaluate whether current regulation suffices to restrict euthanasia to cases that meet the criteria, to see where potential problems occur and to educate physicians to comply with the rules. Various studies have been performed about how physicians perceive the patient's suffering and in what situations patient's requests result in euthanasia [22
]. In the Netherlands as well as Oregon, physicians have been shown to be motivated to engage in euthanasia because of their patients' disease-related experiences, such as severe pain, functional loss, discomfort, fatigue, and expressed loss of dignity of the patient.
The ethical foundation of the five Acts described, is a combination of respect for autonomy and obligations of beneficence. However, for the Dutch, Belgian and Luxembourg Acts, addressing the patient's suffering is the most important principle underlying the Act. The Oregon and Washington Acts, on the other hand, put emphasis on patients' rights and on helping patients to maintain control and independence. Whether or not these differences in emphasis lead to differences in practice and in the review procedure is unclear.
For Dutch review committees, physicians' reports are an important basis for their assessment whether the criteria of due care have been met or not. However, the content of what physicians report about the criteria of due care and how review committees judge this information is for the most part unknown. We studied which arguments Dutch physicians use to substantiate that they have adhered to the requirements of due care and which aspects attract review committees' attention. Furthermore, we compared our findings with existing information about other external review procedures and reflect on whether a different procedure would result in a different focus of attention.