During a year- long tenure at an academic hospital in the Netherlands, I gained some insight into their health care system. I would like to share some aspects that struck me as novel or thought- provoking.

Health security
The most important feature was the universal health care cover for all citizens. The economic status of a patient was never a consideration in determining the choice of therapy. With ever- increasing costs of hightech medical care, this seemed, at times, a non- sustainable situation. The cost of health care is the subject of an ongoing debate in the Netherlands. When restrictions are placed on health care expenditure, they are made uniformly applicable, irrespective of the class or creed of the individual.

The average life expectancy is 79 years - the result of a socialized health care structure. I was often asked about health facilities in India. It was incomprehensible to the Dutch that we did not have guaranteed health care for all citizens. Of course, we do have so- called free public hospitals and dispensaries, but patients still have to pay for expensive procedures such as coronary angiograms and heart operations. Expensive antibiotics and other drugs have to be purchased by our patients.

Equality
The absence of class distinction was especially noticeable in Holland. In the hospital, there was no hierarchy or regimentation. Medical staff, nurses, technicians, cleaners and other employees treated each other, with mutual respect. Except for a few senior professors, everyone was referred to by first name. Medical teaching too was democratic and junior doctors were not ordered around by their seniors. Apparently this egalitarianism was not universal in Western Europe, because in neighbouring Germany the medical staff were referred to as ‘Herr Doctor’, ‘Herr Professor’ and so on.

Sexual discrimination was not visible although most senior positions were occupied by men while secretarial jobs were manned by women. I was told that one reason for this was the preference of married women for part- time jobs that allowed them time for their families. In the cardiology department, where I worked, all 17 medical staff positions were occupied by males. They were amazed to hear that in three of the four university hospitals in Bombay, women headed the cardiology departments.

Doctors and the drug industry
There relationship between doctors and the pharmaceutical industry is open and deep. By this I mean that pharmaceutical companies regularly and officially sponsor medical personnel for conferences abroad, paying for their travel and stay. This phenomenon is hardly discussed and not considered unethical. Obviously these costs will be recovered in the form of high prices of drugs and medical equipment. A bottle of cimetidine tablets, for instance, costs approximately Rs. 4000 (50 times the cost in India). As patients are insured, these high costs don’t directly pinch anyone. Most medical congresses are held in five- star hotels in expensive tourist resorts. Apart from this, the pharmaceutical industry provides funding for academic research in university hospitals. All this is done without any secrecy.

Doctors and patients
The doctor- patient relationship is based on trust. Even when advised invasive therapy such as major surgery, patients rarely shop for opinions. Since most hospitals are state- owned or state- controlled, the profit motive is not strong and this helps greatly in patients developing faith in advice given by their doctors. There is constant peer review of decisions on treatment since there are no individually owned ‘nursing homes’ where one may do many things without question or criticism.

Doctors are generally scientific in their prescriptions. For self- limiting illnesses, such as the common cold, they rarely prescribe any medication. Patients are informed about their illnesses, the therapy planned and the prognosis explained in great detail. The practice of splitting fees (‘ cut- practice’) does not exist.

Normal pregnancy is undergone without any medication. No vaccines, iron, calcium or vitamins are prescribed to healthy pregnant women, If normal labour is anticipated, the choice of delivering at home is offered to the mother. Around 30% of deliveries are electively conducted at home. In familiar surroundings the process of labour is quicker and less uncomfortable.

Euthanasia
Elderly people are, by and large, very well cared for, since great planning has been done to make living and moving around possible for handicapped people.

Euthanasia is accepted and practiced in the Netherlands for those who are severely ill for long or are dying. The family doctor discusses the issue in detail with the patient and the family before a decision not to treat the dying patient is taken. Active euthanasia is defined in the Netherlands as an intentional act to terminate life by a person other than the person involved on request of the latter. (1) Active euthanasia accounts for 1.8% of deaths in the Netherlands. If left alone, 87% of patients subjected to active euthanasia would have lived for a month at most while another 12% would have survived for a maximum of 6 months. (2) Data on tile development of public opinion in the Netherlands stems from a number of surveys conducted in 1966, 1970, 1980, 1985 and 1991 on a range of socio- cultural subjects. General practitioners, nursing home physicians, cardiologists, surgeons, internists,“ chest physicians and neurologists cover approximately 95% of euthanasia cases.

References
1. Dutch State Commission on Euthanasia: Final report. An English summary. Bioethics 1987; 1: 163- 74.
2. van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. The Lancet 1991; 338: 669- 674.

Yash Lokhandwala ,Member, Executive Committee, Maharashtra Medical Council, Member, Central Advisory Board of Education (New Delhi), Ex-member, Medical Council of India