AMSTERDAM (Reuters) - "I am not a monster. I'm also not a God. In the best case I'm an angel," muses a doctor in a Dutch play about euthanasia, before delivering a lethal injection to an old friend, a cancer patient.
"The Good Death" is playing to packed houses across the Netherlands, which became the first country to legalize euthanasia in 2002 despite condemnation by the Roman Catholic Church.
The play reflects the fact that far from becoming standard practice after legalization, euthanasia -- Greek for "good death" -- remains an agonizing decision for all involved.
Official figures actually show a fall in euthanasia cases in recent years and a rise in the use of sedation for the terminally ill.
Dutch campaigners say some doctors are shying away from making a decision about euthanasia and they want the law relaxed further to make mercy killing easier.
While euthanasia is also legal in Luxembourg and Belgium and is permitted in Switzerland if performed by a non-doctor, activists elsewhere in Europe are fighting for decriminalization.
The case of Chantal Sebire, a woman with a face-distorting tumor who was refused assisted suicide, rekindled the debate in France. Sebire was found dead of an overdose at home in March days after a court rejected her bid for medical help to die.
The mercy killing of Belgian writer Hugo Claus, who suffered from Alzheimer's disease but was well enough to express his wish for euthanasia, has also exposed divisions in Belgium between supporters and opponents of legalization.
"The Good Death" follows the last day in the life of fictional lung cancer sufferer Bernhard Keller as his dysfunctional family gathers to bid farewell, deftly mixing black humor with emotional drama and philosophical reflection.
"A lot of people who come who have had to deal with euthanasia do not find much comfort in laws or politics, but they do find it in such a play," said director Wannie de Wijn.
"What interested me is how come people don't go crazy if they know that their nearest and dearest won't be there in 24 hours," he said, adding he was inspired to write the play after a friend's father died by euthanasia.
The number of Dutch euthanasia cases fell to 2,325, or 1.7 percent of all deaths in 2005, from 2.6 percent in 2001. Though it only became legal in 2002, euthanasia has long been an accepted practice in the Netherlands and doctors avoided prosecution if they met certain conditions.
Those conditions were formalized in legislation: patients must face a future of "unbearable suffering" and make a voluntary, well-considered request to die. Another physician must be consulted and an expert panel examines each case.
The Dutch Health Ministry says the fall in euthanasia cases is partly due to improvements in care for the dying and a rise in the number of terminally ill patients who are given sedatives to render them unconscious until death.
Palliative sedation rose to account for 7.1 percent of deaths in the Netherlands in 2005, up from 6 percent in 2001.
Those undergoing euthanasia are usually given a lethal injection that acts within minutes.
Patients who receive palliative sedation are those expected to die within days. To mitigate distressing symptoms they are heavily sedated, life-prolonging treatment and hydration is withheld and they die without regaining consciousness.
A study in the British Medical Journal in March confirmed the trend towards sedation and away from euthanasia.
"It is more than a coincidence that euthanasia has gone down and palliative sedation has gone up," said Rob Jonquiere, director of the Dutch Right to Die society.
"We hear anecdotal evidence from families that patients actually wanted euthanasia but the doctor instead gave palliative sedation," he said, adding he had struggled with euthanasia requests when he practiced medicine.
"Patients say: 'I don't want to be cuddled to death. I'm going to die anyway. Let me die now'."
A survey published this year in the Journal of Medical Ethics showed almost half the Dutch doctors questioned tried to avoid euthanasia because it was against their own values or difficult to deal with.
"There was a concern that once doctors started using euthanasia they would do it more and more easily. What we see is the opposite because they need emotional rest," Jonquiere said.
Activists are pushing for the euthanasia law to be relaxed further to allow those suffering from dementia and who are "tired of life" to die.
"Since it's been legal there is less fear for doctors of being prosecuted, but the rules about 'unbearable suffering' are very limiting," said Hanny van de Velde, a member of the Right to Die organization and a helpline volunteer.
A poll by Dutch research bureau Intomart GfK published in March showed 63 percent of the 1,000 people surveyed supported granting the right to die to the elderly, even if they were not ill, while 74 percent supported the controlled distribution of "suicide" pills to those who felt their lives were done.
But changes to Dutch law look unlikely as the religious Christian Union is a junior partner in the ruling coalition.
The CU opposes euthanasia and says more attention must be paid to the reasons people ask for mercy killing. The cabinet has approved an extra 10 million euros in annual spending on care for the terminally ill for the next three years.
"Good care and the reassuring certainty that effective pain relief is possible can solve the demand for euthanasia," said CU member of parliament Esme Wiegman-Van Meppelen Schepping.
Dutch writer J.J. Voskuil died on May 1 in what his widow said was a case of euthanasia. He was 81.
"My beloved husband chose a dignified end," Lousje Voskuil-Haspers wrote in an obituary.
Stans Verhagen, a cancer specialist who deals with about 800 dying patients a year, said there should be less focus on euthanasia and more on other ways of helping the terminally ill.
"We started with euthanasia in Holland because people were suffering from so much pain -- it's what makes us afraid of dying," he said. He likened the end of life to landing a plane.
"We should give less attention to the emergency exit and more to how not to crash. It is possible to have a good death."
Editing by Janet Lawrence