Amsterdam, The Netherlands, Feb. 11-The pain was excruciating. There was no cure; the doctors believed there was no quality of life to speak of. In most cases, the anguished parents pleaded with the doctor to bring a quick end to the newborn's suffering.

And so it was that the lives of at least 22 infants born with acute spina bifida in Dutch hospitals since 1997 were terminated by lethal injections of sedatives, according to a new study in the Dutch Journal of Medicine. Although each of these cases was reported to legal authorities, none of the doctors involved was prosecuted.

The Netherlands legalized euthanasia in 2002, the first country to do so, but the law excludes children under 12. The study has sharpened the debate here about whether to extend the euthanasia law to children and infants. The idea has drawn a sharp rebuke from the Vatican and outrage from conservative commentators in the United States.

Surveys of Dutch doctors suggest that about 15 to 20 terminally ill or severely disabled newborns are quietly killed each year. Most cases go unreported.

"All over the world, doctors end lives discreetly, out of compassion, without any kind of regulation," said Dr. Eduard Verhagen, author of the study and an advocate of strict guidelines that would allow mercy killings of infants. "It's time to be honest about the unbearable suffering of newborns with no hope of a future," he said in a statement issued by Groningen University Hospital, where he directs the pediatric clinic.

Groningen hospital, in northern Holland, acknowledged that its doctors terminated the lives of four infants in 2003.

In September, doctors at the hospital drafted a 15-page document outlining the criteria for giving an infant "life-ending treatment."

According to what has become known as the Groningen Protocol, the suffering must be so severe that the newborn has no prospects of a future; there is no possibility of a cure or alleviation with medication or surgery; the parents consent; a second opinion is provided by an independent doctor not involved in the case; the life is ended in a correct medical manner.

The Vatican, which strongly opposes euthanasia, said the Groningen Protocol goes "far beyond" all ethical norms.

Monsignor Elio Sgreccia, of the Vatican's Pontifical Academy for Life, warned that the Dutch "will slide further down the slippery slope of euthanasia in years to come, until adult patients deemed incapable of being asked their consent are included, such as ... the mentally ill or those in a persistent coma or so-called vegetative state."

Verhagen, in his statement, acknowledged that there are no easy answers. "But these children face a life of agonizing pain," he said. "For example, we're talking about newborns with hydrocephalus and no brain. Another example may be a child with spina bifida with a sack of brain fluid attached where all the nerves are floating around.

"This child is barely able to breathe and would have to undergo at least 60 operations in the course of a year to temporarily alleviate its problems ... (and) would suffer such unbearable pain that it has to be constantly anesthetized," he said.

The purpose of the Groningen Protocol, Verhagen has explained, is not to make it easier for doctors to terminate the lives of infants, but to impose rigorous safeguards that protect both the child and the doctor. While the Groningen Protocol focuses on newborns, critics fear the standards could easily be applied to older children with incurable cancer or severe mental retardation.

Last year, the association that represents doctors in the Netherlands asked the government to establish a review board to consider euthanasia for those lacking the mental capacity or "free will" to decide for themselves. This would include children, the severely retarded and people in irreversible comas. A decision on forming the board could come later this month.

Wesley Smith, a senior fellow at the Discovery Institute, a U.S. think tank, wrote in the conservative Weekly Standard that Dutch doctors are engaging "in the kind of activities that got some German doctors hanged after Nuremberg."

Other conservative American commentators, mainly from the religious right, have likened the Dutch doctors to Dr. Josef Mengele, the Nazi physician who performed sadistic experiments on children at Auschwitz and dispatched tens of thousands of others to the gas chambers.

Dr. Henk Jochemsen, a specialist in medical ethics at the Lindeboom Institute, a Christian research center in the Netherlands, has been a sharp critic of Dutch euthanasia laws but said comparisons to the Nazis are not helpful. "Portraying the Netherlands in such an exaggerated way makes it easy to dismiss their criticism," he said.

Jochemsen said he accepts that in exceptional cases the level of painkillers administered to a terminally ill patient could be increased to the point of shortening the patient's life, but that it "must be made clear that killing is not a part of medicine."

The Vatican has adopted a similar position.

The problem with the Groningen Protocol, said Jochemsen, is that any attempt to systematically regulate such practices inevitably results in a gradual loosening of the standards. "If you try to regulate everything, including the exceptions, then the exceptions become the rule," he said.

Much of the international criticism of the Dutch, especially from the religious right in America, seems driven in part by scorn for the Netherlands' tolerant attitudes toward drugs, prostitution, and gay marriage, all of which are legal. But according to Paul Scheffer, a prominent social critic, this is a superficial reading of Dutch society.

"This is not a liberal society. It's a very conformist society," he said. The legalization of euthanasia and other activities that many people deem morally reprehensible should not be interpreted as an endorsement of these activities but as an attempt to regulate them, he said.

"We like to control things," he said. "We want to bring everything under control of the law."