Wednesday, 27 March 2013

Letting the terminally ill die with dignity

By Andy Ho, The Straits Times, 25 Mar 2013

FOR many a terminally ill patient, the prospect of severe and unrelenting pain at the end of life may make him or her wish for a quick death as release.

The issue of euthanasia, or physician-assisted suicide (PAS), is never easy. It came up in Singapore recently, when Chief Justice Sundaresh Menon raised it in a lecture. His main point was that Parliament, not the courts, should be the one to decide on whether it should be permitted, and he urged public discussion of the matter.

He also noted that in Singapore, the Advance Medical Directive (AMD) Act allows people to state in advance that they do not want extraordinary life-sustaining measures when terminally ill. The AMD Act does not condone, authorise or approve euthanasia, mercy killing or assisted suicide, he noted. But he added that assisted dying should be a matter of "public debate, private conversations... and personal reflection". He also suggested that the experience in other countries might well be a guide to discussion here.

Experience elsewhere

CURRENTLY, PAS is legal in Switzerland, Belgium, the Netherlands, Luxembourg, Mexico and three US states. In Singapore, however, anyone who assists the suicide of an adult can be jailed up to 10 years and fined. It is time to consider repealing this law for an ageing population that will have more terminally ill patients.

Singapore began that conversation on dying with the AMD Act enforced from 1997, which allows a person aged 21 or over who is of sound mind to make an AMD instructing doctors not to use extraordinary life-sustaining treatment if he is terminally ill and no longer competent to say so.

But the scope of the AMD is limited and confined to pre-deciding to decline extraordinary life-sustaining treatment when one is no longer competent.

In contrast, PAS allows mentally competent adults with a terminal condition and under six months of life, say, to have a physician give them lethal drugs.

The physician usually prescribes secobarbital or pentobarbital, which are barbiturates that put you to sleep at normal doses, but depress the brain and respiration at large doses. The terminally ill person himself takes the pills at high dosages to end his own life.

This is distinct from active euthanasia, where the physician himself administers some lethal medication to the patient with his informed consent.

In active euthanasia, doctors intentionally and directly end another's life. Normally, only the state has legitimate power to take any human life. By contrast, PAS gives back that power to the patient who must take the final step himself in physically swallowing the lethal medication on his own.

But Singapore law criminalises anyone who might help others, doctors or not, commit suicide. It also criminalises suicide: If you don't die trying, you may be fined and/or jailed for up to one year.

This is because, in general, the state seeks to preserve life.

But it is arguable what the state's interest might be when it comes to a patient choosing treatment. Many countries recognise that patients must give consent to treatment, and have the right to refuse treatment. If so, the competent dying patient has the right to ask for medication to be halted, a feeding tube removed or respirator turned off, even if death is thereby hastened.

This, in fact, is the essence of the AMD, where a person who is still competent spells out these end-of-life care preferences when he is no longer competent.

The natural extension of this right to refuse treatment is that the competent patient should also be able to ask for treatment that hastens his death. And if the state recognises it has no business overturning a dying patient's decision to decline treatment that would save him, it should also have no reason to intrude if a person wants to choose death and to determine its timing and manner.

This should be considered part of the sphere of one's privacy, self-determination and personal autonomy, into which the state should not intrude.

While refusing further life-sustaining treatment in this manner may look distinct from swallowing barbiturates to take one's own life, the distinction is one with just one difference. Whereas the goal and end result are the same in either case, PAS leads to a more peaceful, serene and dignified death whereas dehydrating and starving to death entail weeks of severe and needless suffering.

One may argue that access to PAS gives the terminally ill control and comfort, thus preserving human dignity, contrary to claims that PAS violates human dignity.

Doctors who kill?

ANOTHER common objection to PAS is that it makes killers of doctors, violating the Hippocratic Oath, by which the physician had vowed "not to give a lethal drug to anyone if... asked, nor will (he) advise such a plan". But most physicians the world over do not take this outdated oath. This is also omitted from the Singapore Medical Council Physician's Pledge.

Whether a doctor should be involved in PAS depends on his own convictions. The essence of medical practice is "to heal sometimes, to remedy often, to comfort always", so the doctor must decide whether to do so when only ending life affords that comfort.

But he must never drive that decision, which must always be the patient's to make, on his own free will and at his own initiative. The doctor is to be just witness, counsellor and prescription writer.

Yet others argue that legalising PAS may lead society down the slippery slope towards the active euthanasia of the elderly, disabled or poor, who may be coerced or influenced to request PAS.

But this effete argument only denies a right just in case some may abuse it. The answer to that is to regulate PAS to prevent abuse, as American states like Oregon do.

What about the notion that no one but the Almighty may take life? In fact, the state already does take life, wherever there is capital punishment. In any case, this is a religious argument to which the secular state may not give force of law. If access to PAS is legalised, the religious may give it a miss but may not deny others of it.

Without PAS, the terminally ill desperate to die may resort to anything from antifreeze to heroin. He may see multiple doctors to acquire multiple prescriptions of sleeping pills to try to overdose himself. Family and friends sympathetic to his plight may contribute their own stash of drugs.

Without PAS, some sympathetic doctors may covertly prescribe enough medication to hasten death to shorten suffering when medical futility sets in. Rather than such a clandestine system that only some may access, better to legalise PAS so physicians can help the terminally ill die with dignity, yet not be criminalised for doing so. Not doing so in effect means we are saying that people should suffer severe pain before dying if their disease leads to this.

While dying has become highly medicalised, PAS can change that for some, so they can say their last farewells at home, surrounded by close family as it used to and should always be.


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