Friday, October 24, 2008

Look into better care of the dying

Oct 23, 2008

By Andy Ho
THE authorities are promoting Advance Medical Directives, or AMDs. They want us to understand our right to refuse life-sustaining therapies, even if doing so results in death. That is passive euthanasia.

Last week, Health Minister Khaw Boon Wan suggested we might even have to consider legalising active euthanasia - presumably for the terminally ill who are mentally competent.

As no survey to gauge public opinion on this subject has been conducted, we don't know how much support there is for these proposals. But we know this much from the United States: There was considerable public anger over news that doctors had allegedly euthanised some patients who could not be evacuated during Hurricane Katrina.

So far, fewer than 10,000 people in Singapore have signed an AMD in the 11 years it has been available. It is repeatedly asserted that the slow uptake is because a doctor's signature is also required. But it could well be that few want a right that ends all rights, literally.

Active euthanasia is unlike, say, organ trading. That was welcome by some as it can save lives. To give the right to end all rights, however, is a different matter altogether. Active euthanasia cannot be legal unless there is real support for it.

So no less than a national survey to ascertain attitudes will do. Such a survey should avoid the methodological pitfalls of a recent Hong Kong study. That study is instructive since it was done in another former British colony that is also highly urbanised, materialistic, pragmatic and predominantly Chinese.

In a 2005 survey of 618 members of the public and 1,197 physicians published in Death Studies, researchers from the City University of Hong Kong reported that the public - especially older folk - were generally in favour of active euthanasia and 'non-voluntary passive euthanasia', which presumably means not resuscitating terminally ill patients, who had not signed an AMD, at the point of death. The public was neutral about withdrawing life support for the 'comatose', presumably those in a persistent vegetative state.

By contrast, Hong Kong physicians were neutral about 'non-voluntary passive euthanasia' but favoured withdrawing life support for the 'comatose'. However, they were dead set against active euthanasia - not surprising, since all Western-trained physicians swear to never take their patients' lives.

We cannot assume that the attitudes in Singapore would be similar. Aside from using terms like 'non-voluntary passive euthanasia' and 'comatose' without elaboration, the Hong Kong researchers had also translated euthanasia as an le si, which means 'a comfortable death'.

This alone might have biased survey responses by casting euthanasia in a favourable light. After all, an le si is redolent of zhong sen an si, a well-loved Chinese saying that means 'to value life with respect, yet face death with equanimity'.

Mr Khaw stressed that the sanctity of life must be respected. No one disagrees. But the question is which options would do that best. His suggestion for us to mull over active euthanasia may well have short-circuited the debate because it posed a false choice between prolonged suffering and taking one's life, pronto. Instead, taking better care of the dying is an important alternative that lies in between those equally distasteful choices.

Sound public policy must be based on empirical facts about, above all, how good our palliative care of pain and depression in the terminally ill is. Much has been said about palliating physical pain in these patients better but little about alleviating their depression.

Having to deal with progressive debilitation, such patients are naturally depressed. Treating that depression can strengthen their resolve to try to cope with life instead of ending it.

The suicidal, whether terminally ill or not, have similar thought patterns. In The Savage God: A Study Of Suicide, the poet Alfred Alvarez wrote evocatively: 'Once a man decides to take his own life, he enters a shut-off, impregnable but wholly convincing world where every detail fits and each incident reinforces his decision.

'An...expected letter which doesn't arrive, the wrong voice on the telephone, the wrong knock at the door... - all seem charged with special meaning; they all contribute. The world of suicide is superstitious, full of omens.'

The suicidal could, likewise, perceive a physician's willingness and availability to assist in suicide as affirming his decision to end it all. In fact, the terminally ill who are suicidal may be looking for a different kind of affirmation.

Physical pain aside, these people also experience 'existential suffering'. As they lose their roles in society and see their own personalities disintegrating in a downward spiral, they come to fear having to burden their family.

If so, it does not appear very compassionate for a doctor to prescribe lethal drugs for such a patient to take his own life. The compassionate doctor should instead assure such an individual that his remaining days are still meaningful and he would be around to help him through his last days.

Only as we know more about the process of dying can we evaluate what responses would be the most humane. While there is much we don't know yet, one thing is sure: Much more money must be devoted to, and more doctors trained in, palliative care.

We have only four hospices, all run by voluntary welfare organisations, which helped 1,200 patients last year. There were another 3,200 patients receiving home-hospice services. Over half of nursing home inmates are sent to hospitals to die. Many may also be dying (badly) in these homes, not hospices.

Yet just $5 million in subsidies was available last year for hospice care. Much more must be done - and done soon - before the Government tables active euthanasia for public debate.

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