Patient Assisted Suicide

Last month, the SMA News carried an article by Drs Jacqueline Chin and Jacinta Tan about an ongoing research project in the NUS Centre for Biomedical Ethics to study attitudes on "end of life decisions". Such research is critical, as are healthy open debates on these issues. Hopefully, these will pave the way to sound decision making about euthanasia and the related practice of patient assisted suicide.

Personally though I am not hopeful. Attitudes here are relatively conservative and too 'kiasu' about the sliding down the slippery slope. Public opinions are constrained too much by sensitiveness towards perceived religious values. This is not wrong. But it does limit our options to be "progressive".

Let's see what happens.

For those who are interested, you can contact Drs Chin and Tan at: Dr Jacqueline Chin or Dr Jacinta Tan at EOL.Decisions2010@gmail.com.

Euthanasia #9 - quo vadis?

Watching a loved one die an agonizingly slow death from terminal ovarian cancer is not the best way to pass a Sunday afternoon. She has said her goodbyes and now waits patiently for the end. Everyday her body wastes away.... literally rotting away before our eyes. Her body autocannibalizes itself...and the bugs begin to have a go at the rest. Yet she still breathes, blinks....and gasps meaninglessly.

We had some debates about euthanasia 2 years ago after Minister of Health floated one of his balloons on the subject. Since then there has been no progress on the idea. The idea seems to have died a natural death. Almost as soon as the idea was floated, it seems.

What gives.

A Time To Die

A time to die

By Anthony Yeo, Life Lines

I was one of the speakers at a forum on euthanasia held by the Medical Directorate of the National University of Singapore recently.

The controversy surrounding this issue raises various dilemmas, mostly of a moral nature. When one considers the reasons of those who prefer to be assisted in their death, we must appreciate the complexity of the matter.

More than two years ago, I had an intense conversation with a colleague and friend who was suffering from nose cancer.

She was expecting to die in November of the year of her diagnosis. When November came, she was in excruciating pain while expecting her impending death.

That did not happen as she battled her pain and discomfort, wondering when her suffering would end. She even prayed to God for relief from this life so she could join her Maker.

Our conversation covered many aspects of her life, including the legacy she thought she was leaving behind and her readiness to depart from this earth. Somehow she decided she was more than ready to die.

But providence seemed to decide otherwise and she continued in her agony, struggling to make sense of a life that she had released psychologically and spiritually.

One day she peered out the door of her eight-storey apartment and said: 'I wish I have the strength to get over the ledge and end my life. If only you could help me with it.'

We then sat in sombre silence, she placid and composed, I reeling in pain that I could not relieve her suffering that lasted for another five months before she finally breathed her last.

As I pondered over her extended time on earth, filled with nothing but pain and agony, I thought she was feeling a grievous loss of control over her predicament.

There was nothing she could do except be attended to by her maid, get shuttled to and from hospital, and wake each day to contend with what seemed to be meaningless suffering for her.

She must have decided that a possible way to assert control was to find a way to hasten her death. If only she could have someone who could help her to make that happen.

I suppose there might be others who think like her. They must be wishing that they could be given the freedom to do so.

Her situation has challenged my thinking about euthanasia and to consider the possibility that life need not continue if there is no more reason to do so.

If I were to be in a similar predicament as my friend, I would like to go rather than wait for a painful and inevitable death.

Meanwhile, I want to live each day meaningfully and learn not to wish for undue extension of life.

I want to be at peace and grateful for the life that I have had. May I learn to live so that I may learn to die.

Euthanasia #8 - an option of last resort

Euthanasia cannot be an option of first choice in any society. It is always an option of last resort. I am not a champion of euthanasia, but grudgingly recognize that it may represent a final solution to a small group of patients for which palliation has failed.

If euthanasia is to be legalized and offered as a solution, society will have to pay a high ethical/moral price.

Euthanasia, thus should only be an option only for the members of that society. It should not be part of a commercialized set of activities. I could never condone euthanasia, if offered in the context of a globalized medical hub concept. I could never ever support Singapore becoming an euthanasia capital of the world, which it will definitely be should we offer euthanasia services to non-citizens.

Euthanasia #7 - are we missing the point??

Well, it looks like we're jumping right back into the euthanasia debate. The Straits Times carried a Saturday special report on the issue, and Sandra Davie posted something in her blog...

The debate is important to have....but sadly it is beginning to sound tired,...kinda like a broken record that does not go anywhere.

People's positions get hardened around extreme and unrealistic positions. There are deliberate obfuscations so that it seems like everyone is playing in their own soccer fields. There is a general confusion about the AMD which is unfortunate as it is in a totally different playing field. Then there is the almost deliberate blurring of the line between murder and euthanasia, as if it is something done with the patient's full and informed consent. Sadly, after a protracted period of these confused meandering, the government will step in and proclaim that there is enough public debate, and that adequate public opinion has been sought, then proceed to implement its agenda.

How sad. How tragic.


I believe, if the discussions are to be meaningful:

a] The topics and definitions need to be carefully and clearly circumscribed. We need to deal with each problem clearly and specifically.

b] The main points of contention must be clearly identified and dealt with. In this regard, I see one of the major sticking points is the apprehension that the essentially noble idea, will eventually be abused, and extended to less noble ends. In the ST report, bioethicist Margaret Sommerville pointed out this 'slippery slope'. She says, "Once euthanasia is legalized, its availability expands.". She is right.

The government, and proponents of euthanasia must therefore spell out how this creeping availability, and extensions of the application of the euthanasia principle, can be managed and controlled.

c] The government must make more effort to manage the perception that this is somehow linked with the commercialization of health care. Why now?? It didn't help that this was brought up almost in the same breath as the organ trade issue. The public should be rightly concerned that euthanasia is only being surfaced now as an alternative medical option, just when there is this massive national push to establish Singapore as a 'grandmother of all medical hubs'.

If legalized, euthanasia should never ever be part of any activity associated with commercialized medicine. And it should never be offered to anyone who is a non citizen.

Palliating terminal cancer - a reality check

With the ongoing discussions on euthanasia, a number of doctors/agencies have made use of the opportunity to advertise their services. There was a letter in the Straits Times Forum yesterday, which I won't reproduce because it was just blatant advertising. Today's ST carried short report about the Palliative Care Clinic in the Tan Tock Seng Hospital which is worth looking at because it is admirable for a hospital that has to look after its financial bottom line, to set aside resources to manage what is very likely be a loss making service.

Palliation of the terminal cancer patient is not an easy task. It is certainly a complex one. It does not include just treating the cancer pain, but also includes managing the patient's social, emotional , psychological and spiritual needs. You can generally tell the inexperienced doctors from the caring ones by the way they 'chiong' (local slang refering to mindless charging, some what like a bull in a china shop) around the place and waxing eloquently about the use of new expensive, fancy painkillers, and how great the care giver is in being able to provide all this.

Truth of the matter is, the science of managing pain hasn't really moved too far from the use of either anaesthetics or analgesics. The former knocks off all sensation (not really desirable) and the latter tries to selectively reduce the pain without greatly affect consciousness. Neither are fully effective. A majority of patients though can be effectively managed because the pain is not so severe. However, cancer pain can be so wide spread, so severe and intractable that the only way to manage the pain is to increasingly anaesthetize the patient. Narcotic painkillers remain the main mode of managing this severe intractable pain. The downside is with the increasing dose of narcotics, the patient will gradually drift into a deepening coma, and increasing risk of just stopping his urge to breathe. Doctors don't like to discuss this, nor will they readily admit it, but here is where the thin red line between palliation and euthanasia blurs into a broad murky band.

One of the important features of effective palliative care is honesty and true concern. The terminal cancer patient is not a moron, and is trying his or her best to deal with an essentially hopeless situation. Giving false hope or blindfolding the patient is not the solution. The patient knows when he/she is being lied to. Pain in this kind of situation takes on a totally different perspective for the patient. Unlike the usual pain we suffer, for which we know will be self limiting and can only see recovery going forward, terminal cancer pain is intractable and will only get worse. Its presence is a constant reminder to the patient that he is dying. He sees no light at the end of the tunnel, and he knows that it can only get worse. Much worse. He is plagued with fear and uncertainty because he cannot foresee how bad and terrible it will become, and how long it will drag out for.

Therein lies the critical need for a good, sincere friend and caregiver. Often what the patient needs most is to be assured there is someone who will walk with him or her through the final steps. That the best is being done. He doesn't need to lied too that the pain will magically disappear with fancy expensive drugs.

Euthanasia #5 - a silent passage

Not so long ago, my pastor asked if I could accompany him to visit a parishioner who was dying from terminal colonic cancer and had just slipped into coma.

At her home, the grief was palpable. Clearly, she was a very much loved woman in the family. The cancer had taken its toll and her body had been reduced to mere skin and bones. She lay on the bed hardly breathing; her eyes staring vacantly towards the ceiling. She was totally unresponsive and uncommunicative, and I could understand why the family thought she had gone into a coma. But in that small HDB flat, as I stroked her forehead and held her hand, a silent tear rolled off the corner of her eye. The poor woman wasn't in a coma. She was just too weak to respond to anything. Couldn't even move her eyeballs let alone breathe or speak. She was on death's door, and just needed some reassurance and comfort.

We prayed over her, and held her hands for a bit longer. I told her loved ones to keep speaking those words of comfort to her because I was sure she heard all they said.

She passed away soon after.

Euthanasia would have been wrong for her. All she needed was the comfort of her loved ones around her... for someone to hold her hands and to be with her as she stepped across the threshold. As Christians, we were confident God was waiting to receive her as she stepped over, but on this side of the great divide, most would appreciate the company of a loved one until the very last moment.

Euthanasia #4 - the end is nigh

The anti-euthanasia group tends to craft their arguments in black and white tones. Pity. Because life really isn't black and white. It takes wisdom to discern the shades of gray...or better still, to resolve the subtle colours of life and living.

I suspect many of the people who are stridently against euthanasia have not had much of an experience at the bedside of people struggling through the closing stages of their life.

Quite a few years back, my uncle died of lung cancer. He was a smoker. The last days of his life was spent in pain because the cancer had already spread through his body, and were making big holes in his bones. It was agony for him. I think as we gathered around his bedside, if we could have read each other's minds, we would probably have seen how everyone was more or less thinking the same thing..."Was this really necessary? Couldn't something be done to put him out of his misery?"

As it transpired, something was done. The attending physician began giving him larger and larger doses of morphine for his pain. But even as he sank into a deepening narcotic induced coma, the grimace on his face told us he was still very much in distress. Finally after a few days, he passed away. As I watched him then, I held my peace...because my medical background had told me pretty much his passing had probably more to do with the morphine than the cancer itself.

The last days of a terminal illness is often not a fun time. Often there is only pain and distress. Though he/she may be surrounded by loved ones, his/her journey is a lonely and miserable one. Drugs don't help all that much. And we falsely believe that if the patient does not complain, he/she is free from pain. Often he/she is just too weak to say anything. Too weak to argue, or to say any more goodbyes. Just silent tears of resignation from the corners of his/her eyes.

Euthanasia is not the antithesis of palliation, though it is often presented that way. Palliation and euthanasia should be seen as partners in the same process of assisting a fellow traveler in life across the threshold into death. Euthanasia allows him/her to do so in peace, and with grace and dignity. This much we owe to our fellow men.

Euthnasia #3 - a good death?

So this morning the Indonesian government executed the 3 islamists who were responsible for the bombing in Bali. The Singapore government has been characteristically silent. Nothing to say really...considering we had similarly executed 2 Indonesian saboteurs back in 1968. What has been perhaps the most hypocritical was the Australian government's silence about the execution. Typically belligerent and vocal in its anti-death penalty stance, it suddenly seemed acceptable for the Indonesian government to execute these terrorists. Apparently since the Bali bombing had claimed 91 Australian lives, it somehow seemed acceptable to expect their pound of flesh (albeit with a few bullets). Apparently, the morality of taking human life even in the context of a death penalty, can be situational.

The word euthanasia really means "good death". It typically refers to "the practice of killing a human being or animal, especially one suffering greatly or with poor quality of life, as when suffering from an incurable illness or condition."

The attempt by the anti-euthanasia lobby to reduce it to suicide (physician assisted suicide) is I believe quite mischievous. It is correct to equate the two only from a technical perspective since they both involve the taking of one's own life, but truly, the two contexts are really quite different.

In a typical suicide, although the person is in an extreme state of emotional or psychological distress, there is nevertheless some hope (though often perceived as distant) of rescue or of recovery.

In the situation when euthanasia is contemplated, the situation is far from rescuable. While it is true that there is often some degree of depression, often the psychological distress is a reflection of the failure of palliation. It is clear to both patient and care giver that it is really the end of the road, and it is only a matter of time. How often have we as doctors, watch from the sidelines, and wondered about the unnecessariness of the pain and suffering. Words are quite ineffective at times like that.

Once at a well known hospice in South East London, I was briefed on the activities of the care givers. While a large part of the time was spent in managing the palliative component of the care given, I was impressed by how much effort was made to prepare the patient for death. Domestic and interpersonal conflicts needed to be resolved. Wills needed to be written. Debts settled. Reconciliation and forgiveness encouraged. Patients had to be guided towards a recognition of the reality of death. Spiritual help and solace was provided when appropriate. Then, when all has been said and done, if a patient had been prepared well, he or she would be at peace, awaiting the finality of the moment when he/she would depart this world. This was hospice care at its best.

Then when all that's left is just waiting for the final moment, one cannot help but wonder why the suffering need continue. Why would it be wrong for the patient to choose his/her moment of departure? To leave when goodbyes have all been properly said. To leave when your loved ones are all by your side.

This is truly what euthanasia is all about. A good death.

I am not supposed to support euthanasia. But I am not so sure it would be wrong if the context is correct. Death is not the end of life. It is merely a passing of life. Surely a doctor's role is also to assist that passing when the time has come.

Euthanasia #2 - sanctity of life ...or lack of

Life is so fleeting,...so precious...we cling to it. We say there is a sanctity to life. And because God created life, we have no right to take it.

Yet we do.

We take life. Often unflinchingly. Abortions have been legalized not just in Singapore, but many other places in the world. We don't blink. We don't even look away now, so hardened has our hearts become. Sure...we make all kinds of rationalizations...about the age of foetus, about the safety of the mother...But these are all rationalizations. We kill when we execute murderers. Another round of rationalizations. And we kill going to wars.

Sanctity of human life. Hardly.

We are hypocrites, because we profess something and do something contrary. There is an appropriate passage in the Bible, when Jesus turns to his disciples and warns them about the hypocrisy of the Pharisees..."I tell you, my friends, do not be afraid of those who kill the body and after that can do no more. But I will show you whom you should fear: Fear him who, after the killing of the body, has power to throw you into hell."

Jesus makes it abundantly clear. It is not the physical body that is holy...that is worth protecting. It has never been about the physical body, about the physical life.

The EEG and the lubdubs of the heart beats are not all there is to the story. They cannot be.

Euthanasia #1 - views on life...and death -

Copyright © 2008 BBC, Jellyfish Pictures and Marco Iozzi.

I've been struggling with this. This recent spate of discussions about euthanasia has got me thinking, and it's really not an easy issue to wrap your mind around. The issue has been further clouded by a lot of emotive arguments..most of which not very rational. Often public positions have been deliberately hardened around extreme unrealistic situations, which do not help in advancing our understanding.

I'll try and put my thoughts down in a number of posts. I think they will eventually pan out into something rational...I hope. Meanwhile do bear with me. Your comments will help me see though the fog, so please feel free to input your ideas.

It is perhaps unfortunate that the line between life and death is really not something clearly definable other than by means of a empirical physiological measurement. A heart that has stopped beating. A silent EEG. Somehow we know these are inadequate.

As a doctor, we see more than our fair share of death. Perhaps more so than any other profession (possibly more than the clergy). I have seen more than I have wished to. The times I have witnessed death by the bedside have been sobering, humbling...sometimes traumatic moments. When we speak to relatives we use terms like.."(so and so).. has passed away." An euphemism for something we don't want to articulate. Somehow we feel it crude...insensitive...to say the obvious..."he has died". But then, it's not really an euphemism to refer to a passing away of life, because somehow, witnessing death at such close range, it forces you somehow to recognize that there is something else not accounted for...that perhaps the patient has truly passed on to another existence. Another life.

Perhaps it is because of my christian beliefs, but cliched or not, death is not the end ... but a beginning. Notwithstanding this, it is heartwrenchingly painful.

Once I had to deliver an abortus. Seventeen weeks old, it was no bigger than a newborn puppy. I watched it die in the gynae ward sink. No...not die...because technically it wasn't alive, despite moving, gasping. That night, I wept. As a young houseofficer in a cold sterile ward of the old KKH, the sight of that abortus passing away from 'non-life' to death in the cold kidney dish, was far too much for me. That image has stayed with me all my professional life.

Later in my life, hardened by life, I have had to turn off numerous respirators, and watch life pass from lifeless bodies.

How do we draw the line between life and death? Somehow, the beating heart...flat EEGs...seem hopelessly inadequate. We use those only because we have no other means to demarcate that time of passing.