more on euthanasia

fr ST Oct 26, 2008
Can you PLEASE KILL ME?
Should Singapore allow euthanasia? Jamie Ee Wen Wei speaks to doctors who work with the terminally ill, and they all tell her: 'No'

Say you are dying of an illness and your doctor pronounces that you have no more than three months to live. Worried that your last days will be racked with unbearable pain, you ask to die.

Two doctors certify that you are of sound mind and have made the request voluntarily. They administer you with a drug overdose. Several minutes later, you are dead.

Two weeks ago, Health Minister Khaw Boon Wan raised the issue of whether euthanasia should be allowed in Singapore.

He had posed this question after reading about a debate on the topic that raged in the Chinese press.

One man even sent the minister a letter, written in red ink, asking that euthanasia be made legal.

Earlier, Mr Khaw had said that as Singapore comes to grips with an ageing population, it was time to talk about death and 'not sweep it under the carpet'.

Several MPs and doctors interviewed by The Sunday Times welcomed discussion on the highly controversial practice, even as they all said they were personally against euthanasia.

Jalan Besar GRC MP Lily Neo, a medical practitioner, said: 'By discussing it, we can understand how we can be more compassionate towards those who are suffering.'

But some were wary that the discussion would lead to more confusion about the procedure.

Dr Chin Jing Jih, executive director of the Singapore Medical Association's Centre for Medical Ethics and Professionalism, said there must be a consistent definition of euthanasia to ensure a good discussion.

He said this was especially relevant to discussion in the Chinese language, where euthanasia is known as an le si. Literally translated, the phrase means 'a peaceful and painless (or joyful) death'.

Unfortunately, this has led to confusion in the Chinese-speaking community as many tend to confuse euthanasia with palliative care, which involves the management of pain and suffering for terminally ill patients, he said.

As a result, many who merely advocate peaceful death end up on the record as saying they want euthanasia when they are actually not asking to be killed by their doctor, he said.

On the discussion of end-of-life issues, all interviewed said the focus should be on palliative care, which the Government is already looking into.

Dr Fatimah Lateef, an MP for Marine Parade GRC and a doctor for 18 years, said: 'I am more for counselling, proper pain control, and family and peer support in those with advanced disease.'

She added that she supported the Advance Medical Directive, which came into effect here in 1997 and allows an individual to say he does not want extraordinary life-sustaining treatment should he be terminally ill.

Dr Chin said the medical fraternity in Singapore has always been against the practice of euthanasia.

'We take the position that the solution to suffering in terminal illness is to continue to further develop and upgrade palliative care rather than legalise euthanasia,' he said. 'This is consistent with the role of the medical profession as healers and comfort providers, our professional values and underlying ethical tenets.'

Their concern is not only about the ethics involved but also about preventing abuse.

Madam Halimah Yacob, who chairs the Government Parliamentary Committee for Health, also felt the ground was not ready for the legalisation of euthanasia.

She said the feedback from her grassroots is that Singaporeans do not want euthanasia.

'I'm not quite sure if this is an area that we want to lead in,' she said.

jamieee@sph.com.sg

Do you think euthanasia should be legalised in Singapore? Have your say on straitstimes.com or send your views to suntimes@sph.com.sg
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octors disagree with act
Five doctors who work with the terminally ill weigh in on the topic of death and euthanasia

# Dr Noreen Chan, 42, medical director of Dover Park Hospice and consultant at the National University Hospital

'I personally am against euthanasia. Also, the World Health Organisation's definition of palliative care states, among other things, that palliative care 'affirms life and regards dying as a normal process' and 'neither hastens nor postpones death'.

Our response to suffering should be first to acknowledge it, then try to relieve the suffering, rather than to remove the sufferer.

I feel very disturbed when people talk about euthanasia in Singapore. I do not think any society should make euthanasia available when it cannot ensure equal access for all its citizens to pain relief and palliative care.

I am not saying that we can relieve all suffering, or that with palliative care, no one will ask for a hastened death. But if we have not ensured that we have done everything we can for the people and their families who are suffering, and have safeguards to protect the vulnerable and the marginalised, allowing euthanasia could be open to abuse.

Only very few patients express a wish to die sooner. Of those, only a small proportion ask for euthanasia - which is usually expressed as a lethal injection. For example, they may say: 'Doctor, can't you give me an injection so I can go off?'

The wish for a hastened death fluctuates. Most people don't have a sustained desire, and the wish to die faster may be associated with factors such as bad pain or other symptoms, the fear (often unfounded) of unbearable suffering, which are all issues that we can deal with effectively.

Of course, we must be careful that we aren't missing major depression, which is treatable and could be a reason for someone wanting to die.

I don't think people have a problem with the issue of death. We all know one day we will be no more. But it would seem that many people have problems with the process of dying - becoming weaker, more dependent, needing help for even basic needs.

And what are the main reasons for people wanting to die? Not pain, or breathlessness, but losing autonomy, losing the ability to engage in enjoyable activities and losing dignity. There's no medicine for that kind of problem, because it's a state of mind.'

# Dr Cynthia Goh, centre director of Lien Centre for Palliative Care and head of department of palliative medicine at the National Cancer Centre Singapore

'I personally disagree with euthanasia and would be against it being allowed in Singapore. This is because we have too many frail and vulnerable people in Singapore whose voices may not be heard properly, and who may become victims of non-voluntary euthanasia.

Also, I am worried that people who are old and sick, who already feel that they are a burden to their families and to society, would ask for euthanasia, not because they wish to die, but because they feel that it is their duty to die.

I often hear patients expressing a wish to die. But they are not asking for euthanasia, and we must not mistake it as such.

Often, it is an expression of sadness, a way of sharing and ventilating their frustration or grief. They often feel better after they have shared their feelings and find the wish to live on a bit longer. Sometimes, finding someone who will listen to the expressions of their hearts is enough encouragement to find a reason to live.'

# Dr James Low, 43, senior consultant and head of department of geriatric medicine at Alexandra Hospital

'I disagree with euthanasia because it goes against one of the most fundamental principles of medicine, which is first and foremost to do no harm.

To me, ending someone else's life is the worst harm that can ever be done to another person, what more to a vulnerable population such as the sick, elderly and dying.

It is unthinkable that the profession that takes pride in healing, curing and comforting life be also the one that takes it away. It reminds me of the proverbial wolf in sheepskin, except that now the sheepskin is the white coat.

Countries that legalise euthanasia have set conditions for it to be implemented. For instance, they require patients who request euthanasia to be above a certain age, mentally sound, suffering from a terminal condition, suffering - and most importantly, it has to be voluntary.

Unfortunately, these conditions have on occasion not been met. Can euthanasia always be voluntary? Involuntary euthanasia is murder.

Legalising euthanasia would also set off a slide towards widening its applications, so that certain groups may feel a duty to be killed or coerced into requesting it.

Many patients do not know the implications when asking for death. Many are in utter misery and desperation from uncontrolled pain (physical, emotional, psychological and spiritual). What these patients require more than anything else is palliative care - the speciality that manages the person holistically. Many patients who request euthanasia are depressed and their expression of a desire for euthanasia is actually a cry for help from their loved ones, their nurses, doctors and society.

Patients would want euthanasia if they thought that they would die without dignity, in pain and suffering and in total abandonment and there is no other way out. They would want euthanasia if they thought that this is what society wanted of them (if euthanasia is legalised).

It also has to do with what value we put on life. As it is now, suicide rates are rising - this is also a reflection on how we value life. We really have to teach our young important life skills and why life is so precious.

Many people requesting euthanasia do not realise the implications of this not only for themselves but also for their loved ones, the professional carers and society.

Euthanasia, in a way, is an expression of an individual's right to self-determination. This is patient autonomy and is another very important principle of medicine. However, many believe that autonomy is never absolute. My autonomy does not give me the right to take another person's life, neither does it give me the right to take away my own life. This is why suicides in Singapore are not allowed.'

# Dr Tan Yew Seng, 42, medical director of Assisi Hospice

'I do not think that euthanasia should be legalised in Singapore. The legal and ethical issues can be complex and may be difficult for the general public to understand.

There are hospice patients who request the doctor to assist in ending their lives. This, however, tends to represent a 'cry for help', a distress call as a result of physical, emotional or spiritual suffering.

We know that for the majority of them, after we take steps to treat the suffering, such as by treating their pain, bodily distress or depression, the patients no longer express the need to hasten their death.

When patients are able to perceive that the only solution to their suffering is death, they will ask for it.

Therefore, instead of accepting the face value of the request for euthanasia as an individual right, as it is couched in many places, our approach should always be to offer other options to patients to help relieve their suffering.

With choice, almost all patients will choose life instead. Incidentally, enabling patients to live on by managing their suffering is a key tenet in palliative and hospice care.'

# Dr Ang Peng Tiam, 50, senior oncologist and medical director of Parkway Cancer Centre

'I do not agree with active euthanasia. I think it is morally wrong. As a doctor, my duty is to save life and not to take life away. If indeed our society wants euthanasia, then let society decide how to carry it out. It should not be put in the doctor's hands.

Doctors can guide you on medical conditions, like for instance, declare that someone is terminally ill. But the act of killing someone is not for us to carry out.

To me, euthanasia is a cheap option. We should be able to relieve the pain of the dying to help them allow nature to take its course. The heart of the issue now is that we are not offering patients enough support as it is very costly and time-consuming.

Patients want love and care. People who want euthanasia are people who are in despair. They may not have family or community support. It is similar to people who commit suicide. They do it because they feel there is no hope.

I don't think the issue of euthanasia is adequately discussed in Singapore. It is certainly not an issue that the Government should decide, but rather, society should take the responsibility to decide.

I think we should go very, very slow with euthanasia and discuss it in a rational manner.'
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from ST Oct 18, 2008
Red-ink euthanasia letter 'conveyed reader's pain'
By Tan Hui Yee
SHOULD ageing Singapore legalise euthanasia? Health Minister Khaw Boon Wan posed this question last night at the Institution of Engineers' annual dinner and dance, in response to a recent debate in the Chinese press over the issue.

Over the past few weeks, many readers of Lianhe Zaobao have written to the Chinese daily calling for euthanasia - or assisted dying - to be legalised in Singapore.

Mainly older folk, they feel they should be allowed to die with dignity when crippled by illness, instead of seeing their loved ones burdened by high medical bills and caregiving responsibilities.

One particularly desperate reader even sent Mr Khaw a letter, written in red ink, on a photocopy of Zaobao's forum page.

'By writing in red ink, he probably wanted to convey his message of anguish and pain,' said Mr Khaw.

The euthanasia debate was triggered by a letter published on Sept20 from 72-year-old Shen Li Zhen Ni, who said she and her 74-year-old husband lived each day in fear of falling ill and becoming dependent on others for their daily needs.

The elderly, she said, were more afraid of illness than death, and she had no qualms about having her plug pulled if she became 'useless' to society.

She added that taking care of such elderly folk was like 'filling a bottomless pit', as one never knew when the work would end.

The letter sparked passionate letters of support from other elderly folk and their caregivers. One, whose parents are in their 80s and bedridden after suffering strokes and other illnesses, described them as merely 'waiting to eat, sleep and die'. She has told her own children not to save her if she should end up in a similar condition.

The letter writers argued that legalising euthanasia was not about encouraging people to stop medical treatment or shirking the responsibility of looking after ailing relatives; it was about letting people die with dignity.

One reader, however, said Singapore should look into its ageist attitudes and find ways to help the elderly lead meaningful lives before addressing euthanasia.

The debate comes at a time when the Government is trying to get more people to make an Advance Medical Directive, which allows them to state their intention to stop medical treatment should they become terminally ill. Since this living will was introduced in 1997, fewer than 10,000 people have signed up.

Sociologist Paulin Straughan said any discussion of euthanasia needs to take in a host of issues, such as religious beliefs and when a person's medical condition can be deemed terminal.

'The appeal of euthanasia lies in the misconception that it is the individual's decision, and this decision is based on a very noble perception that we don't want to be a burden to our family in the end stages,' she said. 'But in reality, that decision affects so many others.'

Legalising euthanasia could also put pressure on individuals to choose the option against their will, she warned.

'Some may feel that if they love their family, they should opt for euthanasia if they are in the terminal stages of a painful condition, even if they are really not ready to go.'