Killing the Dying

By Dr Wong Wee Nam
23rd March 2010

“You will not mistake my meaning or suppose that I depreciate one of the great humane studies if I say that we cannot learn law by learning law. If it is to be anything more than just a technique it is to be so much more than itself; a part of history, a part of economics and sociology, a part of ethics and a philosophy of life.”

— Lord Radcliffe, The Law and Its Compass

Writing in a recent issue of the Singapore Academy of Law Journal, a National University of Singapore law professor Stanley Yeo and DPP Toh Puay San had proposed that a terminally-ill patient be legally allowed to kill himself with the assistance of his doctor.

They even crafted a piece of draft legislation on this.

The article could have been just a piece of academic musing or it could have been a controversial kite flown to test the winds of public opinion. Whatever it is, a piece of legislation such as this would be an ill-conceived one.

Unlike strict liability, eg, traffic laws, where no moral issues are involved and hence do not need an input from society, the question of euthanasia and physician-assisted suicide is a very complex one. This is not just a medical problem but a moral and ethico-legal problem that has far-reaching effects on the moral fabric of society. Thus the question is: how much feedback have the authors received from the community before they penned the article?

Yes, law sometimes needs to be changed, but it needs to take into consideration human values and societal mores. Lord Simonds in Shaw v Director of Public Prosecutions said, “The law must be related to the changing standards of life, not yielding to every shifting impulse of the popular will but having regard to fundamental assessments of human values and the purposes of society.”

He also said that the moral welfare of the State must also be conserved and protected: “In the sphere of criminal law I entertain no doubt that there remains in the courts of law a residual power to enforce the supreme and fundamental purpose of the law, to conserve not only the safety and order but also the moral welfare of the State and that it is their duty to guard it against attack which may be more insidious because they are novel and unprepared for.”

Thus any law on euthanasia without consultation with the community must end up as a flimsy piece of work.

What is Euthanasia?

We all live in a civilised society where there is general moral prohibition against killing.

Unfortunately there are now some people who find that active euthanasia and physician-assisted suicide is an attractive proposition. This is because medical interventions have, in many cases, made dying very unpleasant. People who have experienced the dying of an aged parent, relative or friend under such circumstances would naturally want death to come quickly and painlessly. It appears to be more compassionate that way.

However, active euthanasia and physician-assisted suicide is not compassionate killing. It is just a way of reducing demands on the compassion of the care-givers.

It is actually nothing more than a perverse way of managing suffering. We are merely trying to solve the problem of suffering by knocking out the sufferer.

The danger of active euthanasia and physician-assisted suicide is that once we accept killing, it just becomes a little easier the second time, and each time thereafter, until it becomes routine and mechanical, totally devoid of compassion.

The Slippery Slope

What then comes next? We will then start using pain, disability, suffering and, worse still, age and economic status to assess the worth of a human life and as reasons for the doctor to end his patient’s life. I hope this is not what Prof Yeo and DPP Toh have in mind when they said, “The rapidly ageing population calls for much more to be done than just the provision of advance medical directives and improved palliative care by the Government.”

Imagine how you would feel when you are old, poor, disabled, sick and an economic burden to have a doctor telling you to get off his uncaring face!

Once human lives become a commodity to be disposed off when it becomes too expensive to maintain, the rot of materialism will set in and the caring ethos of medicine will disappear.

In such circumstances, how are we to safeguard against tendencies to take the easy way out and the possibility of subtle coercion to put pressure on the patient to die?

The real danger of such physician-assisted suicide legislation is that it is the thin edge of the wedge towards a society in which the aged, the handicapped, the mentally deficient and the chronic sick will be faced with a duty to die so that they will not be a burden to society.

Is Assisted Suicide Morally Right?

It is obvious that allowing terminally-ill patients to end their suffering by killing themselves is morally wrong. Even the authors of the report appear to think so. Otherwise why would they want the suicide to be physician-assisted instead of allowing anyone else to do it?

This is because assisted suicide is not a morally correct thing to do and thus the suicide must be medicalised to make it morally right. Making suicide a medical condition and turning it into a medical problem would assuage the guilt of the loved ones. Without medicalisation anyone else would loathe to take on the role of the executioner knowing that it is morally not the right thing to do.

Even then this will not make euthanasia any more psychologically comforting. Ask anyone who has put a pet dog to sleep.

Impact on Medicine

The most humanitarian function of medicine is the relief of suffering and helping patients cope with their physical disabilities.

Active euthanasia and physician-assisted suicide, therefore, runs counter to the traditions of medicine and to the training, inclinations and intuitions of doctors and nurses who care for dying patients. Allowing active euthanasia and physician-assisted suicide will give the doctor the taint of an executioner. It will relieve the community of its obligation to provide good care.

If our doctors start to be pre-occupied with whether a case should be killed or not, then they have stopped doctoring. Instead of being dispensers of care our doctors will become dispensers of death.

Impact on Society

A community needs its aged and dependent, its sick and its dying because they show us the virtues of humility, courage, and patience — just as much as the community needs the virtues of justice and love shown by doctors, nurses and families, and they can only do so with the presence of the aged, sick and dying.

Thus the ability to invoke love, devotion, sacrifice and care is one contribution of the handicapped, sick and dying to the humanity. (To understand this better, readers should read “Soft Sift in an hourglass” by Dr Rosalie Shaw)

Once we have active euthanasia and physician-assisted suicide, human lives would be in danger of becoming commodities to be disposed off when they becomes too expensive to maintain. Would the lives of the terminally ill, the senile, the permanently unconscious, the retarded, the incurable, the chronic sick and even the aged then have any value?

Care of the Terminally-Ill

The challenge in the care of the terminally-ill is not to assist them to die but to make euthanasia unnecessary. It is to find ways to improve the comfort and quality of life for them and not hurrying to dispatch them on their way.

Hospices, for example, by alleviating patients’ pain and comforting them, allow the dying to live as fully and painlessly as possible until death. They also help to relieve the burden on the caregivers and help them to cope.

The palliative care that they provide has made it less common for patients to ask for euthanasia and physician-assisted suicide.

Though there are still many conflicts to resolve and a wide range of issues to be addressed, there is no need to end life prematurely and to try to control death.

The Meaning of Dying

Dying used to be an occasion. Death was a significant part of life. In the past, it was a public ceremony showing the living how to die with dignity. The dying person is surrounded by his loved ones and not isolated in a ward attached to machines and have tubes inserted into all his orifices.

Euthanasia and physician-assisted suicide seems to allow a merciful end to suffering and dying, but what it actually does is to increasingly isolate the rest of us from death’s significance to life. It will make us more likely to abandon the aged and the dying in order to make life easier for us. In the end, it will make us poorer as human beings.

We must, therefore, be careful not to allow the momentum of the right-to-die call to push us over the slippery slope so that the call for the right to die may eventually become a demand for the duty to die.

Conclusion

It was reported that the two authors had also argued that “it is realistic to assert that even with their prohibition, acts of PAS are being conducted in secret.”

In April 2009, Health Minister Khaw Boon Wan made it very clear that “euthanasia, which means helping the patient to commit suicide, is not what Ministry of Health (MOH) is promoting” and that MOH is actually “promoting palliative care for the terminally ill so that they, and their family members, will be able to cope with terminal illness with the least pain and being cared for in the most appropriate setting, which usually means the home they live in.”

With such a clear stand from the Minister, it is hard to believe our doctors can be so reckless as to conduct acts of PAS in secret. Maybe the authors know something that the Minister and the medical fraternity do not?

I always believe that law must have a human face. Thirty-five years ago, when I was studying law, I came across these words of Walter Scott, a lawyer himself, from his novel Guy Mannering and they have stayed with me: “A lawyer without history or literature is a mechanic, a mere working mason; if he possesses some knowledge of these, he may venture to call himself an architect.”

Materialism and selfishness have eroded our soul and made us a less caring society; let us not add on to it by allowing the killing of the dying.

References:

1.  Lord Lloyd of Hampstead Introduction to Jurisprudence

2.  L. A. Hart Concept of Law

3.  Daniel Callahan Setting Limits – the medical goal in an ageing society

  1. complete nonsense, what harm is there in giving people the option?

    I certainly want that option for myself, I’m only 32 and I’ve already sign the advanced medical directive.

    ~~~
    not to mention every dying person expels co2.
    we are all dying already, some sooner than later. so it hardly matters especially if the patient desires it.

  2. i’m not too sure whether to agree with your article. complaining that allowing doctor assisted euthanasia means that people have become less compassionate???? do you think that the families of ill patients will readily accept their relative’s decision to go for euthanasia? that the decision is easily a wilful one? or that families will “take the easy way out” at the first chance? i take offense at the comment that “It will make us more likely to abandon the aged and the dying in order to make life easier for us.”

  3. to the author,

    what are your views on the Advance Medical Directive Act? how different is it from euthanasia? is it acceptable or is it wrong?

  4. christoup, if you are diagnosed to have a cancer and the doctor told you you have only six months to leave, of course you should have a choice whether you want to end your life immediately by committing suicide or live out your 6 mths. Why ask the doctor to do it for you? That I think is the the good doctor’s point in his rather profound article.

  5. There seems to be much confusion between euthanasia, physician assisted suicide and the advance medical directive.

    The objective of the advance medical directive is NOT euthanasia but to ensure that doctors will not carry out FUTILE medical interventions against the wishes of the patients who are at the end of life.

    Euthanasia or physician assisted suicide is the ACTIVE termination of a life

  6. There seems to be much confusion between euthanasia, physician assisted suicide and the advance medical directive.

    The objective of the advance medical directive is NOT euthanasia but to ensure that doctors will not carry out FUTILE medical interventions against the wishes of the patients who are at the end of life.

    Euthanasia or physician assisted suicide is the ACTIVE termination of a life in a patient who is NOT at the end of life on the pretext of ending suffering. This is no difference from a person committing suicide to end his or her emotional suffering.

    It is important to recognize the psychosociospiritual dimension of dying. It is foolish to put our faith in doctors only to cure our diseases instead of seeing them as our fellow and fallible human beings who can use their medical skills to relieve our physical suffering so that we can live our final days with meaning, dignity and grace.

    When my 15 year old dog was dying, she would cry out whenever I leave her side and would be quiet when I stayed by her side and stroke her. I learnt the lesson that putting her to sleep is more for my convenience than for the relief of her suffering. I relieved her pain with morphine and she died a natural and peaceful death two days later. I had chosen to give my dog hospice care rather than to end her life by euthanasia. This made it easier for me to go through my grief of losing my beloved dog.

    Caring for the dying has taught me many lessons. One of my patients was suffering from metastatic cancer of the prostate. When I first saw him he was ambulant and able to look after himself. He was asymptomatic and was struggling with his prognosis as the doctors in hospital had told him that he cannot have any more chemotherapy. He was encouraged to attend a hospice Day Care Centre which he did for two months. Unfortunately, he developed an urinary obstruction and had to use an indwelling urinary catheter. He then stopped going to the Day Care Centre but he remained independent and was able to care for himself at home.

    Four months later, the cancer spread and caused an intestinal obstruction. He then had to have a colostomy. In spite of all the above complications, he was able to live an independent life at home. He was understandably demoralized and depressed by his condition but we encouraged him to live one day at a time.

    Unfortunately, 2 months later, as he was walking to his favourite hawker stall one morning, he was knocked down by a car and suffered a fracture of his right hip. But he was able to walk after his hip operation and died at home after another 3 months.

    It was not an easy time for him and his family and he had expressed a desire for death a couple of times. If euthanasia is permitted by law, I would have to make the choice to encourage him to find meaning in his suffering or to assist him in ending his life.. But choosing euthanasia would have deprive him and his family the last few months of his life which gave them an opportunity to resolve issues and to complete unfinished tasks – to express love, forgiveness, gratitude and to say goodbye in a human way,

    The answer to suffering is not to end life but to see it as a challenge to love and to care more. The evil of euthanasia is that it is a symptom of a materialistic society that measures life only in terms of wealth and health. But such a society is spiritually poor as well as evil for evil is the absence of compassion and love.

  7. Dear student,

    You have posted a very good question and I shall be glad to answer it.

    I am all for Advance Medical Directive and encourage my patients to sign.

    We have to be clear about some of the terms used:
    1. Active Euthanasia (note that I use the term “active” throughout) means a doctor takes the initiative to put down the patient. Giving the doctor this legal right is very dangerous because the doctor may make an error of judgement or there could be percuniary incentive to do it.

    2. Asssisted Suicide – this is to help the patient commit suicide

    2. Letting Die (or passive euthanasia) is to allow a terminally-ill patient to die comfortable and allow death to take its natural course without using high tech medicine to keep the patient alive needlessly. This is the principle behind the Advance Medical Directive and there is nothing morally reprehensive about it.

    I did not write about Letting Die because it would take another long article to discuss the moral issues behind it. But AMD is something I support fully. But remember AMD is not active euthanasia or suicide.

    In fact, one should not just sign AMD and forget about the matter. In time, this will be forgotten. Make copies of it and give it to every member of the family because it is they who have to be very clear about your wishes. They have to leave with the gulit of your death.

    As a student, I hope you will read through the article again and reflect intelligently on the moral issues that I have discussed. It is going to be your world in future.

    Once again thank you for your intelligent question and I hope I have cleared your doubt.