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Euthanasia – The right to self-determination

The earlier article, "Clarify, not prevent, false claims", has been removed as it has been brought to our attention that it has been published before. We apologise for the error.

Richard Woo

I am among the minority when it comes to euthanasia and/or physician assisted suicide [PAS]. It is my opinion that euthanasia and/or PAS, if only to enable patients to die peacefully and with dignity, should be made legal, notwithstanding the divergent opinions expressed as evidenced in articles published in the local newspapers.

Needless to say, the issue of euthanasia and/or PAS needs to be thoroughly discussed, with input from as many people as possible. Then, if the government is of the view that further discussion at government level is merited, it should be introduced for debate in Parliament, and only become legal when there is a consensus that the community as a whole would benefit from euthanasia and/or PAS.

The most recent article, if I am right, was contributed by Jennifer Yeo and Madan Mohan [both from the law firm of Yeo-Leong & Peh]. Dr Andy Ho [senior reporter of The ST] had written several articles, all similar in tone to that expressed by Jennifer Yeo and Madan Mohan – that euthanasia, let alone PAS, should not be legalized, for various reasons: cultivating a culture of illusionary pride, cutting health-care costs, morally or spiritually hazardous, we are living our lives for others, not only for ourselves etc.

Euthanasia can be defined as “the deliberate, intentional termination of a person’s life for the benefit of that person” or as “the intentional ending or mercy killing by act or omission of a dependent human being for his or her alleged benefit”. These definitions are quite similar, except for the use of the words “mercy” and “omission” in one definition. What is specifically stated in these definitions is that euthanasia is for a benefit, the ending of a person’s life for the benefit of that person. If death is not intended, it is not an act of euthanasia.

Although euthanasia and/or PAS have also been hotly debated in other countries in recent years it is still not clear which other countries besides Belgium and Netherlands have legalized both euthanasia and assisted suicide/PAS. Switzerland prohibits euthanasia but has since 1941 allowed physician and non-physician assisted suicide. The US state of Oregon was, until recently, the only state in the US with a law, enacted in 1997, specifically allowing PAS; in Nov 2008, a similar law was passed in the state of Washington. Some form of euthanasia is also legal in the Autonomous Community of Andalusia (Spain) and Thailand. The Luxembourg parliament in Dec 2008 voted in favor of legalizing euthanasia.

Excerpts from the BBC website describing the fine distinctions when we talk about euthanasia:

Active euthanasia

In active euthanasia a person directly and deliberately causes the patient's death. Active euthanasia is when death is brought about by an act - for example when a person is killed by being given an overdose of pain-killers.

Assisted suicide

This usually refers to cases where the person who is going to die needs help to kill themselves and asks for it. It may be something as simple as getting drugs for the person and putting those drugs within their reach.

Indirect euthanasia

This means providing treatment (usually to reduce pain) that has the foreseeable side effect of causing the patient to die sooner.

Voluntary euthanasia

This is where euthanasia is carried out at the request of the person who dies.

Involuntary euthanasia

Involuntary euthanasia occurs when the person who dies chooses life and is killed anyway. This is usually called murder, but it is possible to imagine cases where the killing would count as being for the benefit of the person who dies.

Non-voluntary euthanasia

Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable (for example, a very young baby or a person of extremely low intelligence) to make a meaningful choice between living and dying, and an appropriate person takes the decision on their behalf

Non-voluntary euthanasia also includes cases where the person is a child who is mentally and emotionally able to take the decision, but is not regarded in law as old enough to take such a decision, so someone else must take it on their behalf in the eyes of the law.

Passive euthanasia

Passive euthanasia is when death is brought about by an omission - i.e. when someone lets the person die. This can be by withdrawing or withholding treatment:

If the last act, the act that caused the patient’s death, was intentionally performed by a third party, it would be euthanasia. For example, giving a patient a lethal injection or withdrawing a life-sustaining intravenous feed would be considered euthanasia. Assisted suicide refers to an individual dying or having died as a consequence of using information, guidance, and means provided by another with the intention that they would be used by the former for the purpose of suicide. Thus swallowing a lethal substance or taking an overdose of drugs provided by a doctor for the purpose of causing death is clearly a case of PAS or assisted suicide.

Irrational to opt for euthanasia?

Life can be devastating when one is suffering from paralysis or from an incurable or agonizing disease for which there is no hope of recovery or amelioration. Some people may consider it pointless to continue living if they are in such conditions and are critically dependent on others for physical assistance on a day to day basis. In such a scenario the patient can see himself/herself as a liability to others and hence can feel demoralized. Being immobile or in a vegetative state is definitely one of the worst downsides of being alive, whether one is young or old.

Is there any point in being alive or is it worth to continue, if there are no prospects of recovery?

A person is considered to be in a vegetative state in the absence of behavioral signs of consciousness. Any person may appear to look awake, for instance, with eyes open, yet would still be considered to be in a vegetative state for having failed repeatedly to follow commands or instructions such as “look in my direction” or “touch me” and showing signs of being capable only of reflexive movements. Can one avoid becoming a “vegetable”? A healthy lifestyle cannot amount to a guarantee against such a despairing fate, which must be, short of committing suicide, beyond one’s personal control. A head or spinal injury or an attack of stroke can transform one into a vegetative state, whether one is ostensibly healthy or otherwise.

A persistent vegetative state (PVS) can be considered as a condition in which coma resulting from brain damage has progressed to a state where probability of recovery has diminished and there is no evidence of any detectable awareness. A continuation of coma after one month of the brain injury is usually deemed a PVS case. Besides the emotional and physical strain that may affect family members or relatives who are providing the care-giving, the financial cost can also be a strain on the care-givers, if they have to bear the financial cost. I am not discussing a situation where prospects of recovery are positive and where financial cost for nursing care and/or medication is not an issue. If an adult has been suffering from an incurable ailment with no hope of recovery or amelioration and continuing would just mean misery and a severe drain on precious but limited financial resources, would that person be considered irrational to opt for euthanasia, or PAS, as a way out? My answer would be a resounding NO.

Must life continue on its natural course?

We all live for a time only, but to be able to die peacefully, with dignity and without pain or fuss, can be considered a life achievement. Dr Andy Ho, a senior reporter for The Straits Times made this comment in one of his articles concerning euthanasia: “My self-autonomy does not imply an absolute authority to decide my own life.” This is of course subjective. Others may think differently. Others may hold that the right to life comes with a tacit understanding that one has to die sooner or later, and with the right to die in a manner and at a time of one’s choosing, and with assistance of medical technology, if necessary, to make the exit as peaceful and hassle-free as can be deemed possible.

Some people [and I am one of them] dread living to a stage where their mentality becomes impaired [dementia or Alzheimer’s, for instance]. When a person is at this stage they would not be aware of the problems they may be causing to others. Some of us now alive today may find ourselves going through a state of anxiety and anguish before making our final exit. If continuing to live means enduring or suffering pain, physically and/or mentally, must life continue on its natural course and, if so, on what grounds?  Sometimes it can be hard to die, even if you want to.

And having the financial means may not help in ending the pain or anguish. People who talk of palliative care often forget or omit to mention the financial cost involved. If money is not an issue – for example, employing domestic maids or nurses to provide full-time nursing care - then it may be a non-issue. The situation can, however, be problematic if money and manpower resources are areas of contention. Opting for an early exit through euthanasia or PAS, just to end one’s suffering, may be the preferred choice, even where the government is footing the bill for the palliative or nursing care for the patient.

Can euthanasia or PAS be considered as a solution, then?

My answer is yes, despite all the pro-life arguments about preserving life. If I were in such a condition with nothing to look forward to but misery and death I would opt for an early death. It would be difficult to provide justification for prolonging pain and suffering, including of course mental anguish. Through euthanasia or PAS my misery can be removed and I would consider it as an efficient way to go.  And if someone else has to make a decision on my behalf, I would be thankful for the decision, for giving me a quick and efficient escape route. A lethal injection seems to be a far cleaner, more efficient way to go than starving oneself to death, or jumping, say, from a building if the illness is one that does not affect the patient’s mobility but nevertheless is incurable and painful to him, physically and mentally.

When an animal is perceived to be in agony, resulting say from an injury or an ailment, it would be put to “sleep” through a lethal injection to end its misery if such action is considered to be the best, in the interest of the animal or its owner, or after consultation with a veterinary clinic. But when a person, depending on country location, is in misery because of a painful or incurable illness, with no hope of amelioration, and wants help in terminating his life to end the misery, he can expect zero help if euthanasia or assisted suicide is not legal.

A recent case reported in the newspapers [The Straits Times, Mar 21, 2008] is a case in point:

A French woman suffering from an incurable and disfiguring cancer has been found dead, two days after a court rejected her request for medical assistance to help end her life. No details were immediately available on the cause of Ms Chantal Sebire’s death on Wednesday. …Ms Sebire’s doctors had said she would fall into a coma and die if she stopped taking medication to deal with the rare tumour. But she insisted on going to court to try to secure the right to an assisted suicide, which would be less painful. After her request was rejected, she said she would not appeal the decision and would find life-terminating drugs through other means.

Was her death the outcome of her having stopped her medication, or due to some other cause[s]? We do not know at this juncture.

Terri Schiavo

We have heard some people saying: “Doctors can allow death but not cause it”. If one recalls the Terri Schiavo case in the US, one would remember the controversy that arose from this incident. There was an interesting article in The Straits Times [May 9 2005] from a woman expressing her views in response to an earlier article concerning Terri Schiavo.

It is easy to talk from the sidelines about caring for a terminally ill patient until natural death overtakes him or of the ethos of the medical profession to cure and save lives but not take away any. A slow lingering death is the worst way to die, because those who suffer most may not be the one who is dying but his close relatives who have to take care of him until his death.”

In case you are not familiar, Terri Schiavo had been in a vegetative state for 15 years before her husband, with court sanction, pulled the plug by removing her feeding tube. The earlier article was in essence a critique of the husband’s action and argued, among other things, that doctors “can allow death but not cause it”. One cannot really tell why Terri’s husband acted as he did, unless one was in his shoes for the last 15 years. 

Being alive is not a big deal if you happen to be old and living by yourself; and being old and alive can become a social problem for others. We have seen press reports [in Singapore] of old people dying alone without anybody knowing anything about it until the stench from the dead body caught someone’s attention. The most recent case of death going undetected occurred in Jan 2008 and concerned a father [82 yrs] and his daughter [50 yrs], both of whom were found dead in their home after the stench from their corpses caught the attention of neighbors. When police arrived at the home, a woman [80 yrs] told them that her husband and daughter were sleeping. This is an example, a very sad one, of a severe downside of growing old. And that may precisely be the kind of situation some people dread to be in; dying sooner rather than later seems a pro-choice in such a scenario.

Through its national registration records, a government may have no difficulty ascertaining the names of oldies [say over 80 years?] still alive today. What may be more difficult is to ascertain which oldies are living alone. Probably, some of these old people need help one way or another. A brief visitation once every two or three days by a member from the government social services unit and/or a member of any volunteer group to the home of an aged person who lives alone can go a long way to ensuring that death when or where it has occurred will not remain undetected for long. On a happy note, I am glad to report that under the Neighbors Connect Group project [a community initiative launched in Marsiling, Singapore] neighbors will call on elderly residents in two blocks in this housing estate to get in touch and collect some basic personal information. The effort “aims to connect residents so that, if anything were to happen to one of them, there would always be someone who would find out and act.” This is doubtless a laudable project and it is hoped that other housing estates will launch, similarly, their own initiative.

The right to self-determination

If people are denied the right to self-determination when they are mentally capable of doing so, with the proviso that it is not harmful to others, there may come a time when self-determination is no longer feasible, in terms of their mental state, and thus they may become wholly dependent on the judgment of others, which may or may not be beneficial and may lead to complications that they would not have dreamt of in the first place.

No doubt euthanasia or PAS is appalling to some people. But euthanasia or PAS may just be the solution to pain and suffering. Opponents of euthanasia/PAS may offer their views about the “sanctity of life” or “preservation of life” and so on in their defense but they would do well to pause and then reflect on the evil of pain and suffering a person may be forced to endure. It is easy to talk from the sidelines about caring and so forth, as the woman who wrote to the media stated. One really needs to evaluate who else suffer[s] along with patients who are, say, in a vegetative state, and the financial aspect that may add damage to their family members. When we talk about suffering we cannot exclude mental anguish.  What if the patient is without the financial means to employ, say, a full-time nurse or domestic maid but has two young children and a spouse who is now the sole bread winner and the spouse’s income is at a level that any talk of engaging a full-time nurse or domestic maid is out of the question? Would the government arrange all the essential care for such a patient at its own cost? If the answer is no, should the patient be left to rot to death?

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A mass of information about euthanasia and assisted suicide can be found in Internet websites; a comprehensive question and answer version can be found in http://www.internationaltaskforce.org/faq.htm

Comprehensive information can also be found in British Broadcasting Cooperation’ website: http://www.bbc.co.uk/religion/ethics/euthanasia/

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