Despite being a widely discussed topic, many people are frequently torn between the pros and cons of ‘medically assisted suicide’. A study recently published last week in the New England Journal of Medicine provided further insights into this subject and the reasoning behind it.

The research done was based on Canada's University Health Network in Toronto and represents 74 people who inquired about assistance in dying from March 2016 to March 2017. Most were diagnosed with cancer or a serious neurological disorder like Lou Gehrig's disease. The law passed in Canada, ‘Medical Assistance in Dying law’ (MAiD) allows adults with serious and terminal illnesses to seek aid. The University Health Network requires patients to undergo several levels of evaluations, and upon meeting the criteria, they can receive a lethal medication intravenously at the hospital.

Dying with dignity and be in control

Researchers of this study discovered that assisted suicide stemmed from more than just uncontrollable suffering and the fear of pain.

Madeline Li, associate professor at University of Toronto explained, “It's what I call existential distress. Their quality of life is not what they want. They are mostly educated and affluent — people who are used to being successful and in control of their lives and it is how they want their death to be.”

A major aspect of their decision has to do with “autonomy”. This entails making their own life decisions, being independent, not being restricted and conserving their dignity. For example, one patient in the study was a marathon runner but cancer rendered her confined to her bed. “That was not how she saw her identity,” remarked Li.

A university professor, who was a patient in the study, identified his intellect as his most valued and important quality. “He had a brain tumour, and he didn’t want to get to the point of losing control of his own mind, couldn’t think clearly and couldn’t be present,” described Li.

The necessity for medical aid in advanced care planning

A bedridden patient suffering in pain and undergoing tube feeding has the right to refuse this type of nutrition even if it leads to their death, said senior geriatric specialist at Tan Tock Seng Hospital, Associate Professor Chin Jing Jih. He explained that while the nutrition itself is a basic need, tube feeding is unnatural and considered as medical aid.

Singapore’s shift of focus to community instead of hospital care in recent times substantiates the need for addressing these ethical-related problems outside of the hospital. There are hospital ethics committees set up to assist doctors in decision-making but there is a call for it to be extended to the community.

“Clinical ethics is also relevant and should have an important role in the decisions made in areas such as advanced care planning and long-term care and management plans for the aged and the infirm. We should start to make clinical ethics support more available to clinicians practising in these (community) settings,” said Associate Professor Benjamin Ong, director of medical services at the Ministry of Health, when speaking at the International Conference on Clinical Ethics Consultation recently.

Due to the country’s rapidly ageing population, the population must discuss what it wants done in such situations, he continued. At the same conference, Chin acknowledged that some doctors do not realise that sometimes quantity of life “is not as important as quality of life.” Doctors’ professional bias towards rescue and survival could be the reason behind this. Nonetheless, aggressive therapy might not be just what the patient needs.

Guide to making the right decisions

Studies previously published in 2015 and 1999 also highlighted psychological reasoning being a common factor behind assisted suicide. Researchers wrote in the Journal of General Internal Medicine, “These patients considered a hastened death over prolonged periods of time and repeatedly assessed the benefits and burdens of living versus dying.”

Chin said many patients suffering from advanced organ failure spend the final 6 – 12 months of their lives “undergoing multiple rounds of invasive investigations and interventions.” This leaves them making an unavoidable trade-off “in their already marginal quality of life, as well as limited lifespan.”

Upon being questioned by doctors on when to make the shift from prioritising quantity of life to achieving the best possible quality of life, Chin said that there are no hard and fast rules.

To guide patients and doctors, some Singapore hospitals are putting a process in place where the patients’ conditions and needs are regularly reviewed as their conditions can gradually worsen. This guarantees that the treatment provided is in line with optimum patient care.

Chin concluded, decisions on which path to pursue should be thoroughly discussed with the patient or family, prior to a problem occurring, to ensure doctors do not aggressively treat patients to keep them alive. MIMS

Read more:
Palliative care: The need to act now
The patient’s right to die: Ethical concerns after the first minor in Belgium is euthanised
Legalising euthanasia: The ongoing debate between doctors