THE debate on end-of-life issues that has raged in the media risks being clouded by mixed channels. There are two distinct discussions going on.
The first relates to Advance Medical Directives (AMD), or 'living wills'. This debate is very specific in scope: how to simplify the AMD so it is more easily understood, how to streamline the procedure to sign it, and how to promote it.
This issue was first flagged recently on Oct 14 by Health Minister Khaw Boon Wan when he outlined the ministry's plan to enhance palliative care. He wanted people to think about what they want for the end of their lives.
Since being introduced last year, only 10,000 people have signed AMDs, which let people state in advance that if they are terminally ill, they do not wish to receive 'extraordinary life-sustaining treatment' such as being kept alive by machines when death is imminent. Safeguards include the need for two witnesses, one of whom has to be a doctor, and having three doctors certify terminal illness.
But many people have not signed such living wills, due to inertia, a reluctance to discuss death or a lack of awareness. Many doctors themselves are not knowledgeable about the impact of the will.
It was against such a backdrop that the call to simplify AMDs was made.
It is most unfortunate that an important review on AMDs has been mixed up with the much more emotive issue of euthanasia and whether Singapore may one day legalise euthanasia - although the Government has not proposed any such move.
Debate on euthanasia will always be emotive. Already, major religious groups and doctors have come out strongly against any move to legalise the act, also known as 'mercy killing' and more accurately as 'physician-assisted suicide'.
There is a real risk of the two being conflated into one issue, so that those against euthanasia also end up against making AMDs more accessible.
In fact, the two acts of refusing treatment and active lethal ingestion are distinct.
AMDs or living wills in essence are about letting yourself die, rejecting machines or other strong measures to keep you alive when death is already imminent, and letting nature take its course.
There is merit in encouraging people to sign AMDs to state in advance their intentions, to relieve family members of the emotional burden of making life and death decisions on their behalf.
Euthanasia is an active act, and is about making someone die. As practised in the Netherlands and the US state of Oregon (with Washington state this week also adopting a similar Oregon-style law) euthanasia means a terminally ill person may request and be given, a lethal injection or take a deadly drug, to die.
A host of moral issues surround debate on whether people have a right to die, or whether the state or family members have a paternalistic right to override a patient's wishes. There are concerns about how meaningful informed consent is, when someone is in dire pain and distress. It is not my intention to go extensively into this ethical morass.
But recent research suggests that some terminally-ill patients who choose death have an underlying psychological disorder. Last month, the British Medical Journal online reported a study by researchers at Oregon Health and Sciences University. They had checked for depression or anxiety in 58 terminally ill patients who had requested physician-assisted suicide or had contacted an assisted death organisation. Of these, 15 met the criteria for depression and 13 for anxiety. In other words, one in four who wanted euthanasia was clinically depressed.
A study by Dutch researchers in the Sept 20, 2005 edition of the Journal of Clinical Oncology estimated that at least 50 per cent of patients killed under the Dutch euthanasia programme were suffering from depression.
Such studies lend credence to the view of doctors who care for the dying that dying patients need relief from pain and anxiety in their last days, not necessarily well-meaning but wrong-headed interventions to hasten death.
In any case, a Dutch study estimated that among the 3,600 patients annually who chose assisted suicide or euthanasia, 59 per cent would likely have died within a week, and 32 per cent would likely have died within one to four weeks.
In practical, utilitarian Singapore, debate about stopping treatment or euthanasia always has a sub-text: controlling medical costs, either for the state or families. This is couched politely as 'not wanting to be a burden' to others. But at its core is the unspoken assumption that lingering on in one's last days is too costly.
On cost, a paper in the November 1998 issue of the New England Medical Journal calculated how much physician-assisted suicide may save families and the health-care system in the United States.
Extrapolating from Dutch numbers, the authors concluded that euthanasia may cut total health spending by 0.07 per cent. For each family, the saving from hastening death by euthanasia may be US$20,000 (S$29,600). This was estimated to form one-third of medical cost in the last year of life, and a smaller fraction of the total medical cost over a lifetime.
Singapore's experience may of course be different. But the study suggests that any savings from assisted suicide for the terminally ill may be minimal: in other words, cost concerns are overstated.
The experience of the few jurisdictions which allow euthanasia throws up serious questions on whether patients and society are better off with such an option.
So far, Singapore society does not seem ready for euthanasia. Nor does the state intend to make it law - and rightly so.
So, for now, euthanasia is a non-starter for the Republic. But debate on this issue could end up being a red herring that turns people off the need to have a fruitful discussion on living wills.
Let us be clear: Kill the idea of legalising euthanasia. And resurrect the debate on living wills.
It would be a pity if distaste over euthanasia killed the chance for a sober debate on reviewing living wills.
muihoong@sph.com.sg
This story was first published in The Straits Times on Nov 7, 2008.
