Speaking at the conference were: Bishop Emeritus Dr Robert Solomon (centre, in white), Friar David Garcia (fourth from right), Dr Cynthia Goh (third from right) and Ms Sumytra Menon (second from right).
During my younger days, the thought of dying and death instilled fear in me. But as I grew much older, I realised that there would come a time when I would not be in a position, mentally or physically, to make my healthcare choices. So to take the burden off my family, I have signed a Lasting Power of Attorney (LPA) and made my Advanced Care Plan (ACP) known.
These options, as well as the ethical, theological and practical issues surrounding such decisions, were thoroughly discussed at the recent ‘Dying Faithfully: Ethical Issues At Life’s End’ conference, co-organised by the ETHOS Institute™ for Public Christianity, the Catholic Medical Guild and the Christian Medical and Dental Fellowship. The whole-day conference, held 3 Oct 2015 at the Bible House, touched on four perspectives: Biblical and Theological, Natural Law, Legal, and Medical.
The biblical and theological perspective
Bishop Emeritus Dr Robert Solomon, previous bishop of The Methodist Church in Singapore (2000-2012) and a medical doctor who has also served as Principal of Trinity Theological College and President of the National Council of Churches of Singapore, enunciated three concepts for Christians with regard to biblical teachings on the subjects of physician-assisted suicide (PAS) and euthanasia.
God’s Possession: A person’s life does not belong to him, but to God. God created us in His image (Gen 2:7); when we die, our spirit returns to God. In Job 33:4, Elihu said “The Spirit of God has made me; the breath of the Almighty gives me life”, and in 1 Corinthians 6:19-20, Paul wrote: “You are not your own; you were bought at a price.”
God’s Prohibition: Dr Solomon referred to Exodus 20:13 – “You shall not murder.” The World Medical Organisation opposes PAS and euthanasia. Suicide and attempted suicide is an ethical and moral problem, and illegal in Singapore.
God’s Providence in suffering: Dr Solomon made four points about suffering.
➢ Suffering and Ultimate Meaning – Job did not know about God limiting Satan in allowing Job to suffer disaster after disaster. When ministering to someone who is suffering, it is important to lend a listening ear, as God’s plan and meaning may not be understood by sufferers. Dr Solomon asked us to trust God, for our lives are in His hands.
➢ Suffering and God’s Presence – God is present throughout our suffering.
➢ Suffering and Community – A Christian community should help those who are suffering. PAS and euthanasia will destroy community. According to the Quality of Death Index on palliative care released on 6 Oct 2015, Singapore’s weakest score was in the area of community engagement.
➢ Duty to Care – Suffering is temporary. Glory is eternal. No one should be allowed to die in indignity. A good death is to die like Christ (Philippians 3:10).
The ‘Natural Law’ approach
The Natural Law approach was presented by Friar David Garcia, a Dominican priest of the Order of Preachers, who holds a licentiate in Moral Theology. He noted that the approach differs in different cultures: in Europe, the only moral principle is “the greatest happiness for the greatest number,” whereas in the East, “if only results matter, there is no difference between killing and allowing someone to die when you can do something about it”. On euthanasia, Friar Garcia painted three scenarios:
➢ Deliberate decision to act – Action
➢ Deliberate decision not to act – Omission
➢ Failure to act when you can and should act – Neglect
Friar Garcia said euthanasia was a moral act, not merely physical: “An action or omission which of itself or by intention causes death, in order that all suffering may be eliminated.” By action (active euthanasia), one chooses to kill; by omission (passive euthanasia), one decides to stop treatment or not to initiate it; by neglect, one fails to apply life-saving treatment when it can and should be applied, causing death by intention.
He then went on to discuss disproportionate and proportionate treatment. Treatment may be withdrawn or withheld when the burdens are disproportionate to the benefits of the treatment. Applying proportionate treatment is obligatory; omission of due treatment amounts to passive euthanasia.
Friar Garcia concluded with these points:
➢ We are stewards of our lives and of those entrusted to our care.
➢ Because we are stewards, we may decide which treatment is not worth applying if it has more burdens than benefits.
➢ Asking whether the human life is worth living is an evil question.
➢ We measure treatments, not people.
The legal perspective
Ms Sumytra Menon, Senior Assistant Director at the Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, listed the options available to the public to express their healthcare preferences:
➢ The Advanced Medical Directive (AMD), 1996
➢ The Mental Capacity Act (MCA), 2008
➢ Advanced Care Planning (ACP)
The first two options are legally-binding statutes enacted by Parliament. On the AMD, Ms Menon said it excludes suicide and euthanasia, both of which are crimes in Singapore. It only permits natural death but does not allow accelerating death. The person who signs an AMD will not receive extraordinary life-sustaining treatment if he or she suffers from a terminal illness and if three doctors certify to that effect. It allows for palliative care to continue.
Under the MCA, a person files an LPA document whereby he or she (the donor) gives another person (the donee) the permission to make decisions on his or her behalf. The LPA operates only when the donor loses capacity to make the specific decision at the time when the decision has to be made.
In the case of patients already in the permanent vegetative state (PVS), once there is no hope, treatment is governed by the patients’ best interests.
Ms Menon gave two sets of advice to patients and doctors:
➢ Patients should take the opportunity, while they are able, to explore and express their wishes and preferences for healthcare and treatment.
➢ Attending doctors should have discussions early to inform patients and their loved ones to minimise possible misunderstandings and conflicts with the family.
Medical aspects in a palliative care setting
Dr Cynthia Goh, a Senior Consultant in the Department of Palliative Medicine of the National Cancer Centre Singapore, spoke from a Christian viewpoint. She discussed the fears which patients encounter when they face death:
➢ Physical pain
➢ Loss of independence
➢ Mental suffering
➢ Fear of the unknown
➢ Being unable to breathe
➢ Dependence on others
➢ Being a burden
➢ Retribution in the next life
She said that 5-15 per cent of patients with cancer meet criteria for major depression compared to 2-5 per cent for the population as a whole. Many have a lesser degree of dysphoria or sadness which significantly interferes with their lives. We may be able to control physical symptoms but we may not be able to prevent suffering.
On PAS, Dr Goh advised that the doctor must ascertain what the patient means when he asks to die. Does he mean “let me die” or “kill me”? For those who care for patients near the end of their lives, knowing one’s boundaries is essential. “Mercy killing” is often done out of compassion but is morally wrong and illegal in Singapore. Dr Goh concluded by posing two rhetorical questions: Does one have the right to live? Does one have the right to die?
In my view, Dr Solomon gave a clear message on what God’s Word is on end-of-life issues, and Dr Goh’s talk on palliative care was comforting. Ms Menon showed us the legal and non-legal means of expressing our health preferences when we have the capacity to do so. Friar Garcia’s Natural Law approach was new to me as a Protestant Christian, as I understand that the Natural Law theory has long formed the backbone of Roman Catholic social teaching since the days of medieval theologian Thomas Aquinas (1225-1274), and is meant to serve as a bridge between the church and the secular world.
The subjects of PAS and euthanasia will not disappear from the public spotlight as controversy pervades current debate on the moral and legal status of these issues. Although forms of PAS and euthanasia have been legalised in Belgium, the Netherlands, Luxembourg, Mexico and several states in the USA, I hope and pray that we and our lawmakers will remain informed about these ethical issues, and stand firm as necessary.
Photos courtesy of The Bible Society® of Singapore
Dr Tong Hoo Ing contributes to Methodist Message as a volunteer writer. A retired neurologist, he worships at Wesley Methodist Church, and volunteers with medical mission teams to Third World countries.