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DEATH AND DYING : SOME MEDICAL AND ETHICAL ASPECTS

By Dr Chew Chin Hin

Any topic about “Death and Dying” tends not to be popular. There is a certain reluctance to speak of this, even at funerals. People continue to avoid discussing death as a fact and certain experience. Whether from Eastern or Western culture, to many, death has meant the certain end of a person. This is a foreboding perspective. 

Medically the fact is death is a certainty. But the Christian’s perspective is also that death is not the end of a person. Recently, at a Thanksgiving Service when my aunt, Dr. (Mdm.) Chong Kee Neo, was called home, at the grand age of 95+, our elder Francis Maniam reminded us of this reluctance to speak of death. But he also spoke of one most vital caveat – that for us as Christians, death is certainly not the end; my aunt lives triumphantly and now perfectly in the Lord. By the resurrection of Jesus Christ, death has indeed been swallowed up in victory (1 Cor. 15:54). Mdm. Chong Kee Neo was the oldest surviving medical doctor in Singapore and a faithful member of our church.

Doctors and medical students are taught and reminded that “the practice of Medicine is an art, not a business, a calling in which the heart will be exercised equally with the head”. We all know that our Lord pays utmost importance to one’s heart and mind (Col. 3.2). Most important of all, our Lord is our model found in Matt. 20:28 and Mk. 10:45 – for to Christian doctors He is the Master Physician who came “not to be ministered unto but to minister” (KJV). This is also the motto of the alumni of our medical school in Singapore – 100 years old this year! My late father – Dr Benjamin Chew, also took these words of our Lord for the Chew family. In the NIV, the word “serve” is used in place of “minister”. This comes from the Greek root word “diakoneo” that encompasses many related attributes linked to the doctor’s calling. “Diakoneo” speaks not merely of service but rather service with humility, the active expression of care, compassion and charity, service with a determination to heal and, an awareness and attitude of kindness to the needy. This is true charity and love, and should also characterize the Christian doctor’s perspective of the dying.

The word “ethics” may sound lofty, but this is basically about Truth. Adhering to ethical principles draws us to learning more about the Lofty One – our Master Physician and the source of all Truth (John 14:6); human wisdom simply pales by comparison.

You may recall the God-given wisdom of Solomon found in 1 Kings 3 when 2 mothers appeared before him. One said “My son is alive and yours dead”, while the other says “No, your son is dead and mine alive”. Then the king said “Bring me a sword” and ordered the child cut into 2 – half to be given to one, and half to the other. The real mother whose son was alive was so filled with love for him that she said to the king, “Please Lord, give her the living baby! Don’t kill him.” But the other said “Neither I nor you shall have him, cut him in 2.” Then the king ruled, “Give the baby to the first woman. Do not kill him. She is his mother”. This was indeed God’s wisdom gifted to Solomon. This story documents his first wise decision. This also forms the basis of the medical profession’s timeless ethical principles. These are: beneficence – seeking to do good, non-maleficence – doing no harm, autonomy – respect for the person, justice – giving to each his right or due. We saw in the Biblical record, Solomon did good and no harm – the sword was simply a test; he lent both women respect; and he did justice to the real mother. These pillars of ethics continue to be relevant. 

In these times of frequent controversy, many prefer our ethical principles to be painted “black” or “white”. However, medical decisions in reality are in areas often “grey”. Not uncommonly, doctors experience patients and their families leaving difficult decisions to them, thus placing them in dilemma. It is well to remember that not to decide is really to decide! As such, indecision may well result in guilt and unnecessary stress for all concerned. 

I believe and have always taught doctors to be proactive and to participate with patients in discussions and decision-making. From experience and studies, patients who are personally involved in their own health do better and feel less helpless. While doctors cannot always offer resolution to difficult problems, they can proffer guidance and helpful suggestions that are based on ethical principles.

The National Medical Ethics Committee was formed in 1994, and the then Minister for Health George Yeo kindly asked me to chair. Although it was a privilege to serve again, I had some reluctance as controversies would certainly arise. As God willed, I was fortunate to have among the members several fellow believers including our Brethren, Dr Lawrence Chan. Today Dr. Lee Kok Onn, another Brethren, heads this committee.

One of the first issues we had to address was the care of patients who are terminally ill and dying. To us and for us, sanctity of life is fundamental because it is God who gave and gives life. This means every person matters. Life is precious. It is understandable that many are apprehensive about discussing medical futility and end-of-life issues. Life itself would seem futile unless one’s own human frailty is linked to the strength of God. In contrast, to the eternal life that results from belief in God, all medical treatment is futile since all will in the course of time, physically die. Thus, when we encounter the question of medical futility, we do well to remember that our lives are in God’s hands. Whatever treatment medicine offers, it only aids healing that comes from the Source that gives life.

A doctor has a duty to sustain life. However, he has no duty to prolong the distress of the dying patient; especially today when modern technology is able to sustain essential functions and technically prolong life in the final stages of terminal illness. When there is little or no chance of survival, aggressive treatment in such case should not be advocated. Invasive procedures are all supportive measures used to assist a patient through a critical period of illness towards recovery. To use such measures for a dying patient where there is no hope for recovery is not good medical practice, and actually prevents the patient from dying with dignity.

We have to trust the Sovereign Will of Almighty God for each life while always recognizing there is physically “a time to die” (Eccl. 3.2). Medical means cannot be a substitute for God’s plan. Despite this, some strive by whatever technologies available, even for a few more hours or days, to stave off the inevitable. Such efforts are futile – this is medical futility. In the same way, the deliberate shortening of life has no place in medicine. This goes against the sanctity of life and against the doctor’s calling; so also is the Christian’s perspective. To do so is euthanasia, which remains a criminal offence in Singapore. Even when there are other countries who accept such practices, euthanasia or mercy killing is against Christian ethics and principles.

These were the fundamentals that guided us in forming our recommendations to the Minister of Health and to have available in Singapore an Advance Medical Directive (AMD). This followed consideration of published research and wide-ranging consultations with medical, legal and religious bodies. Such an approach was essential in our multi-racial and multi-cultural society. In short, the AMD allows patients and their families to make more informed choices to instruct their doctors to withhold or withdraw life-supportive treatment when they are terminally ill or dying with no hope of recovery.

At this end stage in life, difficult decisions must be made. Without an AMD, especially with legal litigation now being more common and with financially untenable consequences for all involved, doctors may not be prepared to make decisions on behalf of patients. They may play safe from the legal point of view instead of doing the correct thing from the ethical standpoint. Most importantly, AMD now provides a means for patients to exercise their autonomy with more confidence, during the final stages of life when they are no longer able to express their wish. Thus, the National Medical Ethics Committee agreed that AMD is best made when an individual is in good health. Doctors especially family physicians or GPs, have been advised to raise the issue of advanced planning with sensitivity, and discuss implications of AMDs. This would be important because the doctor must be one of 2 required witnesses to the signing of the AMD. One can revoke the AMD anytime in writing, verbally or in any other way in the presence of only one witness. This is deliberately made easy so if there were any doubt, erring on the side of prolonging life would be of over-riding importance. The Committee also insisted that while the AMD is in existence, palliative care – i.e. the relief of pain, suffering and discomfort and the reasonable provision of food and water must continue. The AMD and recommendations of the Committee were accepted by the Minister of Health and by our Parliament, and became law in 1996.

I had mentioned earlier that the application of ethical and Biblical principles to real life has to be done in areas often “grey”. During the final illness of my father, Dr Benjamin Chew, 11 years ago, the AMD Act was not yet available. However, when he learnt that he had advanced cancer and following much prayer with his sons (Ernest, Jim and I) who were with him in the hospital ward, he expressed his wish that he did not want doctors to intervene unduly or take extraordinary measures to treat his terminal illness. He was convinced that his times were in God’s hands. This was indeed his AMD. During his last days, attention was drawn to Deut. 33:12, “And of Benjamin, He said ‘the beloved of the Lord shall dwell in safety by Him, and the Lord shall cover him all the day long and he shall dwell between His shoulders’ ”. My father replied and with his failing vision referred us to verse 27, “The Eternal God is my refuge and underneath are the everlasting arms.” He was called to Glory amidst prayerful, yet joyful singing, of most of the family around him and my mother beside him, the hymn “Great is Thy Faithfulness”.

Let me conclude with Rom. 8:38-39 by way of summarizing and epitomising the Christian’s perspective of “Death and the Dying”: “For I’m persuaded that neither death nor life, nor angels nor principalities, nor powers, nor things present nor things to come … shall be able to separate us from the love of God which is in Christ Jesus our Lord”. To God be the Glory.

(This statement was presented by Dr Chew Chin Hin at the Family Life Ministry Forum on “The Christian’s Perspective on Dying” held on 1 October 2005.)
 

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