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Smoothing life and death decisions

HONG KONG (SE): Current controversies surrounding medically assisted suicides and possible moral issues coming from proposed new legislation allowing a patient to give legally binding advance directives to both doctors and family on the type of health care or medical treatment they would like to receive in the event of becoming incompetent to make such decisions, were discussed at a seminar at the Caritas Institute of Higher Education in Tiu Keng Leng on September 10.

Currently, the Code of Professional Conduct prohibits a doctor from carrying out any procedure against the will of a patient, irrespective of how medically unwise that decision may seem, but it is when the patient is not mentally competent to make their own decisions that families and health professionals often encounter difficulties in making them on their behalf.

Some countries have introduced legislation allowing a patient to make advanced directives (usually in writing), which are legally binding, while still competent, in an attempt to overcome this difficulty.

These laws are derived from the principle of informed consent and self-determination in health care procedures.

Around 200 people heard speakers address the nature and limits of the responsibility of sustaining the lives of patients and the function of palliative care at the afternoon organised by the Bioethics Resources Centre of the Holy Spirit Seminary College of Theology and Philosophy, together with other organisations.

Patrick Chan Siu-oi, a non-permanent judge of the Court of Final Appeal, said a doctor should help to sustain the lives of patients. 

He pointed out that ending the life of a patient upon request or through indirect means is regarded as assisted suicide, which he said is illegal in Hong Kong and, he believes, is also immoral.

Chan said assisting a patient to end their own life, even at the request of or with permission of the patient, is regarded as killing. 

He added that the concept of physician-assisted suicide covers a doctor giving medical assistance, as well as instigating the process of a patient taking their own life.

He stressed that a doctor can only withdraw treatment when it is not working or when the patient, while still being competent to make such a decision, gives a specific instruction not to use a life prolonging treatment.

Chan pointed out that this is not assisted suicide.

In withholding or withdrawing life support, the judge said medical practitioners must uphold the principles of respecting the sacredness of life, the patients’ right of self-determination and the best interests of the patient, as well as the patients’ consent and needs.

While these principles are all related, he said they can sometimes be contradictory. A doctor is often forced to make a decision that cannot respect all of them.

Chan said decisions about some life-sustaining treatments that can contradict these principles need a consensus among the doctor, the family and the patient (if they are competent to decide) and personally, he is supportive of the proposed legislation on advance directives so that a patient can have an input into the planning of future treatment.

He added that the current guidance of the Hospital Authority is to offer palliative care to comfort a patient with a serious illness or suffering physical pain after a treatment has been ineffective and, at the same time, to give support to the family.

He pointed out that both medical practitioners and the patient’s family should respect any advance directives of the patient when reaching a consensus on further treatment.

On the other hand, there are still legal controversies over who can make the final decision for a patient that is not competent to decide for themselves, and the advanced directives should help to clarify this area.

Rosie Young Tse-tse, a retired professor of medicine from the University of Hong Kong, said patients with chronic diseases and the terminally ill may want to end their lives, as their perseverance has been worn down by years of suffering.

But Young believes that if a patient ends up in this position it reflects there has been a lack of care for the person. She said doctors may find it hard to give them spiritual support, so she really appreciates the work of the palliative care teams.

She also admitted that the advance directives could play an important role, emphasising that palliative care is different from assisted suicide, as it is fundamentally pain control, and while it does not prolong the patient’s life, it does allow it to run its natural course.

Young said that all patients should be treated equally and that it would be unfair if only rich people could have a heart transplant, while the poor are excluded.

Gabriel Matthew Leung, the dean of the Li Ka Shing Faculty of Medicine, said as there is no legislation about advance directives as yet, medical practitioners face a lot of pressure, as doctors and the patients’ families can hold different views, and doctors cannot fully execute advance directives which have no legal binding force.

Leung said that the Law Reform Commission of Hong Kong had suggested legislating on advance directives more than 10 years ago and he urged the government to pass some legislation on the matter as soon as possible, so as to relieve the pressure on co-workers and give protection to the families.

However, until legislation can be formulated and passed, he suggested the authority should first provide measures to help doctors to make decisions, such as setting up a data base of previous cases for their referral.

Father Dominic Lui Chi-man, from the Bioethics Resources Centre, said Christians should learn that they have to let go when their lives are about to end, instead of blindly pursuing ways of prolonging life.

He said the spiritual needs of patients cannot be fulfilled by medicine alone, so Church groups need to strengthen their support for the terminally ill, give them empathy and build up a caring environment in the Church as a whole.

Ambrose Leung Cheuk-sun, from the Guild of St. Luke, St. Cosmas and St. Damian Hong Kong, said there are limited resources allocated to palliative care in hospitals and more support needs to be given to the terminally ill, as the need is growing.

Problems related to euthanasia have aroused controversy again as a 17-year-old cancer patient was allowed to be euthanised in Belgium on September 17. It is the first time in the world a minor has died by legal euthanasia.

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