Angry Doctor

Friday, November 10, 2006

I Won't. Will You?

Alright, this tears it:

Don't leave it to family – you can decide how you go: Khaw
Tan Hui Leng

IT'S not often that you get to discuss death, especially with a Minister. But for Mr Khaw Boon Wan (picture), it's a natural ice-breaker.

"I am extremely aware of death. I think the worst thing is to be unaware, thinking that you are immortal. We are dying every moment. Even as I talk to you, I'm dying. Cells are dying.

"When you're very conscious and aware of death, you are also very conscious of time — the need not to waste time," said the Health Minister in an interview with Today.

There's a certain urgency with which the 53-year-old Mr Khaw, a Buddhist, approaches the whole topic of dying — set against Singapore's ageing population — before it comes under the spotlight in Parliament.

Especially tricky is the issue of the Advance Medical Directives (AMD), a legal document through which adults — while they are still in a position to decide rationally — can indicate that, in the event they are struck by a terminal illness, they would like to refuse extraordinary treatment.

On paper, it makes sense. But the fact that only 4,000 have opted to sign up for this since the Act was passed a decade ago shows that the concept needs to be conveyed more clearly.

Some are not comfortable with the fact that AMDs, which limit a person to just two options — saying either yes or no to such extraordinary treatment — are cast too narrowly.

Mr Khaw readily acknowledges this. "There are people who feel that definition of AMDs is too tight. I think because it was a major breakthrough in society attitudes 10 years ago, it had to be very narrow," he said.

"But I doubt if I could loosen it too much at this stage. I hope we can loosen it more, maybe in 10 years' time."

Still, he thinks that it is time for people to start talking about end-of-life issues again.

And they should talk with their family members about the eventualities.

Otherwise, this "huge burden" of making a choice might end up on the family's shoulders.

The issues or ageing and death need to be discussed; one cannot pretend that the problem does not exist, he said.

"It does. Day after day, if you walk into the intensive-care unit, you will find a couple such cases and see the distress, the anguish that both the patients and their families are going through," said Mr Khaw.

"If the interventions are effective, that's fine. If a patient is young, you go all out. But if you have multiple illnesses, have a patient of very advanced age, and it's terminal, then I think you have to accept that medical science has its limits."

The question is: What does a patient do after that?

If he found the definition of AMD too narrow, then it could be supplemented with other documents that can offer more choices — an option that Mr Khaw is open to.

One example is living wills, which detail the various modes of treatment you want or do not want in your last illness, covering the various scenarios that may arise.

Currently, the United Kingdom is exploring such forms of "complementary documentation", said Mr Khaw.

"The key point is, we want to know what your preference is, and then — within the limits of the law, morals, ethics — we try to accommodate you."

Mr Khaw was not convinced by a proposal by Associate Professor Lee Wei Ling, director of the National Neuroscience Institute, to give "sweeteners" — such as a deduction of hospital bills by 30 or 40 per cent — to those who opt for AMDs.

"My instinct is if you argue all this on dollar and cents, you lose the argument. Then you are saying, alright, you're rich, you can afford to live longer; if I'm poor I should be killed," he said.

"I think it will be caricatured into that kind of an argument which, first of all, is not the intention, and secondly is a destructive way of looking at this very important subject."

Also being reviewed: The need for two signatories in an AMD — a doctor and another person who will not benefit from the death of the person involved, he revealed.

But he made it clear that his ministry is not chasing after numbers, but merely raising the issue of death in the public consciousness.

For the record, Mr Khaw has walked the talk and made an AMD himself.

He said quietly: "I would like to spend my last days happy. The best way to die is to know when you want to die, how you want to die."

angry doc is confused. Very confused.

It seems like only last week when the Minister was reported to have said:"You know something is not quite right. You should be having hundreds of thousands of people signing on" and "... for AMD to really bring about benefits to the person and to the family, you do need many more people to sign on".

Now it seems that his position is that "ministry is not chasing after numbers, but merely raising the issue of death in the public consciousness".

He must have been misquoted then.

angry doc is also confused as to why the journalist would acknowledge that the AMD "limit[s] a person to just two options — saying either yes or no to such extraordinary treatment", yet conclude the article by quoting the Minister when he said "[t]he best way to die is to know when you want to die, how you want to die".

The AMD does not let you make those choices, and it's misleading to end the article on that note. In fact, the title of the article is also misleading.

(angry doc can think of a way to decide exactly the time and manner you wish to die, but even that is contingent on the train arriving at the station on time.)

angry doc also has no idea why an 'ageing population' is relevant to the discussion. As far as he is aware, people from previous 'non-ageing' populations have also died, and the average person has only one pair of parents to worry about, so whether the population is on the whole ageing or not has no relevance to the individual person or family.

angry doc wrote in a previous entry that he witnesses the signing of Advanced Medical Directive (AMD).

He would like to announce that with effect from today, he will cease to do so indefinitely.

angry doc is not against the idea of the AMD.

He still isn't.

But right now, he's not convinced that the media coverage is done in good faith and in the spirit of encouraging a public discussion on end-of-life issues. He is not sure that anyone should decide to sign an AMD at this time when misleading arguments for signing an AMD are being published in the mainstream media.

So he's taking the coward's way out and refusing to have anything to do with the AMD until the campaign fever subsides.

Added: A related letter on the topic published also in today's Today.

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  • All his actions and policies so far has one grand unifying theme: cost cutting.

    Do you think his bonus is tied to the ministry's bottomline?

    By Anonymous Anonymous, At December 14, 2006 10:22 pm  

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