Should AMD be encouraged?

SINGAPORE: The call by Health Minister to encourage more people to sign for the Advanced Medical Directive (AMD) is timely and laudable. The law had been passed 10 years ago but to date only 4000 Singaporeans had signed up. But why would the government want to encourage individuals to "manage issue of death" - something very private?

Being involved with the health industry, I have the (un)fortunate opportunity to experience what a person goes through in the last few days of their life. Sometimes it pains me to have to do procedure on the patient when I know that such procedures will not make any difference to the patient in terms of eventual outcome of treatment, not to mention the quality of life. Unfortunately most of the time such procedure had to be carried out because of the urging of the relatives; all because of good intentions. Maybe this is due to our Asian cultures of filial piety where the decision to let nature takes its course is equal to loss of filial piety. Such procedures will only cause more unnecessary pain to the patient, not to mention unnecessary cost. So AMD maybe make it easier for relatives to come to a decision without feeling guilty, or as the Minister puts it "not passing the buck".

At the national level, with the limited medical resources, unnecessary prolonging life will take up valuable resources for others who may benefit from such intensive treatment. Resources can be better channel to those who will recover or have an improved quality of life. Although this will raise ethical issues, this is a real concern that needs to be looked into. Between a person with terminal disease and another who only suffers from a reversible condition 'fighting' for that last bed in ICU, shouldn't that precious last bed be given to the patient with the reversible condition? This is precisely what the AMD aims to correct.

However currently it is not easy to sign up for AMD. The process needs two witness of which one must be a doctor. According to the directives, the doctor has to ascertain that the person is of sound mind and that he understands the whole AMD process. The other witness can be anybody but not a relatives or anyone who will benefit from the person's death. While this is done to protect from any abuse, the exclusion of the relative as a witness makes it difficult to get the second witness. In our society, not many people wants to get involved with another's business, especially about death. As such to get that second witness becomes difficult. Maybe the government should address this problem.

The AMD law also assumes that a person will only make an AMD after he is diagnosed with a terminal disease and hence the need for the first witness to be a doctor. However, is this practical? How would one expect a doctor who is treating him to bring up the issue of AMD? From experience, rightly or wrongly, most of the time, the terminal nature of a disease is not conveyed to the patient but to the relatives. A lot of time, the patient does not even know that his days are numbered or what disease he is dying from. If this is the case how best can the AMD be brought up?

Should the AMD be made just like a person making a will? This means that a person can just walk up to a lawyer and signed an AMD or he can signed the AMD in front of any witness as stipulated by the law covering the making of a will. This will certainly make AMD easier to sign up. If the government is worried about unsound mind, then this will only hold true for those healthy individual, not one with any diagnosed disease. The AMD law may be made to parallel the law governing the making of wills.

Some in the society may say that the making of AMD or having the doctor to decide the fate between two persons like the scenario above is amounting to playing God. I would counter such claim by saying that the day medicine was created is the day human beings played God. Like it or not, the act to save a life is as much playing God as the act to stop treatment to save life. If God can choose that a person suffer a sickness, by the same reasoning, God can also choose when a person will die. I have seen enough to know that whatever a doctor do, we are still answerable to God; if the time is up whatever measures taken will not change the outcome.

In conclusion, let me relate my own experience. My father died of terminal cancer. His decline was fast and hence spared the sufferings and agonies that many like him had gone through. Being a doctor, I decided that he should not be given a drip on his last day. It has been 7 years since he passed away. Till today, I sometimes still ask myself if I did the right thing. Deep inside, I know I probably did; but as a son, in a way I feel guilty for having made that decision and wondered whether the drip would have made the difference.