Conversation on euthanasia should enter end-of-life discussions here
Assisted dying is a sensitive subject but, with its population ageing, Singapore may need to discuss what we think about it
As more Singaporeans age, urgent discussions are taking place on how we approach end-of-life issues.
The roles of nursing homes, hospices and home palliative care are part of ongoing discussions on easing and widening different approaches towards how we age, and ultimately pass on.
There is, however, one issue that has gained traction elsewhere but which hardly ever figures in our end-of-life discussions here: assisted dying.
Assisted dying can either take the form of assisted suicide, where the final act is undertaken by the person involved, often with the aid of a medical practitioner; or euthanasia, where another person, again often a doctor, performs the act of terminating life.
Assisted dying is illegal in Singapore.
But given that our population continues to age rapidly, and more older people will increasingly find themselves in continuous pain that even palliative care can do little to help, this is not an issue we should entirely ignore. What could be at stake is the dignity and personal choice of a segment of our population.
Several countries are well ahead of Singapore on this count, both in terms of having mainstream discussions, as well as in having legal frameworks on assisted dying.
Most countries that have legalised assisted dying allow both assisted suicide and euthanasia. Some, like Switzerland, which was the pioneer in allowing assisted suicide in 1942, allow the former but keep euthanasia illegal.
Should one or both options be legalised here, to give those desperate to end their lives a way of doing so with grace?
Opinions are divided
There are strong arguments both for and against such a move.
Ms Sim Bee Hia, executive director of the Singapore Hospice Council (SHC), says the council and its 25 member organisations hold a clear stance against euthanasia, as “the hand that offers help, hope and relief cannot abandon those who need it most, or worse still, offer the hand of death”.
Many religions too forbid the taking of life, whether it is one’s own life or that of another. For them, assisted death would be anathema. We must respect their choice.
While this is a factor that Singapore should consider, it should not stop us from at least discussing the topic, with the aim of establishing wider understanding of different and potentially polarised perspectives.
For one thing, Singapore is a secular society. Also, according to the 2020 census, one in five people here says he does not have a religion.
Should the beliefs of some be imposed on others? Or should each person be allowed to decide for himself? Do our lives belong to society, to our families, or to ourselves?
There is fear that legalising assisted dying might see families putting pressure on terminally sick people to end their lives, to relieve themselves of the burden of caring for the person. Or even of children forcing their parents to take that step in order to inherit their wealth.
These are valid, but not insurmountable, concerns. If Singapore decides to legalise assisted dying, it will need to define the conditions under which it is allowed, and have sufficient safeguards to ensure that these are well enforced.
Such conditions vary in countries where it is legal.
How others do it
At the stricter end of the scale, countries allow assisted deaths only for people who suffer from an incurable and painful terminal illness with death expected within months.
Others allow people with chronic mental conditions, such as dementia or even depression, to opt for assisted death. Children too are allowed that choice.
We should learn from countries where assisted dying is allowed, and decide for ourselves how to balance the benefits and pitfalls.
The Netherlands, which in 2002 became the first country in the world to legalise euthanasia, has had more than two decades to work out the kinks in the system. In 2022, 8,720 deaths, or 5.1 per cent of all deaths there, took place through assisted dying.
The country is fairly strict in its criteria for euthanasia. Only requests by patients, and not their families, are allowed, and they must be “experiencing unbearable suffering with no prospect of improvement”.
Canada legalised medical assistance in dying in 2016, a year after its Supreme Court decided unanimously that not allowing it “deprived people of their dignity and autonomy”. It is far more liberal regarding who can request such deaths.
From 2024, people with mental disorders that do not affect cognitive abilities, such as depression, will be allowed to choose euthanasia, even if they have no other medical conditions.
The country had more than 10,000 such deaths in the past two years, accounting for 3.3 per cent of all deaths.
Unlike in the Netherlands or Belgium, which allows assisted dying only to people who have first tried all available treatments to alleviate their suffering, those in Canada merely have to be informed of the alternatives. They may reject the alternatives and opt for euthanasia.
Belgium, which legalised assisted dying in 2002, allows couples to die together if neither of them wants to be left behind when the other dies. Mental anguish was a reason that a pair of deaf twins, aged 45, were allowed euthanasia when they discovered they were going blind.
Last year, 2,966 people in Belgium opted for euthanasia, representing 2.5 per cent of all deaths.
It can be seen that even in countries where euthanasia is legal, the proportion of those taking that route remains small. Those who opt to do so say they want the right to a good death, and that they want to leave on their legs, not on their knees.
So far, no country in Asia or Africa has legalised assisted dying.
Some discussion has started in South Korea, where an opposition Member of Parliament in June proposed allowing terminally ill patients to request a physician to assist in the process of ending their life.
In 2021, a professor of family medicine at Seoul National University Hospital released the results of a survey showing that 76.3 per cent of people say euthanasia should be allowed. The results were a big jump from a similar survey done in 2016, which garnered 41.4 per cent support for euthanasia.
South Korean media speculate that support for euthanasia has increased because more people are getting old and worry about possibly suffering towards the end of their lives, and prefer to be able to live and leave with dignity.
In 2024, South Korea will become a super-aged country, defined by the United Nations as a country with 21 per cent or more of its population aged 65 years and older. Singapore is expected to become a super-aged society in 2026.
Let’s talk about death
There is nothing wrong with super-aged societies if their people are able to age well and continue to enjoy life. Earlier in 2023, The Straits Times featured several centenarians here who were still living a full life – travelling, baking, playing mahjong and even ping pong.
Unfortunately, they are in the minority.
Many more people are suffering in their last years of life. But that doesn’t mean that they will opt for assisted dying.
Most countries require anyone requesting euthanasia to be properly counselled and given a cooling-off period before action is taken. For some people, going through this process may provide them with the help they need to continue living. In such a scenario, legalising assisted death could actually save lives.
But there are others for whom suicide offers a welcome relief.
British grassroots organisation My Death, My Decision, which is lobbying to legalise euthanasia, states that despite the best palliative care in the country, “6,394 people per year would still have no effective pain relief in the final three months of their life”. That number represents about 1 per cent of deaths a year in Britain.
Although attempted suicide is no longer a crime in Singapore since 2019, assisting in it remains a criminal offence. So people suffering from such pain can receive no help to end their suffering. The act of suicide, such as jumping off a tall building, must be terrifying – yet there are people here who choose that option each year.
At the very least, society should try to understand the conditions that push them to take their lives. If they are determined and nothing will change their resolve, can and should they be aided?
Asians generally avoid the subject of death. But we are a mature society and, at the very least, should discuss options such as assisted death at a national level. The views of doctors, religious leaders, and the public should be canvassed.
Although SHC strongly opposes assisted dying, its executive director Sim said: “We firmly believe in normalising discussions surrounding death and dying, aiming to build a more death-literate society through various public education, community engagement and outreach programmes.
“By addressing the topic of death openly and directly, we will be able to dispel misinformation, prepare patients and families, and provide support and care.
“We should not shun discussion on euthanasia as there is always interest given a more aware population. But what is more important is to explain palliative care as a better option.”
Some questions we need to address are: Should assisted deaths be allowed? If they are allowed, what criteria and safeguards do we need to put in place? Who should oversee the process and how should it be carried out?
Should such requests be evaluated only if they come from the individuals involved? Or can their families make such requests on their behalf? What happens if the person is no longer able to make such a decision either because of dementia, or severe illness?
Can euthanasia have the equivalent of the Advance Medical Directive, which allows people to decide while they are still healthy that they do not want any extraordinary life-sustaining treatment to be used to prolong their life?
Such a conversation should start now, so that the implications of such a move can be fully understood before any decision is reached, whether it is for or against legalising it.
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