About Decision-Making at the End of Life: A Singaporean Perspective

This is a complex and tragic case which demonstrates very clearly that the situation constituted a true ethical dilemma. There is no room for negotiating around the issues or for turning them into technical problems; the case makes it clear that whatever decisions are made, there will be compromise of moral principles. The main concern is that of the patient’s best interests.

In Andrew’s case, it is more difficult to arrive at an ethical position on the role of the family in deciding what would be in his best interests than it is in cases of withholding or withdrawal of treatment. This is in part because the family is involved in the care at home, care which is becoming increasingly difficult and ultimately impossible. Also the option of terminal sedation is not a straightforward route as it contravenes Andrew’s wish to remain lucid. To further compound matters, as Krishna points out, Andrew’s own wishes are conflicting because being alert and being comfortable are mutually exclusive in his case. So the healthcare professionals have a very difficult decision to take and, as this case illustrates, it is, in the end, the healthcare professionals who have to take the decision.

This case draws particular attention to the family not least because it is a complex family including two wives, deceased and current, and with children from both marriages. The evident internal disagreement highlights the fact that the family is not as coherent and warm as a social unit as it sounds when invoked in the abstract. When we consider the views of the family, remembering that in some legal contexts, they are only really of interest insofar as they give the healthcare professionals some insights into the wishes of the patient who is incapable of conveying his own wishes. The individual patient is the main concern when we make ethical decisions in healthcare and it is sometimes difficult to focus on this when the family is so vocal and, in this case, discordant. Different cultures of course have different approaches to this question of primacy of interest.

It is interesting to note that in this case, it was the healthcare professionals who had to take the decision to re-admit Andrew to hospital when his symptoms worsened. Ultimately, the onus is on the medical member of the team, who is responsible for taking the decisions which are going to be in the best interests of the patient.

There are difficulties on ethical grounds with the family’s wishes being overruled, because the physician’s first duty is to the patient. Nevertheless, we have to recognise that the experience of working through these decisions in the context of very upsetting circumstances is by no means trivial. The involvement of the family is of course important as family members can be thought of as part of the care team insofar as they are providing care and equally importantly providing information and insights concerning the patient’s wishes. This is always assuming that the family has discussed these matters. In cases where the family has not previously discussed the various options available in situations where continuing to live is unacceptable to the patient, the family voice might be said to lose some of its force in terms of supplying the patient’s view.

All of this points to the needs and wishes of the patient being paramount. In turn, this means that patient consent is important. Herein lies the problem in the context of terminal sedation. In the case Krishna describes, the family has differing views on the issues and indeed are following rather different agendas. George, Andrew’s eldest son, in particular, was unable to bring about consensus on the question of sedation. George’s overriding concern seemed to be to act in such a way as to square his own conscience, rather than to find the best outcome for his father.

The medical profession is concerned with the legality and moral acceptability of the treatments adopted. A part of the moral argument is to act in the patient’s best interests...