Perspective from Singapore

Introduction

Addressing the issue of withdrawing treatment in patients in a persistent vegetative state (PVS) within the Singapore context replete with its strong Confucian ethic poses rather more complex communication issues than those alluded to in the Italian commentary.^1–11 This is made more difficult given the paucity of local commentaries and research in this area. In this commentary, we reflect on our own experiences addressing the issues pertaining to communicating the decision to withdraw feeding in the form of artificial hydration and nutrition (AHN) to the family within the Singapore context and with that touch upon the meaning of “food” and feeding at the end of life within the local setting

Socio-cultural aspects

To begin, Singapore remains a Confucian-inspired family-centric society in the same vein as Hong Kong, China, Taiwan, Korea and Japan.^12–16 Here it is the family rather than the individual that is seen as the most basic autonomous unit within the society. Ho et al. attribute this to the continued adoption of a two-dimensional view of personhood within the local society.⁵ According to Tsai, this two-dimensional view of Confucian personhood sees the individual as having relational and atomistic elements to their personhood.¹⁷ Ho et al. posit that within the end-of-life setting, however, it is the relational element that takes precedence.⁵ Thus, in contrast to the modern Western autonomy-oriented model of healthcare, family members are always consulted when medical decisions about their loved ones are made and they exert significant influence on the final treatment plans.¹⁸

Arising from these Confucian-centric beliefs are two other considerations—filial piety and non-abandonment.

Filial Piety (FP)

In Confucianism, a significant moral belief is that of filial piety. Simplistically, it can be understood as placing an obligatory duty on children to care for their elders, driven in part by a reciprocal appreciation of the care they had previously received.¹⁹ This, it would seem, represents only part of the duty and consideration related to filial piety within the Confucian understanding. FP in some cases represents the main source of familial cohesion and enhancing inter-generational and intra-generational solidarity. It does, however, engender rigidity, patriarchy, and patrimonial and paternalistic views that may actually countermand a patient’s best interests leading to the postulation that FP has two facets: reciprocal FP and authoritarian FP.^19,20 The former refers to the understanding of FP that relates to the recompensing of parental care by children, whilst the latter relates to the assertion of obedience, the dominance and inscrutability of the father’s role, and the maintenance of social structure.^19,20

Within the end-of-life setting, FP is observed through the provision of care and support, which is not infrequently demonstrated through the provision of food. Such provision of food is seen as a sign of non-abandonment and even the maintenance of hope.^5,8,9,21,22 According to Confucian belief, the ability to provide material and emotional well-being to one’s elders is a basic requirement and in turn rewards the individual with a sense of happiness and accomplishment.^17,23,24 The act of preparing food for the patient represents love and care beyond that of maintaining sustenance to the patient.^21,22

It is thus unsurprising given this socio-cultural backdrop related to prevailing Confucian-centric beliefs that acts of withdrawal of AHN are met with resistance and foster significant guilt and distress amongst family members and society alike. Such beliefs may even take precedence over the comfort of the patient who has to risk the complications of the prolonged use of feeding tubes or intravenous devices for hydration.^5–7

It is in these efforts to observe and meet filial and social expectations that practices such as collusion, family-centric decision-making and circumnavigation of direct patient engagement in their own care decisions still dominate the local healthcare backdrop.^1,18,25–27

Communication

Awareness of the beliefs mentioned above help contextualize the complex issues faced by local medical teams.^28...