“Uncle Fred” and Withdrawal of Treatment

This case asks for an examination of the options a medical team has when faced with an incompetent patient deemed as futile but whose existence is maintained by ventilator support in the ICU. Whilst the law in Singapore is not clear in relation to what the doctor can or should do, there are various laws that could apply to this case.

A starting point is to examine if this case falls within the ambit of the Singapore Advanced Medical Directive Act 1996. The Act applies when the patient requires “extraordinary life-sustaining treatment”, which is defined as any medical procedure or measure which, when administered to a terminally ill patient, will only prolong the process of dying when death is imminent, but which excludes palliative care. “Terminal illness” means an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery where death would, within reasonable medical judgment, be imminent regardless of the application of extraordinary life-sustaining treatment; and the application of extraordinary life-sustaining treatment would only serve to postpone the moment of death of the patient.

As the narrative does not at any point describe Uncle Fred as being on the cusp of death, where the ventilator support would have merely served to “postpone the moment of death”, the Advanced Medical Directive Act does not appear to be applicable to this case.

The other relevant Singapore statute to consider is the Mental Capacity Act (MCA) 2008. The patient was ascertained by a psychiatrist to have lacked mental capacity “to decide his own fate”, which taken at face value indicates that the provisions of the Mental Capacity Act relating to people who lack mental capacity to make their own decision applied to the case of Uncle Fred. The narrative suggests that Uncle Fred did not appoint a Lasting Power of Attorney (LPA) while he was competent, nor was there any Court-appointed Deputy. Regardless, the provisions of section 13(8) of MCA would preclude any LPA or Deputy from making the final decision. Section 13(8) MCA states that notwithstanding anything in the lasting power of attorney, a donee authorised to make decisions about P’s personal welfare may not make any decision with respect to the carrying out or continuation of (a) life-sustaining treatment on P, whether or not amounting to extraordinary life-sustaining treatment within the meaning of section 2 of the Advance Medical Directive Act (Cap. 4A); or (b) any other treatment on P which a person providing healthcare reasonably believes is necessary to prevent a serious deterioration in P’s condition. P in this context is defined under section 11(1) MCA as the donor of a Lasting Power of Attorney—“A lasting power of attorney is a power of attorney under which the donor (“P”) confers on the donee (or donees) authority to make decisions.” Whether it is in relation to a court-appointed Deputy or LPA, the same restrictions apply. The strict criteria of the AMD Act would preclude the ventilator from qualifying as “extraordinary life support”, but such ventilator support was essential to prevent serious deterioration in his condition, thus invoking section 13(8) MCA.

Having determined that the AMD Act and MCA would not have applied to Uncle Fred, we now examine the common law provisions. Singapore common law has stated that “when it comes to a situation where the patient is incapable of giving her consent, or where such consent (or lack of it) was not made reasonably clear, the doctors would have to treat the patient according to what they think is in the best interests of the patient … doctors have to concentrate on the medical aspects of treatment. So although the opinions and sentiments of the patient’s family ought to be sought, they are not binding (for indeed, as I have mentioned, they can sometimes be at odds) on either the doctors or the court. Where doctors do not have a clear and express consent of their patient, their only course is to act in the best interest of the patient.” This was expressed by...