Ethics Debate – Advanced Medical Directive (AMD)

The Yong Loo Lin School of Medicine, NUS held its annual inter-class ethics debate in the auditorium, pitting the third-years (M3s) against the fourth-years (M4s). The topic of discussion:

“The AMD raises more ethical issues than it resolves.”

Proposition – M4
Opposition – M3

A point of interest is that both sides decided to restrict their arguments to the local [Singaporean] context, where an Advanced Medical Directive consists of two pages and is basically a Yes/No document to say –

In the event of a terminal illness and if one is unconscious / incapable of exercising rational judgement so that one is unable to communicate his wishes to the doctor, no extraordinary life-sustaining treatment should be applied or given to one.

Repeating the debate verbatim is impossible, but J. had a couple of points that he either raised or tried to raise (but was interrupted by a call from the delivery suite).

Firstly, the opposition in particular made the mistake of over-emphasising the legal benefits and practical benefits of the AMD over the ethical issues.

Practical does not mean ethical. In the event of a terminally ill patient in the Intensive Care Unit (ICU), the pulling of the plug might be practical in the financial sense, but might not be ethical even if the family ends up bankrupt.

Legal does not mean ethical. In many cases, legal change comes after ethical debate and it is a fallacy to believe that once something is legal, it becomes ethical. There are legal ways to swindle people out of money. Not ethical. Some countries practising Sharia (Islamic Divine Law) use amputation as a punishment for theft. Ethical? Probably not. The death penalty is legal in many countries. Ethical? Arguable.

Secondly, the opposition used the terms “dying with dignity” and “choosing when and how to die“.

As far as J. is concerned, the only ways of choosing and/or knowing when and how to die is (a) suicide (b) euthanasia. Neither of these can reasonably be considered ethical choices. There is nothing dignified about dying. Terri Schiavo (a case raised by the opposition) died of dehydration 13 days after her feeding tube was removed. Hardly a fantastic way to die. And it is unlikely that she had the ability to choose to die 13 days after being condemned to starve/dehydrate.

Whatever reasons are proposed for signing an AMD, J. feels that these should be based on practical and possibly ethical beliefs. They should not be based on such popular misconceptions and catchphrases of “dying with dignity” or “choosing the manner and time of one’s death”. If one choose to sign an AMD so the family can save the money wasted (the ICU is one of the most expensive places in the hospital) on a hopeless case, that is perfectly fine.

Thirdly, it surprises J. that the opposition chose to fight the proposition on their home turf. The “ambiguity argument” raised by the proposition could have be blasted off the map by the alternative definition of Advanced Medical Directive used in other countries. As comprising a Living Will and/or Medical Power of Attorney.

The living will, unlike the farce that passes as an AMD in Singapore could have the flexibility of specifying each and every component, including: nutrition, ventilatory support, cardiac support, resuscitation in any situation, including: coma, persistent vegetative state, total paralysis.

On a matter unrelated to the subject matter, J. feels that the tone in a debate should be kept civil, for it is an exchanging of ideas between peers. The competitive spirit should at least be hidden in [not-quite-thinly] veiled insults and insinuations of the opponents lack of competence. Outright hostility, like on the part of one M3 floor speaker is unseemly and alienates both the audience and the judges.

All that said, the M4s won the debate. The last speaker of the opposition (the M3s) won best speaker.

J. is a fourth-year medical student (M4). You wouldn’t have guessed, of course, given the completely unbiased and impartial account written above.

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One response to this post.

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