Nurturing/ Teaching Courses
The Alternative to Euthanasia
By Dr Alex Tang
Total pain management involves four areas: physical, emotional, social and spiritual pain. In this section, we shall deal with physical pain.
There has been much progress made in the management of pain. Nowadays we have ‘pain control’ teams in many hospitals and ‘pain control’ nurses who job is to help patient control their pain. It has been claimed that, in the setting of widespread cancer, although more than half the patients will experience pain, their pain is manageable by oral administration of opioids alone in 70-80% of cases. Another author has claimed that adequate interventions exist to control pain in 90 to 99% of patients.
New pain control methods include radiation therapy, nerve blocks ( including spino-thalamic tractotomy ), NSAID, transcutaneous electric nerve stimulation and direct spinal cord (dorsal column) stimulation. There are also developments in
non pharmacological methods such as distraction and relaxation.
One of the most useful pain control technologies to date is the Patient Controlled Analgesia PCA ( a pump which can deliver a continuous infusion of drugs such as morphine, as well as allow patient-activated doses for breakthrough pain). PCA allows the patient to have a continuous infusion of analgesic as well as a button which allows the patient to press for a single increased dose in the case of worsening pain. Studies have actually shown that PCA may actually lower the amount of medication administrated to patients, while providing them with a safe and effective way to have more control over their treatment. It is a great relief to patient to know that they have available the means to ease their pain and that they are able to do something about it.
Other new treatment modes include a 72 hour analgesic patch which releases controlled amounts of the opioid fentanyl through the skin. This patch allows the patient to sleep through the night, avoiding the need to wake up to take more medicine and time release morphine which reduces the frequency of drugs intake.
Surprisingly, one group that opposes adequate pain control include Christians. Scriptures taught that we live in a fallen world, and one of the results of “the fall” is the “curse” of pain ( Gen 3:16 ). Some Christians were vocal in their opposition to the use of analgesia or anesthesia to relieve the pain of childbirth and in disease related pain. They believe that pain must be tolerated.
Another issue about pain management is the possible lethal effect of the medication used. Morphine which is effective in relieving pain can also cause respiratory depression. Hence there are those who would object to its use. Here the Roman Catholic moral thought : Principle of Double Effect , may be useful. This principle deals with both the intentions and the results of actions. If one action can have good and bad effects, it is ethically permissible to do the act with good intention (for example, use of morphine for pain relief), even if the bad effects (potential for respiratory depression leading to an earlier death) can be anticipated. This is not euthanasia.
The World Health Organisation has defined palliative care as being ‘ the active and appropriate care of patients whose disease is no longer curable. It affirms life…..regards dying as a normal process…and …neither hastens nor postpones death.’ The emphasis is on caring.
During the process of dying, many things may happen. The patient may have a heart attack, the kidney may fail to function or the patient may have a stroke.
Prior to the 1960s, treatment is usually decided by the doctor. This has changed because (a) the development of more treatment options, many of which are invasive, burdensome, and expensive, and some of which has less than ideal efficacy; (b) the emergence of the legal doctrine of ‘informed consent’, and (c) the rise of individual rights as manifested by increased emphasis on minority rights, consumer rights, patient rights, etc. Hence it is appropriate to approach the discussion on limiting treatment in palliative care.
Dr. Robert Orr offers some advice on limiting treatment :
How to Approach Limiting Treatment
1. Prepare in advance by thinking ahead about biblical principles, personal values, and other factors which might influence what you want for yourself or for loved ones. Talk with family members and your physician about these matters, and consider preparing a written advance directive.
2. When confronting these difficult decisions. Gather as much information as possible from physicians, books, classes, etc. Request second opinions if there is significant uncertainty.
3. In some cases, it may be appropriate to seek an ethical opinion as well. Most hospitals have an ethics committee and an increasing number have ethics consultants to help in these situations.
4. Try to have a realistic expectations. Medicine is part science, part art, and part ministry. But it is a human endeavor and, as such, is fraught with human limitations.
5. Do not try to make these decisions alone. Your own pain and stress may color your thinking. Involve fellow believers, search the Scripture, use other Christian resources, and above all, pray earnestly for the guidance of the Holy Spirit.
6. Accept the fact that, even with one God, one Bible, and one Holy Spirit, Christians may honestly disagree about what is the proper course of action in a given situation, so others may not always agree with your decision.
7. If doubts arise about decisions already made, rest in the knowledge that before God and with the help of others you trust you made the most medically informed, morally responsible decision you could make at the time. No one can do any better than that.
The results of these discussion can be written into a Living Will. A Living Will is a legal document that spells out what treatment should and should not be given. [ see Appendix 3: A Living Will ]. They may specify at what limit treatment must stop. Treatment measures can be defined. Ordinary medical measures include resuscitation, giving of antibiotics. Extraordinary measures include artificial mechanical ventilation. Other types of instructions are Advance Directives, Medical Directives and Value History Advance Directives.
Having a specific limiting treatment instruction is good Christian stewardship. Then we are sure that our wishes are known and that our physicians will not prolong our death when it is due. It is also good stewardship to have our will for our affairs in order so that estate management will not be a hassle for our family.
Modern hospice care is a remarkable recent development. The Hospice organisation was founded in London in 1967 by Dr. Cicely Saunders at Saint Christopher’s Hospice and imported to the United States the next year by Florena Wald, then dean of Yale University’s School of Nursing. Its subsequent rapid growth is a testimony to the urgent need of helping patient to ease their dying process as opposed to the use of medical technology to keep them alive.
The National Hospice Organization in the United States defines the hospice philosophy as:
Hospice affirms life. Hospice exists to provide support and care for persons in the last phases of incurable disease so that they might live as fully and as comfortably as possible. Hospice recognizes dying as a natural process whether or not resulting from disease. Hospice neither hastens nor postpones death. Hospice exists in the hope and belief that, through appropriate care and the promotion of a caring community sensitive to their needs, patients, families may be free to attain a degree of mental and spiritual preparation for death that is satisfactory to them.
The hospice philosophy encompasses more than the standard medical palliative care. It includes physical, psychological, social, and spiritual therapies. Physicians, nurses, counselors, clergy, social workers, occupational and physical therapists, and volunteers work as a team to provide various hospice services.
The well-known Christian apologist and pastor, Francis Schaeffer’s death offers a good example:
The decision came on Easter Sunday of 1984. Schaeffer, a world-famous champion of the Christian right-to-life movement, had been dying from cancer for several years. As his condition worsened, he had moved with his wife, Edith, from their long time residence in Switzerland to a new home near the Mayo Clinic in Minnesota. Extensive treatment allowed him to write and lecture to the very end. But when final treatment decisions had to be made, Schaeffer was no longer able to make them himself. A team of Mayo doctors called his wife aside, and the leading consultant asked her, “He is dying of advance cancer. Do you want him to be placed in intensive care on machines? Now is the time to make the choice.”
Edith Schaeffer knew precisely what she and her husband wanted. “You men have already done great things during these last years and these last few weeks. You fought for life and gave Fran time to complete an amazing amount of work,” she replied, reflecting on the distinction that her husband had drawn between preserving life at all costs and prolonging deah. The time has come for her husband to go home, surrounded by the familiar things he loved. Soon he was home, in a bedroom with a large window overlooking colorful flowers put there everyday in pots because it is still winter in Minnesota. Treasured memorabilia from Switzerland filled the room, and his favorite music by the masters flooded the air. Ten days after leaving the hospital, amid the sounds of Handel’s Messiah, Francis Schaeffer died without the treatment that could have prolonged his death. His wife had made their home into a hospice.
We are well aware of how important financial planning is. Many of us do financial planning for our retirement, making sure we have enough money to see us through our ‘golden’ years. Yet few of us plan for medical treatment. Some of us do have a medical hospitalisation insurance plan that pay us a certain sum of money when we are hospitalised for a certain number of days. Others have health benefit from their jobs. Yet how many of us prepare for a long period of hospitalisation or a regime of treatment that will cost us a large sum of money.
Cancer treatment regimes may last for 1-2 years and cost around RM 200,000.00. A bone marrow transplant cost RM 100,000.00. Treatment costs of this nature can easily wipe out our retirement savings. We cannot depend on subsidised government healthcare. For example, if you are 55 years old, suffering from kidney failure and need daily haemodialysis, you will never get into a government dialysis program. The reason is that you will not get priority. A younger patient with a young family will get priority to get into the program over you. Hence there is a need to plan for major illnesses. There are a number of insurance schemes that cover major illnesses. It is good Christian stewardship to buy into one of these policies. Then in times of illness, we will not feel a financial burden and think of euthanasia as a way to save medical fees!
The church is a caring community and has much to offer as an alternative to euthanasia. People will not look to euthanasia if their needs are being met and the church has a major role to play.
The church should encourage us to face the limit of our mortality before the critical moments of imminent death when we face those hard choices of whether to treat or not to treat. The church should have more preaching on facing limits, living with mortality, suffering and death. Waiting for a funeral to address these issues is too late. The church should also have educational program that help people to stay well, cope with stress and face death. Educational programs on death and dying should include the writing of living wills and discussing the issues of euthanasia. In making a right-for-life stand, the church has not always been successful in teaching its members the reason for its stand.
The church must be hospitable in the way it provides for members who can visit and communicate to the sick, the shut-ins and the dying. They must be shown that they are worthy of respect, that their lives have meaning, and that they are not being isolated or abandoned. Suffering in those with chronic illnesses and as life ends, is exacerbated for those who are unable to sustain relationship of any meaning and value. The loss of contact with others in any meaningful way spawns hopelessness and despair. Hence the ministry of visitation is especially important in the elderly, the sick and the dying. Everyone who has these contact with them must be conspicuously visible and keep company with them often, be willing to talk about what is important to them and to listen to their needs, fears, questions, and hope. We must offer them emotional support and when necessary call in professional help.
We must not forget to care for the care-givers; the pastors, the relatives and members of the family caring for the ill and dying. The heart of the issue in responding to debilitating, chronic and lingering disease is the human heart. We must help the care-takers to cope with their own fears and their needs. Care-takers needs support emotionally and spiritually. When we deal with the mortality of another, we are also dealing with our own mortality.
The church as a community must also take into account the social needs of the elderly, terminally ill and dying. It is easy to be too spiritual. The terminally ill and dying will need help in getting to the hospital for their appointments, legal help to settle their affairs, domestic help, food and getting groceries. As church should be involved in serving these needs.
Finally but not the least, the church should be the champion for hospice care. This author is surprised that as he read through more than one hundred books, journals and newspaper reports for this thesis. Much has been said by many learned theologians, physicians and ethicist on the rightness and wrongness of euthanasia. The proponent of euthanasia often discuss on how to proceed with euthanasia and their proposed plan to lobby legislation. Opponent of euthanasia will write pages and pages on why euthanasia is morally wrong. Yet when it comes to what one is to do if one does not take up euthanasia, there is silence! How can you defend an issue if you do not offer solutions. Only a handful of authors offers alternatives to euthanasia and often in a cursory manner.
If the church is to the champion for the right-to-life movement and to stand against euthanasia, it must be pro-active in hospice care. It is in the hospice care that we can offer a dignified death. It is in a hospice care that we can overcome many of the fears that drives people to seek euthanasia.
Herbert Hendin comments:
“My experience with churches has been fairly grim. If I call up a minister of a church a person attended for 30-40 years in the prime of her life but now she’s disabled, and I ask, ‘Is there anything you can do to help this person’s burden?’ I’d say I’m no better than 50-50 to get a favorable response.” Lynn notes. “Take the last 20 members who have died in your congregation and ask their families how the church responded. I’ve had patients who were furious when they received cards telling them people were praying for them. ‘Well, why don’t they pray with me in person while holding my hand?” Based on his intimate knowledge of people in pain, popular psychiatrist and theologian, M. Scott Peck concludes, “ I submit that the answer to the problem of assisted suicide lies not in more euthanasia but in more hospice care. The first order of business should be to establish that dying patients have a constitutional right to competent hospice care.”
The church can either set up hospice care in a center (building) serving the community with a group of nurses (hospice trained), physiotherapist, counsellor, physicians and volunteers. Hospice care can also be offered to patient in their own home. In Malaysia, the church are beginning to be aware of hospice care as a ministry. The Hospice Association of Malaysia is a non-government organisation and surprisingly do not have much support from the church in Malaysia In the author’s home state of Johor Darul Takzim, he is also not aware of any churches offering hospice care. Again it is the non-Christians who took the initiative and started a hospice program. It is indeed time for churches in Malaysia to take a good hard look at itself and to see whether they are indeed God’s caring community in Malaysia.
Soli Deo Gloria
 A good overview of pain control is found in Cicely Saunders, Mary Baines and Robert Dunlop, Living with Dying: A Guide to Palliative Care (New York : Oxford University Press,1995 Third Edition). Here the authors share on their experience on pain control in their work with St.Christopher’s Hospice, the first modern hospice established in 1967. See also David Cundiff, Euthanasia is not the Answer : A Hospice Physician’s View (Totowa, New Jersey : Humana Press,1992) p.104-132
 Robert Truong and Charles Berde, “Pain, Euthanasia and Anesthesiologists” Anesthesiology (Feb 1993) 78 : 357
 Albert Einstein, “Overview of Cancer Pain Management,” in Judy Kornell,ed, Pain Management and Care of the Terminal Patient (Washington: Washington State Medical Association, 1992 ) p.4
 Robin Gill ed, Euthanasia and the Churches : Christian Ethics in Dialogue (New York : Cassell, 1998)p.98
 Advance Medical Directives – a legal document to appoint a health care proxy ( e.g. a durable power of attorney for health care) has the advantage over the living will in that it is more flexible,and should thus obviate the need to go to court to make a decision in an ambigious situation. Orentlicher, Advance Medical Directives JAMA 1990:263(17):2365-2376
 Medical Directives – allows a person to indicate which of the 12 treatment modalities he or she would or would not want to have used if he or she should be incapacitated in 4 different clinical situations. The modalities listed are: cardiopulmonary resuscitation, mechanical breathing, artificial nutrition and hydration, major surgery, kidney dialysis, chemotherapy, minor surgery, invasive diagnostic testing, blood and blood products, antibiotics, and pain medications. The 4 clinical situations are: permanent unconsciousness, persistent unconsciousness with a small chance of improvement, irreversible dementia accompanied by a terminal illness, and irreversible dementia without other illness. Emanuel LL, Emanuel EJ, The Medical Directives: A New Comprehensive Advance Care document ( Journal of American Medical Association, 1989 ) 261: 3288-3293
 Values History – advance directive designed so that surrogates can make the decision for patients after they have lost their competence. They propose that more important question on “what are the patient’s values?” They then offer an alternative advance directive that focuses on the patient’s values rather than their desires about specific treatment modalities. Lamber P, McIver-Gibson, Nathanson, The Value Hisotry: An Innovation in Surrogate Medical Decision-Making ( Law, Medicine & Health Care,1990 )18(3):202-212
 Dame Cicely Saunders had studied under Oxford scholar C.S.Lewis before World War II and travelled in Christian circles that included Dorothy L. Sayers. While serving as a nurse during the war and a social worker after it, Saunders become interested in the plight of the terminally ill, and serving them became her ministry. She attended medical school to learn ways to control the pain of dying cancer patients and in 1967 founded the first modern hospice.
 For information on the Hospice Movement see Dame Cicely Saunders and Robert Kastenbaum edd, Hospice Care on the International Scene ( New York : Springer Publishing Company, 1997). For a personal account, see DaVid Cundiff, Euthanasia is not the Answer, A Hospice Physician’s View ( New Jersey : Humana Press, 1992 )
 National Hospice Organization, “Standards of a Hospice Program of Care” 1982 p. 1
 Edith Schaeffer, Forever Music (Nashville:Nelson,1986)p. 62-63. Quoted in Edward J. Larson & Darrel W.Admundsen, A Different Death : Euthanasia and the Christian Tradition (Downers Grove,IL: InterVarsity Press, 1998 ) p. 175
 An example is Malaysian Assurance Alliance (MAA) Pro Life 36 Super (PLS) policy. The 36 illnesses covered are cancer, heart attack, coronary artery bypass surgery, balloon angioplasty, stroke, kidney failure, cardiomyopathy, pulmonary hypertension, heart valve disease, coronary artery laser therapy, surgery of aorta, brain surgery, major organ transplants, major burns, paralysis-paraplegia/hemiplegia/quadriplegia, blindness, deafness, loss of speech, coma, chronic lung disease, chronic lover disease, fulminate viral hepatitis, HIV by blood transfusion, Occupationally acquired HIV infection, full blown AIDS, aplastic anemia, parkinson’s disease, Alzheimer’s disease, multiple sclerosis, motor neurone disease, muscular dystrophy, bacterial meningitis, encephalitis, poliomyelitis, benign brain tumour and terminal illness. The policy pays a lump sum insured ( 10%; 10%; 80%) over 3 years – enough to pay the medical expenses.
 Herbert Hendin, Seduced by Death : Doctors, Patients and the Dutch Cure (New York:Norton,1997)p.203; Gary Thomas, “Deadly Compassion,” Christianity Today, June 16, 1997p.21; M.Scott Peck, “Living is a Mystery,” Newsweek, March 10, 1997, p.18 quoted in Edward J.Larson & Darrel W. Admundsen, A Different Death : Euthanasia & the Christian Tradition (Downers Grove, IL : InterVarsity Press, 1998)p.249
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