Dr. TSE Chun-Yan
Society for Life and Death Education
November 2009
 70歲男士，末期癌症，神智清醒
 身心極度痛楚
 不時接受無效用的化療
 死時還施行心肺復甦
 慘不忍睹
 為什麼不把安樂死合法化，讓病者可以安祥地離世？
Why should we not vote at this
stage?
What do you mean when you say “euthanasia”?
To relieve the suffering of the patient
 provide good palliative care (紓緩冶療), including the
provision of strong opioids, e.g. morphine
 forgo (放棄) futile (無效用) life-sustaining treatment (維持
生命治療)
 kill the patient by a lethal injection
Which option is classified as
euthanasia?
 Euthanasia could be defined narrowly or
broadly
 Medical and legal field: narrow definition
Medical Council of Hong Kong does not support
euthanasia, which is defined as “direct intentional
killing of a person as part of the medical care
being offered”
 The term refers to “active euthanasia”
One says “Euthanasia is legalized in the
Netherlands and Belgium”
 The term refers to “voluntary active
euthanasia”
In public debates and in bioethics literature
 forgoing life-sustaining treatment (LST) is often
considered as one form of euthanasia, labeled
as “passive euthanasia”
Problems
 forgoing LST is legally acceptable in most parts of the
world in appropriate situations
 wish of a mentally competent patient
 when the treatment is futile
 active euthanasia is illegal in most parts of the world
To avoid any unnecessary confusing connotations
 the term “passive euthanasia” is not recommended
by the medical and legal field
 the term is not used in relevant guidelines and
legislations
Forgoing LST is itself a complex ethical issue, and what
constitutes futility is not easy to define
 non-controversial: forgoing cardiopulmonary
resuscitation in a terminally ill
 controversial: withdrawal of ventilator support in a
conscious quadriplegic patient

It would not help public discussion to lump all
these together under the label of “euthanasia”
To relieve the suffering of the patient
 provide good palliative care (紓緩冶療), including the
provision of strong opioids, e.g. morphine
 forgo (放棄) futile (無效用) life-sustaining treatment (維持
生命治療)
 kill the patient by a lethal injection
Case 1
 A patient with advanced incurable
cancer is suffering from severe pain
despite strong analgesics. He requests
the doctor to kill him by a lethal
injection.
 What should the doctor do?
Basic question:
 Could the pain of the patient be better
controlled?
Comments:
 Pain and suffering of the great majority of
terminally ill patients could be controlled with
appropriate palliative care.
 Adequate pain control needs an appropriate choice
and appropriate dose of analgesics, often with
other modalities of treatment including
psychological, social and spiritual support.
 Failure to control pain usually means that the
treatment is not optimal.
Next level of discussion:
 In the rare situation where the pain of the
patient is still not adequately relieved by
optimal treatment, should the doctor kill
the patient by a lethal injection?
Question redefined:
 Should euthanasia be legalized in Hong
Kong to allow killing of such patients?
 Should the doctor kill this particular patient
though euthanasia is illegal in Hong Kong?
Next level of discussion (optional):
 Are there other alternatives to alleviate the
suffering of the patient without resorting to
killing?
Comments:
 Palliative sedation (terminal sedation) could
be used as a last resort to alleviate the
suffering of a terminally ill patient.
 The patient is given sedatives to reduce his
awareness of the symptoms. However, the
patient will become drowsy and his life will
likely be shortened by this.
 It should be noted that the appropriate use of strong
analgesics like morphine does not shorten life. Palliative
sedation is not the same as the use of strong analgesics.
Follow up question:
 Is palliative sedation ethically justified?
 How is palliative sedation ethically
differentiated from euthanasia?
Comments:
 One can discuss the principle of double
effect here.
Case 2 (This should be used as a
follow up discussion to case 1)
 A 30 years old quadriplegic patient with no hope of
recovery is living with his parents aged over 60.
 His lower limbs are totally paralyzed and he could
barely move his upper limbs. He is wheelchair bound
and needs assistance in feeding.
 The whole family is on CSSA. The healthcare team has
arranged reasonable social support to the patient,
including visits by members of patient groups. He has
declined living in an institution because he wants to
stay with his parents.
 He sees no hope in his future. He strongly feels that his
existence is meaningless and a burden to his parents.
 He has been assessed by a psychiatrist. He is clinically
not depressed, but is suffering from existential distress.
 He requests the doctor to kill him by a lethal injection.
What should the doctor do?
Point to note:
 In the Netherlands, patients eligible for
euthanasia are not necessarily terminally ill,
nor suffering from physical pain.
Question redefined:
 Should euthanasia be legalized in Hong
Kong to allow killing of patients who are not
terminally ill and not suffering from
physical pain?
 Are there REALLY no other alternatives to
alleviate the suffering of the patient without
resorting to killing?
Comments:
 One may refer to the book 我要安樂死 by 斌
仔 and the website of 路向四肢傷殘人士協
會 for discussion.
Case 3
 The son of a 70 years old terminally ill unconscious
patient is informed by the doctor that the patient will
die soon, and the doctor recommends no
cardiopulmonary resuscitation (CPR) when the
patient dies, in order not to prolong the dying process.
 The son agrees with the doctor that it is meaningless
to carry out CPR.
 However, the daughter of the patient does not agree.
She considers that, due to filial piety, life must be
prolonged at all cost, and CPR must be done.
 What should the son do?
Question redefined:
 How should one assess the best interests of
an unconscious patient?
 Does filial piety means that all possible lifesustaining treatment must be given?
 How should the final decision be made?
Comment:
 Approaches to questions 1 and 3 are outlined
in the Hospital Authority Guidelines on
Life-sustaining Treatment.
Case 4
 A 60 years old patient is suffering from severe chronic
chest disease which has a relapsing course with a
downhill trend.
 After attending a public seminar on advance directives,
the patient tells his son that he wants to make an
advance directive, saying that he does not want
intubation and mechanical ventilation when he has
respiratory failure again.
 His son remembers that the patient had a previous
episode of respiratory failure which was
successfully treated by intubation and mechanical
ventilation, and he does not agree to the decision of
the patient.
 The patient expresses that he had a lot of suffering
during the past episode of intubation, and he prefers
no further intubation. The patient understands that he
will probably die by refusing such treatment in a
relapse.
 What should the son do?
Question redefined:
 The patient and the son have conflicting views on
this. Whose view is more correct?
 How should a final decision be made?
 If the patient finally makes a valid advance
directive stating his refusal of intubation and
mechanical ventilation, could the son override the
advance refusal when the patient goes into
respiratory failure again?
Comments:
 Quality of life decisions are value laden, and
sometimes there is no absolute answer.
 A properly informed mentally competent patient’s
decision should be respected.
 A valid advance refusal of life-sustaining treatment
is legally binding, and should be followed in an
applicable situation.
Case 5
 An infant with Down’s Syndrome suffers from
intestinal obstruction. A major operation could cure
the obstruction.
 His parents however refuse to sign consent for the
operation, saying that the life of a child with Down’s
Syndrome is miserable, and it is not worthwhile for the
infant to go through the suffering of the major
operation.
 The infant will die without the operation.
 What should the doctor do?
Question redefined:
 Is the life of a child with Down’s Syndrome
miserable?
 What factors should the parents consider
when making the decision?
 Could the doctor override the decision of
the parents?
Comments:
 While it may be acceptable to forgo complex
surgery with poor outcome in infants with severe
mental and physical disability, many people would
consider that this case does not belong to this
group.
 If the doctor considers that the decision of the
parents is not in the best interests of the infant,
the case could be brought to the court.