End-of-life choices
生死的抉擇
TSE Chun-Yan
謝俊仁
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
Should we provide good palliative care (紓
緩冶療), including the provision of strong
opioids, e.g. morphine?
Should futile (無效用) life-sustaining
treatment (維持生命治療) be forgone (放棄)?
Should we 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 definitions
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”
Forgoing futile LST is a necessary sequel
of advancement of medical technology.
Acceptance of forgoing futile LST does not
necessarily lead to the acceptance of
euthanasia.
Loose usage of the Chinese term安樂死
sometimes used to describe the state of
the dying process or even palliative or
hospice care
Such a loose usage of the term
euthanasia or 安樂死 leads to difficulties in
public discussion.
Public opinion in support of euthanasia
may actually include support for forgoing
futile life-sustaining treatment and support
for palliative care.
This confusion is totally unnecessary
and should be avoided.
To relieve the suffering of the patient
Should we provide good palliative care (紓
緩冶療), including the provision of strong
opioids, e.g. morphine?
Should futile (無效用) life-sustaining
treatment (維持生命治療) be forgone (放棄)?
Should we kill the patient by a lethal
injection?
Forgoing (放棄) life-sustaining
treatment(維持生命治療)
Life-sustaining treatment (LST) refers to
“all treatments that have the potential to
postpone the patient’s death”.
Appropriate to withhold (不提供) or
withdraw (撤去) LST
When it is the wish of a mentally
competent patient: principle of autonomy
When the treatment is futile (無效用):
principles of beneficence and nonmaleficence
Determination of futility
balancing the burdens and benefits of the
treatment towards the patient, and asking
whether the treatment is in the best
interests of the patient.
involves quality of life considerations and
can be value-laden.
The decision-making process in most
cases is thus a consensus building
process between the healthcare team and
the patient and family.
Forgoing futile LST implies the acceptance
of the fact that human is mortal.
This is medically and legally distinct from
euthanasia.
Many medically advanced countries in the
world have issued guidelines on this.
Hospital Authority guidelines of 2002:
If the patient is not mentally competent
Medical decisions are based on the best
interests of the patient.
A decision on futility of LST involves
consensus building between the
healthcare team and the family if possible.
Sometimes, such decisions are difficult
especially if the prior view of the patient is
not known.
 In the recent years, the concepts of
advance care planning 預設護理計劃 and
advance directives 預設醫療指示 are
promoted in various parts of the world.
Special points
There are no legal or necessary morally
relevant differences between withdrawing
and withholding LST.
The withdrawal of artificial nutrition and
hydration is controversial except when
death is imminent and inevitable, or it is
the wish of a mentally competent patient.
Must remember
Forgoing LST in appropriate
circumstances does not at all mean
abandoning the patient.
Basic care, symptom control, care and
concern should always be offered.
Thank you!