Tag Archives: South Africa

Week 5: Assisted-Dying

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“A belief in assisted-dying is by no means a fringe view in western society.
There is broad agreement, associated with notions of modernity and evolved thinking,
that assisted-dying is an appropriate action to take in certain cases and should be allowed by law”
Bruce Falconer

dignity

Discussing this concept of assisted-dying, which is a choice at the end of the day, with anyone can be difficult and challenging, not just because of differences in religious/spiritual beliefs, moral values, legislation and medical-ethical considerations, but for the multiplicity of terms used to describe it.  Terms I think are relevant to this discussion are active and passive, voluntary and involuntary assisted-dying and physician-assisted-dying. Many other terms such as suicide and euthanasia (active/passive, voluntary/involuntary, by omission/action) and are also used but carries social stigma and negative religious connotations.

This week’s theme of assisted-dying and end-of-life decision-making, has been difficult for me as a physiotherapist and a Buddhist, trying to see both sides of the coin… The individual right to life and to be treated with dignity and respect versus the bigger picture of the society and the impact of such legislation.  Buddhists are not unanimous in their view of physician-assisted dying, and the teachings of the Buddhadharma don’t explicitly deal with it. In Buddhism, the way life ends has a profound impact on the way the new life will begin. So a person’s state of mind at the time of death is important – their thoughts should be selfless and enlightened, free of anger, hate or fear. This suggests that suicide, albeit assisted or not, is only “approved” for people who have achieved enlightenment and are at peace with themselves and the life they had.

Personally I do not believe in artificial means of prolonging life.  I believe in the “do not resuscitate” order, also known as the “No Code”, which may be seen as a passive assisted-dying by some.  Dying does not scare me as it’s part of life, the natural progression of life, or if your life is cut short, it’s part of the path you had to or need to walk. Perhaps my perspective will change once I have children.  Then the thought of leaving them behind will make me reconsider.  But at this stage in my life, I believe that your time is your time and letting nature takes it’s course after you’ve exhausted all your options in medicinal and therapeutic terms.  But science has made it possible to cure disease, recover from disability, reduce perceived pain and suffering and improve quality of life, so I do believe that you should make use of what is available.  Therefore I am not pro assisted-dying for myself, but I am not against it for others.

The potential negative consequences or effects after resuscitation and prolonging life artificially is a reality, so too are the life saving chances. I have seen this with some of the kids I have treated.  One is a little boy who was brain dead after a car accident and his parents instructed the doctors to save him and keep him on life support as long as possible.  They had to resuscitate him 3 times and after 5 months of living on machines, he only recovered enough to sustain breathing through a trachi (tracheotomy), with a “Glasgow Coma Scale” of 3 (Eye 1 (no reaction or movement), Verbal 1 (no expression, sound, attempt), Motor 2 (reacts to painful stimuli)), which hasn’t improved or deteriorated in the last 2 years.  But he needs 24h care, therapy and constant medical attention and intervention.  Is this a life worth having or living, or is it selfishness to have forced life despite the package it comes in?

Then there’s the question of physician-assisted-dying.  This really hit home in 2012, when Sean Davison, a physician, professor and head of the Forensic DNA Analysis Lab at The University of Western Cape in South African, returned home after five months’ house arrest in New Zealand for helping his terminally ill mother die.  He was found guilty of the lesser charge of counselling and procuring the suicide of his mother, by giving her, as requested and consented, a lethal dose of morphine after she tried to starve herself to death.  He has formed a non-profit organisation, Dignity SA and hopes to educate people and champion a law change in South Africa.

I agree with the slogan of Dignitas, “To live with dignity, to die with dignity” and that this is the last human right, or it should be.  But unfortunately the mastermind behind the Dignitas organisation (an international centre for assisted-dying), Ludwig Minelli (a self-described humanitarian and lawyer), who might have had the best intentions to start with, has become something of a side show and with his toxic reputation, has resorted to shocking the public and forcing his opinions on others.   Under Switzerland’s permissive and unique legal environment,  assisted-dying has developed into suicide-tourism.

The problem we have is that every human being has the right to life and a quality life at that, but quality is subjective and each person has their own perspective on what living a quality, full life means.  Two people with terminal cancer will not consider assisted-dying the same, they will not consider medical management and intervention the same… but is their suffering the same, as pain, stress, discomfort and fear are all perceived emotions, reactions and sensory processing which varies from person to person?  So why does one person choose to fight to the end, whilst another lets nature takes it course?  And what about people who are choosing to “give up” or end the suffering and requires assistance?  Should they have the choice?  Tony Nicklinson who suffers from Locked-in Syndrome has been fighting against the legal system for “Death with Dignity” laws.  These laws allow a terminally ill patient to hasten an inevitable, insufferable and unavoidable death. It’s not suicide or euthanasia; rather, a possible option if the physical or emotional  pain from the underlying illness gets to be too much or quality of life too degraded. If one is of the opinion to agree with legal active and passive assisted-dying for compos mentis, suffering, living, human beings, what would be the criteria? Should this be a right to all suffering human beings, a choice of how they want to live and die? But what about a person who has lost the will to live?  Should they have this right or is this only for people who have exhausted all medical or health/healing interventions and therapies in trying to recover, reduce or manage the pain and disability?  And then, is emotional and physical pain the same?  Are we to say that such people are weak? Are we to say that everyone should endure?

If we think about it, compared to abortion, it makes the moral question a bit more simple.  In South African it is legal to have an abortion, even from the age of 13, as shocking as it may be for some.  Medically speaking in terms of anatomy and physiology, the embryo as a blastocyst has living cells after implantation on day 8-10 and then the embryo develops into a fetus at 8 weeks gestation when heart cells start beating.  Furthermore, from 10-13 weeks gestation, the fetus’s nervous system sensitizes and develops integration of pain/noxious stimuli which cannot be termed a mere reflex. The fetus also bears all human traits at this stage including the basic/core structure of cardiac-circulatory and nervous system cells, which are reactive.  But abortion is legal up to and including at 13 weeks gestation.  Thus it can be seen as involuntary assisted-dying of the unborn fetus (although the mom is the active participant and decision maker).  Others might call this murder.  Just because the baby is inside the womb, once it has a heart beat, it is considered alive, a living human being. So what makes a born living human being’s life more important or special than a unborn human being’s life?  Thus scientifically speaking within morality and ethics, the answer to involuntary and passive assisted dying is quite straight forward, it’s wrong.  I believe that voluntary assisted-dying is a choice as you alone are responsible for your own life, and the choices you make.

A great video on the assisted-dying debate:

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For PHT402 Professional Ethics Course: Week 5 – Assisted-Dying

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Week 4: Torture & Human Rights

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“The argument cannot be that we should not torture because it does not work.
The argument must be that we should not torture because it is wrong.”
Jason Michelich 

human rights

Next month will mark the 36th anniversary of the death and case resolution of anti-apartheid activist Steve Biko, who in 1977 died of head injuries sustained during interrogation/torture while in South African Security Police custody, with identified gross inadequacies in the medical management.  In addition, since 2008, Xenophobia hit South Africa like a disease, and it’s still relevant.  Many black South Africans living in the townships felt that the massive, uncontrolled influx of “illegal immigrants” or “asylum seekers” were taking the job opportunities from the “native black South Africans”, which has led to acts of Xenophobia (including discrimination, violence and torture) in a community already suffering from social crises and poverty.  The concern needs to be on the protection of the human rights of all human beings, including foreign nationals.  Another relevant issue of  torture and human rights violation occurred in the South African “Marikana” massacre in 2012, with 44 deaths and 76 injured South Africans.  Police brutality (lethal use of force) reared its ugly head again, but this time it was not the white Apartheid Police Force firing upon black South Africans, it was the “new South African” Police Force, firing on their own people, supposedly in self-defense and crowd control.  The South African president commissioned an inquiry to investigate matters of public, national and international concern arising out of the tragic incidents at the Lonmin Mine in Marikana.  Should the police have acted so brutally and opened fire on all the strikers or just those that were attacking them, those that “initiated” the attack?  What about those human beings, the “strikers”, who were shot in the back as they were running away and those that were “gunned down” and even tortured before death?

These events have led to Amnesty International publishing a document in 2012 on the current status of and recommendations to the South African Prevention and Combating of Torture of Persons Bill, urging that its scope be expanded to reflect the full extent of South Africa’s obligations under the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and to uphold and protect the rights of asylum seekers and refugees.  As we have discussed in week 3 on the topic of equality, violating, suppressing basic human rights of any human being, is legally, morally and ethically wrong.

There has also been much talk and controversy surrounding the 2013 released blockbuster “Zero Dark Thirty” as it depicts the use of military and intelligence interrogation and torture-practices in the “fight against terror”.  Torture, carried out or sanctioned by individuals, groups and states throughout history from ancient times to modern day, is the act of deliberately inflicting intense physical pain, combined with emotional/psychological stress and deprivation of basic care and needs, to a person who is unable to protect himself.  The reasons for torture include interrogation, punishment, revenge, political or the sadistic gratification.  Many support the anti-torture argument on the fact that torture is hugely unreliable means of obtaining information, that often turns out to be redundant or misleading.  Others argue that the “well-being and protection of defenseless human beings and for the greater good of the country” it is more important than the issue of violating Human Rights of  a terrorist or criminal/prisoner of war.  Pro-torture individuals or groups often state that “brutalization brings breakthroughs”, and that torture is at times necessary or required to gain valuable intelligence/insight/information to stop future attacks/violence and to bring criminals/terrorists to justice.  For me, more importantly, and from a Human Rights point of view, torture is morally and ethically wrong.

We all know that terrorist activity violates various Human Rights, including the right to life; rights to non-discrimination, including equal rights for women and girls; right to a fair trial; freedom of religion and belief; freedom of expression and information; the right to vote and participate in public affairs etc.  Therefore, measures against terrorism can have an important role in protecting human rights but counter-terrorism laws can also have a profound impact in limiting fundamental human rights and freedoms, including the right to a fair trial; the right not to be subjected to arbitrary detention; freedom from torture and cruel, inhuman or degrading treatment or punishment; the right to freedom of expression; the right to freedom of movement; the right to privacy; the right to non-discrimination and the right to an effective remedy for a breach of human rights.

So the question is, should a terrorist “loose” his rights as a human being?  What about a criminal who took the life of an innocent human being or child?  Should he/she still have rights?  I believe we should respect the rule of law and the principle of upholding fundamental rights and freedoms, for all, even when we personally feel that a person (terrorist or criminal) is not deserving of any rights as a human being.

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For PHT402 Professional Ethics Course:  Week 4 – Torture & Human Rights

Week 3: Equality

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It has been said that equality is central to basic human rights that every human being in the world should be entitled to. But lets be honest, are we all equal, or are some more equal than others?

 

equality

 

The problem with equality in our modern world, is that often times the political or social climate (power & superiority) reduces the quality of life, freedom and growth of certain groups and in turn forces the enhancement and above-the-law protection of specific politically/socially suited “lesser” groups,  in order to attain this ideal of equality and protect against discrimination.  But  there cannot be true equality, real fairness without freedom. You cannot sacrifice the one for the other.  There will never be true equality under such a system.  Equality means that every human being should see and treat every other human being equally before the law regardless of their race, gender, sexual orientation, gender identity, national origin, ethnicity, religion or disability without privilege, discrimination or bias.  Yes, you need to protect and create opportunities for the ‘weaker or lesser’ groups of people, but not by sacrificing, impeding or discriminating against other groups or individuals.  This system also allows people the protection and right to make excuses for their behaviour by blaming external factors and ‘getting away with murder” as they are the politically favoured group.  Forcing equality can create massive divides and socio-economic break-down within a community and a nation.  Thoughts and feelings of hate, jealousy and frustration with power-hungry mindsets and egocentricity are driving forces for inequality. In our country South Africa, there is blatant discrimination and inequality happening in almost every sector, level and facet of our lives.  And the whip is in the hands of the politically and financially privileged and powerful.  

 

People fear what they don’t understand, and that leads to dangerous thoughts and behaviour.  People will also hide behind or grab onto what makes them feel comfortable and safe.  Is it then acceptable or understandable to be judgmental or opinionated on the behaviour or rights of others, because of your personal, religious or cultural beliefs? My answer is no. You have no right to judge or discriminate against another human being because you don’t approve of their choices or behaviour.   It is with sensitivity and an open mind that we need to approach matters of equality, as seen in the current debate on marriage equality, racism, sexual orientation and gender identity.  

 

With that being said, I believe that focussing on how you act and engage with others, is what is important. It is a personal goal to try and see people without judgement, as your equal, a human being, deserving of equal respect, protection, understanding, kindness and care.

 

Yes, we have freedom, but not equality:

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For PHT402 Professional Ethics Course: Week 3 – Equality

Week 2: Morality

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Morality exists within the limits of reason.
But is there a universal moral code, a right or wrong answer to any moral question?

morality

Our experiences of the world and life are realised in the brain. Scientific research has found that the contributions of religion and society/culture affects neuroscience, therefore it affects how people, individually and in a group, view, process and act on context-specific information. Explicitly religious or societal/cultural beliefs and behaviors are at times in stark contrast with the “universal concept of morality”. Furthermore, religion and culture are often times the lens through which people view moral questions. Many view religion or societal/cultural beliefs/practices as a moral compass or guideline through the messy bits of life. Some may argue that a community, religious groups (often seen as dogmatism) or culture, needs to view itself as responsible for the moral growth of it’s members. But what about non-conformists, spiritual individuals or atheists…? Do they have no moral compass to guide them?  If two people are considered right from their cultural worldview and if moral variation exists, why not rather look at moral relativism instead of morality?

In health care, what my beliefs and opinions are with regards to my religious, spiritual, cultural or societal upbringing and experiences, has no place in the relationship with my patients nor, how I engage with them and what level and quality of care I provide. It comes down to universal human well-being, dignity and respect. If a parent of a patient of mine refuses to allow me to undress her child’s trunk to examine her spine, due to personal/religious or cultural beliefs, I need to respect that decision and value the difference of opinion. I need to educate and inform them of why that specific examination is crucial from a scientific/evidence-based point of view, but then explore and exhaust all other options to ensure they feel comfortable with their decision, that was not made under duress, within their religious or cultural context. Perhaps try radiography or palpation with marking of anatomical points… This has happened to me before in a clinical setting. Agree to disagree, and move on. This relates to our previous discussion on empathy with professional distance.

Yes, one can become frustrated with patients who have very idealistic and perhaps, from your perspective, limited or flawed views of the world and their health, but your job is to be neutral and see each patient as a human being. Your job is to provide excellent care and evidence-based health care education and support to all your patients within the universal code of morality guided by ethical laws, professional bodies and the legal framework of your country. An example is when a patient (of the Jehova’s Witness faith) refuses a blood transfusion, that could save his life. A compos-mentis person of legal age (age of consent or majority), as determined by law, can make his own informed decisions about his body and the way he chooses to live (including in health care). You cannot force treatment upon him, even if you are of the opinion, that what you are doing,  in terms of morality, is right, without exceptions. You are only relatively righteous in your opinion or behavior, as relative to your perverse contemporaries, not necessarily when observed out of context, or ”judged” by an absolute standard.

What about the Hippocratic Oath? Is this our moral high ground in health care? It requires a physician or health care provider to take an oath/pledge commitment, to uphold a number of professional ethical standards… So can this be seen as universal morality, a recognised standard of justice or goodness?

Other examples of moral questions are: A South African patient finds out that her child has an 80% chance of having Down Syndrome after going through the screening process as recommended by her Obstetrician/Gynaecologist (OB/GYN). With sensitivity and neutrality, she is educated about her options of termination/fetal abortion (legal in South Africa) or pregnancy progression and what the diagnosis entails regarding potential associated medical and functional problems, evidence-based medical and therapeutic interventions and quality of life. The OB/GYN cannot advocate termination because that is her opinion. Nor can she refuse to help the patient or inform her of termination because she is of opinion that she is making a terrible mistake. If the patient chooses to abort the fetus, is she a terrible human being who is killing a baby, a murderer? Or is she thinking about the well-being of her unborn, sparing the child of a life of disability, pain and suffering? Then, what if a woman was raped and carries the child of her rapist… Is abortion within the South African law, then OK? As a health care professional… My opinion on this doesn’t matter. And neither do yours. It is not your place to judge nor condemn the actions of others, as it is not your life and it does not affect you. That is the problem with morality, it is subjected to religious, personal and cultural beliefs/practices and if we believe in human connection, understanding and respect, we should practice what we preach. Leave all judgement at the door.

Ideally, we would want everyone to be guided by a universal moral code as some religious and societal/cultural sensibilities, attitudes, beliefs, dispositions and behaviors can lead to human suffering. That is why we have ethical guidelines and laws, to guide our clinical practice. What leads to universal morality, is the ability to reflect objectively about questions related to human dignity, respect, freedom and well-being. Just take yourself out of the picture for once.

I follow the Buddhist-philosophy (dharma), as a spiritual human being. It is a choice I made as an adult after many years of soul searching.  I grew up in a South African, Afrikaner-Christian home with my parents always telling us to educate and empower ourselves with information to make up our own minds about what kind of life we want to lead and person we want to be. I disagree with a lot of things that are fundamental to the Christian faith and the Afrikaner/Boer culture, but I value some aspects too. I believe in a lot of things, I have certain opinions and make certain decisions. But I believe that spirituality and my personal opinions and beliefs are private. I will not, nor should I force my opinions or beliefs on anyone else, or judge/condemn them for seeing the world differently. No one is perfectly ethical or moral, in every situation or context, but reflection, accepting your/other’s flaws and understanding why people do, say or act the way they do, will help this world become more tolerant, less judgmental and balanced where relative morality is focused on universal human well-being and “ubuntu” (human kindness).

A very inspirational speaker is Dan Ariely. I found his presentation  (especially the first few minutes) on “Our buggy moral code” very interesting and an eye opener to morality and health care.

“A man does what he must.
In spite of personal consequences.
In spite of obstacles, pressures and dangers.
And that is the basis of all human morality”
Winston Churchill

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For PHT402 Professional Ethics Course