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End-Of-Life Care in Taiwan from the Perspectives of Asian Bioethics

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End-Of-Life Care in Taiwan from the Perspectives of Asian Bioethics Asia Pacific Journal of Health Law & Ethics Vol.10 No.2, March 2017, pp.69-80 End-of-Life Care in Taiwan from the Perspectives of Asian Bioethics Michael Cheng-tek Tai* Abstract 69 The aging population is a new reality in the world. Asian countries are facing the question of how to take care of their senile citizens who, when younger, have contributed much to society yet are now needing more medical attention and therefore are consuming a big portion of the health care budget. How to extend care to this growing number of citizens is a new social issue. This paper will first give a brief discussion of a new legislation adopted in Taiwan on December 18, 2015, named the Patient Self-determination Act, which allows patients suffering from incurable diseases or those in their last phase of life to say no to life sustaining treatments. Medicine, however, is supposed to save life, which raises a question: would this new legislation violate the principle of medical ethics? This paper will then discuss this act from the perspective of Asian bioethics. Humanization and harmonization are the two main emphases of Asian bioethics. Keywords: Asian Bioethics, Patient Self-determination Act of Taiwan, Humanization, Harmonization, Elderly care. I. Introduction The aging population is a new reality in the world. Asian countries are facing the question of how to take care of their senile citizens who, when younger, have contributed much to society yet are now needing more medical attention and therefore are consuming a big portion of the health care budget. How to extend care to this growing number of citizens is a new social issue. This paper will first give a brief discussion of a new legislation adopted in Taiwan * Chair Professor of Bioethics and Medical Humanities, Chungshan Medical University, Taichung, Taiwan 69 Asia Pacific Journal of Health Law & Ethics Vol.10 No .2 (2017) on December 18, 2015, named the Patient Self-determination Act, which allows patients suffering from incurable diseases or those in their last phase of life to say no to life sustaining treatments. Medicine, however, is supposed to save life, which raises a question: would this new legislation violate the principle of medical ethics? This paper will then discuss this act from the perspective of Asian bioethics. Humanization and harmonization are the two main emphases of Asian bioethics. These two characters reflect the social ethos of the societies that are somehow influenced by the teaching of Confucianism and Taoism, such as Korea, Japan, China, Singapore, Vietnam, Hong Kong and Taiwan. Humanization is a process whereby all are treated with kindness and compassion and harmonization refers to a mutually-respected interaction among people. With these two teachings in mind, the care of the elderly or the dying has to be based on the bioethical principles of autonomy and beneficence. The bioethical principle of autonomy, however, is not a familiar theme to Asia. Asians emphasize a virtue of respect toward the elderly. If the elderly has any preference, the younger will always try to fulfill it as an expression of filial piety. Is this an expression of humanization and harmonization? How do we apply these two characters to the care of the elderly or the dying in Asia? The new legislation in Taiwan, a first in Asia, allows patients to refuse treatment if they suffer from the following conditions: terminal illness, irreversible comatose state, severe mental incapacitation, untreatable illness or suffering from unbearable pain. As long as the patient has willed the request not to be treated, this wish will be respected. Is this act ethically viable? Does it reflect the Asian ethical characters of humanization and harmonization? At the end, this paper will discuss how we should treat the diseased aging elderly with respect that is really humanized and harmonized. II. Taiwan’s Patient Self-Determination Act Does a person have a right to refuse treatment when ill? Or more precisely, does a person have a right to die before the time is up? Traditional understanding is that 70 End-of-Life Care in Taiwan from the Perspectives of Asian Bioethics everyone is born with a purpose,1 thus he or she has a duty to live. But more and more countries have started debating a person’s right to die and many have even legislated to allow for patients’ choices. Taiwan has moved a step forward in this regard after much deliberation, so that a new legislation was adopted on December 18, 2015 to allow patients the right to direct their wish when facing incurable diseases or suffering from uncontrollable pain. This new legislation is called the Patient Self-determination Act, which was initiated by a physically disabled legislator named Yang Yu-hsin, who was confined to a wheelchair since the age of 19 due to a muscle disorder. This rare disease is caused by a gene mutation that also crippled her two other siblings. Yang said the act is about the dignity and autonomy of human beings.2 The purpose of this act is to emphasize the importance of patients’ rights when it comes to medical decision-making, especially when it is about a matter of life or death. Because of this act, patients can make their own advance directive by stating whether they wish to accept or refuse any kind of medical treatments when diagnosed with the following conditions: terminal illness, a coma or persistent vegetative state, advanced dementia or incurable diseases that include unbearable pain.3 If any patient belonging to one of these categories signs a directive witnessed by two fully capable adults and notarized, then it will be registered in the National Health Insurance system. In the process, two specialist physicians are required to confirm that the concerned patient falls in one the five categories stated in the act. An immunity is also introduced to this act that will free medical institutions and physicians from being persecuted when suspending, removing or refusing life sustaining treatments according to the patients’ advance directive. In the case when patients and family members hold different opinions, this act allows the medical institution and 1 The ancient Chinese poet Li-Pai wrote: “All things in their beings are good for something,” indicating that every person is born with a reason and purpose. Sun Szu Miao, the first Chinese medical ethicist, wrote in the 7th century that life is as valuable as thousand pounds of gold and should be treated with respect. These views represented a Chinese way of expressing the preciousness and sanctity of life. 2 The Legislative Yuan of the Republic of China, www.ly.gov.tw/03_leg/0301_main/leg_bill/billView.action?id =10464. 3 Ministry of Health and Welfare, http://www.mohw.gov.tw/news/531953241. 71 Asia Pacific Journal of Health Law & Ethics Vol.10 No .2 (2017) staff to focus on the patients’ will and prevents family members from interfering. The Taiwan Hospice Organization called this act a major step forward in respecting patient’s autonomy to end the suffering.4 For the first time, the terminally ill or those in coma, a vegetative state, with advanced dementia or incurable diseases are allowed to express their wish either to accept or deny medical treatment. As stated above, to have a valid directive, patients must be required to be consulted by medical specialists to ensure their consciousness and comprehension. This act is by no means euthanasia; rather, it gives the patients a right to say no to a futile treatment that prolongs the painful death process. This act does not mean those who sign the document will be abandoned by the medical team. Taiwan has a very solid hospice program to care for those who receive no more active medical procedures to ensure a peaceful way of resting into eternity, if so requested. III. Hospice Care in Taiwan Every major hospital in Taiwan is required to have a palliative care unit that provides hospice. An association of hospital hospice whose members come from all teaching hospitals had been established in 1990.5 Any individual willing to promote and share the philosophy of hospice can also become a member. In Taiwan, besides government sponsored hospitals, there are also hospitals established by religious groups and the business sector. This association is trans-denominational and trans-religious including all the Protestant, Catholic, Buddhist, Taoist, veteran and general hospitals that are funded by the government. All hospitals adopt the model of C. Saunders’ hospice philosophy and program to give total care that is physical, social, psychological, spiritual and familial in dimension. The goal of this end-of-life care is to make sure every patient will pass on with support, comfort and dignity, without too much pain. If a patient has any unfinished business or dispute or broken relationship with family members, the hospice teams will assist to make sure the reconciliation is reached 4 “Hospice Association’s statement on PSDA,” People’s News, October 2, 2015. 5 Sheau-Feng Hwang, Hospice Palliative Care in Taiwan (Taiwan: Taiwan Hospice Organization, 2007). 72 End-of-Life Care in Taiwan from the Perspectives of Asian Bioethics before the last breath. We can say Taiwan’s end-of-life care aims to give each dying person a worry-free death, so to speak. IV. Taiwan’s Patient Self-Determination Act and Asian Bioethics The Patient Self-Determination Act has been legislated to allow those suffering from incurable and excruciating pain a right to choose their care. The advanced directive will ensure that they do not go through the agonizing process of rescuing that deprives them of a qualitative life and a dignified death.
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