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Euthanasia and Advance Directive in Hong Kong

In order to understand euthanasia and advance directive we need to firstly understand the term life-sustaining treatment. It means any medical procedure, device or medication to keep a person alive. It includes: medical devices put into the airway for breathing; food and water supplied by medical device (tube feeding); intravenous fluid; cardiopulmonary resuscitation; major surgery; blood transfusions; dialysis; antibiotics; pacemakers; vasopressors; and anything else meant to keep a person alive.

The Position of the Hong Kong Government

The former Secretary for Health and Welfare Dr. EK Yeoh explained on 26 January 2000 at the Legislative Council and he mentioned that the acts involved in euthanasia are illegal in Hong Kong by virtue of the provisions in the Offences Against the Person Ordinance (Cap 212) which provides that a person “aids, abets, counsels or procures the suicide of another to commit suicide, shall be guilty of an offence”. A person also commits the crime of murder if he unlawfully kills another person with the intent to kill or cause grievous bodily harm.

The Position of the Hong Kong Medical Council

According to the Professional Code and Conduct published by the Hong Kong Medical Council in November 2000, the Hong Kong Medical Council does not support the practice which is illegal and unethical. Where death is imminent, it is the doctor’s responsibility to take care that a patient dies with dignity and with as little suffering as possible. The rights of the terminally ill patients for adequate symptoms control should be respected. This includes problems arising from physical, emotional, social and spiritual aspects. The withholding or withdrawing of artificial life support procedures for a terminally ill patient is not euthanasia. Withholding/withdrawing life sustaining treatment taking into account the patient’s benefits, wish of the patient and family, when based upon the principle of the futility of treatment for a terminal patient, is legally acceptable and appropriate. It is important that the right of the terminally ill patients be respected. The views of his relatives should be solicited where it is impossible to ascertain the views of the patient. The decision of withholding or withdrawing life support should have sufficient participation of the patient himself, if possible, and his immediate family, who should be provided with full information relating to the circumstances and the doctor’s recommendation. In case of conflict, a patient’s right of self-determination should prevail over the wishes of his relatives. A doctor’s decision should always be guided by the best interest of the patient.

The Position of the Hospital Authority

The Hospital Authority of Hong Kong is firm in its stand against euthanasia. The authority issued “Guidelines on In-Hospital Resuscitation Decision” in July 1998. It is essentially a set of clinical guidelines to enable clinicians to arrive at a professionally and ethically sound resuscitation decision which will safeguard the best interest of the patient and clinician. It serves to give health care professionals guidance in decisions to administer or withhold cardio-pulmonary resuscitation (CPR) based on the patient’s medical conditions, the overall treatment plan; the likelihood of the patient benefiting from the resuscitation; and the patient’s expressed wishes. The attending physicians should exercise clinical judgment in the best interest of the patient. Hospital Authority guidelines in 2002 mentioned that if the patient is not mentally competent, the decision of withholding or withdrawing the life-sustaining treatment (LST) should base on the best interest of the patient and a decision on futility of LST involves consensus building between the healthcare team and the family if possible.

The Position of the Hong Kong Society of Palliative Medicine

The society opposes euthanasia and upholds the principle of palliative care. They believe palliative care should have priority over euthanasia because it has developed in Hong Kong for more than 20 years with recognized quality and impact, and yet still with gaps in coverage. They believe the government should consider accessibility to quality palliative care as a policy before discussion of legislation of euthanasia. They believe patients request euthanasia because they are afraid of a painful dying process but not death itself, they suffer from uncontrolled symptoms including pain, they perceive themselves as burden to the family, they have undiagnosed depression which is treatable and they feel hopeless as defined by “no use, no time and no cure”.

Public Attitudes towards Euthanasia in Hong Kong

According to a research done by the City University of Hong Kong, there was a tendency in both household and physician sample to support euthanasia. Respondents in both the household and physician sample tended to support the concept of the right to decide to die. Most respondents agreed that euthanasia is a humane act and euthanasia gives a person a chance to die with dignity. The household respondents tended to support active euthanasia but most physicians felt this was not acceptable. Physicians supported passive euthanasia. Among the household respondents those with higher income tended to support all types of euthanasia. Physicians with more experience treating terminally ill patients tended to disagree with euthanasia. Both parties ranked self as the most important decision-maker and the wishes family members should also be respected. The role of doctor in the decision making process was comparatively speaking less important. The study was limited by the lack of popular discussion of euthanasia in the society and the household respondents may not fully understand the technical term when compared with healthcare professionals.

Attitudes of Acute Ill Patients towards Euthanasia in Hong Kong

According to a study by the Chinese University of Hong Kong, 77 out of 129 patients responded (59.7%) and a high proportion of patients agreed with the use of euthanasia in the following circumstances: “where they were a third party”, if “someone they loved” was affected, or if “they themselves were the patient”. Of the 77 patients, 54 agreed with active euthanasia (70.1%) and 65 with passive (84.4%). The patients who had a lower monthly income and were older in age showed a higher acceptance of euthanasia. More female than male patients supported the use of euthanasia.

Advance Directive in Hong Kong

The Law reform Commission of Hong Kong has recommended in 2006 that the concept of advance directive should be promoted in Hong Kong by non-legislative means. They also encourage “advance care planning” which is the process of communication among the patient, the family members and the healthcare team to allow improved understanding, reflection and decision-making regarding end-of-life care. The Law Reform Commission had completed a sample advance directive and the sample was currently used by the Hospital Authority of Hong Kong. Their advance directive includes only instructional directive.

Awakening Research Foundation Hong Kong Limited

An opinion survey on voluntary active euthanasia was carried out by personal and telephone interviews from 19 November 2012 to 11 December 2012. Five hundred and twenty five persons were interviewed and 152 of them had responded. The response rate was 29%. Seventy five of them (49.3%) agreed euthanasia if they suffered from terminal illness with unbearable pain. Thirty two of them (21.1%) did not agree with euthanasia and 45 of them (29.6%) said ‘don’t know’. The result was compatible with previous studies but the target of this survey is on general public instead of acutely ill patients. The Foundation is fully devoted to promotion of both instructional directive and proxy directive in Hong Kong. An opinion survey was carried out from 9 November 2012 to 16 November 2012 by telephone interview. The interviewees were selected randomly. A total number of 964 phone calls were made and 320 persons responded to the questionnaire. The response rate was 33.2%. Three hundred and eighteen persons (99.3%) had never heard of advance directive. Sixty-three persons expressed their opinion concerning the formal legislation of advance directive in Hong Kong. Forty of them (63.5%) said ‘don’t know’, 10 of them said ‘Yes’ and 13 of them (20.6%) said ‘No’. The late Awakening Research Foundation also completed a document known as ‘My Advance Directive’ for the purpose of advance directive promotion and it includes both instructional directive and proxy directive. In view of the lack of publicity and lack of promotion of euthanasia and advance directive by the Hong Kong government, the Foundation had made videos on YouTube and set up a blog on Twitter for promotion of the relevant policy. Awakening Research Foundation closed down in January 2016 and its role is now replaced by a new private company known as Eternity Living Life Company Limited.

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