加護病房裡的選擇題

早幾天打書釘時翻了一本名為《加護病房裡的選擇題》的書(由一個30年資深醫生執筆)，由醫生的角度，透過其從醫生涯中的真實事件，探討一些具爭議性、亦未必有答案的問題：

• 病人不想再治療，希望求死，可以嗎？
• 醫生有責任無止盡地為病人延長生命？
• 到底誰可以決定不要救(一個人)了？
• 最後一段時間，是為病人還是為家人存在？

尤記得在之前的課堂，同學們的討論中提及了要「醫生」來當執行「安樂死」的劊子手是一件殘忍的事，也違背了醫生「治病救人」的崇高使命。在閱讀了這本書後，我想以此書的作者 Dr. Hillman的體會嘗試回應同學的看法。

在書的第四章「大象墳場」中，Dr. Hillman提及在加護病房(ICU)中，常接觸不少重症病人，當中有不少都是「已沒有治癒可能」的病人，大部分都是靠 「維生機器」或投以重藥來維持生命，有些更陷於全身癱瘓的狀況超過二十年以上，需要醫護人員二十四小時全天候的照顧。

Dr. Hillman每天例行巡房時望着這些重症病人，感到「越來越困窘不安」，甚至反思「究竟該不該花這樣大的努力去延續生命，實在值得質疑。」Dr. Hillman對「醫生有責任無止盡地為病人延長生命？」這一問題有深刻的反思，他認為，隨著醫學日漸昌明，要無限期延長病患的生命，已經是輕而易舉的事，只要患者本人或家屬願意，為重症病人繼續提供積極治療，在社會上，已被視作理所當然的事。可是，Dr. Hillman認為，醫生在努力延長病人生命的同時，亦應該為病人的整體情況作出客觀的評估，例如：究竟病人維持了性命後的生活品質將如何？救治後是否真正達到有意義的康復狀況？面對這些沒有答案的提問，醫生只能站在人道立場，「一股腦兒把可以做的治療通通塞給病人」。

看到Dr. Hillman如此坦率的告白，我沒有感到太大的驚訝。隨著醫學的進步，人類的壽命確實比以往延長了很多，可是，生命的長度是延長了，生存的質素又有沒有一樣提高？誠然，醫生的職責是治病救人，拯救病人的性命；可是，當一個人的生存模式已不能回復以往的面貌時，這被救回來的「生命」，是否仍值得我們去感激？病人痛苦地生存著，醫生是否仍能「處之泰然」？Dr. Hillman並沒以為大家在書中解答以上的疑問，可是，他以過來人的經常，和我們剖白了他的迷茫、他的矛盾，令讀者能從另一角度思考以上議題。

Justifying euthanasia based on different type of suffering?

In our class discussion last week, we discussed three different kinds of euthanasia:

The first type of euthanasia about PVS seems easiler to accept by most of us.
However, it's the second type and the third type of euthanasia (sorry I forgot the exact name we used in class) which we find it controversial.

It appears that we tend to give more justification to 2nd type of euthanasia than the 3rd type. It sounds intuitively right but I still found it kind of puzzling. The arguments we talked about in class do not seem a very compelling reason for me to accept this kind of thinking as I think the same argument can support both 2nd and 3rd type of euthanasia.

The only and most plausible explanation I can think of is that we give more weigh to physical suffering than to psychological suffering. But is it the true? One of my psychology teachers used to tell me that being rape is worse off than being murder which I found it plausible true. And I also believe that there exist some kind of psychological suffering which would be worse off than phsycial pain.

But on the other hand, it also seems that psychological suffering is not as worse as phsycial suffering as psychological suffering might be able to "recover" one day while some physical suffering can never be relieved.

So, do different type of sufferings make a different in our justification of euthanasia at all? Or are there some other important factors which make 2nd type of euthanasia more justifiable than the 3rd type that I have missed?

Right to die: 'there's no dignity left in his life – it's just existing'

Probably the thing that gives Tony Nicklinson the most pleasure is watching the rugby, his wife says. Photograph: Jane Nicklinson/AP

We've been at it now for about two years, so it's a small battle that we've won in the war. Tony is really pleased about it, it's what he wants, so he's happy and at least we're going to get our day in court. If it had been thrown out now, without us even having a chance to fight our case, that would have been incredibly disappointing, but at least this way – even if we lose in the end – we've done absolutely everything we can.
We're getting huge amounts of support from the public. Tony flagged up an online poll by one of the newspapers: it asked whether someone who's physically unable to take their life should be able to use a doctor to take their life. And I think 83% said yes, so there's a huge amount of support out there for us. But there's always going to be those – especially those with religious views – who are never going to change their minds.
We get loads of emails sent through our solicitor in which people offer their support but I don't think anyone's got an idea really about how difficult Tony's life is unless you come here and see what goes on in his room. And it's all the things that go on behind closed doors that you don't want to talk about.
He's got absolutely no dignity left and he says it's the manhandling by the carers – which has to be done, and they're all very nice and they do their best – but he says it becomes more and more difficult for him to accept it. He says there's no dignity left in his life at all. It's just existing.
It's incredibly hard and it breaks my heart seeing him like it, especially knowing what kind of person he was. It would be incredibly difficult for anyone to accept, but he was such a huge, larger-than-life character, the life and soul of the party. He was very active, doing silly things: jumping out of planes and walking cables on bridges and all sorts of silly stuff like that. He was always on the go, he was a huge party animal and a typical ex-rugby player. He played hard but he worked very hard as well.
I have thought about ending his life myself, and I've been asked about it many times, but I just don't have the guts. And he wouldn't let me because I'd be risking life in prison, so it's out of the question.
I admire people who can do it but I just don't think I could. If it was legalised, maybe. But I just haven't got the guts. It doesn't matter how much you love someone, I think you need to be incredibly brave to be able to do that.
Twenty or perhaps 30 years ago, he probably would have died. He wouldn't have survived the stroke, and I think that's nature's way. Medicine has overtaken the law and that's one of Tony's main points: something needs to be done and it's a huge subject that needs to be addressed.
I can quite understand why Tony's saying that it would be better if the doctors hadn't saved his life in Greece, and in many ways I agree with him. He says he called for help knowing that something was wrong and he says he wishes he'd just gone to bed and let nature take its course. He says if he had known then what he knows now, that's what he would have done.
He says he's got nothing to look forward to. People have said: "What about your girls getting married and having families?". And he says: "That just makes things even worse." He was never one to sit back and watch life go by, which is all he can really do now.
He says there's nothing that gives him much pleasure. Probably the thing that gives him the most pleasure is watching the rugby – and that's only when England wins, which doesn't happen very often these days.
He says he doesn't know [when he might choose to die, if he were able to choose]. He says you never know, maybe even knowing that he does have a way out will be enough for him to carry on. He says it's agony for him knowing that he has no way out.
• Jane Nicklinson was talking to Sam Jones

Reference: http://www.guardian.co.uk/society/2012/mar/12/right-to-die-no-dignity?INTCMP=ILCNETTXT3487

安樂死與親情的深層衝突

Sinner

美國佛州植物人泰莉的安樂死官司，已經引起了全美民眾的關注。泰莉是在十五年前，因為體內鉀離子失衡，心臟一度停止跳動，導致腦部缺氧，後來成為永久性植物人。在１９９８年，泰莉的丈夫以泰莉陷入植物人之前曾經表示過，不希望以這種方式活著，因此主張拔除泰莉的餵食管（亦即消極安樂死），但是泰莉的父母認為，泰莉還有恢復的希望而拒絕拔管。因此，是否要對泰莉執行安樂死，演變成了丈夫與父母之間的親情拔河。 　　泰莉的丈夫與父母已經司法纏訟了七年，三度拔管又插管，這期間在佛州經過六個法院，十九名法官審理。如今，由於州政府與國會的介入，泰莉的生存權事件儼然成為了法律爭議、政治角力，以及自由派、保守派的新戰場。同時也引起宗教人權團體、司法界與醫療界的扞格，這是因為佛州地方法院在三月十八日判定要拔除泰莉的餵食管，而在剛剛聯邦最高法院也駁回了泰莉父母的上訴案，也就是說，在病床上已經七天未進食的植物人泰莉，即將走到生命的終點。 　　泰莉的父母說，泰莉的嘴唇已經裂開，他的舌頭腫脹，他的鼻子流血，他的皮膚龜裂，能不能請法律拯救他的生命！但是泰莉的丈夫說，現在該是適可而止的時候，泰莉一定不希望這樣沒有尊嚴地再活十五年，所以讓泰莉平靜地離開人世吧。在泰莉的病房之外，有人權團體的詩歌與祈福燭光，但是也有超過大半數支持拔管的民眾民調。植物人泰莉的拔管事件，不但突顯了生存權的司法爭議與生存權的價值審思，另一方面，這裡還有安樂死與親情之間的深層衝突。 　　這裡最為衝突的是，泰莉的雙親百般設法要維持泰莉的生命，他們認為自己的愛女將來是會復原的，他們認為要不計代價地延長泰莉的生命，可是，泰莉的丈夫卻認為泰莉不希望以這種方式活著。在綜合泰莉丈夫的意見與醫療團隊的診斷之後，法院同意採取消極安樂死的作法（即以不作為或中止延長某人生命的作法）。這裡的曖昧難解是源於，我們無法得知植物人的生存意願與感知痛苦的可能性，這裡的嚴肅性還包括，死亡與生命是不可共量的，亦即是不可相互比較的，並且死亡也是不可逆轉的過程。 　　我們只能以旁人的一般心理來推斷，如果你身為植物人，你會願意失去尊嚴感地，在病榻上苟活十五年嗎 ？你會願意與病痛、無奈與無法動彈的身體相消磨個十五年嗎？你會願意無止盡地等待奇蹟？以為這奇蹟會不可思議地讓你恢復健康嗎？你會願意因為自己不能正常活動，而無止盡地帶給週遭人負擔嗎？站在一般人的立場，在這種非樂觀的情形下，很少人會願意無限制地延長生命。安樂死是大多數人在這種情況下的選擇，安樂死是出於「善意」而讓病人能夠選擇自己死亡的時機，或者是為病人爭取求死的機會，安樂死也是一個人在已經生不如死的狀況下，讓他死亡。 　　但是只要有一絲機會，一絲奇蹟可能降臨的機會，深愛子女的父母是願意這樣繼續等待的，是願意繼續維持植物人的生命的，這種愛可能會真確地感知到植物人的生存意願，然而，這種愛也有可能強加自身的期望到病人身上。如果你沒有身陷過這種安樂死與親情的兩難 ，如果你沒有以一個父母的角色，祈求過躺在病榻的親人能夠重新恢復生機的那種執著，一般人的確是很難體會，為什麼泰莉的雙親要百般設法維持泰莉的生命，要不計一切地在法院上訴。親情的愛在這種生與死的對抗裡，是沒有意義的嗎？親情的愛應該改變在司法與醫療方面的見解嗎？我們知道類似地，正是這種親情的愛，能夠讓羅倫佐的油挽救不少遭受腎上腺白質退化症病痛的小孩，也正是這種親情的愛，能夠讓人們更加體會生命的價值 ── 但是在這個事件裡，這種愛卻加深了生存權與安樂死之間在不同層面的衝突。 　　歷經十五年，這種衝突並未停止，一方是代表醫療領域的見解、普遍的大眾心理與社會成本的一般考量，一方是代表與病人關係極為強烈的情感聯繫。基於人本原則，我們堅信「人可以以自身意願來選擇自己的生命狀態」是一項權利，但是，瀰漫於這兩方的詭譎氣氛卻是，我們無法保證無誤地判斷植物人的心理意願，即使植物人仍然具有生命的特徵，但是，最後結果都是我們必須以某一方的選擇加諸到植物人身上，然而在這些過程裡，那唯一的當事人都無所表態。 This is a case of non-voluntary. In the sense that the human who is in PVS is not a person. I think allowing enthanasia is not immoral.