SAMA also called for increased access to palliative care, rapidly expanded palliative care training, both for practicing doctors and undergraduates, and closer working relationships between itself, the Hospice and Palliative Care Association of SA, (HPCA), psycho-social services, religious/spiritual bodies and hospitals in the private and public sector. According to HPCA figures, just over two percent of public sector hospitals have a proper palliative care service and only four percent of South Africans who clinically qualify for palliative care are receiving it. While increased emphasis is being placed on home-based care (where patients request it), a lack of funding has meant that the number of hospices has dropped from 202 to 153 over the past four years with SA Medical Research Council Burden of Disease 2101 statistics showing that 258 268 people who could have benefitted from palliative care died.
SAMA chairperson, Dr Mzukisi Grootboom, said that while SAMA accepted the constitutional right of an individual to decide how he or she can end his or her life, doctors could not use their medical training to kill, adding; ‘the dying phase must be recognized and respected as an important part of a person’s life’. He acknowledging growing global public pressure in favour of Euthanasia and physician-assisted suicide, but said the ‘ethical imperative’ to improve palliative care had been brought into sharp focus by the local court ruling. ‘The primary responsibility of the doctor is to assist his or her patient in obtaining the optimum quality of life through controlling symptoms and addressing psycho-social needs and to enable the patient to die with dignity and comfort,’ he said.
Grootboom was speaking after a high-level ‘End of Life Decisions’ symposium hosted by the Steve Biko Bioethics Centre at the University of Witwatersrand on May 14th – just weeks after Judge JH Fabricius, of the Pretoria Division of the Gauteng High Court , granted retired Cape Town advocate, Robin Stransham Ford, 65, and his doctor, the right to end his life. In the landmark ruling, Judge Fabricius highlighted the unconstitutionality of existing South African legislation (outlawing euthanasia), saying it should be ‘developed,’ and take into account the government-shelved recommendations of the South African Law Commission 17 years ago (in favour of safeguarded, physician-assisted euthanasia). He emphasized that his granting of legal indemnity to Stransham Ford’s doctor was guided by the applicant’s particular circumstances and should not infer similar legal rights on any other healthcare workers. The respondents (all the relevant government departments), are filing appeals against the ruling, paving the way for a full bench of the Constitutional Court to either back or reject Judge Fabricius recommendations. Ironically, the ruling came just hours after Stransham-Ford died of natural causes, prompting instant appeals by government lawyers that this made the ruling null and void. However the Judge said the issue of physician-assisted suicide was of ‘over-riding public importance’, even had he known of the applicants’ death before ruling.
SA ‘not ready,’ for legal euthanasia
Expanding on SAMA’s position, Dr Grootboom said he agreed with the ‘profound point,’ made by Professor Dan Ncayiyana, Editor Emeritus of the SA Medical Journal at the Wits University End of Life symposium. This was that South Africa was not a ‘safe and appropriate place,’ for liberalized voluntary euthanasia legislation. This ‘recourse of last resort,’ (euthanasia) could only really be justified in a country with the very best medical care for all, a well-organised and universally acceptable palliative care and support system, stable and well-functioning (particularly judicial) systems and a strong culture of respect for human life. ‘With our severe constraints on health care facilities and the totally inadequate allocation of resources for effective medical treatments, there is a real risk of euthanasia becoming a substitute for proper care for the terminally ill and other patients in dire medical straits,’ Grootboom added.
The ground-breaking court applicant, Stransham-Ford was suffering from terminal Stage 4 cancer with only weeks to live. The court heard he had no cognitive impairments, fully understood the nature, cause and prognosis of his illness and was in severe pain with nausea, vomiting, stomach cramps, constipation, disorientation, weight loss, loss of appetite and was increasingly weak and frail with kidney metastasis. Stransham-Ford submitted that there was no logical distinction between withdrawing treatment to allow the process of natural death, and physician-assisted suicide, labelling it ‘intellectually dishonest’. Unable to get out of bed and taking injections and drips, he was unable to sleep without morphine or other painkillers which made him drowsy. Tellingly, he said that while not afraid of death, he was ‘anxious about dying while suffering’.
‘Fear of death worse than the reality:’ World Palliative Care Chief.
Dr Liz Gwyther, president of the World Hospice and Palliative Care Association and CEO of its’ South African equivalent, said that pain, with all its concomitant maladies of depression, indignity, hopelessness and lack of control, was ‘eminently manageable’ using opioids (mainly morphine). She believes that both the Stransham-Ford court application and much of the current debate are driven by our own personal fears and imaginings of how we might die. ‘Often our fears and imaginings are a lot worse than reality,’ she added. Gwyther, who has seen hundreds of people die in her 23 years of palliative care, said the body adjusted well to morphine well within seven days, allowing full lucidity to return. Death was ‘an opportunity and a process’ in which there could be, ‘a lot of living, richness, incredible growth and family interaction’. She emphasized that euthanasia, like suicide, was a ‘one-way street with no possibility of return,’ adding that patients emotions swung ‘like a pendulum’. Research had shown overwhelming relief and gratitude by those people who’d contemplated euthanasia in a moment of despair, but chose holistic palliation. Grootboom backed these sentiments, adding that doctors should discuss with the patient and their relatives the availability, benefits and potential effects of palliative care. ‘There must also be a discussion and information given about the psycho-social and spiritual services which must be made available in order to help them deal with the fear, anxiety and grief associated with terminal illness,’ he added SAMA recognized the right of patients to develop advanced directives (living wills) that described their wishes regarding their care in the event of terminal illness. This included the patient’s right to refuse treatment. ‘The cardinal point however, is that the doctor has a duty to heal and where possible relieve suffering and protect the best interests of the patient. We cannot abandon the patient just because the illness has reached a terminal stage’.
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