The end of life … assisted dying … a vexed question

Currently South African law states the following, “Any person who aids, abets, counsels or procures the suicide of another, or the attempt by another to commit suicide, shall be guilty of an offence and liable to imprisonment for fourteen years.” This statement which outlines the current legal position in South Africa frames any debate of this issue in this country. In several other countries the legal position is different with physician assisted dying or suicide legal under very specific conditions.

I will sketch three scenarios as my background to this vexed question.

My mother was diagnosed with disseminated pancreatic cancer at the age of 66. Her diagnosis was delayed due to failure to consider malignancy as the cause of persistent back pain during the preceding months but even if the diagnosis had been made earlier, her chances of long term survival given the nature of pancreatic cancer were minimal. This did not dissuade her treating doctors from embarking on aggressive chemotherapy that resulted in her losing all her hair. She had not been sufficiently warned that this might occur and to her this was almost worse than the diagnosis itself. At which time she said that life was not worth living.

As she lay dying in hospital five months later, attended by one of then doyens of internal medicine, I came upon a nurse inflicting excruciating pain in her attempts to reinsert an intravenous line to administer high dose antibiotics for a presumptive diagnosis of septicaemia. At my insistence this was stopped and morphine was administered orally to relieve her discomfort against the strong objections of her esteemed physician. Thankfully my mother passed as I sat at her side in the early hours of the next morning slipping slowly away at peace after the trials of the previous five months.

My father four years later after falling from a ladder in his garden and fracturing his spine was left paraplegic. When I visited him in the now defunct Conradie Hospital which at that time housed the spinal unit of the Western Cape Department of Health, still intubated after surgery, he scribbled a note which I still have, “This is the end of my road”. Later he asked me whether I could assist him ending his life as after almost 70 good years he did not see himself in a future that restricted him to a wheelchair. As a practicing specialist clinician aged 40 with a young family if I had acceded to his request I would have seen my career ended and the possibility of criminal charges of murder as a result. Just under a month later my father passed after a stroke while still in Conradie Hospital and I was spared the difficult moral dilemma of how to respond to my father’s request.

Some years later as described in my book¹ I sat at the bedside of a young girl who had been my patient for a number of years with cystic fibrosis and end stage lung disease resulting in respiratory failure. During a long night with the support of her parents I administered small doses of morphine to relieve her anxiety and distress as she slipped away. Today some 30 years later her memory remains vividly with me and will do so always.

I have just read Sean Davisons book The Price of Mercy² which outlines his much publicised direct involvement in the assisted suicides of firstly his own mother in New Zealand and subsequently three other people in South Africa for which he served three years house arrest having been sentenced for the crimes of premeditated murder. I do not intend to outline the contents of Davison’s book but both my own experiences, some of which I have described above, and his book have made me ponder my own views on this sensitive subject and whether the medical profession has done enough to address the challenges of people faced with incurable and terminal conditions.

My father asked for assistance in ending his life while my mother needed compassionate palliative care, neither of which were provided in their last weeks of life. The last days and hours of the little girl that I described earlier were peaceful and she passed with assistance in the loving presence of her parents and younger sister.

I currently serve on the board of a hospice that provides palliative care to support those with terminal conditions as well as their families and loved ones. Palliative care was not a subject that received much if any attention when I trained as a doctor but thankfully there is now a greater focus on this aspect of medicine in modern curricula. While the increased focus on palliative care is a positive and very necessary development, there are conditions where the lives of people become intolerable and their self respect and dignity is stripped away by the conditions from which they suffer beyond the limits of which palliative care can assist.

Dying is an uncomfortable topic for many but one that we will all face. Professor Davison in his book accuses the medical profession of failing to take a stand on the matter of assisted dying and indicates his view that in terms of the South Africa criminal justice system “a law that criminalises dying is inhumane”. Understandably suicide is a vexed issue in the minds of many and those who commit suicide are often condemned but in the face of terminal illness resulting in intractable pain or disability that results in loss of human dignity the justification of such condemnation becomes less certain. I am also uncertain decisions in this regard should be determined in the province of the courts as has occurred in the past.

While I may not fully agree with all that Sean Davison proposes and I feel strongly that if legalised that assisted dying must involved a medically trained person under very clear and detailed conditions. This was not the case in the four people assisted by Sean Davison but resulted primarily because they were precluded from doing so by law. I also agree that South Africans need to address this subject, uncomfortable as it may be, and that health professionals who deal directly with those who are at the end of their lives in particular are those who should play a major role in the debate. It is not a matter that should be left in the hands of politicians and religious leaders alone.

1. Walking the Road of Healthcare in South Africa. My Forty Year Journey. Dr Craig Househam page 45 Quickfox Publishing 2021
2. The Price of Mercy. A fight for the right to die with dignity. Sean Davison Melinda Ferguson Books 2022