CORRESPONDENCE

To persuade or to inform?

To the Editor: I refer to the article 'Medical students' perspectives on euthanasia and physician-assisted suicide and their views on legalising these practices in South Africa'¹ in your June 2018 edition, in which Jacobs and Hendricks studied the attitudes of medical students towards euthanasia/physician-assisted suicide (PAD).

I would like to commend the authors on having done this study. It is high time that we prepare for what seems to be the inevitable introduction of patients being allowed to request euthanasia/PAD in South Africa (SA). We need to understand what doctors' attitudes to it would be, as they will be the ones performing euthanasia or assisting these patients. However, I would like to bring up a point that emerges from the data which was not discussed by the authors.

The authors stated that 63.5% (n=176) of the respondents in the study indicated that they would attempt to persuade a patient to choose a palliative treatment method instead of a life-ending intervention. This is in contrast to another answer, where 57.0% (n=158) of respondents believed that the patient should have the ultimate say in choosing to end their life. The authors unfortunately do not provide a breakdown of the data and do not indicate whether those who wanted to persuade their patients to have palliative care were also the ones who were against euthanasia.

I found the response given by the medical students disconcerting. If a doctor is trying to persuade a patient to do something, is it to be viewed as denying the patient the right to their autonomy or is it a beneficent act on the part of the doctor who is trying to help the patient make the best possible choice, even if this choice is what the doctor thinks is best and may not objectively be so?

The concept of autonomy is one of the ethical pillars that forms a key part of the medical profession. It refers to the right of every individual to make the final decision regarding his or her treatment.²It has become for many the most important concern in our time. This is evident in the change to the term 'patient' being used less, in favour of the term 'medical user'. 'Medical user' indicates that a person has come to the doctor to find out the options available. If we as a profession are still trying to change the user's mind based on our own beliefs of what is right or wrong, have we truly overcome our paternalistic instinct to advise the patient what we would do? Paternalism is defined as 'the intentional overriding of one person's known preferences or actions by another person, where the person who overrides justifies the action by the goal of benefiting or avoiding harm to the person whose preferences or actions are overridden'.³

In my opinion, it is important in the bioethical training of medical professionals to remind them that medical users are there to find out options so that they can make a decision based on their own beliefs and wants. It is for us to explain these options to them fully and then allow them to make these decisions without judgement from us. The fact that students are still trying to persuade patients to do certain things shows that we have a long way to go to topple our own biases that have plagued the profession from time immemorial.

However, the principle of beneficence is a crucial part of being a doctor. Beneficence refers to doing good by one's patients and the active promotion of goodness, kindness and charity.⁴ A medical professional must always be doing good and thinking about what is best for the patient. Yet we must be cognisant of the fact that changing people's minds about what they think is the best medical option and thereby overriding the medical user's own opinions could be viewed as an act of control.

People have different opinions. This is a fact of life. As medical professionals who have been trained in the art of treating people, we have a vast knowledge of specific treatment plans that will help our patients. Unfortunately, a textbook does not take into account all the emotions, biases and opinions that a patient has. This can only be done between a doctor and a medical user. I would argue that the principle of beneficence dictates that we should present the facts to our patients but not forget that ultimately the patient is a human being with their own autonomy. To try to control another cannot be beneficent. It is degrading that person to an automaton who cannot exercise their own will. For this reason, I believe that we need to educate our medical students in understanding the fine line between advising patients based on medical facts and placing our own opinions on them. The time will come when euthanasia/ PAD is accepted in SA. Here, as in other medical situations such as abortion, it will become very important to make sure that our subjective views do not influence the advice that we give. We should try to act as objective third parties who are able to help the patient but not to influence.

Avi Barit

PhD candidate, Faculty of Law, University of Pretoria, South Africa. tirab18@gmail.com

References

1. Jacobs RK, Hendricks M. Medical students' perspectives on euthanasia and physician-assisted suicide and their views on legalising these practices in South Africa. S Afr Med J 2018;108(6):484-489. https://doi.org/10.7196/SAMJ.2018.v108i6.13089        [ Links ]

2. Moodley K, ed. Medical Ethics, Law and Human Rights: A South African Perspective. Pretoria: Van Schaik, 2010:42.         [ Links ]

3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press, 2001.         [ Links ]

4. Moodley K, ed. Medical Ethics, Law and Human Rights: A South African Perspective. Pretoria: Van Schaik, 2010:57.         [ Links ]