In rapidly ageing Asian countries, a growing number of people are starting to worry about what their old age will be like. Medical advances may make it possible for us to live to 100, but what if the last decades of life are filled with infirmity, pain and suffering?
A good quality of life should include a good death, say those who advocate for living wills and other measures that give patients control over their final days. But in tradition-bound Asia, talk of more radical steps such as physician-assisted suicide (PAS) has made little headway.
Taiwan, where the number of deaths exceeded the number of births for the first time in February last year, is among the countries trying to come to grips with new realities. Its legislators passed the Patient Right to Autonomy Act in late 2015 but it only took effect this month.
Yiting Lin, writing in CommonWealth magazine in Taiwan, expressed the dilemma succinctly:
"As the population ages, a growing number of families will have to face the awful decision of 'saving' or 'not saving' a loved one, but voices in Taiwan advocating 'a good quality of death' and the idea of 'better to die well than live badly' have already bubbled to the surface."
The Taiwanese act, considered Asia's first "natural death" law, represents an evolutionary step from the Hospice Palliative Care Act, which was passed in 2000 and allows for a living will.
In the 18 years since the first law took effect, a total of 530,000 people have signed letters of intent in which they can specify in advance whether they want to receive hospice and palliative care or life-prolonging treatments if they fall terminally ill.
But the old law was not applicable to people in a vegetative state, which left about 3,600 Taiwanese families without recourse. The push for a new law began in 2012 and eventually became the Patient Right to Autonomy Act. It allows Taiwanese the right to refuse or accept treatment in advance rather than having to decide their fate when they got sick, or leaving it to their families when they cannot think for themselves anymore.
DEBATE IN INDIA
The passage of the Taiwanese law sheds light on a sensitive issue that has been discussed in Asia for decades. In India, the case of Aruna Shanbaug, a nurse who was raped and strangled and spent 42 years in a coma before dying in 2015, sparked a national debate over the legalisation of euthanasia.
Last year, the Supreme Court of India ruled that individuals had a right to die with dignity. The country is now starting to debate passive euthanasia, which allows the withdrawal of medical treatment with the intention to hasten the death of a terminally ill patient. As it stands, the court ruling only allows Indians to draft a living will while they are in a normal state of health and mind.
A living will in India can specify that a person will not be put on life support if they slip into an irreversible coma. Passive euthanasia will be applicable only to terminally ill people with no hope for recovery.
But active euthanasia, which is available in Europe and North America, will never be accepted in Asia, experts say, citing differences in ways of thinking, advancement of social welfare and traditional practices.
"A passive form of euthanasia, such as a living will, which is also allowed under Thailand's 2007 National Health Act under Section 12, is the limit of where euthanasia and PAS can go in Asia," says Pisit Sriakkpokin, senior technical officer at the National Health Commission Office (NHCO) in Thailand.
"I do not think India, or any country in Asia, will go as far as what Europe or the US have done with euthanasia," he told Asia Focus.
"People who are thinking about opening up a 'suicide clinic' in the region are only thinking about making the practice into an industry, similar to what is being done in Europe and North America, but it will never take root here."
Mr Pisit, who has written a legal paper on euthanasia for the office, said euthanasia was not widely debated in Asia in the past because Asian societies place "more weight" on traditional practices over personal freedoms.
In some headline-making local cases, terminally ill patients who killed themselves did not do so because they wanted to control how their lives would end. In some cases they had lost hope of getting better with the current level of health care they were receiving, or they did not want to become a financial burden on their families because of huge private hospital bills.
"There was an article in the past headlined 'Pakhoma Kae Puad' (using a towel to suppress the pain) that tells a story of a cancer patient who killed himself because he could not tolerate the pain from the lack of morphine in the country," Mr Pisit recalled. "My question is, would the patient have killed himself if he could afford the medication that would lessen his pain?"
While more liberal social attitudes may take hold in Asia in the future, advances in health care will also give people facing serious illnesses more hope. The centuries-old debate about euthanasia will certainly come up again, but it will never go beyond palliative care and living wills, he believes.
LIBERAL ATTITUDES
In Europe and North America, however, more liberal attitudes that took root in the 20th century have led people to seek more control over every aspect of their life, including how it would end.
The Netherlands, Switzerland and Belgium have been in the vanguard of the movement to allow both passive and active euthanasia.
"The cherishing of personal freedom over other values is why they even allow for people with disabilities or ageing people who do not want to live any longer, not only terminally ill patients, to apply for assisted suicide," said Mr Pisit.
One high-profile case last year involved Dr David Goodall, an Australian academic who decided at age 104 that he had lived long enough. He was not terminally ill, but chose to end his life through assisted suicide in a Swiss clinic run by Dignitas.
fDignitas is a Swiss non-profit society supported by membership fees, providing assisted/accompanied suicide. Founded in 1998, it has provided its assisted suicide service to around 200 people a year in recent years.
In extreme cases in countries where palliative care is inadequate and if there is an applicable law, there is an option for a patient to draw up a living will, which would allow the physician withdraw life support without having to worry about going to jail.
The challenge in Thailand is that most people refuse to talk about death as they believe it is a bad omen. There are still cases where family members refuse to allow the physician to withdraw life support even when the patient has made a living will. This reflects one of the highest Thai values, katanyu, or respecting one's elders.
"We see it every single day; family members do not talk about whether they want the patient to die naturally or be connected to life support," Amphon Jindawatthana, former secretary-general of the NHCO, told the Bangkok Post in 2015.
"Meanwhile, doctors are taught to do all they can to help a patient survive, ultimately intervening in what might have been a natural death."
DIGNITY IN DYING
In North America, Europe and Australia, the Catholic church is normally the main opponent of euthanasia in any form, citing the fifth commandment: "Thou shalt not kill." In Asia, social and economic factors, not religion, are playing a more prominent role in preventing euthanasia and PAS from being practised.
In 1995, the Northern Territory of Australia became the first jurisdiction in Asia Pacific to legalise voluntary euthanasia under the Rights of the Terminally Ill act.
Bob Dent, then aged 66, became the first person to use the law to end his life in September 1996. He was suffering from prostate cancer for five years before he asked his physician, Dr Philip Nitschke, to connect him to a computer-driven syringe that ultimately put him to rest.
"What right has anyone, because of their own religious faith, to demand that I behave according to the rules until some omniscient doctor decides that I must have had enough?" Dent wrote in a farewell letter.
Dr Nitschke helped three more patients end their lives under the law despite fierce opposition from the Catholic community. However, the law was replaced in 1997 by a more restrictive euthanasia law that he deemed "useless". He has been campaigning for euthanasia and PAS in Asia Pacific ever since.
The difference between PAS and euthanasia is that the former involves the physician providing the means for death, such as a prescription. The patient, not the physician, will ultimately administer the lethal medication. The latter, on the other hand, involves the physician acting directly, for example by giving a lethal injection.
Dr Nitschke told AFP in 2012 that one of his goals was to make it easier for people who wanted to end their lives to be able to do it legally here in Asia instead of travelling to Europe to do so.
Such a clinic, he said, would be similar to the Dignitas centre in Pfaeffikon, Switzerland. Other assisted suicide clinics exist in the Netherlands, Belgium, Canada and eight states in the US.
At Dignitas, services to members include counselling on all end-of-life issues, legal instructions on refusing treatment or writing a living will and finally, an "accompanied suicide" if requested.
But suicide prevention is also a big part of what Dignitas offers. As of 2017, it had more than 8,400 "members" who were looking to go through their "dying phase" with Dignitas. However, the total number of assisted suicides in Switzerland in 2014 was just 742, according to the country's Federal Statistical Office.
From Asia Pacific, the Dignitas membership includes almost 100 Australians, with others coming from Japan (25), South Korea (24), China (23), Hong Kong (22), Thailand (18), Taiwan (16) and Singapore (15).
Back in Australia, where Dr Nitschke burned his medical registration certificate in 2015, the debate surrounding euthanasia and assisted suicide has surfaced again with "voluntary assisted dying" for the terminally ill in Victoria.
Effective from June this year, the Voluntary Assisted Dying Act will give patients the right to request a lethal drug to end their lives. It will apply only to adults who have decision-making capacity and are suffering from a terminal illness likely to be fatal within six months, excluding people with disability or people who feel they are too old and no longer want to live with ageing.
If approved by at least two physicians and only after three separate requests to end their life, the patient will then be given a lethal dose of pentobarbital, which they will mostly administer themselves.
Under certain circumstances, doctors will be able to administer the medication if the patient is unable to do so. Medical practitioners in Victoria also have the right to refuse to take part in such procedures.
Tasmania is also looking to pass a voluntary euthanasia law by the end of 2019.