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Death with Dignity

By Karnjar iya Sukrung
Bangkok Post issued date 13 September 2011

Mental anguish precipitated by the murder of his family helped a country doctor reach a clearer understanding of what really matters tothe living – and the dying

Death is a familiar, everpresent part of our lives,and yet so many of us are troubled by it.The National Health Act (2550) was considered very progressive when it was passed into law back in 2007, particularly in the way it seeks to ensure the protection of patients’ rights.Section 12 has proved controversial, however, probably because it is the first piece of Thai legislation to lay down guidelines for how health professionals should accommodate patients who have written a living will indicating that they do not want their lives artificially prolonged.

Dr Amphon Jindawatthana, secretarygeneral of the Office of the National Health Commission, is now in the hot seat for his involvement with the drafting of the original bill, with a group of physicians recently filing a lawsuit against him in the Administrative Court.

Undeterred, Dr Amphon remains adamant that terminally ill people should have the right to refuse medical intervention in the final stages of life. He even believes that this step can be beneficial, in a spiritual sense, to both the dying person and his or her relatives.

“Section 12 is not a question of legalities; it’s about life!” he declared with feeling “It’s a choice … a way to live with dignity until you draw your last breath.”

He decried the fact that many people have misinterpreted Section 12 as permitting euthanasia, which, he said, is not the case at all. Euthanasia, he pointed out, is a practice whereby the process of dying is deliberately speeded up, which was never the intention of Section 12.

“A living will is an instrument that allows all of us to reflect on an inevitable phase in human life and prepare ourselves for it as best we can. Also, I am convinced that being aware of death encourages us to lead more careful and much healthier lives.”

Dr Amphon gained these insights through many years of treating illness and after confronting death first-hand when he and his family were targeted by an emotionally disturbed colleague. “Being a doctor means constantly learning new things throughout the course of your life,” said the 59-year-old,”especially when it comes to pain and suffering.”

His ambition to become a doctor, which he remembers having from an early age, was put in jeopardy by his father’s death, leaving his mother to shoulder the responsibility of raising 13-year-old Amphon and his five siblings on her own. Hard-working and frugal, she managed to eke out a living and provide for her children from the proceeds of the small corner shop she ran.

After obtaining a degree in medicine from Mahidol University and doing a one-year residency at a hospital in Bangkok, the young doctor was transferred to a small, newly built hospital in Pattana Nikhom, a district of Lop Buri province.

“It was located in the middle of a rice field, the perfect habitat for snakes of all kinds! It was truly a challenge, but something I had expected somehow,” he recalled with a smile.

Being the only doctor at the hospital, and therefore its de facto director, gave him ample opportunity to sharpen his medical skills, as well as learn valuable life lessons.”Our best teachers are our patients,” he said.

The first thing he learned was that having a medical degree did not automatically earn him the trust of the locals.

“At first I didn’t understand why they went to see midwives and monks. They would even go to a hospital in another district, which was quite a distance away. ‘Why aren’t they coming to see me, a qualified doctor?’ I used to ask myself.”

After months of bewilderment and disappointment, however, he began to understand the villagers’ motives, which led to a radical rethink in his approach to practising medicine.

“When I first came to this rural area I thought of myself as some sort of god who had come to save the local people. I also thought that my medical knowledge was superior to what they might be acquainted with in terms of healing,” he recalled.

His change in attitude encouraged him to begin paying visits to people’s homes and befriending some of the villagers. Gradually, he began to understand their beliefs and way of life and to better appreciate the benefits of traditional medicine. It wasn’t long before he was allowing midwives or monks to be present in the examination roomwhile he was seeing a patient.

“I really began to enjoy my work,” he recalled with a fond smile.”One time, a man came in with a terrible knife wound and needed an immediate transfusion. But we soon ran out of his blood type and so I had to give him some of my own blood. There I was, treating a patient as I lay prone on the bed right next to him!”

To be a good physician, one who accepts full responsibility for a patient’s life, Dr Amphon learned that “we first need to establish good relationships with people. And we shouldn’t only look at the bodily needs of a patient. There are other human factors and other aspects of life that doctors must consider as well.

“One time, for instance, a child with asthma was brought in to see me. He needed in-patient treatment, but he also needed to keep up with his studies. So I admitted him, but on weekday mornings I’d let him out to attend school, which was nearby. In the afternoons, he came back to hospital to continue his treatment.”

The relationship between doctor and villagers improved dramatically. Eight years after he started there, the small hospital was expanded from 10 to 30 beds.

By the age of 33, Dr Amphon said he felt he had acquired everything a person could want in life: a successful career;the recognition and respect of patients and fellow rural doctors; a sweet-natured and supportive wife; plus two loving children.

Yet he also had what everyone wishes they didn’t have: character flaws.”I was young, careless and carried away by worldly pleasures,” he said.”I did something wrong and never imagined the potential for horrible repercussions.”

One fateful night, neighbours were awakened by the sound of gunfire coming from the doctor’s house. The next morning the whole district was abuzz with the news: the doctor’s wife and two children, aged four and seven, had been shot dead. The murderer was a female co-worker for whom he had developed some feelings.

Even now, 26 years later, he clearly finds it difficult to discuss a personal tragedy which made newspaper headlines at the time.”It’s only in the last few years that I’ve been able to open this book again,” he said, plucking a funeral memorial folio, printed for his wife’s funeral, from a shelf in his office. The pain may have subsided in the wake of the fresh start he made in life and the new family he subsequently acquired, but he cannot forget the hard lessons that altered him forever.

Dr Amphon was badly injured badly in the attack, suffering gunshot wounds to the arm and face, the latter shattering his nose and lodging in his neck.

As he lay recuperating in a hospital bed, he remembers being devastated by guilt and regret.

“I’d lost my entire family. I didn’t know whether or not I’d been fortunate to survive. My wounds and the series of operations I had to undergo were painful, but not as great as the pain in my heart. At times I thought it’d be better if I were to die.”

Restructuring work to repair extensive damage to his facial bones meant that he couldn’t utter a word or eat solid food for months after the attack. A comment made by Prof Prawase Wasi, the Magsaysay Award-winning physician “There is no pain that a human being cannot endure”-was particularly useful in helping him get endure that ordeal, he said.

During that period of physical and emotional torment, he also had ample time to reflect on the karma of his past actions.

“The shooting made me recall hobbies of mine. I used to love fishing, shooting birds and catching frogs and lizards. I thought about all the animals I had killed, the many lives I had ended.

“I wasn’t able to hold grudges against anyone. I felt that it was all my own fault. I had ruined things for my wife and children as well as for that woman; her life was destroyed, too.”(The woman was convicted of murder and served 18 years of a life sentence.)

Despite his role in the terrible misfortune that had befallen him, Dr Amphon said he was blessed with good friends and family members.”They didn’t reproach me for my mistakes, for which I was so grateful to them. Their kindness and support enabled me to stand on my own two feet again and resume my life and work.”

Several months in hospital restored his physical health but not his mental wellbeing. So after being discharged he entered the monkhood and went to stay at Wat Suan Mokh, the forest temple near Chaiya, Surat Thani, founded by Buddhadasa Bhikkhu, the reformminded Buddhist thinker.

After telling Buddhadasa the details of his “life accident”, the abbot apparently gave a rueful chuckle and said to him,  “Things are just as they are. The effects come from the causes.”

Recalling these words recently, Dr Amphon mused, “Sad but true, I understood dhamma and the [Buddhist]precepts more deeply when the tragedy happened. It’s a mistake I dare not repeat and I wish that others wouldn’t.”

Three months later he left the monkhood filled with a new determination to resume his career.

“Acharn Buddhadasa said that dharma is the duty of life. No matter what we are or what we do, we must carry out our duties well for the benefit of others.”

Grabbing the opportunity given him to start over, Dr Amphon returned to medicine, his first and enduring passion. He subsequently worked in many areas and departments at the Ministry of Public Health. A project in which he invested a good deal of time and energy was a scheme to boost the number of doctors working in the provinces by making it easier for rural students to gain entry to medical college on condition that they return to their hometowns to practise after graduation.

“If life is like a boat,” he said, “my boat is now sailing on the ocean. My work is no longer about the care and treatment of individuals; it’s now for the wellbeing of society at large.”

Now in his 12th year with the Office of the National Health Commission, Dr Amphon seems content in his role at the helm of an organisation which he sees as a vital tool for social transformation in matters of healthcare.

“Health is an issue that concerns everyone so members of the public should be allowed to have their say about policy and systems. I believe that when people become active and engaged in promoting their wellbeing, our health systems will be greatly improved.”

One novel mechanism introduced by the NHC were the health assemblies set up throughout the country.” This is a tool to enable people to participate in public-health policy and raise their concerns,” he explained.

“We have plans to change health service systems, structures and, most importantly, we aim to change people’s attitudes towards health matters,” he went on, noting that of the four cycles of life – birth, ageing, sickness and death – the last is the one about which both medical practitioners and the general public are least well informed.

“In medicine, we are continually making advances in technology and our knowledge about birth. For ageing and illness we develop technology and medicine to rejuvenate or to slow down the deterioration. But as for death, we rarely learn anything about it and thus we suffer from it.”

Section 12 of the National Health Act (2550) was supposed to promote understanding among health professionals about the meaning of “having a good death”, he said; it was intended to create the conditions in which the wishes of a terminally ill patient for a peaceful death could be accommodated.

As for Dr Amphon, working on the phrasing of Section 12 has changed his attitudes to death.

“I see death as a part of life. This insight I owe to getting old,” he said with a chuckle.”Old age gives me a wider and clearer perspective on life.”

A good life that leads to a good death need not be a complicated issue, he said.

“We need to take care of our health, physically and spiritually; look after our families; do our duty at work; and contribute to the betterment of society. That’s all, I think.” This last delivered with another of his beatific smiles.