Advance euthanasia directives: a controversial case and its ethical implications

Abstract

Authorising euthanasia and assisted suicide with advance euthanasia directives (AEDs) is permitted, yet debated, in the Netherlands. We focus on a recent controversial case in which a Dutch woman with Alzheimer's disease was euthanised based on her AED. A Dutch euthanasia review committee found that the physician performing the euthanasia failed to follow due care requirements for euthanasia and assisted suicide. This case is notable because it is the first case to trigger a criminal investigation since the 2002 Dutch euthanasia law was enacted. Thus far, only brief descriptions of the case have been reported in English language journals and media. We provide a detailed description of the case, review the main challenges of preparing and applying AEDs for persons with dementia and briefly assess the adequacy of the current oversight system governing AEDs.

Dementia and advance directives: some empirical and normative concerns

“…The authors of the JME paper ‘Advance euthanasia directives: a controversial case and its ethical implications’ articulate concerns about the conduct of euthanasia in persons with dementia based on advance directives 1. We agree with the authors that the practice of the two described cases are ethically problematic and the clinical use of advance euthanasia directives (AEDs) may be limited in its current form because there is too little attention for such directives in the preparation phase.…”

AEDs are problematic, but Mrs A is a misleading case

“…Dutch physicians tend simply to assert their capacity judgment without detailed justification…, [and the law does not] require an independent consultation for patients preparing AEDs, as it does for physicians implementing them’. 1 …”

“…To the doctor’s surprise, she still tried to get up during the injection, and ‘the patient’s family helped to hold the patient in place’ while the physician finished the injection. The physician explained his use of a sedative as necessary to avoid one of the very things, distress, that Mrs A wrote her AED to avoid, and he thought her apparent resistance to the euthanasia at its moment of implementation should be discounted because she was no longer competent 1. Such dismissal of resistance was a primary reason the RTE reprimanded the physician, for the Code of Practice stipulates that physicians must ‘be alert to any behaviour and utterances that may indicate resistance or objections to termination of life,’ and if and when it occurs, ‘euthanasia may not be performed’ (quoting from the Code) 1.…”

‘Mrs A’: a controversial or extreme case?

“…At first blush, the case of ‘Mrs A’—outlined in this edition by Miller et al 1—is both. The article by Miller  et al raises a series of ethical questions concerning Advanced Euthanasia Directives (AEDs) and highlights weaknesses in the Dutch regulatory procedures.…”