Dementia and advance directives: some empirical and normative concerns

Abstract

The authors of the paper 'Advance euthanasia directives: a controversial case and its ethical implications' articulate concerns and reasons with regard to the conduct of euthanasia in persons with dementia based on advance directives. While we agree on the conclusion that there needs to be more attention for such directives in the preparation phase, we disagree with the reasons provided by the authors to support their conclusions. We will outline two concerns with their reasoning by drawing on empirical research and by providing reasons that contradict their assumptions about competence of people with dementia and the (un)importance of happiness in reasoning about advance directives of people with dementia. We will draw attention to the important normative questions that have been overstepped in their paper, and we will outline why further research is required.

First prosecution of a Dutch doctor since the Euthanasia Act of 2002: what does the verdict mean?

“…If one however accepts the idea of an AED, the question remains whose interests are at stake and should be followed. This is discussed extensively in the literature and often described as the ‘then-self versus now-self’’ problem 12 13. The core question here is whether one should follow the wishes of the then-self as put down in the AED or follow the apparent interests of the person with dementia.…”

Euthanasia in the case of dementia: a survey among Flemish GPs

“…This might be explained by an intergenerational difference in norms and values, and with the fact that younger doctors grew up with the debate on euthanasia. 5,[7][8][9][10]21 Younger doctors also lack experience and therefore may not have been confronted with difficult and delicate situations. 9 It is noteworthy that doctors aged 41-55 years answered the questions more conservatively compared with both the older and the younger generation.…”

‘Mrs A’: a controversial or extreme case?

“…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. Also included in this edition are responses to the Miller et al article, by Menzel2 and Jongsma  et al 3. These responses challenge some of implications that Miller et al seek to draw from the case.…”

“…In their response, Jongsma  et al explain that ‘[c]hanges in behaviour or a change of preference by dementia patients may be caused by the disease itself, rather than by a conscious adjustment to the disease’ 3. It follows for Jongsma  et al that we should be careful not to overlook the patient’s prior preferences, in favour of the patients current desires and feelings, since the patient’s ‘changed behavior is most likely caused by the loss of the ability to hold on to prior preferences, not by a (sub)conscious choice to change or adapt’ 3. In response to Miller et al , Menzel seems to imply that although the case of Mrs A cannot be defended through respect ‘reflective critical interests’, the controversy of the case does not ‘decimate’ the argument for AED for patients with dementia 2…”