{"id":3290,"date":"2018-03-05T17:16:59","date_gmt":"2018-03-05T16:16:59","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3290"},"modified":"2018-03-05T17:16:59","modified_gmt":"2018-03-05T16:16:59","slug":"advance-euthanasia-directives-in-the-spotlight","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/03\/05\/advance-euthanasia-directives-in-the-spotlight\/","title":{"rendered":"Advance Euthanasia Directives in the Spotlight"},"content":{"rendered":"<p><strong><em>Guest Post:\u00a0<span class=\"name\">David Gibbes Miller,\u00a0<\/span><span class=\"name\">Rebecca Dresser,\u00a0<\/span><span class=\"name\">Scott Y H Kim<br \/>\n<\/span><\/em><\/strong><strong><em>Paper:\u00a0<a href=\"http:\/\/jme.bmj.com\/content\/early\/2018\/03\/03\/medethics-2017-104644\">Advance euthanasia directives: a controversial case and its ethical implications<\/a><\/em><\/strong><\/p>\n<p>Dutch law allows advance directives to authorize euthanasia for people who can no longer make a voluntary and well-considered choice to end their lives. \u00a0People make advance euthanasia directives (AEDs) with the goal of protecting themselves from the burdens of living with dementia.\u00a0 But it\u2019s become apparent that AEDs don\u2019t always work as they should.\u00a0 <a href=\"https:\/\/www.wsj.com\/articles\/in-the-netherlands-the-doctor-will-kill-you-now-1500591571\">Stories<\/a> in the media describe troubling cases of euthanasia based on AEDs, as well as other contentious cases in the <a href=\"https:\/\/www.nrc.nl\/nieuws\/2017\/06\/16\/de-euthanasiegeest-is-uit-de-fles-11123806-a1563406\">Netherlands<\/a><a href=\"#_ftn1\" name=\"_ftnref1\">[1]<\/a> and <a href=\"http:\/\/abcnews.go.com\/Health\/wireStory\/death-dementia-patient-stirs-belgium-euthanasia-fears-53136682\">Belgium<\/a> involving euthanasia for people with dementia.<\/p>\n<p>A <a href=\"https:\/\/www.dutchnews.nl\/news\/archives\/2017\/09\/public-prosecutor-investigates-euthanasia-of-woman-with-dementia\/\">2016 case<\/a> involving a woman with Alzheimer\u2019s disease (we call her Mrs. A) highlights many of the issues that make AEDs controversial.\u00a0 A close look at the Dutch euthanasia review committee\u2019s report on the case reveals gaps between the legal standards governing AEDs and the realities of AED application.\u00a0 The report also exposes weaknesses in the Dutch oversight system.<\/p>\n<p>The committee gives a detailed account of the disturbing circumstances surrounding Mrs. A\u2019s death. \u00a0According to the committee, the language in Mrs. A\u2019s AED was ambiguous, failing to constitute a clear request for euthanasia.\u00a0 Her doctor performed the procedure without telling Mrs. A that she was about to die.\u00a0 Although the doctor gave her sedatives, Mrs. A \u201ctried to get up\u201d in the midst of the procedure.\u00a0 Family members then restrained her so that the doctor could complete the euthanasia.<\/p>\n<p>The committee focused on the doctor\u2019s failure to meet two legal requirements: advance euthanasia requests must be voluntary and well-considered; and euthanasia must be performed with \u201cdue medical care.\u201d\u00a0 In an unprecedented action, Dutch prosecutors have opened a criminal investigation into the case.\u00a0 Their findings should supply more guidance on the requirements for legal euthanasia based on AED requests.\u00a0 Our own analysis points to three features of the Dutch system that deserve further attention.<\/p>\n<p><!--more--><\/p>\n<p>First, the case illustrates how difficult it is to prepare a thoughtful AED. \u00a0It\u2019s hard to imagine what it would be like to live with dementia, much less to know when life would become bad enough to make death a welcome alternative.\u00a0 Putting one\u2019s wishes into clear instructions is another challenge.\u00a0 Compounding these problems, empirical data suggest that people often prepare AEDs after a dementia diagnosis.\u00a0 Cognitive decline could compromise their capacity to perform the already difficult task of making an AED.<\/p>\n<p>Second, Mrs. A\u2019s case reveals weaknesses in AED oversight. \u00a0Although physicians must consult outside doctors before providing euthanasia, there is no requirement for consultants to be part of the AED preparation process, which is when people actually express their euthanasia requests. \u00a0At that point, just one doctor is responsible for evaluating the person\u2019s decision-making capacity and understanding, as well as the clarity of the advance instructions. \u00a0Mrs. A\u2019s case also demonstrates the limitations of a retrospective review system. \u00a0Errors and abuses in AED application will be uncovered only if doctors report all the relevant details. \u00a0Mrs. A\u2019s doctor was quite forthcoming (she reported that she was trying to set a precedent for future euthanasia of patients with dementia), but other publicized cases suggest that not all doctors are as open about the circumstances in which euthanasia occurs.<\/p>\n<p>Third, Mrs. A\u2019s case raises concerns about the power of individual doctors to control the euthanasia process.\u00a0 Her doctor was free to make her own judgments about whether euthanasia would promote Mrs. A\u2019s autonomy and interests, as well as whether deception and coercion of the patient were justified. \u00a0We find it concerning that the physician was free to act on her own, rather than going through a more formal process to determine how to proceed.<\/p>\n<p>Mrs. A\u2019s case also raises more fundamental philosophical questions about euthanasia for patients with dementia\u2014how to resolve conflicts between the instructions in an AED and the welfare of the person with dementia, when someone can tell a person with dementia is suffering intolerably, and whether family and other outside interests should influence decisions to end the life of a person with dementia.\u00a0 These questions will undoubtedly be the subject of ongoing debate.<\/p>\n<p>At the same time, the ethical debate should expand to address problems apparent in existing assisted death policies.\u00a0 Mrs. A\u2019s case illustrates challenges in constructing rules that both permit euthanasia for people with dementia and uphold requirements for voluntary, well-considered, and clearly expressed assisted death requests. \u00a0Mrs. A\u2019s case also shows that systems could be designed to protect patients with dementia better than the Dutch system seems to do. \u00a0As other jurisdictions move forward with creating their own assisted death rules, we hope that officials will learn from cases like Mrs. A\u2019s, constructing systems that achieve adequate protection for people living with dementia.<\/p>\n<p><a href=\"#_ftnref1\" name=\"_ftn1\">[1]<\/a> Dr. Trudo Lemmens\u2019 English translation of this article is available <a href=\"https:\/\/trudolemmens.wordpress.com\/2017\/06\/19\/the-euthanasia-genie-is-out-of-the-bottle-by-boudewijn-chabot-translation\/\">here<\/a>.<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Guest Post:\u00a0David Gibbes Miller,\u00a0Rebecca Dresser,\u00a0Scott Y H Kim Paper:\u00a0Advance euthanasia directives: a controversial case and its ethical implications Dutch law allows advance directives to authorize euthanasia for people who can no longer make a voluntary and well-considered choice to end their lives. \u00a0People make advance euthanasia directives (AEDs) with the goal of protecting themselves from [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/03\/05\/advance-euthanasia-directives-in-the-spotlight\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2153,443,591,7988],"tags":[],"class_list":["post-3290","post","type-post","status-publish","format-standard","hentry","category-guest-post","category-jme","category-life-and-death","category-regulation-and-regulators"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Advance Euthanasia Directives in the Spotlight - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/03\/05\/advance-euthanasia-directives-in-the-spotlight\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" 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