Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy

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Abstract

For many years there has been a controversial international debate on physician-assisted suicide (PAS). While proponents of PAS regularly refer to the unbearable suffering and the right of self-determination of incurably ill patients, critics often warn about the diverse risks of abuse.

In our article, we aim to present ethical arguments for and against PAS for patients in an early stage of dementia. Our focus shall be on ethical questions of autonomy, conceptual and empirical findings on competence and the assessment of mental capacity to make health care decisions. While the capacity to make health care decisions represents an ethically significant precondition for PAS, it becomes more and more impaired in the course of the dementia process.

We present conditions that should be met in order to ethically justify PAS for patients with dementia. From both a psychiatric and an ethical perspective, a thorough differential diagnosis and an adequate medical and psychosocial support for patients with dementia considering PAS and their relatives should be guaranteed. If, after due deliberation, the patient still wishes assistance with suicide, a transparent and documented assessment of competence should be conducted by a professional psychiatrist.

Introduction

In day-to-day clinical practice, psychiatrists and physicians from other disciplines regularly encounter patients who have attempted or at least contemplated suicide. In the overwhelming number of such cases, the expression of suicidal thoughts or attempt at suicide is due to crisis situations in the context of a mental illness (e.g. depression or schizophrenia). Such crises can be overcome with compassionate professional and personal assistance (cf. Hawton and van Heeringen, 2009, Lonnqvist, 2009). In these situations one certainly cannot speak of a self-determined or well-considered decision of the patient. Rather, suicide attempts are often impulsive acts, and the great majority of patients — in the case of survival — are happy to still be alive (cf. Bronisch, 2007, 117–127; Blaustein and Fleming, 2009, Rosen, 1975).

In contrast to this common clinical situation and mental illness, there is quite a different situation involving a much smaller patient group. These patients are incurably ill and experience or anticipate extreme suffering. These patients consider making an autonomous, well-considered decision to end their lives at a time of their own choosing. In this situation, the physician must either prevent the suicide, accept it or even support it as part of physician-assisted suicide (PAS). Therefore the role played by the physician is very controversial both among the general public and among physicians, lawyers and ethicists (cf. Birnbacher and Dahl, 2008, German National Ethics Council, 2006, Vollmann, 2011, Warnock and Macdonald, 2009).

Our article explores PAS from an ethical perspective in the special case of patients with dementia disorders. We focus on the problem of patient autonomy because mental capacity, which is viewed as an important prerequisite for the legitimacy of PAS, is first impaired and then irretrievably lost in the further progression of the dementia. Since the number of people affected by a neurodegenerative dementia disease will increase significantly in the coming years and decades due to demographic change (cf. Alzheimer's Disease International, 2009, Fratiglioni et al., 2008, Qiu et al., 2007), it is surprising that PAS in the context of dementia has drawn comparatively little attention in the international debate. In view of the rising number of old and very old people in many countries, we can assume that, in the future, more and more patients with dementia will ask their physicians for counselling and assistance in ending their lives (cf. The Royal Dutch Medical Association (KNMG), 2011, Lauter, 2011). This article, therefore, is not only a contribution to the current medical ethical discourse on PAS but also has implications for clinical practitioners.

Section snippets

Definition

Assisted suicide is generally understood to mean aiding a person in the preparation or the execution of a suicide. Physician-assisted suicide (PAS) is the term used when a doctor prescribes a lethal drug for a patient, gives the patient the drug, and/or is present when the patient takes the drug (cf. German National Ethics Council, 2006, 50). In current practice, a barbiturate is generally used in PAS; usually about 10 g are dissolved in water which the patient then drinks. Alternatively, the

Switzerland, the Netherlands, and Oregon

There are countries in Europe and other jurisdictions in the world where PAS has become permissible to varying extents, and where PAS is exempt from prosecution under certain conditions. The practice in the respective countries is based on quite different legal and societal conditions which cannot be presented in detail here. Instead, we shall provide a brief overview of the situations in Switzerland, the U.S. state of Oregon and the Netherlands and focus on aspects that are relevant to our

Dementia disorders

Neurodegenerative dementias are a group of neurological disorders that are currently incurable and usually, over the course of several years, lead to a progressive loss of intellectual capabilities and a profound change of the patient's personality. Depending on the dementia subtype (e.g. Alzheimer's disease, frontotemporal dementias, Lewy–Body dementias, etc.), additional mental and physical symptoms occur in varying sequence and degrees of severity. As a consequence, these patients become

Conclusion

Patients who suffer from a neurodegenerative dementia sometimes express the wish to commit PAS rather than having to live through the increasing deterioration of their intellectual abilities. Due to demographic change and the associated rise in the number of dementia patients and the increasing ethical pluralism in society, it is expected that physicians in the future will be confronted with such requests more and more often (cf. The Royal Dutch Medical Association (KNMG), 2011, Lauter, 2011).

Disclosure statement

No conflicts of interest.

Acknowledgements

This article in part contains results presented within a Master's thesis by Jakov Gather in the Philosophy Department of Johannes Gutenberg University, Mainz, Germany.

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