Ethical Foundations of Palliative Care for Alzheimer Disease

FOURTEEN: Alzheimer Disease and Euthanasia

mc h a  t e r f o u r t e e n Alzheimer Disease and Euthanasia Bert Gordijn, Ph.D. Alzheimer disease (AD) is the most common form of irreversible dementia.It is a progressive,irreversible brain disorder.There is still a lot to learn about the causes of the disease and a cure has yet to be developed. Among the symptoms are memory loss, confusion, impaired judgment, personality changes, disorientation, and loss of language skills. Although AD starts with relatively mild symptoms, it finally results in a severe loss of mental function and makes patients completely dependent on other people for their everyday care. Thus, loss of control and increasing dependency on others are pivotal traits of the life of a person with AD. At the same time, empirical research has demonstrated that fear of dependence on others and the prospect of loss of control are important reasons to ask for euthanasia. Hence, the dreadful prospect of progressive dementia may drive persons with AD to request euthanasia. Moreover, there are different developments that will most likely cause the phenomenon of persons with AD requesting euthanasia to become more significant in the decades to come. First, in several countries policies concerning euthanasia are on the brink of becoming more liberal. In the Netherlands, for example, a new law came into force in April 2002 that legally embodied grounds for exemption from punish- ment for physicians who conduct euthanasia and comply with certain requirements (Law on certification of life termination on request and physician assisted suicide, 2001). Thus, the new law transforms the practice of pragmatic tolerance into a legally codified practice of euthanasia, making the Netherlands the first country in the world to legally allow euthanasia under specific circumstances (Gordijn,2001; Gordijn & Janssens,2001).In May 2002,a new euthanasia law was also adopted in Belgium, making this country the second, after the Netherlands, to allow doctors to terminate the life of their patients under specific circumstances . Similar, though generally less radical, developments and tendencies to decriminalize and liberalize euthanasia can be seen in other countries (e.g., France, Switzerland, Australia, Japan). Second, through a further development of palliative care, the treatment of distressing symptoms that can play a role in the causal pathway leading to a request for euthanasia (e.g., pain, clinical depression, dyspnea, vomiting, fatigue, anorexia, constipation, bladder disturbances, bedsores) will most probably be ameliorated. Loss of control and dependency, however, do not seem to be readily amenable by a program of palliative care. Hence, through a further development of palliative medicine, the relative importance of fear of dependency on others and the prospect of loss of control as reasons to ask for euthanasia will increase . Third, against the backdrop of increasing life expectancy and demographic changes, the number of persons with AD will significantly increase worldwide in the decades to come. For these reasons, the topic of persons with AD requesting euthanasia will increasingly present itself as an ethical problem that will have to be discussed. In this chapter, I analyze the question of whether it can be ethically justified to perform euthanasia on persons with AD. First, however, I will clarify the concept of euthanasia, sketch the main characteristics of AD, and review some of the research done on reasons to ask for euthanasia. Moreover, I distinguish three di- fferent scenarios: (1) an incompetent person with AD asks for euthanasia; (2) an incompetent person with AD has an advance directive in which he asks for euthanasia ; and (3) a competent person with AD asks for euthanasia. Presented in this order, the case for euthanasia becomes stronger with each successive scenario . Nevertheless, it will be argued that the arguments against performing euthanasia are stronger even in the last scenario. Alzheimer Disease and Euthanasia 227 m The Concept of Euthanasia The word euthanasia comes from the Greek. Taken literally, it signifies a good (happy and painless) death. Nowadays, however, the concept of euthanasia signifies different forms of medically induced death. In the international discussion on the ethical aspects of euthanasia, three different distinctions are made. First, passive euthanasia and active euthanasia are distinguished. Passive euthanasia means letting die by foregoing or withdrawing life-sustaining treatment , for example by removing life-support equipment (e.g., turning off a respirator) or not delivering cardiopulmonary resuscitation and allowing a person , whose heart has stopped...