1. Professor Cees M. Hertogh geriatric ethics IPA international congress The Hague, 8 september 2011 Euthanasia for patients with dementia: Never allowed or ultimate act of autonomy?

2. My position: Sometimes allowed, Never solely an act of autonomy, For autonomy is only one of three relevant moral principles

3. Marcus Aurelius: Meditations “For in dementia, the power of making use of ourselves …and considering whether a man should depart from life…and whatever else of the kind absolutely requires a disciplined reason, all this is already extinghuished.”

4. Dementia today: A move from the right to a well-considered suicide to the right to a self-determined death with the help of a physician, including: the right to hand over responsibility for decision-making and executing life-termination to others through an advance directive for euthanasia

5. Two scenario’s Physician assisted death in early dementia –Competent patient, oral request –Due care criteria apply Active euthanasia in advanced dementia –Incompetent patient, written request –Advance directive for euthanasia (ADE): Legally valid (article 2.2 Euthanasia Act) Morally based on the principle of (precedent or prospective) autonomy –Due care criteria apply “in a corresponding way”

7. Survey among Dutch elderly care physicians: –434 completed questionnaires –110 case histories (most recent case of patient with dementia and ADE) –5 cases of euthanasia (all competent) (semi-structured) interviews: –11 elderly care physicians –8 relatives of deceased patients

8. Reasons for non-compliance with ADE Survey:% –No unbearable suffering38,2 –Nursing home policy15,5 –Personal belief15,5 –AD not applicable 15,5 –No hopeless suffering12,7 –(present opinion unclear / no communication)10 Interviews: –Lack of meaningful communication

9. Conclusion: ADE are a resounding failure! Communication is considered essential for physicians to consider adherence to an ADE of a person with dementia. WHY?

10. Due care criteria 1. voluntary and well considered request=> 3 2. ‘hopeless’ and ‘unbearable’ suffering=> 4 3. information on situation and prospects=> 1 4. Joint conclusion: no alternative solution=> 2 5. assessment by independent physician 6. professional life termination

11. Unbearable suffering: shared conclusion based on dialogue and assessment of alternatives (pre)supposes a relation of trust and ‘shared decision-making’. Ergo: not a unilateral but a bilateral assessment

12. Moral principles behind due care criteria 1. Autonomy 2. Mercifulness / Benificence Fourth due care criterium: –“The physician together with the patient”

14. Moral principles behind due care criteria 1. Autonomy 2. Mercifulness / Benificence Fourth criterium: –“The physician together with the patient” –The gift of death  mercy killing Dilemma of AED in dementia demonstrates:  Mercifulness implies responsiveness  Reciprocity / receptiveness as a third moral pillar