Life-terminating actions with severely demented patients: critical assessment of a report of the Royal Dutch Society of Medicine.

• Author: Cusveller, Bart

For several years, Dutch society has been involved in lively debates on euthanasia, life-terminating actions without a request, and physician-aided suicide. To an important degree, these debates have been stimulated by the Royal Dutch Society of Medicine (KNMG) or, more precisely, by the KNMG Committee on the Acceptability of Life-Terminating Actions (CAL). Since the mid-eighties, this committee has been reflecting and publishing on life-terminating actions with incompetent patients, i.e., severely handicapped newborns (Report No. 1),(1) long-term comatose patients (Report No. 2), and, more recently, severely demented patients (Report No. 3). In the present article we will investigate the committee's reasoning and its corollaries in this latter report.(2) First, we shall summarize the relatively complex argument of the report; secondly, we shall assess its contents; and, thirdly, we will present our own perspective on the matter.

Summary of the Report

The report distinguishes four kinds of life-shortening actions near the end of life:

1. Withholding treatment

2. Stopping treatment

3. Treatment of symptoms, accompanied by a shortening of life as a side effect

4. Life-terminating actions in a strict sense(3)

For the sake of clarity, it is important first to take note of the report's terminology. The term euthanasia is totally avoided. Instead, the committee distinguishes between life-terminating action (i.e., active, nonvoluntary euthanasia) and life-shortening action (i.e., passive, nonvoluntary euthanasia). The report's final conclusion is that life-shortening actions with severely demented patients may be justified in each of the four ways when certain conditions have been met.(4) For present purposes, it will be useful to discuss these ways in reverse order, since the most elaborate discussion takes place concerning (1) and (2).

Termination of Life in a Strict Sense

The first way of shortening life is a life-terminating action (or nonvoluntary euthanasia) in a strict sense, i.e., by administering some lethal drug. Here, the committee points out some "relevant arguments" (these are arguments pro, not contra, euthanasia), distinguishing between two kinds of situations.

The first situation obtains when (a) the presently demented patient wrote a living will or advance directive when he or she was still mentally competent, stating the request for euthanasia under circumstances such as severe dementia or when (b) a convincing reconstruction of the supposed will of the patient is available, and (c) besides the severe dementia other symptoms point to severe suffering. In such a situation the committee is of the opinion that the (Dutch) criteria for permissible voluntary euthanasia are met, i.e., intolerable and continuing suffering without prospect of improvement. Therefore, a physician would be justified in granting the written or reconstructed request.(5) The committee especially has in mind situations in which stopping treatment due to the patient's advance directive leads to an "unacceptable and inhumane situation."(6) A substantial part of the committee is of the opinion that these circumstances offer sufficient arguments in favor of life-terminating actions.

The second kind of situation is the following: (a) there is no written living will or advance directive, nor a convincing reconstruction of the will of the patient, but (b) the patient is in a situation that is evidently incompatible with human dignity, in which the patient's suffering cannot be alleviated in any acceptable manner. In such a case only the intention to end this situation may provide a ground for life-terminating actions.(7) Here, however, the committee does not want to take a stand, but proposes that reflection and discussion on this issue be continued. In any case, in situation (b) it must be clear that physicians do not act against the patient's explicit or supposed will because then active life-termination by physicians would not be permitted, according to the committee.(8)

Treatment of Symptoms, with the Shortening of Life as a Side Effect

The shortening of life as a side effect of symptom treatment may be justified.(9) Its justification lies in the justified intent to treat symptoms, of which life-shortening may be a foreseen and acceptable side effect. Without any comment, the committee remarks almost by the way, namely only in its summary, that the life-shortening effect in this form may also be intended by some. This means, we conclude, that according to the committee treatment of symptoms, accompanied by a shortening of life as a side effect, is an acceptable form of shortening life.'(10) In some respects, then, these actions by physicians may sometimes also count as a form of life-termination in the strict sense.

Stopping or Withholding Treatment

When discussing the justification of the remaining two forms of life-shortening actions, i.e., by withholding or stopping medical treatment, the committee refers to the justification of life-prolonging treatment. A decision to perform a life-shortening action is in fact the "direct consequence" of the decision that life-prolonging treatment is no longer justified, so it says.(11) In the following, then, we shall first try to see wherein the justification of life-prolonging treatment lies, and, secondly, how from the absence of such a justification an argument for the shortening of life is derived.

First, according to the committee, the justification of life-prolonging treatment, such as antibiotics or artificial feeding, is to be determined by considering the patient's point of view. When the patient is able to express his or her own wish, then that should be decisive.(12) When that is no longer possible, for instance, because of severe dementia, the prime question is whether medical treatment is justified. Such justification may follow from (1) the supposed or reconstructed will of the patient, (2) the burden of the treatment that is given or considered, (3) the positive effects of the treatment, and (4) the interest of the patient.(13) The report is not entirely clear on the proper order and proper weight of these considerations.

Consideration of the positive effects of the treatment calls for an assessment of the value of the effects of such treatment. According to the report, this value should be judged on the grounds of (a) insight into the (supposed) will of the patient, (b) the burden of the treatment, (c) the prognosis of the patient, and (d) the justification of the treatment.(14) If we understand correctly, then, the justification of life-prolonging treatment is (partly) based on the justification of life-prolonging treatment.

Secondly, the committee derives the justification of life-shortening treatment from the justification of life-prolonging treatment. It states that the justification of the shortening of life by withholding or stopping treatment is the "direct consequence"(15) or the "mirror image"(16) of the justification of stopping or withholding life-prolonging treatment. According to the report, it follows that the shortening of life, in particular by withholding antibiotic treatment or artificial feeding, may be justified(17) and also by (b) stopping antibiotic treatment or artificial feeding.(l8) For the justification of both kinds of life-shortening actions, the committee again refers to the considerations mentioned above.

In regard to insight into the (supposed) will of the patient, and concerning withholding antibiotic treatment, the report mentions the following: (1) The supposed will of the patient will seldom pertain to a specific medical treatment and will therefore offer no clue for decisionmaking...