Patients diagnosed with progressive dementia may know exactly how much deterioration they are willing to endure.
uncertain
they → diagnose → deterioration
They can articulate their wishes, discuss alternatives, and put their instructions in writing.
asserted
They → articulate → writing
Should losing the ability to repeat those instructions invalidate them?
asserted
losing → lose → them
Canada is preparing to address that question.
asserted
Canada → prepare → question
On October 23, its Justice Department announced planned rules that would allow adults diagnosed with an incurable illness expected to destroy their decision-making capacity to consent in advance to assisted suicide (or, as Canada calls it, medical assistance in dying (MAID)).
asserted
Canada → announce → dying
Ministers will discuss the proposal on October 27, but it must pass both houses of Parliament and receive formal approval from Canada's governor general before becoming law.
asserted
it → discuss → general
Parliamentary committees can hear testimony and consider amendments along the way.
asserted
committees → hear → way
The announcement promises safeguards but offers few details.
asserted
announcement → promise → details
Those details will determine how well the proposal respects patients' choices.
asserted
proposal → determine → choices
A free society recognizes individuals as sovereign over their own bodies provided they respect the rights of others.
asserted
they → recognize → others
That freedom includes deciding how much suffering they are willing to endure.
asserted
they → include → suffering
A competent adult's decision deserves respect even when physicians, relatives, or public officials would choose differently.
asserted
physicians → deserve → respect
Competent adults should be free to choose clinician-assisted suicide or clinician-administered euthanasia, provided they give fully informed, voluntary consent and those assisting them do so willingly.
asserted
those → choose → them
That freedom should include planning for the loss of decision-making capacity.
asserted
freedom → include → capacity
A patient's loss of decision-making capacity should not automatically grant the government authority to override instructions given while the patient was competent.
asserted
patient → grant → instructions
Physician-assisted deaths are now authorized in 13 states and Washington, D.C.
asserted
deaths → assist → states
Twelve states and the district enacted laws; Montana permits it under a state Supreme Court ruling.
asserted
Montana → enact → ruling
American statutes generally follow the Oregon model: Patients must have decision-making capacity, have a terminal illness expected to cause death within six months, and self-administer the medication.
asserted
Patients → follow → medication
These restrictions exclude people who suffer greatly but cannot meet the government's timetable or physically perform the final act.
asserted
who → exclude → act
Progressive dementia creates another barrier.
asserted
dementia → create → barrier
By the time patients reach the condition they hoped to avoid, they may no longer qualify.
uncertain
they → reach → condition
In 1999, Michigan convicted Jack Kevorkian of second-degree murder after he administered lethal drugs to Thomas Youk, a patient with amyotrophic lateral sclerosis ("Lou Gehrig's disease") who had consented to the procedure.
asserted
who → convict → procedure
As I wrote in Reason, patients' bodily autonomy includes the freedom to request a willing physician's assistance in ending their lives.
asserted
autonomy → write → lives
Requiring patients to administer the medication themselves denies that choice to people whose illnesses have stripped them of the physical ability to act.
asserted
illnesses → require → ability
Dementia raises a further question: whether an informed decision can survive the loss of the capacity to express it.
asserted
decision → raise → it
Other countries give patients more latitude.
asserted
countries → give → latitude
At least a dozen countries permit some form of assisted dying, though their rules vary considerably.
asserted
rules → permit → dying
Canada does not require a terminal prognosis.
asserted
Canada → require → prognosis
In the Netherlands, euthanasia is permitted for unbearable suffering with no prospect of improvement, subject to statutory safeguards.
asserted
euthanasia → permit → safeguards
Some countries also recognize advance requests, though under different conditions.
asserted
countries → recognize → conditions
In the Netherlands, a written advance request can replace an oral request once a patient loses the ability to express a choice, including in advanced dementia.
asserted
patient → write → dementia
The remaining legal requirements, including unbearable suffering without prospect of improvement, still apply.
asserted
requirements → remain → improvement
Belgium permits advance requests more narrowly, only when a patient becomes irreversibly unconscious.
asserted
patient → permit → requests
Patients who lose decision-making capacity due to dementia while remaining conscious cannot obtain euthanasia under an earlier directive.
asserted
who → lose → directive
Respecting a patient's earlier wishes raises difficult questions.
asserted
Respecting → respect → questions
How clearly must patients describe the circumstances in which they want assistance?
asserted
they → describe → assistance
Who determines whether those circumstances have arrived?
asserted
circumstances → determine → ?
What happens if a patient who can no longer understand the directive resists the procedure or appears content with life?
asserted
who → happen → life
Legal scholars, working with clinicians and patients, must help lawmakers answer these questions.
asserted
lawmakers → work → questions
Finding the right answers is difficult, but the obstacles are not insurmountable.
asserted
obstacles → find → answers
…and 22 more, not listed.
The Aporia
