Medical Aid in Dying: Not for Dementia

 I’m Art Caplan. I'm at the Division of Medical Ethics at the NYU Grossman School of Medicine. 

A topic that we often find up in the air for discussion is medical aid in dying or assisted suicide, or the practice of helping terminally ill people to die. 

We have to return to it again because a new issue is coming up in various countries, and that is medical aid in dying for people with dementia —people who are suffering from Alzheimer's, Lewy body disease, had many strokes, and are losing their cognitive capacity or losing their identity. Just talking to people, death is feared; becoming demented and losing personal identity is feared more.

Almost expectedly, we're starting to have discussions as to whether we should extend medical aid in dying to people with dementia. It's not permitted right now in the US. Some states allow it for people who are terminally ill, but they have to be competent. 

By the way, that restriction is in place in places like Germany, Japan, and Israel, but other countries do permit people with dementia to be aided in their dying.The Netherlands is one, and Canada — particularly the province of Quebec — is quickly moving in this direction as well. 

Surveys show a little bit more support than I might have guessed. Up to one third of American doctors say that for people with dementia, maybe it would be appropriate to help them to die sooner. There are big numbers in Europe, with up to 70% in Belgium, saying, yes, they agree with that, too. 

By the way, one of the surveys I found reported that about 1 in 3 doctor respondents said if they were becoming demented, they would consider using lethal drugs that were at their disposal to end their own life.

Still, I oppose extending aid in dying to people with dementia. I think we have a number of ethical reasons that still make this a practice that I don't think the United States should move toward. 

First, the very fact of dementia makes it uncertain as to whether somebody knows what they're asking for. They're not competent. Maybe they could fill out an advanced directive, but again, would they really feel that way if they're demented but are eating and happy and watching television? I don't know. It's very difficult to say you're going to choose to die earlier, and say that's a real choice, when you're in the middle of rapidly advancing or full-fledged dementia.

I worry about abuse. There are exhausted caregivers. There are people who just can't bear anymore the relative who's becoming demented. That is not a reason to help the demented person die. It's a reason to provide more support than we do to caregivers and families, and we don't do a good job there.

I think the cost is huge. Telling people they have to die sooner because there's a huge expense is not the ethical thing to do either. We have to provide care to the demented, and the care has to be good quality. If it is expensive, then we should look for ways to lower it.

I am not opposed to medical aid in dying for people who can choose it and who are terminally ill. I don't think it violates the do-no-harm injunction because people are going to die anyway and fear the mode of that death due to terminal illness. They have the right to ask for help, and whether they do it or not, that's a choice I think we could give. There's no choice when it comes to dementia.

https://www.medscape.com/viewarticle/medical-aid-dying-not-dementia-says-ethicist-2025a1001082