Euthanasia

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We cannot choose the moment of our birth. And death usually comes in its own time, not ours. Sometimes, however, we can decide to end our life. The reasons for suicide are various. Most common is the desire to end intractable suffering. Faced with the prospect of a prolonged period of pain and suffering at the end of life, most rational people would prefer euthanasia – a “good death.” This term first came into English in Francis Bacon’s Advancement of Learning (Book II, X.7). Bacon was encouraging physicians to assuage the pains and agonies of death: to practice what we now call palliative care.

Over the course of time “euthanasia” became differentiated from palliative care, and now generally means the inducement of death so as to prevent intolerable pain and suffering in patients with incurable disease (Young, 2012; Sumner 2011). Euthanasia may be voluntary or involuntary, based on whether the patient provides consent or not. Involuntary euthanasia, where the patient does not provide consent although capable of so doing, is sometimes distinguished from non-voluntary euthanasia (“mercy killing”), where the patient is unable to either object or consent. Some would consider both involuntary and non-voluntary euthanasia as equivalent to murder and limit the term euthanasia to cases wherein consent is explicit. Euthanasia may be active or passive, based on whether death is induced by the administration of a lethal medication or by the withdrawal of life-sustaining treatment, nutrition or hydration. Active euthanasia may be initiated by the patient, in which case it is essentially suicide, or by someone else (a physician or a nurse acting under the direction of a physician), in which case it can be described as assisted suicide or assisted dying. Sometimes voluntary euthanasia, where the lethal medication is administered to the patient, is distinguished from assisted suicide, where the patient takes the drug, but this distinction appears unnecessary. When the word is unmodified, euthanasia generally means physician-assisted suicide performed at the request of the patient.

Historical Backgound

Our attitudes to euthanasia have changed over the centuries (Dowbiggin, 2005). Developments in religion, law, and medicine have all contributed to these changes. Over the past century or so medicine has increased its ability to treat disease and manage pain. We are now more able to make end-of-life decisions than we have ever been. Nevertheless, the decisions remain extremely difficult, since they involve our cherished belief in the sanctity of human life and our ancient laws against killing (Pappas, 2012). Any proposal for euthanasia must address our general prohibition of suicide.

In the Eastern religions, suicide was not forbidden. In India, a wife could cast herself on the funeral pyre of her husband in the process of sati. Elderly yogis with no remaining responsibilities could seek death by starvation – prayopavesa. In Japan, suicide by means of seppuku could preserve one’s honor. Since one of the goals of Buddhism is to relinquish any attachment to the world, suicide might even be considered as a means to this release, though this should only come after enlightenment has been attained (Attwood, 2004). However, some Chinese and Japanese Buddhist monks sought enlightenment through a process of sokushinbutsu or self-mummification, accomplished by slow starvation and self-suffocation.

In the Abrahamic religions, however, suicide was considered an unpardonable sin, tantamount to murder (Cholbi, 2012). Suicide was contrary to the commandment “Thou shalt not kill” (Exodus 20:13). The main scriptures, however, do not specifically prohibit killing oneself. The Bible provides various examples of suicide (Samson, Saul, Judas) without ever stating that this is prohibited. However, the scriptures convey a general sense that one should not interfere with divine providence: “My times are in thy hand” (Psalm 31:15). One verse of the Qur’an (4:29) is sometimes translated as “Do not kill yourselves,” though it is more usually rendered as “Do not kill each other.”

Through most of its history, the Christian Church has adamantly condemned suicide. The body of a suicide was denied burial in consecrated ground and the soul denied access to salvation. In recent years, the churches have relaxed their condemnation, though suicide is still considered a mortal sin. Until recently, suicide was illegal in almost all European countries, and the property of the suicide was confiscated by the state. Part of the reason why Christian societies have been so severe in their condemnation of suicide may have been the attractiveness of heaven. Without severe sanctions, believers might easily choose the happiness of an after-life to the suffering of a present life.

During the Renaissance and Enlightenment, thinkers began to question the Church’s stance. When one is coming to the end of life and faced with unrelenting pain, one should be able to choose a quick and painless death rather than undergo prolonged and unnecessary suffering

In Thomas More’s Utopia

…when any is taken with a torturing and lingering pain, so that there is no hope either of recovery or ease, the priests and magistrates come and exhort them, that, since they are now unable to go on with the business of life, are become a burden to themselves and to all about them, and they have really out-lived themselves, they should no longer nourish such a rooted distemper, but choose rather to die since they cannot live but in much misery; being assured that if they thus deliver themselves from torture, or are willing that others should do it, they shall be happy after death: since, by their acting thus, they lose none of the pleasures, but only the troubles of life, they think they behave not only reasonably but in a manner consistent with religion and piety; because they follow the advice given them by their priests, who are the expounders of the will of God. Such as are wrought on by these persuasions either starve themselves of their own accord, or take opium, and by that means die without pain. (More, 1516, pp 140-141).

One cannot be sure whether More was advocating euthanasia or just presenting the policy for discussion. The title of his book means “nowhere” – only later did it assume the additional connotation of eutopia or “good place.” As a devout Roman Catholic, More likely supported his church’s opposition to euthanasia. Death should come when God wills, not when we want.

In an essay that was only published posthumously, David Hume provided a rational view of suicide. He proposed that it is no more contrary to divine providence than building houses to protect ourselves from the weather or cultivating the earth to prevent ourselves from starving. Furthermore, when we become old and infirm suicide is no longer contrary to our duties to society, since we may have become more of a burden than a benefit to our fellows. Thus

both prudence and courage should engage us to rid ourselves at once of existence, when it becomes a burthen. ’Tis the only way, that we can then be useful to society, by setting an example, which, if imitated, would preserve to every one his chance for happiness in life, and would effectually free him from all danger of misery. (Hume, 1777)

In the concluding note to his essay, Hume quoted Pliny the Elder who described suicide as an advantage that man possesses over God.

Deus non sibi potest mortem consciscere, si velit, quod homini dedit optimum in tantis vitæ poenis. [God cannot put himself to death even if he wanted to, since among the many ills of life he gave away this best of boons to man]. (Pliny, 79, Book II Chapter V)

The modern interpretation of euthanasia can probably be traced to the much-discussed essay on the subject by Samuel D. Williams published in 1870 (Kemp, 2002). He proposed

That in all cases of hopeless and painful illness it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform, or such other anæsthetic as may by-and-by supersede chloroform, so as to destroy consciousness at once, and put the sufferer at once to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient. (Williams, 1870, p 212).

In the decades subsequent to this essay, many groups in England, Europe and North America began to advocate the legalization of euthanasia.

Unworthy Lives

In the 20th Century euthanasia became entrammeled with another idea that promoted the good of society – “eugenics.” Unfortunately, joining the “good death” with the “good birth” led to actions of great evil.

Darwin’s Theory of Evolution had proposed that humanity’s current success derives from the selection of the fittest for survival and propagation. Followers of Darwin warned that we should not alter the course of evolution by social policies to protect the weak and vulnerable. Rather we should encourage our best and brightest to have more offspring, and we should prevent the feeble-minded, criminal and insane from multiplying. These ideas formed the basis of eugenics.

In the first few decades of the 20th Century several jurisdictions in North America and Europe enacted eugenic laws enforcing the sterilization of the mentally defective and the insane. The most efficient of such programs was brought in by the German Nazi government when it came to power in1933 (Proctor, 1988, Chapter 4; Pichot, 2001, Chapter 10). The Law for the Prevention of Genetically Diseased Offspring required the sterilization of patients suffering from feeble mindedness, schizophrenia, manic-depression, Huntington’s chorea and alcoholism. While the program was in operation between 1933 and 1939, about 400,000 patients were sterilized (compared to about 30,000 patients over a much longer period in the USA).

A more effective eugenics program would not only prevent offspring but also remove from society the costs involved in the long-term care of feeble-minded and mentally ill patients. The possibility of the involuntary euthanasia of patients who were a burden to society had been thoroughly evaluated in the 1920 book Permitting the Destruction of Unworthy Life by Karl Binding, a legal scholar, and Alfred Hoche, a physician. They considered the question

Is there human life which has so utterly forfeited its claim to worth that its continuation has forever lost all value both for the bearer of that life and for society?

They answered affirmatively, and proposed that society was justified in putting patients with incurable disease to death.

In 1939 the war began and the German sterilization program ceased. In its place a secret program called Operation T4 was instituted to provide a mercy death (Gnadentod) for the incurably sick and mentally ill. Patients were killed either in specially constructed gas chambers or by such other means as were found expedient. The number of patients euthanized by the time the war ended was probably around 400,000 (Proctor, 1988, Chapter 7; Pichot, 2001, Chapter 11). The techniques developed in the early stages of this program were then used when the Nazi government decided to murder Jews, homosexuals, communists, Gypsies, Slavs and prisoners of war.

The history of euthanasia in Germany is a horrifying example of the “slippery slope.” By accepting that some people have more of a right to life than others or that a doctor may agree to a patient’s request for death, we slide slowly and inexorably toward complete immorality. Leo Alexander, a medical expert at the Nuremberg trials, stated the problem of the “small beginnings:”

Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans (Alexander, 1949).

Double Effects

For many years after the war, the ethics of active euthanasia were not discussed. We became more concerned with the relief of pain. New protocols were developed to facilitate analgesia, the speciality of palliative care became a medical specialty, and hospices became available to provide a peaceful and pain-free death to patients with terminal illness.

Sometimes, when medication dosages were increased to levels sufficient to relieve severe and unrelenting pain, death also resulted. Such protocols invoked the principle of “double effect:” that an action intended to bring about a morally desirable effect (the relief of pain) is not wrong if it also leads to a morally reprehensible effect (death) even when this second effect is foreseen. This state of affairs is both morally and medically confusing (McIntyre, 2001). Who is to say what is intended and what is just foreseen? The increased pain medication probably does not in itself bring about the death of the patient. Death results from a combination of causes: limiting the patient’s nutrition and hydration adds to the effects of sedation and the ongoing disease. “Terminal sedation” should probably not be considered as an example of double effect, but simply treated as a type of euthanasia.

End-of-Life Decisions

In the second half of the 20th Century, medicine developed techniques for cardiopulmonary resuscitation and mechanical ventilation. Although these procedures often prevented unnecessary death, they sometimes resulted in unresponsive patients being maintained alive without any reasonable hope for the return of normal consciousness.

These developments led to the principle that life need not be artificially continued if recovery is futile. A patient may decide to forego resuscitation or mechanical ventilation in such situations. This decision may be made by means of an advance directive or “living will.” In cases without such directives, the decision can be made by the patient’s family and caregivers. Accepting these protocols has been a long a complicated process that is outside of the main topic of this posting (see discussion in Pappas, 2012, Chapter 4). Issues remain for patients who have no advance directives and when the family and physicians disagree on whether to maintain life support. Nevertheless we have come to general terms with the idea of passive euthanasia when a patient is unresponsive and the prognosis is futile. Outside of a few jurisdictions, however, active euthanasia remains illegal.

Legalization of Voluntary Euthanasia

Voluntary euthanasia has been legal in Oregon since 1997 (Lindsay, 2009; Lee, 2014), in Switzerland at least since 1998, and in the Netherlands (Onwuteaka-Philipsen et al., 2012) and Belgium (Cohen-Almagor, 2009) since 2002. Each of these jurisdictions requires a formal application from a patient judged competent to understand the nature of their suffering and the consequences of their request (Lewis & Black, 2013).

The incidence of voluntary euthanasia is low but varies greatly among the jurisdictions. In Oregon the incidence is 0.2% of all deaths, but in Belgium and the Netherlands the incidence is between 1.5 and 3 % (the incidence in Switzerland is not accurately known). The incidence would be significantly higher if cases of euthanasia without consent, and cases of terminal sedation were included together with those of voluntary euthanasia.

Investigations of patients undergoing voluntary euthanasia indicate no clear evidence that vulnerable populations are unfairly targeted, or that coercion plays a significant role in the patients’ decisions. In Oregon most patients requesting euthanasia were white, well-educated, and medically insured (Lindsay, 2009). Furthermore, euthanasia does not substitute for adequate palliative care, since most patients ultimately seeking euthanasia have already tried palliative care or been admitted to a hospice.

Nevertheless, two significant issues remain unanswered. The first is the incidence of euthanasia without explicit consent. Although this is not reported in Oregon, it has been documented in Belgium and the Netherlands. When faced with an incurable patient in severe pain who is not able to provide consent, a compassionate physician may nevertheless proceed with euthanasia. The incidence of this is extremely difficult to assess, particularly if one includes “terminal sedation.” The incidence of euthanasia without consent probably equals the incidence with consent (Cohen-Almagor, 2009; Lewis &Black, 2013; Meussen et al., 2010, Onwuteaka-Philipsen et al., 2012).

The second issue concerns the euthanasia of patients with psychiatric disorders. This has become particularly frequent in Belgium (Thienpont et al., 2015; Aviv, 2015). By arguing that mental anguish can cause as much suffering as physical pain, one can make a philosophical case for euthanasia to relieve “existential suffering” (Varelius, 2014). However, we usually believe that psychiatric disorders can be treated, and that even without treatment depression will alleviate with the passage of time. Psychiatric patients are certainly vulnerable and often may have difficulty providing fully informed consent. Thienpont et al. (2015) report that the female/male ratio was 3.3 for psychiatric patients requesting euthanasia and 2.9 for those patients who were ultimately euthanized. They suggest that this is in keeping with the increased incidence of psychiatric disease in women, but the ratio is nevertheless disconcerting.

Objections to Euthanasia

Euthanasia has engendered much public debate (Andorno & Baffone, 2014; Materstvedt et al., 2003; New England Journal of Medicine, 2013; Quill & Greenlaw, 2008; Somerville, 1993, 2014; Smith, 2006; Sumner, 2011, Young, 2012). The main reason for making euthanasia legal is that individuals have a right to decide that a rapid painless assisted death is preferable to one that is prolonged and painful, and to have medical assistance in bringing this about. The main objections are

(i) Euthanasia is unnecessary if there is adequate palliative care. A variant of this argument is that if euthanasia becomes legal, patients and physicians will prefer euthanasia to palliative care. Palliative and hospice care can render the end of life peaceful and pain-free in most patients. Nevertheless, pain medication must sometimes be brought to such levels that the treatment of pain becomes essentially the same as euthanasia.

(ii) Patients may not be able to provide proper informed consent. A state of state of severe pain and distress may preclude proper consent – the patient may agree to anything to stop the pain. This objection could be countered if the patient simply confirmed a previous decision made before the terminal period.

(iii) Patients near the end of life may be very vulnerable to coercion. Opponents of euthanasia suggest that families and caretakers may improperly convince disabled or elderly patients to accept euthanasia. Their ulterior motive might be to be relieved of the expense and effort involved in the care of their elderly relative or to free up an inheritance.

(iv) Allowing voluntary euthanasia is a “slippery slope” that will ultimately lead to killing all individuals whose lives are considered “unworthy.” If we become used to letting people die, we may become inured to killing and allow the old, the disabled and the mentally defective to be euthanized without consent. The story of Jack Kevorkian (Pappas, 2012, Chapter 5) represents the horrors of the slippery slope. Though there may have been some support for his early actions, ultimately he was killing patients who were obviously unable to give consent. Refutations of the slippery-slope argument hinge on strong safeguards to guarantee proper consent and strict sanctions against euthanasia outside of the legal guidelines (Stingl, 2010). The slope may be slippery but we can construct barriers to prevent us from falling into the abyss.

Public Opinion

Despite the objections, the great majority of people in North America support the legalization of voluntary euthanasia. Gallup polls (McCarthy, 2014) show that about 70% of respondents in the USA answer yes to the question

When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his or her family request it?

Support varies with the wording of the question (Saad, 2010). Only 51% agree if the question is worded:

When a person has a disease that cannot be cure and is living in severe pain, do you think that doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?

Both Somerville (1993) and Callahan (2008) have remarked how easily public opinion on euthanasia may be swayed by the choice of words.

In a Canadian poll taken in 2013 at the behest of an anti-euthanasia group the key findings were that

Canadians are about twice as likely to support (63%) as to oppose (32%) a law allowing physician-assisted suicide in Canada. Support is slightly lower for legalizing euthanasia (55% vs. 40% who oppose it), which is likely due in part to providing respondents with information about the rate of euthanasia deaths occurring without patient consent in Belgium. (Environics, 2013).

A year later, an Ipsos-Reid poll performed for a pro-euthanasia group showed 84% of Canadian respondents in favor of physician-assisted suicide. (Ramsay, 2015).

A final survey worth noting is one conducted by the Canadian Medical Association (2011). They found in a survey of their members that

only 20% of respondents would be willing to participate if euthanasia is legalized in Canada, while twice as many (42%) would refuse to do so. Almost a quarter of respondents (23%) are not sure how they would respond, while 15% did not answer.

The Hippocratic Oath asserts

I will neither give a deadly drug to anybody who asks for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy.

Most present day physicians do not swear to this oath, but the idea that a physician should not bring about death has merit. When one is sick and in pain, a physician who will not kill is preferable to one who might be willing to do so. Even if ultimately one could choose suicide.

Canadian Law

In Canada active euthanasia is a crime though suicide is not. The Canadian Supreme Courts has examined the issues of euthanasia in three cases: Rodriguez vs British Columbia (1993), R vs Latimer (2001), and Carter vs Canada (2015).

In 2001 Sue Rodriguez, suffering from amyotrophic lateral sclerosis, wished to be allowed to die by means of assisted suicide when she became totally incapacitated. She wanted to live life to its fullest, and therefore did not wish to take her life before becoming unable to do so. She proposed that the law prohibiting physician-assisted suicide was discriminatory

since it prevents persons physically unable to end their lives unassisted from choosing suicide when that option is in principle available to other members of the public without contravening the law.

The judgment of the court was that the blanket prohibition of assisted suicide was justified since its purpose was to protect life. The court expressed concerns about the possible abuse of assisted suicide were it to be legalized, the difficulties in creating appropriate safeguards against such abuse, and the need to protect those members of society who might be vulnerable to such abuse. The court therefore decided against her request. Sue Rodriguez committed suicide with the assistance of an anonymous physician in 1994.

In 1993, Robert Latimer brought about the death of his 12-year old daughter Tracy by means of carbon monoxide poisoning. Tracy suffered from severe cerebral palsy, epilepsy and mental retardation. She had undergone numerous operations to relieve her spastic and painful state. Faced with further surgery for her constantly dislocating hip, her father decided that dying would be preferable to continuing a life of pain and torture. Latimer was convicted of second degree murder and given the minimum 10-year sentence allowed for this crime. The case went through several appeals. In 2001, the Supreme Court considered a request to reduce the sentence, but affirmed both the conviction and the sentence. They found no justification for non-voluntary euthanasia. Robert Latimer began serving his sentence in 2001 and was release in 2010.

The Supreme Court of Canada re-considered the law prohibiting physician-assisted suicide in its judgment of Carter vs Canada. The case was instigated by Lee Carter, who had been forced to take her mother, suffering from an incurable neurodegenerative disease, to Switzerland for assisted suicide, since this was not legally available in Canada. The court summarized the reasoning of the 1993 Rodriguez judgment:

The object of the prohibition is not, broadly, to preserve life whatever the circumstances, but more specifically to protect vulnerable persons from being induced to commit suicide at a time of weakness.

However, the court acknowledged that since that 1993 judgment assisted suicide had been legalized in several jurisdictions and that safeguards against abuse have been effective. The court agreed that some people may wish to end their lives but not have the ability to do so without the assistance of a physician. The law prohibiting such assistance thus discriminates against these individuals:

An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty. And by leaving them to endure intolerable suffering, it impinges on their security of the person.

The court therefore temporarily invalidated the law prohibiting physician-assisted dying and called upon the federal government to provide new legislation more consistent with the Canadian Bill of Rights. However, the present government seems loath to address the issue, despite the weight of public opinion (Ramsay, 2015). The government of the Province of Quebec has voted to allow euthanasia, although this decision may be legally contested by the federal government.

Where Do I Stand?

Euthanasia should be legal when a patient with an incurable illness is suffering pain that cannot be adequately relieved by analgesic medication. The diagnosis and prognosis should be confirmed by at least two physicians. Modern palliative care should have been provided and demonstrated to be inadequate. Euthanasia should only be allowed at the patient’s request and only after his physicians have ensured that the request is freely made.

Terminally ill patients who are in obvious pain but unable to consent to euthanasia pose a significant problem for both medicine and the law. We need to develop guidelines and safeguards to allow consent to euthanasia from the family and caretakers in these cases. Otherwise non-voluntary euthanasia may occur and go unreported.

In the absence of unrelenting pain, euthanasia of the elderly, the demented, and the mentally defective should continue to be prohibited.

At the present time there is no adequate justification for assisted suicide for existential suffering. Euthanasia in psychiatric patients is far too susceptible to abuse to be allowed.

Physicians should not be forced to provide euthanasia. Nevertheless, any patient requesting euthanasia should be referred to other physicians who can evaluate the request, judge its validity and conduct the euthanasia. Such referrals should be readily available.

 

References

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Attwood, M. (2004) Suicide as a response to suffering. Western Buddhist Review, 4

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2 comments

  1. Tony Guzman says:

    Would like to discuss the late demented with you sometime.
    Tony.

    • terry says:

      End-of-life decisions in patients with severe incurable dementia are ethically disconcerting. The Alzheimer’s Association (2015) has a good brochure on the issues surrounding the end-of-life and dementia. The following are some personal comments. You have far more experience and wisdom in these matters than I do.
      In general, I am against any idea of involuntary active euthanasia. The present-day argument might be couched in terms of freeing up medical services for other patients. However, involuntary euthanasia would be the same as the Nazi program targeting those whose lives were not worthy of living. Who can determine which life is worthy? How could this ever be determined?
      What about voluntary euthanasia? Could there be an advance directive (living will) wherein an individual requests euthanasia if and when he or she becomes severely demented? A criterion frequently suggested is the inability to recognize family members. The problem is that the demented person is not the person who signed the advance directive (de Boer et al., 2010). The present person may have completely different ideas about the life they consider worth living. They may be perfectly happy to be taken care of by others.
      When patients are initially given a diagnosis of Alzheimer’s disease, the idea of their future cognitive decline might be unbearably painful. While they are still considered competent, they might therefore request assisted suicide so that they do not have to undergo this deterioration (Berghmans et al., 2009). Some European physicians will honor such a request. I am not sure that we should do so at the present time. We first need to see how assisted suicide works in cases of unbearable physical pain.
      One issue that is common to dementia and other terminal disease involves the uncertainty of medical prognosis. I am very skeptical about the possibility of curing or even alleviating severe Alzheimer’s disease in the near future. However, some discoveries have suddenly and totally changed the course of neurological disease, for example, the use of L-dopa in patients with post-encephalitic Parkinson’s disease. Should patients with dementia therefore be kept alive in the hope of a similar breakthrough? Or can we state with some certainty that there will not be a cure within a set period of time – say 5 or 10 years – during which the patient would likely die from other causes? There should be ways to assess these probabilities. Nothing will ever be certain, but perhaps we can make more reasonable decisions if we know more about the risks.
      Passive euthanasia seems justified in cases of severe dementia. The patient’s family and/or caretakers in consultation with the physician should decide about the level at which active treatment should be withdrawn. Physicians should propose that cardiopulmonary resuscitation not be attempted in the event of cardiac arrest. They might also argue against treating ongoing acute diseases (Evers et al., 2002). Infections should perhaps be allowed to run their course without antibiotic intervention but with appropriate analgesic medication. A reasonable case can be made against intravenous hydration or tube feeding, since these actually have no significant effect on the course of the disease (Gillick, 2000).
      Alzheimer’s Association. (2015). End-of-life decisions Honoring the wishes of a person with Alzheimer’s disease. (https://www.alz.org/national/documents/brochure_endoflifedecisions.pdf)
      Berghmans, R., Molewijk, B., & Widdershoven, G. (2009). Alzheimer’s disease and life termination: the Dutch debate. Bioethica Forum, 2, 33-34.
      de Boer, M. E., Hertogh, C. M. P. M., Dröes, R.-M., Jonker, C., & Eefsting, J. A. (2010). Advance directives in dementia: issues of validity and effectiveness. International Psychogeriatrics, 22, 201–208.
      Evers, M. M., Purohit, D., Perl, D., Khan, K., & Martin, D. B. (2002). Palliative and aggressive end-of-life care for patients with dementia. Psychiatric Services, 53, 609-613.
      Gillick, M. R. (2000). Rethinking the role of tube feeding in patients with advanced dementia. New England Journal of Medicine, 342, 206-210.

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