RESUMEN
Progressive dementia afflicts millions of people, ultimately entailing precipitous mental decline and years of complete dependence on others. Many people deem the prospect of serious cognitive dysfunction, helplessness, and dependence to be intolerably degrading (as well as overly burdensome on others). To avoid being mired in prolonged dementia, they prefer to hasten death by advance instructions rejecting life-sustaining medical intervention at a point of decline they define as unacceptable.Some health care providers resist implementation of such advance instructions, especially as applied to patients with dementia who are not ostensibly suffering in their demented states and no longer recall their prior instructions and the dignity concerns that underlay them. The clash between advance wishes to hasten death and some health care providers' preference to maintain the well-being of nonsuffering patients will be surfacing, in coming years, in institutional ethics committees, professional disciplinary forums, and the courts. This article defends the legal and moral status of advance instructions seeking to shorten the unwanted limbo of deep dementia.
Asunto(s)
Disfunción Cognitiva , Demencia , Directivas Anticipadas , Humanos , Inmersión , RespetoRESUMEN
Some people will confront Alzheimer's with a measure of resignation, a determination to struggle against the progressive debilitation and to extract whatever comforts and benefits they can from their remaining existence. They are entitled to pursue that resolute path. For other people, like myself, protracted maintenance during progressive cognitive dysfunction and helplessness is an intolerably degrading prospect. The critical question for those of us seeking to avoid protracted dementia is how best to accomplish that objective. One strategy is to engineer one's own death while still mentally competent to do so (even in the stage of mild dementia). If I were to use a preemptive strategy in the face of a dementia diagnosis, I would probably choose to stop eating and drinking, a process known as voluntarily stopping eating and drinking. An alternative tactic for avoiding prolonged dementia would be to allow oneself to decline into moderate dementia-thus losing capacity to perform self-deliverance or even to make serious medical decisions-but before getting to that point to provide advance instructions rejecting prospective life-sustaining medical interventions. These advance instructions would authorize palliative but not curative measures. My current personal instructions define the point of intolerable cognitive decline triggering medical nonintervention as "mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook." These instructions dictate allowing my demise at a point of moderate dementia when I may not be perceptibly suffering, when I may still be getting some rudimentary satisfaction from my debilitated life, and when I no longer recall the preoccupation with personally intolerable indignity that motivated my instructions. Can I expect that my advance instructions will be implemented in those circumstances? Is it lawful, and is it moral for a surrogate decision-maker and associated caregivers to allow an uncomprehending, ostensibly content but demented individual to die? My analysis herein contends that it is not only lawful and moral but also legally required to implement clear, considered advance instructions even at a stage of moderate dementia.
Asunto(s)
Lesiones Encefálicas , Familia , Donadores Vivos , Nefrectomía/ética , Trasplante de Órganos/ética , Opinión Pública , Respiración Artificial , Cuidado Terminal/ética , Consentimiento por Terceros , Recolección de Tejidos y Órganos/ética , Obtención de Tejidos y Órganos/ética , Confianza , Privación de Tratamiento/ética , Humanos , MasculinoAsunto(s)
Toma de Decisiones/ética , Cuidados para Prolongación de la Vida/ética , Inutilidad Médica/ética , Estado Vegetativo Persistente , Autonomía Personal , Cuidado Terminal/ética , Privación de Tratamiento/ética , Conducta de Elección/ética , Disentimientos y Disputas , Asignación de Recursos para la Atención de Salud/ética , Humanos , Manitoba , Política Organizacional , Defensa del Paciente/normas , Defensa del Paciente/tendencias , Rol del Médico , Guías de Práctica Clínica como Asunto , Privación de Tratamiento/legislación & jurisprudenciaAsunto(s)
Cadáver , Familia , Obligaciones Morales , Política Pública , Consentimiento por Terceros , Recolección de Tejidos y Órganos/ética , Actitud Frente a la Muerte , Autopsia , Análisis Ético , Cuerpo Humano , Humanos , Consentimiento Informado , Opinión Pública , Valores Sociales , Obtención de Tejidos y Órganos/ética , Estados UnidosAsunto(s)
Conducta de Elección/ética , Ingestión de Líquidos , Ingestión de Alimentos , Métodos de Alimentación/ética , Derechos del Paciente/ética , Cuidado Terminal/ética , Negativa del Paciente al Tratamiento , Privación de Tratamiento/ética , Humanos , Competencia Mental , Autonomía Personal , Apoderado , Cuidado Terminal/métodos , Negativa del Paciente al Tratamiento/éticaAsunto(s)
Toma de Decisiones , Tutores Legales/legislación & jurisprudencia , Competencia Mental/legislación & jurisprudencia , Personas con Discapacidades Mentales , Consentimiento por Terceros/legislación & jurisprudencia , Toma de Decisiones/ética , Humanos , Relaciones Padres-Hijo , Calidad de Vida , Cuidado Terminal/ética , Consentimiento por Terceros/éticaAsunto(s)
Apoderado/legislación & jurisprudencia , Calidad de Vida , Valor de la Vida , Privación de Tratamiento/legislación & jurisprudencia , Directivas Anticipadas/legislación & jurisprudencia , Personas con Discapacidad/legislación & jurisprudencia , Humanos , Legislación Médica , Competencia Mental , Autonomía Personal , Gobierno Estatal , Decisiones de la Corte Suprema , Negativa del Paciente al Tratamiento/legislación & jurisprudencia , Estados Unidos , Privación de Tratamiento/éticaRESUMEN
A chapter from his forthcoming book "Deciding for the Profoundly Mentally Disabled," Professor Norman Cantor argues persuasively for the right of incompetent persons to have a surrogate make critical medical decisions on their behalf, particularly in the context of refusing life-sustaining treatment. While abusive surrogate decision-making is always a concern, Professor Cantor recommends both substantive and procedural protections in order to preserve intrinsic human dignity for the profoundly disabled.