Abstract
Euthanasia is a deliberative intervention embracing the determination of ending a life so as to alleviate awkward and unbearable suffering. It is only taken into consideration when by the person is mentally competent. With the advance of medical knowledge, there is a better understanding of the prognosis of dementia. Individuals’ diagnosed with dementia often expresses that they do not want to be a burden to their family members as the disease progress and often expresses they want to end their life before they are not able to take care of themselves. The aim of this paper is to critique the feasibility and ethical considerations of euthanasia among individuals diagnosed with dementia using ‘MORAL’ ethical decision-making model. Patient (individual diagnosed with dementia), caregiver, nurses and physician should be included in order to have a deeper understanding of the euthanasia ethical dilemma. Different options such as treatment available, type and strategies appropriate for the dementia case, appropriate ethical theories in the dementia case (beneficence and autonomy). Then, it is essential to review and “look back” at the case. In order to enhance the possibilities of euthanasia among individual with dementia, advance directives on euthanasia could be an option.
Keywords: Euthanasia; Dementia; Moral ethical model
Introduction
Euthanasia is a subject of much controversy worldwide in that it touches on different parties’ rights and responsibilities as well as diverse ethical concerns. Euthanasia is a deliberative intervention embracing the determination of ending a life to alleviate awkward and unbearable suffering [1,2]. Euthanasia is embraced and legislated in some countries, including Dutch, Belgium, Luxembourg, Colombia, Canada, several States in America [2]. In Dutch, patients who have a desire for euthanasia must be proved by two physicians that they are under unbearable suffering with no anticipation of improvement which is no need to be linked up with terminal diseases and not restricted to physical illnesses, and they must be competent, well-informed with sufficient information which ensures that their requests are constructed on a voluntary basis and after a careful deliberation [2,3].
Desires and concerns over euthanasia among patients being diagnosed as dementia have arisen in recent years. However, there is limited evidence that whether the request of euthanasia made by | dementia patients should be accepted and whether it is the best option for them. Therefore, ethical dilemma emerged ascribed to the difference between patients’ desired goal and current mainstream situation worldwide. In order to explore and resolve the ethical dilemma of this controversial issue, this paper had used Crisham’s ‘MORAL’ model as a framework for guiding the analysis of ethical dilemma on individuals diagnosed with dementia patients and future recommendation on the issue was discussed.
Dementia
Dementia refers to an incurable, progressing deteriorating and chronic syndrome with a gradual decline of cognitive functions, including memory loss and impaired judgement which impedes activities of daily living and quality of life [4,5]. Deterioration in emotional control, personality change and behavioral problems are also commonly seen in patients with dementia [4,6]. There are several types of dementia, which Alzheimer’s disease which is the most common form of dementia, vascular dementia, dementia with Lewy bodies, Parkinson’s dementia, frontotemporal dementia, etc. [5,6]. According to Boyd 2014 [4], course of dementia can be classified into three stages: Mild stage is manifested by loss of memory, mood swing, diminished judgement and aphasia; Moderate stage is characterized by inability to retain new knowledge, behavioral change such as aggression and agitation; In severe stage, patients will demonstrate motor disturbance like apraxia, immobility, inability to perform activities of daily living and inability to communicate.
Different Types and Strategies of Euthanasia
Euthanasia can be categorized into three types namely
1) Voluntary euthanasia arises based on patients’ request to die on his/her own free will (British Broadcasting Corporation, 2014a) [7,8].
2) Involuntary euthanasia is the one without the patient’s request and consent, or even when patient expressed intention to life, yet euthanasia is enacted according to the physician’s decision (British Broadcasting Corporation, 2014a; Shea, 2010) [7-9].
3) Nonvoluntary euthanasia is when patients are unable to give informed consent, such as patients who are unconscious or in a persistent vegetative state, children who are not mentally or emotionally competent (British Broadcasting Corporation, 2014a; Jones, 2011) [7,8,10].
Euthanasia can be carried out in either active or passive way. Active euthanasia occurs when a patient’s death is directly brought by a deliberate act by a facilitator [1]. While passive euthanasia refers to patient’s death is obliquely brought by an exclusion like withholding or withdrawing life-sustaining treatments such as surgery or apparatus such as respirator and Ryles Tube, for the maintenance of the patient’s life [1].
‘MORAL’ Ethical Decision-Making Model
Gaining a thorough understanding and getting into a deep analysis, an ethical decision-making model called ‘MORAL’ Crisham, 1985 [11] was used in the decision-making on euthanasia request in persons who have been diagnosed as dementia. According to Crisham1985 [11], this model consists of five parts: ‘M’ for Massage the Dilemma: In order to evolve a thorough and ample understanding of the issue, it calls for collecting relevant and vital data such as values, concerns and interests between parties involved and point out conflicting contexts [8]; ‘O’ for Outline Options: It entails impartial and systemic consideration and reflection of every possible choice which helps solve the conflicts; ‘R’ for Review Criteria and Resolve: This step emphasized on recognizing moral criteria and ethical principles that help generate moral judgement; ‘A’ for Affirm Position and Act: It requires to execute the planned actions; ‘L’ for Look Back: it highlights evaluations on change of person’s perceptions, comprehensiveness of options, effectiveness and practicability of actions implemented and whether the conflicts are resolved [12].
M: Massage the Dilemma
This process aims to identify whose interests are involved in the conflict, define the dilemma from and consider options of the all the major parties’ perspectives or values [13]. This includes patients, caregiver, nurses and physicians.
Patients
Dementia is a medical condition that leading to gradual loss of abilities over a lengthy period of time [14]. It has impacts on a patient’s social, psychological, emotional and economic aspects. By the knowledge that dementia is a progressive disease that the condition will get worse, typically involving loss of memory, mood and behaviours changes and deterioration with cognitive functions [14], patients considered the state of advanced dementia is devoid of dignity and unbearable [3]. Patients do not want to be obliged to undergo the future decline and suffering. This is a main reason for those who opt for euthanasia in the early stage of the disease [3].
There are social factors affecting the patient’s decision on euthanasia. Patients might be directly or indirectly pressured into requesting euthanasia by caregivers who are no longer able or willing to carry the burden of care; or they might request euthanasia in order to alleviate the burden of their care for their caregivers [15]. Besides, religious perspectives on euthanasia would be a consideration factor. Most of the major religious organizations, including Christianity, Buddhism are opposed to euthanasia as treated their lives were a gift from God and they prohibited intentional killing [16]. Therefore, those believers would not perform euthanasia.
Caregivers
Caregivers suffer from tremendous physical and psychological stress. Caregivers sacrifice their own needs and well-being to provide care for dementia patient, including managing changing demands and unexpected behaviours [17]. Patients may wish to not only relieve their own suffering but also the suffering of the people they love [15]. Supporting euthanasia to relieve patients and the caregiver suffering. However, it is noted that not all caregivers had distress and burden. Some of them reported satisfaction with providing care, such as feeling needed and useful, developing appreciation of life and strengthen the relationship between them and patients [17]. Those caregivers might object to dementia patient’s request for euthanasia.
Physician
Health care providers play an important role in euthanasia. Physicians are the gatekeeper as their duty is to sign approval for euthanasia of patients, so they face high psychological stress. In the Netherlands, where euthanasia is legal, nurse’s role includes registering the request, making the decision, assisting the euthanasia, and aftercare [18]. Nevertheless, euthanasia may be seen as intentionally hasten the end of life in some of the medical professional views [19]. This is because both specialists Code of Professional Conduct stress on do minimize harm to patients, so performing euthanasia should be the last resort if no alternative, such as palliative care is available [20,21]. However, it is crucial that both specialists acknowledge that patients are fellow human beings who are worthy of dignity and respect [22].
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