Court rules that a person with dementia can be forcibly euthanased

The district court in the Hague has ruled that a person with dementia may be euthanased even if the person is actively resisting the process provided that an advanced directive requesting euthanasia was completed when the person was considered competent.

The case involved a 74 year old woman whose coffee was drugged and who was forcibly restrained by family members while a doctor administered a lethal injection. She had said just a few days before that she didn't want to die.

However, the Court ruled that as she was now demented neither her contemporary expressions of a desire to live nor her active resistance were of any legal value. They were trumped by her previous written declaration.

The legal question posed by the case was stated by the Court:

Does the physician have a duty to verify the current desire for life or death of an incapacitated, deeply demented patient in order to speak of a voluntary, well-considered request for euthanasia?

The Court's answer was a clear no.

The court is of the opinion that the doctor did not have to verify the current wish to die. The patient was deeply demented and completely incapacitated. The use of pre-medication [that is drugging her coffee] was discussed with the family and doctors and was not negligent in this case. 

The written advanced declaration signed by the woman included the following paragraph:

This euthanasia request remains in full force regardless of the time that may have elapsed since it was signed. It is completely clear to me that I can withdraw this euthanasia request. By signing this euthanasia request I therefore consciously accept the possibility that a doctor will respond to the request, about which I might have started to think differently in the case of current awareness.

There is an apparent contradiction in this paragraph. On the one hand the request can be withdrawn; on the other hand the doctor can act on the request even if the person has "started to think differently".

The Court essentially decided that as soon as a person with dementia becomes incapable of the level of decision making required to make a valid request for euthanasia, the person then can no longer validly revoke a previously made advanced directive for euthanasia.

In the opinion of the court, it would be contrary to the purport of the [euthanasia law] that a person who once became incapable of doing something would be able to revoke a legally valid euthanasia request previously made by him or her.

The Court considered evidence from the woman's GP who had met with her on 28 January 2016, three months before she was euthanased on 22 April 2016. The GP testified:

I wanted to know what she was like and what she thought about this [euthanasia]. I asked how it went and she said "it goes well". I then asked about admission and euthanasia. She didn't know what that was, the euthanasia. I explained it to her and at that moment she said, "no, I don't want that." I explained to her that she would be admitted and that she had to stay there and that she had previously indicated that she did not want that and then I started talking about euthanasia. She said: "yes, maybe I want it, but not now." You ask what my impression of her was, if she still understood. No. (…) For me it was the moment that she did not know exactly what euthanasia meant. You ask if I had the impression that she understood me after I explained what euthanasia meant. Yes, because I explained it to her. Because of her reaction to this, I felt that she understood what I meant. (..)

Counsel asks me whether (patient) was competent on euthanasia on this day, 28 January 2016. Not as far as I can judge. You, Commissioner-in-Law, ask me to explain why not. Before my explanation of euthanasia, she did not know what it meant. I had to go so far that I told her she would get an injection and not wake up. Only then did she say "no, no".

The geriatrician who euthanased the woman testified about an exchange with her on 10 March 2016, just seven weeks before she was euthanased:

(…) March 10, 2016 (...) Then I ask if she hates dementia. She does not recognize that word. I ask further whether she is troubled by the fact that she has less good memory and whether she finds it bad. She replies that she had that, but that this is already better, luckily. Then I ask her if she would rather be dead: yes, if I get sick, I will, but not yet

The Court dismissed medical guidelines requiring a doctor to check whether a person has a current desire before euthanasing him or her.

The court is aware that in the medical world guidelines have been drawn up about medical treatment in euthanasia in which the position is taken that the treating physician must also try to verify the patient's position on his current euthanasia desire even in the case of incapacitated persons. However, as is clear from the legal history cited above, that position is stricter than the law. From the point of view of medical care it may be advisable to speak with the person. However, the court was unable to see the need for this, let alone that there is a legal obligation to do so.

Any resistance can just be dismissed as "reflexive reactions that did not penetrate the consciousness of the patient."