Do Alzheimer's Patients Have a 'Duty to Die?'

Sept. 25, 2008— -- When Dr. Jonathan Groner, a surgeon and ethicist at Ohio State University, heard of a suggestion by a well-known British philosopher that those with dementia have a "duty to die" in order to minimize the burden they place on society and their families, he was troubled.

First, there were the moral implications of the comments that 84-year-old Baroness Mary Helen Warnock shared with the Church of Scotland's Life and Work magazine last week, in which she stated, "If you're demented, you're wasting people's lives -- your family's lives -- and you're wasting the resources of the National Health Service."

Such a policy could put society on a slippery slope, he said. And he noted many of the potential moral pitfalls accompanying the suggestion that those suffering from dementia should make a decision to end their own lives.

But Groner said losing his own father to Alzheimer's in January has perhaps given him the most insight into the issue -- and why the lives of dementia sufferers must not be devalued.

"I think that people with dementia are not worthless," Groner said. "Dementia is a huge problem, and it will be a growing one as more people get dementia. But trying to kill them off is probably not the best solution."

Groner is not alone in his opinion. Ethicists and Alzheimer's advocacy groups alike are expressing outrage over Warnock's comments last week, which echoed the opinion she put forth in an article she authored for a Norwegian periodical, titled "A Duty to Die?"

"The suggestion made by Baroness Mary Warnock is ignorant, insensitive and cruel, and denies the humanity of people with Alzheimer's and dementia," the Alzheimer's Association said in a statement issued Wednesday.

"We dispute the fact that if you have dementia or some part of Alzheimer's that you cannot have a quality lifestyle," noted Paul Williams, director of public policy for the Assisted Living Federation of America. "We've seen in the last 10 years that these residents have been able to have the most independence and the quality of life that can be expected of them. ... Just because you have a memory disease [doesn't mean] that we let you die and we can kill you."

And Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he was "shocked" by the comments when he read them.

"No one has a duty to die," he said. "The notion that society should 'expect' someone to end their lives because they fear being a burden upon others is simply ethically repugnant."

Sacrificing Dementia Patients: The Legal Question

Not the least of the ethical concerns associated with Warnock's suggestion is the concept of obtaining informed consent from someone with dementia.

"The demented person cannot undertake a 'duty to die,'" said Dr. Sam Gandy, chair emeritus of the National Medical and Scientific Advisory Council for the Alzheimer's Association. "Insight is lost early in many demented people, so that at the moment that Baroness Warnock thinks that they should die pro-actively -- at their own hand, I presume? -- all those people will have lost the capacity to make informed consent and many will have lost insight as well: The demented don't realize that they are demented. They often think that everything is fine."

Gandy said that this situation would subsequently put family members in the position of choosing whether to assist a relative who has dementia with their suicide -- or enlist a doctor to bring about death.

"That still amounts to murder in this country, which is why I say that [Americans] must first debate and draw the boundaries of euthanasia before the Warnock proposal can be entertained here," he said.

Indeed, current laws would prohibit anything approaching a mandate to artificially hasten the death of those with dementia.

"As we search for ways to bring mounting health care costs under control, it is tempting to want to give preferences in access to expensive care to people who are highly functional, at least mentally," said Maxwell Mehlman, director of the Law-Medicine Center at Case Western Reserve University School of Law. "Oregon tried to do this when it adopted its Medicaid rationing program in the early 1990s, and was blocked by both the Bush and Clinton administrations, which interpreted the Americans with Disabilities Act to prohibit discriminating against persons with disabilities in allocating access to health care services."

Since this law is still on the books, Mehlman said, any government attempt to put Warnock's ideas into practice would be illegal.

An Old Idea

Mehlman added that Warnock is not the first to put forward the idea of limiting health care for the elderly. In 1987, American bioethicist Daniel Callahan expressed a somewhat similar idea in a book titled "Setting Limits."

"Callahan advocated that Medicare stop paying for the elderly after they reached a certain age," Mehlman said. "Although Callahan was not absolutely clear on this, it appeared that the cut-off age was to be around 82. ... Callahan was roundly criticized for his view, including by me."

And in at least one instance in recent history, Groner said, such Machiavellian principles have been put into practice.

"In the beginning of the era leading up to World War Two, Hitler decided that he would need more hospital beds," he said. "If you were an individual with dementia or a child with a deformity, you didn't stand a chance."

But Groner said he felt there are better ways to control health care spending.

"In terms of costs to society, I think smokers cost more," he said. "Alcohol abuse I think is pretty expensive, too. So why pick on elderly people with dementia?"

Lara Salahi contributed to this report.