Controlling the End Game of Dementia

In her New York Times article of January 20, “Complexities of Choosing an End Game for Dementia”, Paula Span reviewed the use of advance directives to withhold food and water as a way of avoiding living long into dementia. She wrote that “ethicists, lawyers and older adults themselves have begun a quiet debate about whether people who develop dementia can use VSED [voluntary stopping eating and drinking] to end their lives by including such instructions in an advance directive.” Part of that debate was conducted in the Hastings Center Report last May-June in an essay by us that Span cites.

Span’s article elicited more than 400 comments, with opinions ranging from vigorously supportive of such directives to strongly critical. Our purpose here is to put some of the main criticisms expressed in these comments in perspective by viewing directives to withhold food and water by mouth in their larger context, as one among an array of strategies that people can employ to control how long they live.

Even among those who were sympathetic, some who commented on Span’s article criticized such directives as inadequate. Dying by starvation and dehydration, while often comfortable, may still involve suffering; legal difficulties remove the assurance that such directives will be implemented; and death may still come objectionably late if implementation of the directive has to wait until dementia is so severe that life retains little subjective value. The picture that focusing on such limitations paints is unduly pessimistic.

Let’s first clear aside an unrealistic wish. Some critics advocate active aid-in-dying as a far superior way to die than stopping eating and drinking.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.