Chuang Elizabeth, Flicker Lauren Sydney
Hastings Cent Rep. 2018 Jul;48(4):24-25. doi: 10.1002/hast.866.
In "On Avoiding Deep Dementia," Norman Cantor astutely notes that, for some individuals, the concept of "protracted maintenance during progressive cognitive dysfunction and helplessness is an intolerably degrading prospect." This cannot be argued with. Cantor's solution, however-that in the wake of a dementia diagnosis, patients should have the option to direct, in advance, instructions for voluntary stopping of eating and drinking should they develop a state of deep dementia-is more ethically challenging than it may first appear. Respect for autonomy is one of the most fundamental principles of bioethics, and it requires that we allow patients with capacity to refuse life-sustaining treatment, even when that treatment is something as seemingly innocuous as nutrition and hydration. If a capacitated person uses an advance directive to prospectively refuse artificial nutrition or hydration, then that treatment must be withheld if the person develops dementia and loses the ability or willingness to eat. Cantor is incorrect, however, in suggesting that an advance directive can require that nutrition and hydration be withheld from a patient with dementia who actively requests to eat or drink. Regardless of the language in an advance directive, caregivers cannot be compelled to abandon their duty to attend to the person's human dignity, nor can physicians be compelled to sedate a person with moderate or severe dementia because that person continues to be receptive to eating and drinking.
在《论避免深度痴呆》一文中，诺曼·坎托敏锐地指出，对一些人来说，“在进行性认知功能障碍和无助状态下长期维持生命是一种令人无法忍受的有辱人格的前景”。这一点无可争议。然而，坎托的解决方案——即在痴呆症诊断之后，患者应该有选择权，提前指示如果他们发展到深度痴呆状态，可自愿停止进食和饮水——在伦理上比乍看之下更具挑战性。尊重自主权是生物伦理学最基本的原则之一，它要求我们允许有行为能力的患者拒绝维持生命的治疗，即使这种治疗看似无害，比如营养和水合作用。如果一个有行为能力的人使用预先指示前瞻性地拒绝人工营养或水合作用，那么当这个人患上痴呆症并失去进食能力或意愿时，就必须停止这种治疗。然而，坎托认为预先指示可以要求不给主动要求进食或饮水的痴呆症患者提供营养和水合作用，这是不正确的。无论预先指示中的措辞如何，都不能强迫护理人员放弃照顾患者人格尊严的责任，也不能强迫医生给患有中度或重度痴呆症的患者镇静，因为该患者仍然愿意进食和饮水。
