Medical Assistance in Dying committee  Oregon was the first state in the United States to legislate end-of-life physician-assisted suicide. If you look at the Oregon reports, you see that one of the repeated drives for requests is the fear of becoming a burden on the family. People don't like it, and therefore they'd rather die.

Medical Assistance in Dying committee  It's because maybe at that time he doesn't want to die anymore, and it happens quite a lot. Orders don't—

Medical Assistance in Dying committee  You want to enforce the autonomy of the previous stage of the person, when the person actually changed. What I want to say is that we always change all the time. When we are competent, we change, let alone when we don't know or understand the brain enough to make a decision about the patient now when he is in advanced dementia.

Medical Assistance in Dying committee  I want to clarify that I'm not opposed to advance directives for competent, autonomous patients; I'm opposed to advance directives when it comes to incompetent patients. As I said, I sat on the committee that legislated the Dying Patient Law—

Medical Assistance in Dying committee  I refer in my testimony to the issue of dementia particularly, because I know that it's an issue in Canada. Just imagine the following. A person has been diagnosed with dementia. It's the starting of a process that can last years. At the start, he says that he would like to die in the later stages of dementia.

Medical Assistance in Dying committee  I'll make two very short comments. One is that any advance directive should be restricted by time. When I assisted the legislation of the Israeli law, we set up a framework whereby people could renew the living will or advance directive every five years. That's the first comment.

Medical Assistance in Dying committee  I want to say something general about advance directives for competent patients and for incompetent patients. I studied this in nine countries, including Canada, although I was last in Canada in the early 2000s, so I haven't been here in the past 10 years or so. In my studies, you can see time and time again that doctors who deal with dementia patients tell you time and time again that it might be the case that when a person in a certain situation comes to their end of life, knowing that they're going to end up not recognizing their own life, their relatives and so on, they change their mind.

Medical Assistance in Dying committee  I've spent a lot of time in Belgium and in the Netherlands. In the Netherlands, I saw advance directives of, let's say, something like “I would like to die if I don't recognize my children anymore.” This is a statement made by a competent patient with a sane mind and so on, but God forbid it comes to the later stages.

Medical Assistance in Dying committee  —and, of course, nobody is going to take this seriously. I went to a nursing home in Amsterdam and spoke with Dr. Bert Keizer, who wrote a very famous book, Dancing With Mr. D. Bert supports euthanasia for patients, but he finds it very difficult to support it for patients with dementia because he understands what it means.

Medical Assistance in Dying committee  Yes. What we should do is humanize care for the living. The liberal state has an obligation to protect all people, especially the vulnerable. To resolve the conflict between past competent and current incompetent interests, it is suggested that instead of simply enforcing all prior directives, doctors, families, and other people involved in the care of incompetent patients should be able to examine whether the patient's interest would be best served by actions contrary to advanced directives.

Medical Assistance in Dying committee  Good afternoon, good evening. Thank you for your invitation to present my views on end of life today. My name is Raphael Cohen-Almagor. For more than 30 years, I've been studying end-of-life concerns. Ethically speaking, I think patients should be able to receive medical aid to end their lives.