Thank you for your question.
That was part of the last section of my brief. I didn't have the time to read it all, because of the stress. I'm sorry.
Regarding autonomy, it must actually be exercised in context. We need the context, we need to know who is involved in the decision, what the environment is, and what the social and health context is.
Imagine that I asked you, three years ago, to make a decision concerning your end of life care. You would probably not have made the same decision as you would now, after the pandemic, after everything that has gone on in long-term care homes. Autonomy has to be exercised with the elements that are present in the decision.
Doing it in advance, we are not really in a context involving the exercise of autonomy. Advance medical directives, while we believe they promote autonomy, serve much more as a decision-making guide, that is, to guide the substituted decision. I am talking here about a substituted consent given by family or a decision that is, at best, much more benevolent and more beneficial for the patient.
So we are in a register that is not really one of autonomy, with advance medical directives, because we are not exercising autonomy in context; it is really autonomy at the time the decision is made. However, at that point, we don't know what is going to happen in the future. None of us is capable of predicting what will happen, especially not in a situation of dementia or evolving cognitive impairment. The context can always change, particularly in the case of geriatric care, as we have seen in recent years.
As geriatricians, we were aware that there were problems in long-term care homes, but the pandemic really revealed them to the public. Imagine if you had made a decision five or ten years ago. Would your decision have changed? That is what I would say about the context.
As well, the person also changes with dementia. The experience of dementia is extremely unsettling. It changes the lives of everyone around the person affected. We are not even talking about the same person anymore. The person has changed. They no longer exercise their autonomy, at that stage. It is very risky to permit medical assistance in dying in a context in which the person is not in a situation of autonomy, and is rather in a situation of substituted consent or even the benevolent decision of the medical or care team. It should not be permitted in that context.
That would be a seriously bad practice. I spoke about ageism, ableism and issues of discrimination and stigmatization associated with mental health problems. Even the decision concerning the use of medical assistance in dying in a dementia situation is very warped by all these components, which may be internalized by the person. In my opinion, this is not genuine autonomy. Autonomy must be exercised in context. The risk of including medical assistance in dying in advance directives is a very big one because, in medical terms, there may also be all sorts of elements that create conflicts of interest, for example the need to free up emergency beds, to allocate resources differently, and so on.