Rational suicide and dementia.

In this opinion piece, Davis proposes that suicide is a reasonable response to impending dementia and that the move towards pre-symptomatic diagnosis of Alzheimer's disease (AD) now makes rational suicide a more feasible option for those so inclined. Three broad reasons are proposed for earlier death through rational suicide: to conserve financial assets; to reduce family burden of care; and to allow people to end their lives 'with a final chapter that is consonant with the narrative as a whole'. There are numerous barriers to ending one's life to avoid living with dementia. Even though Davis admits that few types of dementia have accurate genetic prediction, clinicians are criticised for their paternalistic attitudes in not doing genetic tests and divulging results to people who indicate an interest in rational suicide. The 'Catch-22' dilemma with dementia is discussed – people don't want to die while they remain competent, but they are unable to suicide when they have lost capacity. In jurisdictions where assisted suicide is legal, the person must be competent to make the decision. Advance directives can be ignored and many authorities believe that 'they lack the full moral force of contemporary choices and that respect for precedent autonomy is misdirected or downright unethical'. Davis does not accept these viewpoints but concedes that they are difficult to refute and add further weight to the notion of pre-emptive suicide for those so inclined. The increasing accuracy and availability of biomarkers may herald an era when the onset of dementia can be predicted in time for the person to make a rational decision to suicide. Davis believes that 'direct to consumer' genetic testing bypasses the clinician barrier. She states that 'it has become increasingly possible to diagnose AD by laboratory tests' and mentions the revised AD research criteria that incorporate biomarkers for pre-symptomatic diagnosis. Finally, Davis argues that gatekeepers such as researchers, clinicians and policymakers need to acknowledge the option of pre-emptive suicide when deciding how to allocate resources and provide information about biomarkers to research participants and patients so that they can make an exit strategy if desired. COmmENTary There is divided opinion about the rights and wrongs of rational suicide, 1 but that debate is not the focus of this article. The two key issues raised are the accuracy of biomarkers in pre-symptomatic AD or other types of dementia and about the obligations of clinicians and researchers to provide this …