2009: Healthcare and decision-making in dementia
Consent to medical treatment
The issue of consent is addressed in paragraph 2a of the Health and Medical Services Act (1982:763) which states that "health and medical services shall be conducted so as to meet the requirements of good care" - one such requirement being the obligation to respect the patient's self determination and integrity. This article further stipulates that care and treatment shall as far as possible be designed and conducted in consultation with the patient.
According to Leenen et al. (1993), relatives are generally consulted but they do not have a specific right to consent to treatment on behalf of an incapacitated person. Consent can be obtained from a custodian who is responsible for ensuring that his/her ward receives the care that he/she needs. If this is not possible and the patient is unable to consent, the doctor must decide on the appropriate treatment in the light of medical science and proven experience. Patients who are subject to involuntary internment are consulted whenever possible during the period of care. However, questions concerning treatment are ultimately decided by the chief medical doctor of the unit in which the patient is being cared for.
Where appropriate, a patient's next-of-kin is also consulted. The significance of the next of kin (anhöriga) is somewhat unclear in that opinions often vary as to who is entitled to represent a patient. (Leenen et al., 1993).
According to Karin Sparring Björkstén (1999), ECT can be given to people with dementia without their consent, but this is extremely rare as one of the consequences of ECT is memory loss.
Consent in case of emergency
People can also be treated without their consent in case of emergency.
Consent to research
The Swedish National Council on Medical Ethics is an advisory board to the Swedish Government on ethical issues which arise as a consequence of scientific and technological advances in medicine. The council analyses the issues from a broad national perspective.
In 2004 a new law was introduced in Sweden: The Act on the Ethical Review of Research Involving Humans (SFS 2003:460). It covers research on living persons, but it also covers such fields as research on the deceased, research based on biological material from people and research that deals with sensitive information about people including information regarding criminal offences.
There are six regional research ethics committees and one central ethics board. According to the law, these bodies are given detailed instructions regarding their work i.e. what their duties consist of. This year, the Government is proposing to Parliament some revisions in the law with the aim of elucidating certain paragraphs.
The law contains extensive rules on information and consent. In principle, research involving living people requires that the person in question has been informed and has given his/her consent. In some cases, research can be carried out without consent from the person concerned if he or she suffers from a mental disorder or poor health. In these cases, close relatives or guardians should be consulted.
Access to information/diagnosis
The right to be informed
In accordance with the Health and Medical Services Act (SFS 1982:763) patients must be informed of their state of health and of the treatment methods available. If this information cannot be supplied to the patient, it must be supplied to a close relative. This obligation is echoed in chapter 2 paragraph 2 of the Health and Medical Personnel (Duties) Act (SFS 1998:531).
The doctor’s right to withhold information
According to chapter 2 paragraph 8 of the Health and Medical Personnel (Duties) Act (SFS 1998:531), confidentiality of information also applies to the patient in that information about a patient's state of health may be withheld if it is felt that, bearing in mind the purpose of the care or treatment, it is highly important that it is not supplied to the patient.
Confidentiality/disclosure of information to other people
In the Health and Medical Personnel (Duties) Act (SFS 1998:531) it is stated that health professionals may not improperly divulge matters which come to their attention concerning the state of health or other personal matters of individuals. Provisions covering public health and medical care are also contained in the Secrecy Act (SFS1980:100).
Confidentiality in the case of potential danger
If a person who possesses a firearm is admitted to hospital for the care of a mental disturbance and the doctor who is directly responsible for his/her care is of the opinion that he/she should not possess one, it is this doctor's responsibility to report the matter to the police (Arms Act (SFS 1996:67).
End-of-life care and issues
The Swedish criminal code does not specifically deal with euthanasia.
A person who helps another to commit suicide or brings about his/her death can be faced with an accusation of murder or manslaughter. Please see 220.127.116.11 below.
A person who helps another to commit suicide or brings about his/her death can be faced with an accusation of murder or manslaughter.
The relevant articles relating to murder and manslaughter can be found in Chapter 3 of the Swedish Criminal Code (SFS 1962:700):
Whoever causes the death of another person is guilty of murder and condemned to ten years' imprisonment or to life imprisonment.
If the crime mentioned in paragraph 1 is considered less serious as a result of particular circumstances or other factors, the sentence is that envisaged for involuntary (guilty) homicide, at least six and at most ten years' imprisonment.
In the Swedish criminal code, tribunals can, under certain circumstances, inflict sentences which are less severe than those foreseen by the law. In the case of murder or manslaughter, as well as in certain circumstances, the criminal code grants the tribunal discretionary power to determine the punishment. In particular, the judge can inflict a lighter sentence on a person, if the accused is motivated by profound human compassion. The relevant dispositions are covered in Chapter 29 of the Criminal Code which states:
In order to ensure a uniform administration of justice, punishment shall be determined within the framework of punishment applicable according to the crime or crimes altogether.
At the time of the determination of punishment, special attention should be paid to damage, violation or danger engendered by the act, to the perception of the accused or that which he/she should have, as well as his/her intentions or motives.
At the time of determining punishment, the following points must be borne in mind – besides those which apply to particular cases – as attenuating circumstances.
Was the criminal act provoked by the serious reprehensible behaviour of somebody?
Was the ability of the accused to control his/her actions seriously diminished due to mental disorder or a state of excitement or another cause?
Has the behaviour of the accused been clearly influenced by a developmental retardation, lack of experience or a diminished judgmental capacity?
Is the crime the result of a great compassion for another individual?
Lighter sentences than those foreseen for such crimes can be given in these circumstances.
Leenen, H., Gevers, S. and Pinet, G. (1993),The Rights of Patients in Europe, Kluwer Taxation and Law Publishers, Boston
Sparring Björkstén K (1999), Information provided in the context of the original Lawnet project
 Senior psychiatrist and geriatrician
Last Updated: Wednesday 27 April 2011