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Surgical intervention in dementia.

In this issue Mr George Gafner describes a proposal to quieten the incessant yelling ofa severely demented old man by cutting one of the nerves supplying his vocal cords in order, in effect, to turn down the volume ofhis shouting. The proposal was accepted by a multidisciplinary group within the hospital concerned and by the patient's wife (who, although at the time was feeling guilty, ambivalent and anxious and 'like I'm on an emotional roller coaster', nonetheless a year after her husband's death still believed that the operation would have been justified and that her husband would have opted for it had he been able to do so). However, the operation was turned down by the Department of Surgery at the hospital on the grounds that it carried some risk and involved non-medical surgery: 'it was unethical to operate on healthy tissue'. In a commentary on Mr Gafner's paper Dr George Robertson rejects the option of such surgery, suggesting that if a surgical solution is sought tracheostomy would be simpler, safer, more effective and reversible if circumstances changed. But he adds that to concentrate on the pros and cons of surgical interventions in such a case would be inadequate-instead the broader issue of the aims ofmedical care for severely demented patients requires analysis. For example the patient had had 'recurrent pneumonias'-what was the good of treating these? Was such treatment likely to 'improve the general condition of the patient'? A host of drugs had failed to quieten the patient-was this because of under-dosage so as to avoid periods ofunconsciousness and reduce the risk of pneumonias? Why? Should not the achievement of a more dignified state for the patient than that of continuing shouting be aimed at? Would written evidence of what the patient would have wanted in such circumstances have helped to resolve matters, including written evidence about whom he would have wished to be his proxy decision-maker? In trying to analyse such issues it is often helpful to start with the normal case. In the case of loud and protracted shouting by a patient in a hospital the 'normal case' is hard to discern but perhaps help can be gleaned from some 'philosopher's examples'. Thus, suppose a hospital patient voluntarily and persistently shouted, severely disturbing other patients, family and staff, then steps would properly be taken to change the person's mind by reasoning. If that were unsuccessful then depending …