The risk group for AAA screening includes people (men) aged 64+. It does not exclude people of (much) higher age and disability. The risk of mental illness, especially dementia, increases with age, which is likely to result in a higher proportion of incompetent people in this age group who will need eventually to be patronised. Approximately 1% of 65 year olds and more than 50% of 90 year olds have a dementia disorder. {17} The prevalence of severe dementia increases with age, from 6% (for people 65–69 years of age) to almost 25% (for people 95 years of age or older) {18}.

Who decides about screening and following treatment in the case of a positive screening result for a patronised person?

Can there be a legally based general rule? (i.e. cut off for people in nursing homes?)

Can it be ethical to treat everybody?

What might influence the decision of the guardian (inheritance law, co-payments)?

States Parties recognise that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. {19}

There are several court decisions about the treatment of patronised persons. {20}

"...most authorities are of the view that mature minors should be fully informed and be allowed to have a say in health decisions, coaching them with few exceptions. Ultimately, because of the importance of respect for human dignity, autonomy and self determination along with medical disclosure in today's world, it will be recommended that laws in a number of jurisdictions need to be reviewed to reflect the current international trend and amended or replaced as the need might be." (Bello 2010) {21}

The decision about screening for AAA in minors is not the main problem in this field. In accordance with their right to the same healthcare as others they have the right to equal access to AAA screening. The severity of the problem starts with a positive result of AAA screening (i.e. an existing AAA which needs to be treated surgically) and the need to decide about the surgery procedure.

In the case of a decision to refuse surgery there must be proper controls to ensure that the patient's interests have priority, and to assess whether there are interests in possible benefits for the guardian (inheritance law, co-payments), especially if a family member is the guardian and the potential inheritor.

In the best case, the AAA is detected by screening, the repair with a stent is done by endovascular means with minimal invasive surgery and everything is fine. It would make sense to everyone to protect the person from a sudden (painful) death due to rupture.

In the worst case the detected AAA is in a bad location requiring an extensive surgical procedure including extracorporal circulation time. This would raise the question of whether the benefit for the patient (% probability of survival, % probability of rupture) exceeds the harm for the patient (OP risk, burden of intensive care, pain, torture, etc.). {22}