13. autonomy and dementia

Advance directives

• Instructions given by

individuals specifying what

actions should be taken for

their health in the event that they are no longer able to make decisions due to illness or incapacity.

• E.g., "Turn off life support if I've lost most mental

faculties."

Margo

• Alzheimer's disease

• Very happy

• "Despite her illness, or maybe because of it, Margo is undeniably one of the happiest people I have known."

Whose right to autonomy matters here?

• We are not considering someone who was always demented, but someone who was once competent and is now demented.

• We can view this person in two ways:

1. A demented person (looking at their present situation and capacities).

2. A person who has become demented (looking at the course

of their whole life).

• Does a competent person's right to autonomy include the power to

dictate that life‐sustaining treatment be denied them later (if, for example, they become demented)?

two views of autonomy

the evidentiary view and the integrity view.

Evidentiary view

we should respect the decisions people make

for themselves, even when we regard these decisions as imprudent, because each person generally knows what is in their own

best interests better than anyone else.

Margo on the evidentiary view

• On the evidentiary view, demented Margo has no right to autonomy.

• Demented Margo is no longer a reliable judge of what is best for her.

• How about Past Margo? Should her advance directive decide what

happens to Demented Margo?

• We can't accurately predict what dementia will be like for us.

• Past Margo could reliably judge what was best for Past Margo, but her choices about Demented Margo may not track what is best for Demented Margo.

• So maybe not.

Some problems with the evidentiary view

• The evidentiary view doesn't seem to line up with why we think autonomy matters.

• We let people make decisions that aren't in their best interests all the time out of respect for their autonomy.

• Smokers

• People who give kidneys to stranger

• Dworkin prefers the integrity view of autonomy.

Integrity view

we should respect the decisions people make for themselves, even when we regard these decisions as imprudent, because people have a right to live a life structured by their own values.

• Autonomy as kind of self-

authorship.

• What the right to autonomy protects: our capacity to structure a

coherent, value-expressive life.

Margo on the integrity view

• On the integrity view, Past Margo plausibly has a right to decide what will happen to Demented Margo.

"A competent person making a living will providing for his treatment if he becomes demented is making exactly the kind of judgement that

autonomy, on the integrity view, most respects: a judgement about the

overall shape of the kind of life he wants to have led."

Summing up Dworkin

• Neither the evidentiary or integrity view recommends a right to autonomy for severely demented people.

• Integrity view supports respecting the person's earlier, non-demented preferences.

• If the integrity view is right, we have a reason to follow an advanced directive like "if I become severely demented, withdraw life-sustaining treatment".

• (Of course, depending on the case, there might also be some other overriding reason to not respect autonomy.)

Experiential interests

good experiences (playing softball, eating well, walking in woods, sailing).

Critical interests

the hopes and aims that lend genuine meaning

and coherence to our lives (friendships, children, competence at work).

• "Our critical interests explain why many of us care about how the final

chapter of our lives turns out ... For most people, Dworkin writes, death

has a "special, symbolic importance: they want their deaths, if possible, to

express and in that way vividly to confirm the values they believe most

important to their lives"

Dworkin: critical > experiential interests

• Dworkin thinks these critical interests outweigh experiential interests.

• Past Margo's choices matter most.

• Even if Demented Margo enjoys her life, Past Margo's directives should prevail.

• "To honor the narrative that is Margo's life, we must honor her earlier choices."

• Dresser disagrees.

(Some of) the issues with Dworkin's model

• People don't always value "life narratives" as much as Dworkin assumes they do.

• The distinction between critical vs. experiential interests is often vague. E.g., we value some of our critical interests precisely

because they will lead to good experiences.

• Advance directives can be contradictory, may not always be created competently.

• Personal identity in dementia cases is uncertain. Demented

Margo may be a different person than Past Margo.

The state's interest in keeping Margo alive

• Demented Margo is a sentient being.

• She has an interest in continuing to enjoy positive experiences.

• Therefore, the state may have a derivative interest in protecting her life.

• This is basically Dworkin's own reasoning about abortion (for sentient post-viability fetuses).