Dresser - Dworkin on Dementia (1)

Dworkin on Dementia: Elegant Theory, Questionable Policy

Overview

• Author: Rebecca Dresser

• Source: Hastings Center Report; November 1995; pg. 32

• Focus: Dworkin's theoretical framework concerning dementia and autonomy

Key Concepts

Dworkin's Position on Autonomy and Dementia

• Dworkin emphasizes the importance of honoring prior autonomous decisions of individuals like Margo who develop dementia.

• His inquiry revolves around values such as autonomy, beneficence, and the sanctity of life.

• Precedent Autonomy: Dworkin argues that individuals should retain the right to make decisions about their end-of-life care based on their prior wishes even if they lose the capacity to judge their best interests over time.

Types of Interests in Dworkin's Framework

1. Experiential Interests

   • Represent momentary pleasures, e.g., activities that individuals enjoy.

   • Are less emphasized in Dworkin's theory due to individual variability.

2. Critical Interests

   • Associated with the meaningful pursuits that give coherence to one’s life.

   • Considered more important than experiential interests, especially in discussions of autonomy and individuals like Margo.

Arguments for Dworkin's Approach

• The integrity view of autonomy allows for honoring the critical interests of individuals who are unable to express their current wishes:

  • Dworkin supports the idea that family members should apply their understanding of the patient's critical interests when making decisions on their behalf.

  • He labels disregard for prior directives as an unacceptable form of moral paternalism.

Compassion and State Interest

• Dworkin argues for the state to respect the directives set forth by individuals experiencing dementia, emphasizing a compassionate approach that supports their choice at the end of life.

• The decisions made should reflect the earlier values and lifestyle of the individual, honoring the narrative of their life.

Concerns and Critiques

Dresser's Perspective

• Dresser expresses skepticism about Dworkin’s theories regarding dementia, particularly focusing on the following:

  • Subjective Experience of Dementia: Many individuals with dementia experience varying levels of distress, which contradicts the idea that all patients experience life similarly once they become incapacitated.

  • Quality of Life: The quality of life for dementia patients can be significantly influenced by their environment and social interactions, which Dworkin might downplay.

  • Advance Directives: There is often a lack of public understanding and support in exercising advance directives, which results in many people failing to articulate their wishes prior to becoming incapable.

  • Change of Heart: Individuals may change their preferences over time, and rigid adherence to prior directives can undermine their current interests.

Community Reflection Needed

• Dresser suggests that society must reassess its views on individuals with dementia and find ways to interact that allow these individuals to experience life fully and meaningfully.

• Disability Perspective: A shift away from the tragic view of dementia to one that recognizes the value and enjoyment in the present moments of life is essential.

• A policy aimed at enhancing the quality of life for dementia patients while respecting their critical interests would align more closely with a compassionate society.