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Publication Date

2001

Abstract

Patients with dementia present difficult issues for health-care decisionmaking. This article addresses the moral and legal issues posed by end of life decisionmaking for such patients. In general, the ethical goals of care are to assure that patients' choices are respected and that patients' best interests are protected. These goals may not always recommend the same decisions about care, however, and there is controversy about how they should be balanced when they conflict. In addition, the law may not always further these goals, nor be as helpful as it could be in resolving conflicts between them. In the bioethics literature, respect for patients' autonomy is generally taken to be the more weighty value. In the literature about dementia, however, this priority has been questioned. Some commentators have argued that, given the immense personal changes involved in the development of dementia, the best interests of a now-demented patient ought to take precedence over the choices of the previously-competent person. This article begins with issues raised by the value of autonomy, then turns to questions about the patient's interests, and finally discusses the resolution of conflicts between the two. The first section considers the patient's own participation in decisionmaking about care, emphasizing the importance of preserving present autonomy to the extent possible. The second section discusses precedent autonomy and the mechanisms by which it may be fostered, such as living wills and special powers of attorney for health care. The third section examines arguments undermining the authority of precedent autonomy, including empirical data about the instability of preferences and the significance of radical alterations in personality.' The fourth section takes up accounts of how to assess the best interests of patients with dementia, including hedonic accounts, preference accounts, and theories of objective interests. The final section defends a balance between precedent autonomy and best interests, arguing that as expressions of prior choice become clearer, they should bear the greater weight; correspondingly, when there are very strong interest based considerations that involve the patient's present experiences, they should prevail over less clear indications of prior choice.

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