Forgetting Advance Directives: Dementia, Autonomy, and Euthanasia

A diagnosis of dementia is frightening for patients, as well as their family. Faced with such a diagnosis, some patients may opt for suicide, assisted death, or euthanasia. In some jurisdictions, advance euthanasia directives allow for these wishes to be fulfilled after patients lose decision-making capacity. But such directives face a unique challenge in the context of dementia, particularly because of the changes the disease inflicts on patients. On strong views of the longevity of advance directives, such changes are insufficient to challenge the authority of advance directives. Weak views, by contrast, assert that the changes wrought by dementia are often sufficient to negate the authority of advance directives. Despite their differences, both strong and weak views accept precedent autonomy as justifying a prima facie obligation to follow advance directives. This reliance on precedent autonomy, I suggest, is at the root of the challenge that advance directives face in the case of late-stage dementia. In response to this challenge, I will propose that a cohesive understanding of advance directives without the concept of precedent autonomy is possible. On such an account, advance directives may be authoritative insofar as they are reflective of current or future contemporary autonomous wishes. This nullifies the obligation to follow advance directives for the patient’s own sake, when they lack contemporary autonomy and/or will not regain it. Despite this, incorporating the contemporary interests of the patient’s family into treatment decisions may justify adherence to an advance directive when it yields a permissible outcome for the current patient. Such an account is not only plausible in theory, but faces the challenge of dementia with more permissible results than either strong or weak views of advance directives. Specifically, this account allows for both robust consideration of the contemporary experiential interests of the patient in late-stage dementia, as well as adherence to an advance directive when permissible. Abandoning precedent autonomy, I argue, more plausibly explains the role that advance directives should play in the context of euthanasia for late-stage dementia patients