The problem of value change: Should advance directives hold moral authority for persons living with dementia?

TL;DR

The paper questions whether advance directives should still be followed when a person with dementia changes their values over time.

Contribution

The paper argues that contemporary values of individuals with dementia should override advance directives, challenging existing ethical frameworks.

Findings

Value changes in dementia patients may reduce the moral authority of advance directives.

Contemporary values should be respected even if they conflict with past preferences.

The 'losing and choosing' distinction is critiqued as morally irrelevant to respecting current values.

Abstract

As the prevalence of dementia rises, it is increasingly important to determine how to best respect incapable individuals' autonomy during end‐of‐life decisions. Many philosophers advocate for the use of advance directives in these situations to allow capable individuals to outline preferences for their future incapable selves. In this paper, however, I consider whether advance directives lack moral authority in instances of dementia. First, I introduce several scholars who have argued that changes in peoplewith dementia's values throughout disease progression reduce the validity of their advanced wishes. I then outline Karin Jongsma's rejection of this claim, which she calls the “losing and choosing” distinction. Jongsma argues that changes in people with dementia's values should not be respected, because they are unchosen and dictated by the disease. I critique her claim that the process of value change is morally relevant when determining which values we respect. I argue that if individuals with dementia are capable of valuing, their contemporary values should be respected, even when they conflict with past preferences outlined in an advance directive. As such, situations of value change diminish the moral authority of advance directives for individuals with dementia.