ADVANCE DIRECTIVES, DEMENTIA, AND`THE SOMEONE ELSE PROBLEM’ Analyze the article according to the outline in the attached reaction critique guide.
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Advance Directives, Dementia, and ‘The Someone Else
Problem’
Article in Bioethics · November 1999
DOI: 10.1111/1467-8519.00166 · Source: PubMed
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Bioethics ISSN 0269-9702
Volume 13 Number 5 1999
ADVANCE DIRECTIVES, DEMENTIA, AND
`THE SOMEONE ELSE PROBLEM’
DAVID DEGRAZIA1
ABSTRACT
Advance directives permit competent adult patients to provide guidance
regarding their care in the event that they lose the capacity to make
medical decisions. One concern about the use of advance directives is the
possibility that, in certain cases in which a patient undergoes massive
psychological change, the individual who exists after such change is
literally a (numerically) distinct individual from the person who
completed the directive. If this is true, there is good reason to question
the authority of the directive Ð which is supposed to apply to the
individual who completed it, not to someone else. This is `the someone else
problem’.
After briefly introducing advance directives as a basis for medical
decision-making, this paper elaborates `the someone else problem’ in the
context of severe dementia. The paper then reconstructs the reasoning that
leads to this putative problem and exposes the important underlying
assumption that we are essentially persons. An alternative view of what
we are, one that regards personhood as inessential, is then considered,
before several arguments are advanced in favor of that alternative view.
The paper next explores implications for advance directives: `The someone
else problem’ is effectively dissolved, while it is noted that a related problem
(one beyond the paper’s scope) may persist. A few implications beyond
advance directives are also identified.
1
My thanks to David Wasserman and Robert Wachbroit for helpful
discussions of some of the issues discussed in this paper. A draft was presented
on May 12, 1998 at the Kennedy Institute of Ethics, Georgetown University,
where the feedback of attendees, especially Madison Powers and John Hasnas,
was quite helpful. I would also like to acknowledge the insightful comments of
two reviewers for Bioethics, Julian Savulescu and another who remains
anonymous.
ß Blackwell Publishers Ltd. 1999, 108 Cowley Road, Oxford OX4 1JF, UK
and 350 Main Street, Malden, MA 02148, USA.
374
DAVID DEGRAZIA
Advance directives are an increasingly important instrument for
medical decision-making. These documents permit competent
adult patients to provide guidance regarding their care in the
event that they lose the capacity to make medical decisions. One
concern about the use of advance directives is distinctively
philosophical: the possibility that, in certain cases in which a
patient undergoes massive psychological change, the individual
who exists after such change is literally a (numerically) distinct
individual from the person who completed the directive. If this is
true, there is good reason to question the authority of the
directive in question, since it is supposed to apply to the
individual who completed it, not to someone else. This may be
called `the someone else problem’.
After briefly introducing advance directives as a basis for
medical decision-making, this paper elaborates `the someone else
problem’ in the context of severe dementia. The paper then
reconstructs the reasoning that leads to this putative problem
and exposes the important underlying assumption that we are
essentially persons. An alternative view of what we are, one that
regards personhood as inessential, is then considered, before
several arguments are advanced in favor of that alternative view.
The paper next explores implications for advance directives:
`The someone else problem’ is effectively dissolved, while it is
noted that a related problem (one beyond the paper’s scope)
may persist. A few implications beyond advance directives are also
identified.
HOW `THE SOMEONE ELSE PROBLEM’ ARISES
Advance directives are widely accepted as a basis for medical
decision-making on behalf of formerly competent patients,
because these documents are recognized as a reasonable
extension of the decision-making authority of competent
patients.2 The latter have a right to informed consent Ð that
is, a right to make an informed, voluntary decision as to whether
to accept or refuse medical care that is offered to them. In
paradigmatic cases of informed consent, the patient is competent
both when authorizing medical care and when receiving it (or
perhaps shortly before receiving it, as with surgery requiring
general anaesthesia). Cases involving advance directives are
2
I use the terms `competence’ and `decision-making capacity’
interchangeably, while recognizing that some may find it useful to distinguish
the terms for certain purposes.
ß Blackwell Publishers Ltd. 1999
ADVANCE DIRECTIVES
375
different. A competent patient completes a directive that gives
instructions that are to apply only at future times when she is
incompetent.3 Here respect for patient autonomy is conceived of
as extending from one point in time into a future in which
competence is lost. (There are various more specific ways of
conceptualizing the authority of advance directives, but our
purposes do not require enumerating them.)
Several concerns about advance directives suggest the need to
limit their authority and to recognize that sometimes they should
not be honored. One such concern is the fact that people
sometimes cannot grasp in detail the circumstances in which the
directive will apply, so that one’s present decision regarding
those circumstances is significantly uninformed. Suppose a fiftyyear-old completes a directive that authorizes withholding life
supports in the event that he becomes demented, a preference
based on his belief that he will despise such an existence while in
it. Moderately demented ten years later, he is in fact cheerful
much of the time and has no desire to die. The present directive
is vitiated by the fifty-year-old’s limited ability to know what it is
like to be demented.4
Another concern about the use of advance directives involves
major change in an agent’s values and preferences between the
time of completing the directive and the time when it applies. In
principle, one may always rescind an existing directive and issue
another that better expresses one’s new priorities. But, in
practice, people may neglect to do so due to time constraints,
procrastination, forgetfulness, or laziness. Suppose an
intellectual completes a directive that authorizes withholding
life-supports in the event of dementia, because he regards such
3
These instructions can either specify types of care to be provided or
withheld, designate an individual to serve as a proxy decision-maker, or both.
For simplicity, I will focus on the care-specifying aspect of advance directives.
4
While health care providers can educate patients about common medical
conditions such as dementia, arguably no amount of education would have fully
informed the man what it would be (or feel) like for him to be demented. Of
course, such incomplete information Ð and therefore imperfect understanding
Ð characterizes all medical decisions involving new conditions or experiences,
not just those concerning future conditions of incompetence. Thus, someone
who consents to chemotherapy, having never undergone it before, is not fully
informed regarding the consequences of this treatment. Fortunately, what is
needed for informed consent is substantial, not perfect, understanding of
treatment options and their likely consequences (see Ruth R. Faden and Tom
L. Beauchamp, A History and Theory of Informed Consent [New York: Oxford
University Press, 1986], pp. 251±53). The present concern about advance
directives is that even substantial understanding is often hard to come by.
ß Blackwell Publishers Ltd. 1999
376
DAVID DEGRAZIA
an existence as degrading. But soon afterward, his wife dies and
in his grieving he draws comfort from religion for the first time in
his life. His worldview changes significantly and he comes to
cherish all human life, regardless of its intellectual quality. A few
years later, he is moderately demented. His advance directive is
now at odds with the value system he most recently held (or still
holds, to the extent that someone in his condition can be said to
have a value system).
An advance directive requires its agent to project her own
values into various possible future circumstances. The concerns
just described highlight two major ways in which such a
projection may prove inadequate: A person’s life may change,
or she may change, in ways that she fails to predict or fully
appreciate. The next concern, however, focusses on a much more
radical kind of change.
What I call `the someone else problem’ is usually raised in
connection with dementia, so a brief description of that
condition will be helpful. Alzheimer’s dementia is characterized
by gradual onset of symptoms and ongoing cognitive decline, and
it is not due to specific causes associated with certain other types
of dementia. These other types include vascular dementia (which
is associated with multiple infarctions involving the cortex),
substance-induced persisting dementia, HIV-related dementia,
and dementia due to head trauma, Parkinson’s Disease,
Huntington’s Disease, or various other medical conditions.
What the different types of dementias have in common are
these three features:
(1) memory impairment;
(2) one or more of the following cognitive disturbances: (a)
aphasia (language disturbance); (b) apraxia (impaired ability
to carry out motor activities despite intact motor function);
(c) agnosia (failure to identify or recognize objects despite
intact sensory function); (d) disturbed executive functioning
(planning, organizing, sequencing, and abstracting); and
(3) as a result of the above symptoms, significant impairment in
social or occupational functioning that represents a
substantial decline from a previous level of functioning.5
In addition to varying by type, cases of dementia vary in degree of
severity. The symptoms of early Alzheimer’s, for example, can be
5
This summary draws from the American Psychiatric Association, Diagnostic
Criteria from DSM-IV (Washington, DC: APA, 1994), pp. 85±93.
ß Blackwell Publishers Ltd. 1999
ADVANCE DIRECTIVES
377
subtle: a patient may experience mild memory loss and feel
unusually disorganized at times, yet be unaware that she has a
significant medical condition. Severe cases of dementia, by
contrast, can be shocking for associates to behold: a patient may
be unable to talk, to plan one hour into the future, or to identify
loved ones.
The remainder of this paper concerns severely demented
patients, for these individuals provoke `the someone else
problem’. This putative problem arises against the backdrop of
a triad of theses concerning the nature of persons, their identity
over time, and their essence. Let me elaborate.
What I will call the Psychological View about human persons is
the conjunction of two philosophical theses (with which an
important third thesis, discussed later, is sometimes associated).
These two theses have their home in a long philosophical
tradition that stems from Locke, derives recent inspiration from
Parfit and others, and currently dominates the literature.6 The
first thesis concerns the nature of persons. According to the
Lockean tradition, persons are beings with a certain kind of
conscious or psychological life. While, on this view, the capacity
for consciousness (which, importantly, a person retains even
while sleeping) is necessary for personhood, it is not sufficient; if
it were, then all animals who have any states of consciousness at
all would qualify as persons. Persons are taken to be conscious
beings of a particular sort, having such traits as rationality, selfawareness, and purposive agency. The precise details of an
adequate elucidation of personhood are not required here.7 It
will suffice for our purposes to state the first thesis in this way:
Persons are beings with the capacity for complex forms of
6
The classic statement is found in John Locke, Essay Concerning Human
Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to
refine Locke’s view that did not generate much discussion at the time is found
in H.P. Grice, `Personal Identity,’ Mind 50 (1941): 330±50. More distinctively
contemporary versions of this broadly Lockean approach Ð within which there
is considerable variety of theoretical detail Ð appear, for example, in Sidney
Shoemaker, `Persons and Their Pasts,’ American Philosophical Quarterly 7 (1970):
269±85; John Perry, `Can the Self Divide?’, Journal of Philosophy 69 (1972): 463±
88; David Lewis, `Survival and Identity,’ in Amelie Rorty (ed.), The Identities of
Persons (Berkeley: University of California Press, 1976): 17±40; Robert Nozick,
Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch.
1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W.
Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin,
Self-Concern (Cambridge: Cambridge University Press, 1998).
7
I defend my own view of what persons are in `Great Apes, Dolphins, and
the Concept of Personhood,’ Southern Journal of Philosophy 35 (1997): 301±20.
ß Blackwell Publishers Ltd. 1999
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DAVID DEGRAZIA
consciousness (a capacity found, for example, in normal postinfancy human beings).
The second thesis stemming from the Lockean tradition
concerns the (numerical) identity of persons over time.8 What
makes me the same person as a certain youth who lived most of
his teens in the 1970s? According to the present tradition, for A
at one time and B at a later time to be the same person, there
must be sufficient psychological continuity (exemplified by
memories, intentions and their fulfillment, and enduring desires
and beliefs) between them. Articulating a fully adequate
statement of the relation of psychological continuity proves to
be agonizingly complex.9 But it will suffice for purposes to state
the second thesis, somewhat vaguely, as follows: The identity of
persons over time is a function of psychological continuity.
The two theses just stated, along with the clinical facts of
severe dementia, help motivate `the someone else problem’.
(The crucial third thesis, which functions as a suppressed
premise in the reasoning that generates this putative problem, is
discussed in the next section.) In some cases, according to one
line of thought, a demented patient will have such weak
psychological connections with the pre-dementia person in
question that the two are literally different persons. If a
competent patient wrote an advance directive refusing life
supports in the event of severe dementia, and years later such
dementia results in a different person, then the directive, if
honored, would seemingly direct care for someone else Ð
someone other than the earlier agent. That would be a problem
because advance directives are supposed to give guidance for
one’s own medical care.10 But I don’t think this way of posing
`the someone else problem’ is optimal. For it requires a very
subtle judgment about when person A has so little psychological
8
A at one time is numerically identical with B at a later time if and only if
they are one and the same entity; such identity is logically compatible with
significant qualitative change in the entity over time. Thus a house may persist
over a hundred years even if the old house is qualitatively very dissimilar from
the house as it was originally. By contrast, pieces of paper may be qualitatively
similar (in principle, even identical), but they are not numerically identical if
they are different objects. Hereafter, `identical’ and `the same’ will be elliptical
for `numerically identical’ and `numerically the same,’ respectively.
9
See the twentieth-century works cited in note 6 for some efforts to
characterize psychological continuity.
10
See, e.g., Rebecca Dresser, `Life, Death, and Incompetent Patients:
Conceptual Infirmities and Hidden Values in the Law,’ Arizona Law Review 28
(1986): 373±405.
ß Blackwell Publishers Ltd. 1999
ADVANCE DIRECTIVES
379
continuity with person B as to be a distinct person, and such
discriminations are difficult to make with any theoretical
confidence.11
A better way of posing the problem goes like this. Assume that
B is so demented as not to be a person at all. Indeed, let us
reserve the qualifier `severely demented’ for individuals who are
so demented. Given the conception of persons as beings with the
capacity for certain complex forms of consciousness, and even
allowing that the concept of person is somewhat vague at the
boundaries, undoubtedly some demented individuals fail to meet
this standard. One can draw a line (or mark out a grey area)
wherever one wants. So long as one is working within the
Psychological View (as opposed to defining personhood in terms
of possession of a soul or a human genetic code, say), one should
be prepared to identify some demented individuals as
nonpersons. With respect to those demented individuals, `the
someone else problem’ can be posed quite starkly. Since B is not
a person at all, B is a fortiori not the same person as A. Thus,
according to the present line of thought, an advance directive
that was completed by A and would apply to B is problematic. For
the severely demented patient is someone else Ð someone other
than the author of the directive.
THE CRUCIAL ASSUMPTION THAT PERSONHOOD IS
ESSENTIAL
Let us call A `Granny-at-fifty’ and B `Granny-at-sixty’. The above
reasoning about identity over time, which generates `the
someone else problem’, may be reconstructed as follows:
1. Granny-at-fifty is a person.
2. Granny-at-sixty is not a person.
11
Cf. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of
Surrogate Decision Making (Cambridge: Cambridge University Press, 1989), pp.
157±58. Also, in real-life clinical scenarios, if A (who wrote the directive) and B
(who is demented) both qualify as persons, it seems doubtful that they would
fail to be the same person. For example, even if person B could not remember
life as person A, B would probably have many overlapping chains of memory
that extend bit by bit to that earlier time. Moreover, A probably had some plans
and intentions (a few of which are stated in the advance directive) that extend
into the future that B occupies. B is also likely to retain many beliefs and skill
memories (e.g., regarding the meaning of words), and at least some desires and
character traits, from the days of A.
ß Blackwell Publishers Ltd. 1999
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DAVID DEGRAZIA
Therefore 3. Granny-at-sixty is numerically distinct from
(specifically, a `successor’ to) Granny-at-fifty.12
But the conclusion 3 does not follow. For it is an open question
whether the two `Granny-stages’ might be the same individual
even if not the same person. So to make the argument
intelligible, we must bring to the surface a suppressed premise:
1a. Granny-at-fifty is essentially a person.
Presumably, this is assumed on the basis of the more general
assumption that all human persons are essentially persons Ð
providing the third thesis, which is sometimes associated with the
Psychological View. This thesis, which we may call `person
essentialism’, does not simply mean that we (persons) find
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