Dementia, Advance Directives, and Second-Order Volitions

Area of Science:

• Bioethics
• Philosophy of Mind
• Neuroethics

Background:

• Advance directives are crucial for patient autonomy.
• Dementia poses challenges to respecting patient autonomy due to evolving preferences.
• The philosophical basis for prioritizing past versus present wishes in diminished capacity is debated.

Purpose of the Study:

• To explore the authority of advance directives when dementia patients express conflicting desires.
• To apply Harry Frankfurt's theory of second-order volitions to resolve conflicts between pre-dementia and post-dementia selves.
• To establish a framework for prioritizing patient preferences in end-of-life care decisions for individuals with dementia.

Main Methods:

• Philosophical analysis using Harry Frankfurt's concept of second-order volitions.
• Argumentative reasoning to weigh the preferences of the 'then-self' against the 'now-self'.
• Case analysis focusing on scenarios where dementia impacts the capacity for volitional judgment.

Main Results:

• The pre-dementia self's preferences ('then-self') should typically take precedence over the post-dementia self's ('now-self').
• This prioritization is particularly relevant when the 'now-self' lacks the capacity for second-order volitions.
• The ability to meaningfully repudiate prior values is a key factor in assessing the weight of current preferences.

Conclusions:

• Upholding advance directives from the pre-dementia self respects enduring values and commitments.
• This approach offers a principled way to manage conflicting desires in dementia care.
• The capacity for second-order volitions is central to determining the authority of current preferences in advance care planning.