Indeterminacy of identity and advance directives for death after dementia
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SCIENTIFIC CONTRIBUTION
Indeterminacy of identity and advance directives for death after dementia Andrew Sneddon1
© Springer Nature B.V. 2020
Abstract A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these—epistemic indeterminacy and metaphysical indeterminacy—should be addressed in laws/policies regarding advance directives for euthanasia. Keywords Dementia · Personal identity · Medical assistance in dying · Derek Parfit · Ronald Dworkin
Introduction An enduring 1 question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity. Three sorts of indeterminacy are distinguished. Two of these—epistemicindeterminacy and metaphysical-indeterminacy—should be addressed in laws/policies regarding advance directives for euthanasia.
Dementia and medical assistance in dying The last few decades have been marked by increased official acceptance of assisted suicide and active euthanasia (hereafter glossed, in the Canadian fashion, as MAID, for “medical assistance in dying”). For example, the Netherlands made MAID legal in 2001, Belgium in 2002, and Canada in 2016. Generally, MAID is restricted to patients able to form and express rational preferences about themselves, their condition, and what they want to happen to them. One practical
* Andrew Sneddon [email protected] 1
University of Ottawa, Ottawa, Canada
issue is whether to extend MAID services to dementia patients. For instance. Belgium is currently going through social and governmental consideration of such a change to their Euthanasia Act (Cohen-Almagor 2016, pp. 76–77; Crisp 2019). As another example, when Canada enacted its MAID law in 2016, it simultaneously commissioned several reports from the Council of Canadian Academies (CCA) on tricky cases and the question of whether to extend MAID to them. One of these reports, which was delivered in late 2018, is entitled The State of Knowledge on Advance Requests for Medical Assistance in Dying (CCA 2018). The panel therein reports that interest in being able to make such requests is driven to a significant extent by “capacity-limiting conditions” such as dementia (2018, pp. 39–41). Dementia is marked by deep, often irreversible changes to memory, personality, and reasoning that interfere with the kind of preference formation and expression recognized as important in MAID policy. In many cases, dementia is symptomatic of a fatal condition. In these cases, the underlying cause of the dementia eventually makes the person who has it a
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