Abstract

Advance directives and other forms of advance medical decisionmaking provide ways for people to decide now what medical treatment they will receive later when they are incapacitated and unable to decide. Both critics and supporters of advance directives tend to agree that a directive's moral authority, if any, has two sources. The first source of support is a "surviving interest," where a patient's interest in, for example, dignity or certain religious practices, survives into a period of dementia or other mental incapacity. The second source of support for advance directives is the claim that we should respect autonomy exercised in advance , just as we should respect decisions made by patients concerning their present treatment. ;However, many writers are sceptical about both sources of support. If an interest does not survive after one no longer cares about it, then arguably it ceases to exist when one no longer can care about it, as in dementia. I compare cases where an interest survives sleep to other cases of progressively greater losses to argue that interests can survive dementia for the same reason they survive sleep. It turns out that interest survival is a function of whether the patient would still care about the object of the interest if the patient could still care. ;However, although interests survive, a patient's intentions concerning such interests do not survive mental incapacity. Intentions survive only while the patient has an actual disposition to consciously affirm them, and that requires mental capacity. Because intentions do not survive, we seem unable to respect patient intentions concerning later incapacity. ;However, this concern assumes we must respect only current preferences. I argue that we must instead respect the patient's most-inclusive preferences---the preferences the patient preferred to satisfy over other, competing preferences . For competent patients, the latest preference will almost always be the most-inclusive one. But for patients with declining capacity, an earlier preference---even a former one---may be the most-inclusive. In such cases we must respect even former intentions and the surviving interests they concern