This article presents a critique of an article previously featured in Nursing Philosophy (10: 26–33) by Ursula Naue and Thilo Kroll, who suggested that people living with dementia are assigned a negative status upon receipt of a diagnosis, holding the identity of the ‘demented other’. Specifically, in this critique, we suggest that unwitting use of the adjective ‘demented’ to define a person living with the condition is ill-informed and runs a risk of defining people through negative (self-)attributes, which (...) has a deleterious impact upon that person's social and relational personae. Moreover, use of the locution ‘demented’ reinforces a divide between the ‘demented’ (them) and the ‘healthy others’ (us). Social constructionist theory, malignant positioning and viewing people with dementia as semiotic subjects are the philosophical pillars through which we construct the main arguments of the critique. The article concludes with the voice of one of the authors, a younger person with dementia, asking for language in dementia care to be carefully reconsidered and reframed and for the recognition of the diagnosed person's agency in the conduct of their day-to-day lives. (shrink)

In the paper, after clarifying terms such as ‘identity’, ‘self’ and ‘personhood’, I propose an empirical account of identity based on the notion of “whole phenotype”. This move allows one to claim the persistence of the individuals before and after their being affected by dementia. Furthermore, I show how this account permits us to address significant questions related to demented individuals’ loss of the capacity of moral decisions.

Kritik af tidens fremherskende funktionalistiske, historieløse kultur, der fratager os evnen til at koncentrere og fordybe os, og efterlader et samfund uden rødder og retning.

What can postmodernism do for, or to, educational research? The article discusses its potential for resisting closure and simplification. Developing a ‘preposterous’, anachronistic postmodern method that is caught up with surrealism and the baroque, the article plays with trompel'oeil paintings and outmoded popular entertainments such as magic lanterns, peep shows and clockwork automata as figures for critique and analysis. It argues for defamiliarisation, fascination, recalcitrance and frivolity as methodic practices for research in the compromised conditions of postmodernity, and as forms (...) of ethical resistance to the risk-averse literalism that pervades contemporary education policy. (shrink)

In this paper I address the relation between just claims to health care and severe cognitive impairment from dementia. Two general approaches to justice in allocation of health care are distinguished – prudential allocation and interpersonal distribution. First, I analyze why a patient who has died has no further claims to health care. Second, I show why prudential allocators would not provide for health care treatment should they be in a persistent vegetative state. Third, I argue that the destruction of (...) personal identity from severe dementia implies that only claims to palliative, but not life-sustaining, health care remain. Finally, I argue that the prudential allocator approach is indeterminate regarding life-sustaining care for the moderately demented and that social policy should not deny that care to patients. Keywords: elderly, health care, the severely-demented, justice CiteULike Connotea Del.icio.us What's this? (shrink)

One question of applied ethics is the status and proper treatment of marginal cases, i.e., of people who are not yet or not anymore in full possession of their rational capacities, such as elderly demented people. Does one belittle them if one does not treat them like normal human adults, or would it be disrespectful and demanding too much if one did? Are elderly demented even the proper object of respect? In this paper I explore what Kant would (...) say about these questions if he had addressed them. I look at what Kantian respect is, how he justifies the requirement to respect others, and what it demands more specifically. My claim is that Kant conceives of respect as a maxim of not exalting oneself above others. One should adopt this attitude independently of what the other is like. Differences between normal human adults and marginal cases are important for how one should treat them, but ultimately not for the question of why one should treat them with respect. Accordingly, elderly demented people should be respected, and it depends on the individual case what kind of actions this implies. (shrink)

This paper explores the impact of the concepts of identity and difference on demented persons (especially on persons with Alzheimer's disease). The diagnosis of dementia is often synonymous with the assertion that demented individuals are no longer capable of making reasonable decisions. But rationality is an important aspect of characterizing a person's identity. Hence, this prevailing image of dementia as a loss of self and a change of identity leads to the situation that demented persons represent difference (...) and otherness. Here, the brain and the mind act as the source for difference. The paper discusses several identity concepts with regard to demented persons and the relationship between identity and difference in dementia. This analysis is accompanied by an examination of the current biopolitics of dementia and ageing as biopolitics constitutes the socio‐political‐medical understanding of dementia. Challenges and possibilities for dementia care will be explored in the context of this complex relationship between theoretical concepts and political, medical, and health‐care practices. (shrink)

The paper investigates whether it is plausible to hold the late stage demented criminally responsible for past actions. The concern is based on the fact that policy makers in the United States and in Britain are starting to wonder what to do with prison inmates in the later stages of dementia who do not remember their crimes anymore. The problem has to be expected to become more urgent as the population ages and the number of dementia patients increases. This (...) paper argues that the late-stage demented should not be punished for past crimes. Applicable theories of punishment, especially theories with an appropriate expressivist, or communicative element, fail to justify the imprisonment of the late-stage demented. Further imprisonment would require a capacity for comprehension on the part of the punished, and, under certain narrowly specified conditions, even a capacity to be at least in principle capable of recalling the crime again. (shrink)

Tape-recorded semi-structured interviews were conducted with 21 nursing aides and enrolled nurses in the geriatric clinic in Umeå, Sweden. The interviews focused on the difference between the care of demented and non-demented patients and ethical conflicts in dementia care. The results indicate that caregivers have problems in providing the demented patients with opportunities to act autonomously in everyday matters on the ward, mainly due to the difficulty of understanding what the patients wish and the fact that their (...) wishes, when understood, often seem irrational. Measures to provide the demented patients with more opportunities to act autonomously in everyday matters are suggested. (shrink)

Parmi nos « contemporains » majeurs , Friedrich August von Hayek a formulé une « vision du monde » qui marque notre temps et qui lui vaut l’admiration ou la détestation résumées dans un terme utilisé souvent mal à propos : « ultralibéralisme ». Avec la « crise du..

The philosophy of science between the two world wars, 1920s-1930s.

Structured interviews were held with 149 registered nurses in seven countries in America, Asia, Australia and Europe concerning the feeding of severely demented patients who do not accept food. The most common reasons for nurses being willing to change their decision to feed or not to feed were an order from the medical head, a request from the patient's husband and/or the staff meeting. There was a connection between the willingness to feed and the ranking of ethical principles. Nurses (...) who were most prone to feed the patient most often gave a high rank to the ethical principle of sanctity of life, while those who primarily chose not to feed the patient gave a high rank to the ethical principle of autonomy. All nurses stressed the ethical principle of beneficence. Des interviews structurés ont eu lieu avec 149 infirmiers/ères dans sept pays en Amérique, Asie, Australie et Europe concernant l'alimentation des malades gravement dément qui refusent de manger. La raison la plus générale pour des infirmiers/ères d'être prêt à changer leures décisions de donner à manger ou non sont: un ordre du médecin, la demande du mari de la malade ou de la réunion du personnel. Il y avait un lien entre la volonté de nourir et le rang des principes éthiques. Les infirmiers/ères les plus enclins de nourir la malade le plus souvent donnaient un rang supérieur au principe éthique de la sainteté de vie, pendant que ceux et celles qui choisissaient de ne pas nourrir la malade donnaient un rang supérieur au principe éthique de l'autonomie. Tous insistaient sur l'importance du principe éthique de la bienfaisance. Konstruktive Interviews wurden mit 149 ausgebildeten Krankenschwestern und Pfleger in sieben Ländern in Amerika, Asien, Australien und Europa gehalten über die Ernährung von schwer von Dementia praecox leidenden Patienten, die das Essen verweigern. Die gewöhnlichsten Gründe des Pflegepersonals für die Bereitwilligkeit, ihre Entscheidung, zu ernähren oder nicht, zu ändern, waren Anordnungen vom medizinischen Chef, Anfragen vom Ehemann der Patientin und/oder einer Personalsitzung. Es bestand ein Zusammenhang zwischen der Bereitwilligkeit zur Ernährung und dem Rang der ethischen Prinzipien. Die Pflegenden, die sich am meisten neigten, die Patientin zu ernähren, gaben dem ethischen Prinzip der Heiligkeit des Lebens einen hohen Rang, während die, die meistens vorzogen, die Patientin nicht zu ernähren, gaben dem ethischen Prinzip der Autonomie einen hohen Rang. Alle Pflegenden legten grossen Wert auf das ethische Prinzip der Wohltätigkeit. (shrink)

A high level of confidence in the identity of individuals is required to let them die as ordered by an advance directive. Thus, if we are animalists, then we should lack the confidence required to apply lethal advance directives to the cheerfully demented, or so I argue. In short, there is consensus among animalists that the best way to avoid serious objections to their account is to adopt an ontology that denies the existence of brains, hands, tables, chairs, iced-tea, (...) and lemonade. The adoption of such an ontology reduces the justificatory force of commonsense, which is key in arguing that we are animals and that we persist as long as we are biologically alive. With this loss of justification comes the loss of a high level of confidence that Quinn-pre-dementia’s lethal advanced directive applies to Quinn-post-dementia, via identity. If we do not have a high level of confidence that Quinn-pre-dementia’s advanced directive applies to Quinn-post- dementia, then it is not enough (on its own) to let Quinn-post-dementia die. (shrink)

It may seem paradoxical to speak of the ‘goodlife’ for demented elderly. Many people consider dementia to be a life-wrecking disease and nursing homes to be terrible places. Still, it is relevant to ask how we can make life as good as possible for demented nursing home residents. This paper explores what three standard philosophical accounts of well-being — subjective preference theory, objectivist theories, and hedonism — have to say about the good life for demented people. It (...) is concluded that the relevant differences between the various philosophical theories manifest themselves not so much in their general account of the substantial content of ‘the good life’ but in a number of specific controversies. These concern the nature of well-being, the necessity of endorsement by the patient, the value of experience and the need for experiences to be rooted in reality. Moreover, it is argued that further research should pay detailed attention to the process of dementia and to the effects of this process on patients' identities, self-conceptions, capacities, preferences, values and the like, and that a narrative approach which incorporates the factor time may offer a more comprehensive account of the good life for demented elderly. (shrink)

Should advance directives (ADs) such as living wills be employed to direct the care of the severely demented? In considering this question, I focus primarily on the claims of Rebecca Dresser who objects in principle to the use of ADs in this context. Dresser has persuasively argued that ADs are both theoretically incoherent and ethically dangerous. She proceeds to advocate a Best Interest Standard as the best way for deciding when and how the demented ought to be treated. (...) I put forth a compromise position: both ADs and the Best Interest Standard have roles to play in guiding the care of the severely demented. (shrink)

In the present paper, we evaluate the grounds on which therapeutic approaches are determined in elderly demented patients as a typical group of patients who are conscious but lack the ability to make competent judgments. It is argued that none of the factors that the patient as an individual being has at present and that are complete in that individual - the age of the patient, dementia, personhood, and the ability to feel pain - is likely to be a (...) genuine reason for care-providers including health care workers and patient’s family to discontinue the treatment for severely demented patients. It is also claimed that reasons for discontinuation of the treatment for severely demented patients arise from the relationship between the patient and the care-providers, especially the patient’s family. The human relationships between the patient and the family may be maintained as long as the latter find some significance in the presence of the severely demented patient and recognize him/her as “one of them”. When the patient ceases to be “one of them” for the family and is excluded from “their company”, the reason for supporting the demented member of the family is lost. The benefit to the patient and the value of his/her presence lose the individuality or specificity and are subjected to interpretation by the family. Therefore, the reason for discontinuation of the treatment for a severely demented patient is termination of the relationship between the patient and his/her family. The significance of our conclusion is briefly discussed. (shrink)

Objective: Little has been written in the medical literature concerning the ethics of treatment of the elderly demented patient with bowel obstruction. It is one example of the issues with which we are becoming increasingly involved. We conducted a survey of our colleagues' opinions to determine current practice.Design: A postal questionnaire study . Questions were posed that related to a case scenario of an elderly demented patient presenting with a presumed sigmoid volvulus.Setting: The northern region of England.Participants: Thirty (...) seven surgical members of the Association of Coloproctology of Great Britain and Ireland, Northern Chapter.Results: Sixty five per cent of respondents felt that surgery would be inappropriate, and 26% that any intervention at all upon the subject in the case scenario would be inappropriate. More would operate, however, at the request of relatives. An advance directive not to treat would be respected by 70% despite a relative's wishes.Conclusions: Overall there was a wide variation in the approach of the surgeons to a demented patient with bowel obstruction. In an era of clinical governance, and an increased awareness of the ethics of consent, this study presents one example of the difficult decisions with which we are increasingly faced. The greater use of advance directives may provide one possible solution. (shrink)

How aggressively should we pursue life-sustaining treatment of the demented patient? This question becomes increasingly important as our population ages and medical technology offers ever more life-prolongation. In Life'sDominion, Ronald Dworkin addresses the issue in the context of an Alzheimer patient who had previously declared the desire to avoid life-sustaining intervention. Dworkin argues for the primacy of what he calls precedent autonomy: In 1995, the HastingsCenterReport carried thoughtful rebuttals by Daniel Callahan and Rebecca Dresser. Much of Callahan's article is (...) devoted to patients who never executed an advance directive, but he states unequivocally that such directives can be overridden, basing much of his argument on the writings of Sanford Kadish. Together, Dresser, Callahan, and Kadish define a clear position opposed to precedent autonomy. (shrink)

BackgroundThe aim of this study was to explore the construct validity and diagnostic properties of the Reading the Mind in the Eyes Test in non-demented patients with amyotrophic lateral sclerosis.MaterialsA total of 61 consecutive patients and 50 healthy controls were administered the 36-item RMET. Additionally, patients underwent a comprehensive assessment of social cognition via the Story-Based Empathy Task, which encompasses three subtests targeting Causal Inference, Emotion Attribution, and Intention Attribution, as well as global cognitive [the Edinburgh Cognitive and Behavioral (...) ALS Screen ] and behavioral screening [the Frontal Behavioral Inventory ; the Dimensional Apathy Scale ; the Beck Depression Inventory ; and the State and Trait Anxiety Inventory-Y]. The construct validity of the RMET was tested by regressing it within a stepwise model that encompassed as predictors the abovementioned cognitive and behavioral measures, covarying for demographic and motor confounders. Receiver-operating characteristics analyses allowed exploring intrinsic and post-test properties of the RMET both in discriminating patients from HCs and in identifying patients with a defective SET-EA performance.ResultsThe RMET was solely predicted by the SET-EA and SET-IA. RMET scores showed high accuracy both in discriminating patients from HCs and in identifying patients with a defective SET-EA score, with adequate-to-optimal both intrinsic and post-test properties.DiscussionThe RMET is a convergently and divergently valid measure of affective social cognition in non-demented ALS patients, also featuring optimal intrinsic and post-test diagnostic properties in both case-control and case-finding scenarios. (shrink)

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients.The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's (...) health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians , the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a “checklist of considerations” . Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline . The accordingly adapted “checklist of considerations” was tested in a pilot study , after which all experts endorsed the checklist .The resulting “checklist of considerations” structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest. (shrink)

Volume 20, Issue 8, August 2020, Page 96-98.

Are we justified in keeping the demented in prison for crimes they committed when they were still healthy? The answer to this question is an issue of considerable practical importance. The problem arises in cases where very aged criminals exhibit symptoms of dementia while serving their sentence. In these cases, one may wonder whether lodging these criminals in penal institutions rather than in normal caretaking facilities is justifiable. In this paper, I argue that there are justificatory reasons for punishing (...) the demented for their past crimes. In part 2, I examine three theories of punishment—retributivism, prevention theories and expressivism—with regard to the question of whether they provide justificatory reasons for punishing the demented. I argue that only expressivism provides these reasons. In part 3, I defend the view that expressivism, though not convincing as a general theory of punishment, is plausible if applied only to a specific subclass of punitive actions. More precisely, expressivism, or so I argue, is plausible with regard to those acts of punishment that consist in intending to inflict suffering without actually inflicting suffering. Since the punishment of demented patients falls within this class, it can be justified on an expressivist basis. In part 4, I discuss six objections to my view and rebut them. (shrink)

In this article author considers the rights, not of someone who was born and always been demented but of someone who has been competent in the past. He asks if a competent person´s right to autonomy includes the power to dictate hat life prolonging treatment be denied him later, even if he, when demented, pleads for it. To answer this question he considers the extension of contemporary and precedent autonomy and the consecuences holding and evidentiary view or the (...) integrity perspective of autonomy implies. (shrink)

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the (...) debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons. (shrink)

According to Jewish law, to make a judgment that a life has no purpose and is not worth saving is contrary to the concept of justiceTraditional medical practice dictates that when patients are unable to eat or drink enough to sustain their basic nutritional requirements, artificial feeding and hydration is indicated. Common clinical examples of this problem are patients with senile dementia and those in a persistent vegetative state . In recent decades, however, the practice of mandating artificial feeding has (...) been increasingly questioned. A combination of legal, ethical, and clinical considerations has resulted in broad support for withholding and withdrawing artificial nutrition. The guiding ethical principle in the current clinical standards is that patient autonomy must be honoured. In the context of an incompetent adult , advance directives or surrogate decision making are legally binding. Such requests to withhold artificial nutrition are considered appropriate and even encouraged.1 Such a view, however, is not unanimous. For example, Catholic writers have questioned the current consensus. The New Jersey Catholic Conference has written that withholding nutrition and hydration from such patients “ultimately results in starvation, dehydration, and death,” and that withdrawing such basic care from patients who are not dying but in a PVS “is a clear statement that the patient’s life has no moral value”.2 This question is also of great concern in Jewish law . In contrast to secular medical ethics, halachah requires that artificial feeding be given to patients with dementia or in a PVS. The following discussion gives an overview of the pertinent arguments that have led to the consensus in secular ethics that artificial feeding may be withheld from the severely demented and the halachic considerations that argue against this practice.CLINICAL ARGUMENTS IN FAVOUR OF WITHHOLDING ARTIFICIAL FEEDINGThe most obvious …. (shrink)

Zusammenfassung. Die Entwicklung und die Verwendung von Antidementiva, die die Verzögerung des kognitiven Abbaus bei Alzheimer Patienten zum Ziel haben, werfen eine Reihe ethischer Fragen auf. Diese beziehen sich, neben anderen, auf die Bedeutung dieser Medikamente für das subjektive Wohlbefinden und die Lebensqualität des Patienten und auf Aspekte der Zustimmung zur Verwendung dieser Mittel nach Information, insbesondere im Rahmen der medizinisch-wissenschaftlichen Forschung. Der Wert und die Bedeutung der Antidementiva hängt nicht nur vom Effekt auf den kognitiven Abbau ab, sondern auch (...) im weitesten Sinne von der Auswirkung auf die Lebensqualität der Patienten und ihrer primären Versorger. Die subjektiven Erfahrungen der unmittelbar Betroffenen bedürfen daher mehr Aufmerksamkeit als bisher, sowohl in der Forschung als auch in der Praxis. (shrink)

A growing elderly population, dwindling health care resources, and intense and widespread fear of dementia have forced an uncomfortable question: should patients with dementia be slated as off‐limits for life‐sustaining treatment?

Definition of the problem: The development and use of drugs aimed at a positive influence on the cognitive decline in patients suffering from Alzheimer's disease raises a number of ethical issues. Arguments: Among other things, these issues are concerned with the significance of these drugs for the patient's subjective well-being and quality of life and with aspects of informed consent to the use of these drugs, particularly in connection with their use in scientific medical research. Conclusion: The value and significance (...) of antidementia drugs depends not only on their effect on cognitive decline, but also on their wider significance for patients' quality of life and their primary carers. The subjective experience of those directly involved deserves more attention in research and practice. (shrink)

The circumstances surrounding Gordon’s care are complex. Although his acute septicemia has been managed, there remain concerns regarding the need for ongoing care to ameliorate his current pressure...

This chapter contains section titled: I II III Acknowledgement.

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the (...) debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons. (shrink)