Advance directives, dementia, and best interests

Abstract

Consider the following scenario. Margo is a mentally incompetent patient suffering from dementia. She is currently happy and content. However, she made an advance directive when she was competent, stating that she should not receive treatment for any potentially fatal condition if she should become demented. Suppose she now contracts pneumonia, which would be fatal if not treated. Should her advance directive be followed? The traditional view understands this case as a case of conflict between respect for autonomy and self-interest (or beneficence, or well-being, which I will use interchangeably): while respect for autonomy requires following the advance directive, the self-interest of Margo requires the contrary. Ronald Dworkin, however, argues that Margo’s self-interest would actually be promoted by following the directive, and, accordingly, there is no real conflict between respect for autonomy and self-interest in this case. Dworkin’s claim on Margo’s self-interest was rejected in a recent paper by Jennifer Hawkins. My aim is to challenge Hawkins’s critique of Dworkin but call Dworkin’s conclusion into doubt on separate grounds.