Diet, changing desires, and dementia
Cross-post from the Uehiro Centre's Practical Ethics blog
Last week saw the launch of a campaign (run by the group Vegetarian For Life) that seeks to ensure that older people in care who have ethical commitments to a particular diet are not given food that violates those commitments. This is, as the campaign makes clear, a particularly pressing issue for those who have some form of dementia who may not be capable of expressing their commitment.
Those behind campaign is quite right to note that people’s ethical beliefs should not be ignored simply because they are in care, or have a cognitive impairment (see a Twitter thread where I discuss this with a backer of the campaign). But the idea that one’s dietary ethics must be ‘for life’ got me thinking about a more well-established debate about Advance Directives. (I should stress that what I say here should not be taken to be imputing any particular motivation or philosophical commitments to those behind the campaign itself.)
Briefly, one way of thinking about advance directives is that they are a way for people to, while we retain the relevant cognitive capacities, direct what happens to them at a future point where they lack capacity. Ronald Dworkin (in Life’s Dominion) draws a distinction between two kinds of interests. Some interests are purely experiential – it is in my interest to enjoy this piece of cake, for instance, merely because of how it tastes in the moment. But other interests are critical: they lend coherence and shape to our lives (he acknowledges that people may have such interests to greater or lesser degree).
When it comes to certain kinds of advance directives, these interests may come into conflict. For instance, someone may write an AD which says that if they are suffering from severe dementia, and have lost the capacity to do various things that currently give their life meaning (e.g. writing; certain kinds of interactions with loved ones), they should not be resuscitated if they fall ill. Their critical interest in shaping their life (exercised initially while still possessing capacity) may come into conflict with their later experiential interests if their quality of life is still good at the time when doctors are deciding whether to resuscitate. While dementia can of course negatively impact quality of life, many individuals with dementia lead good, enjoyable lives, full of valuable relationships, pastimes and experiences.
In Dworkin’s view, it is the critical interests that should win out. Up until now I have been convinced by a response to Dworkin from Rebecca Dresser. Dresser argues that it is far from clear that critical interests should always take precedence. Dresser raises a number of important issues, but a particularly compelling example of hers, to my mind, is that of pain relief: we can imagine a person whose religious or philosophical commitments led them to value the experience of physical pain, perhaps seeing it as more authentic than using pain relief. But imagine such an individual later on, as a patient suffering dementia and having forgotten all about these commitments. It is hard to see the value in nonetheless respecting her past critical interests, and refusing to give a confused, frightened patient pain relief when doing so would benefit her immensely.
In such a case, we allow a person’s current experiential interests to override our respect for her past critical interests. And it seems to me that we do so quite defensibly; indeed, I think it would be indefensible to insist on respecting her past commitments which have no resonance with her now. To my mind, the case of life-prolonging care is of the same kind; if a patient with dementia no longer has any sense of the commitments that led her to request that her life not be extended if they were to suffer from such a condition, and her continuing life is of a good quality, then our moral obligation is to save her life.
The Vegetarian for Life campaign has, I admit, given me pause for thought. As someone with ethical dietary commitments, I am certainly unsettled by the thought that I might one day unwittingly violate those commitments, even if I no longer explicitly hold them. So I will end by offering a couple of thoughts about what might justify a difference in approach between diet on the one hand, and pain relief and the extension of good quality life on the other.
1. No harm done: If I am denied pain relief, I am directly harmed. Although philosophically more controversial, many of us believe that we can be harmed by being deprived of good quality life. In many cases, though, there is no harm done to someone by feeding them, say, a vegan diet. As such, the experiential costs of respecting the critical interest is lower.
Such a defence will, of course, be limited. If a patient’s tastes change so that they will only eat previously abhorred foods, then there would be a serious cost to maintaining their past commitment.
2. Evidence: We typically get fairly direct evidence that someone is in pain, and that the patient in pain wants it to stop. Judgements of whether an individual life is overall good are more difficult, but if a patient seems happy on a day-to-day basis, we have little reason not to judge that they would benefit from continuing to live. It is perhaps more controversial to say that we can attribute to a patient with dementia a desire to go on living; but we can typically attribute a desire to carry on various pleasurable activities, for which living is of course a requirement. In both these cases then, we have evidence of the patient’s individual experiential preferences.
Contrast this with dietary preferences. In general, the evidence we could get that a patient’s preferences had changed would not come about organically (as with the preference against pain, and for the continuation of life), but through a conscious decision by carers to change the patient’s diet. But there is usually no good reason to make that change.
3. Moral wrong vs. ideal life: Even among people with particular dietary values, reasons vary. My own reasons are other-regarding moral ones of a fairly standard kind (animals have rights, and it’s thus wrong to kill them for food). What’s more, I think that it would still be wrong of me to eat meat even if I changed my mind.
This contrasts to some extent with at least one way of viewing Dworkin’s example of critical interests. Imagine someone who values abstract philosophy, who knows he will have no interest in that sort of thing once he has dementia. He currently sees his life as valuable in a very specific way. But he may not (and, I would suggest, should not) see other kinds of life as without value, at least for other kinds of people. What’s more, even if he does see a life without philosophy as containing some kind of mistake, it would be odd to see it as a moral mistake. Is there anything to be said for the idea that a person’s deep moral commitments have a greater claim to being respected (so long as they are reasonable) than other kinds of evaluative commitments? I expect many people will want to say no!
Of course, my varying intuitions may just be due to personal value prejudice. While I have a strong commitment to my dietary values, I have no similar commitments that would make me want to prematurely end my life if I were to suffer from dementia (it is not exactly that I welcome dementia as Charles Foster does, but that I recognise that my life may well have significant personal value, albeit of a different kind than it does now). And I certainly don’t have any commitments against avoiding pain (authenticity schmauthenticity, I say). So it may be that I’m just being parochial, and insisting that while the things I care about in a critical sense are deeply important and should be respected, the things others care about aren’t, and shouldn’t.