Introductory Chapter to the _Cambridge Handbook of Situated Cognition_ (CUP, 2009).

When patients have progressive and incurable dementia, should their advance directives always be followed? Contra Dworkin, Dresser argues that when patients remain able to enjoy and participate in their lives, directives to hasten death should sometimes be disregarded.

: In this paper, I consider objections to advance directives based on the claim that there is a discontinuity of interests, and of personal identity, between the time a person executes an advance directive and the time when the patient has become severely demented. Focusing narrowly on refusals of life-sustaining treatment for severely demented patients, I argue that acceptance of the psychological view of personal identity does not entail that treatment refusals should be overridden. Although severely demented patients are morally (...) considerable beings, and must be kept comfortable whilst alive, they no longer have an interest in receiving life-sustaining treatment. (shrink)

Where does the mind stop and the rest of the world begin? The question invites two standard replies. Some accept the demarcations of skin and skull, and say that what is outside the body is outside the mind. Others are impressed by arguments suggesting that the meaning of our words "just ain't in the head", and hold that this externalism about meaning carries over into an externalism about mind. We propose to pursue a third position. We advocate a very different (...) sort of externalism: an _active externalism_, based on the active role of the environment in driving cognitive processes. (shrink)

Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if the purpose of a theory of personal (...) identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular set of actions, experiences, and characteristics is that of a given person rather than someone else. (shrink)

Autonomous decisions are decisions that reflect the self who makes them. Since patients in need of surrogate decision making can no longer enjoy the dignity of being free to express who they are through choice and action, surrogates should strive to, at least, make sure that decisions on behalf of the patient reflects that patient's self. Concepts of the self, then, underlie views about the role autonomy should play in surrogate decision making. Alzheimer's disease (AD) complicates the situation because it (...) is a disease which effects the self and theorists disagree about which aspect of the AD self the decision should reflect. This disagreement has led to a seemingly irresolvable split between those who favor the then self and those who favor the now self. The debate has stalled because while both of these views are attractive, neither seems adequate. That is, neither view is complete because each focuses only on one aspect of a whole self. In this paper, I argue that a good mode of surrogate decision making is one that focuses on the whole self and I offer practical advice concerning how we can begin to think about how such a decision might be made. (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 this paper I consider, in connection with dementia, two views of the person. One view of the person is derived from Locke and Parfit. This tends to regard the person solely in terms of psychological states and his/her connections. The second view of the person is derived from a variety of thinkers. I have called it the situated-embodied-agent view of the person. This view, I suggest, more readily squares with the reality of clinical experience. It regards the person as (...) embedded in a history and culture. The human person is also an embodied agent. I contend that this view encourages a more appropriate approach towards the ethical issues that arise in dementia and towards people with dementia. (shrink)

The leading accounts of the ethics of proxy decision making implicitly draw on internalist conceptions of the philosophy of mind, or so this essay tries to demonstrate. Using the views of Ronald Dworkin as its jumping‐off point, the essay argues that accepting the sort of externalism associated with writers such as Putnam and Burge would alter Dworkin's conclusions concerning how we should respond to the current or precedent decisions of people suffering from dementia. Building on the views of Agnieszka Jawarska, (...) it argues that accepting “active” externalism à la Clark and Chambers would provide currently competent people with new resources for establishing the authority of their present values over inconsistent values they might come to entertain should they become demented. (shrink)

The authority of the intact self over the future severely demented self is based on notions of integrity and precedent autonomy. Despite criticism of this authority, the principle of precedent autonomy in the care of people with Alzheimer disease or other progressive and irreversible dementias retains its moral significance.

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

Advance directives such as living wills are attractive in that they give us a sense of control over our futures. But they also tend to obscure conflicts between a patient's competent wishes and later, incompetent interests. They allow caregivers to avoid evaluating quality of life in assessing the best interests of incompetent patients.

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)