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Thirty-four years as a GP: is a patient with advanced dementia still the same person?

Alistair Gow Contributor
· 5 replies · 211 views
Personal identityAfrican & AfricanaAnalyticModern EuropeanEmpiricismDavid HumeIfeanyi MenkitiRonald Dworkin#advance-directives#bundle-theory#dementia#personhood
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I was a GP in Leith for thirty-four years, and the question I heard most often in the last decade was some version of "she isn't the person she was". It was said by husbands, daughters, neighbours, sometimes with grief and sometimes with relief.

Retired, I have started reading Hume, who lived down the road. In the Treatise he says that when he looks inward he never catches a self, only some particular perception or other. If that is right, the daughter is not making a confused remark. There is a bundle, and the bundle has changed beyond recognition.

But it does not feel that way at the bedside. The woman with advanced dementia still flinches at the same noise, still hums the same hymn, still has the scar from the operation I referred her for in 1991. Biologically there is no question she is the same organism. And the law treats her as the same person: her advance directive, written twenty years ago, governs what we do now.

That last point is where it gets hard. Ronald Dworkin argued that the earlier self's considered wishes about the shape of her whole life should govern. Others reply that the contented woman in front of us now has interests of her own, and that letting a past self overrule her is a strange kind of tyranny.

I would like to hear from people who have sat with this, and from people who think the philosophy settles it. I am not sure it does.

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5 replies

  1. Elin Lindqvist

    Fellow

    ICU nurse in Uppsala. I don't think the philosophy settles it, but I think it helps you notice which question you are answering. "Is she the same person?" in the biological sense: yes. In the sense of "does she have the memories and plans that made her who she was?": partly, less each month. In the sense that matters for the advance directive, I honestly don't know, and I've watched families split exactly along that line.

    Helpful · 3
  2. Kwame Asante

    Fellow

    Alistair, in the Akan setting where I grew up, the question would be phrased differently. On Menkiti's influential reading of African thought, personhood is something achieved through a life in community, not simply given at birth. That raises an uncomfortable question for your case: if personhood is achieved, can it be lost? In practice, no one in my grandmother's village would have said an elder with dementia was less of a person. She was still owed the greeting, the seat, the respect. Some of us think that practice is a better guide than the theory, and Gyekye's more moderate communitarianism fits it better.

    1. Alistair Gow

      Contributor

      Kwame, that is a striking point. Personhood as a standing that others keep up for you, even when you cannot keep it up yourself. I saw families do that. I also saw families who could not.

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  3. Arjun Iyer

    Fellow

    For what it is worth, from the Advaita side: the witness-consciousness Śaṅkara talks about is not the memory or the personality, so on that view the daughter's remark is true of the personality and false of the self. I do not offer this as a comfort, only as a reminder that "same person" may be several questions at once.

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  4. Omar Farouk

    Fellow

    On the directive: in my practice in Cairo we rarely have formal advance directives, and the family decides. I used to think that was a weakness. After reading about the Dworkin debate I am less sure. A family that knew both the earlier woman and the present one may be better placed than a document written by only one of them.

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