The Problem of Advance Directives for Alzheimer’s Disease and Personal Identity Over Time

Abstract

Advance directives record our voluntary choices and provide guidelines for competent adult patients making decisions on our behalf when we are no longer capable of making substantiated, reasoned choices for ourselves. These devices are to try and predict the most critical decisions and to set out prior instruction to determine what happens should one be unable to make a contemporaneous choice so that these are recognized as a way to respect for self-determination. Such advance directives only have moral authority (at least) if the person who issued the directive and person whom the directive would be executed are the same person. Our concern about the use of advance directives is the possibility that, in certain cases in which a patient undergoes massive psychological change, the individual who exists after such change is literally a distinct individual from the person who completed the directive. The critique is philosophical in nature and maintains that the moral authority of advance directives is undercut by a failure of personal identity to survive the loss of decisional capacity. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority. For the aim of study, I examine the authority of advance directives for patients with Alzheimer’s disease, who have conflicts between the interests of the earlier and current self, in accordance with concepts of person and perspectives of personal identity over time. I first focus on the claims of Ronald Dworkin. He argues that advance directives one drafted when he was competent represents the best evidence of his critical interests. Since critical interests are more important than experiential interests to lead his life as a narrative unity, they should be given priority and effectively act as trump cards. Regardless of the fact that one’s body persists with experiential interests, Dworkin claims that a patient with dementia should be stuck forever in that timeless point that is his earlier choice, even if he cannot espouse it now, in order to become a person again. This allows Dworkin to tend to argue that since the incompetent person cannot rescind the competent advance directives, for his best interests, they should be respected. In contrast to Dworkin, Locke-Parfit argues that the most important relationship for survival is that of psychological connectedness. Over time, one body may house more than one morally relevant entity. This view of successive selves within a single body raises the question of why the self who presently inhabits the body should be bound by the decisions of the self who previously inhabits the body should be bound by the decisions of the self who previously inhabited that body. This allows Locke-Parfit to tend to argue that there will be some human beings who lack a sufficient connection to their previous self for advance directives to be morally or legally binding. I reject both theories. Both Dworkin’s and Locke-Parfit’s views have one characteristic in common: extreme concentration on mental mechanisms. First, I disagree with Dworkin’s main presumption that “one’s own sense of integrity and critical interests” should be the essence of a person and a requirement for being the same person over time. I also disagree with the argument of Dworkin’s theory that a patient with Alzheimer’s is “living dead” who physically exists but mentally is extinct. Throughout life, I believe that both in times when our “the ability to act out of genuine preference or character or conviction or a sense of self” is fully mentally developed and active, and in times when these abilities are diminished or quiescent, we are physically present in an embodied form as the unity of body and psyche. At the same time, I deny the Locke-Parfit view that a person is constituted solely by psychological phenomena so that the person, in essence, is no more than an amalgamation of connected mental states. The psychological criterion is not sufficient to explain what constitutes a person and personal identity since one’s mental mechanisms cannot be independent from his body. Locke-Parfit perspective needs to be expanded to take into account the reality of mental content, which acquires meaning within the context of the world in which the person lives, as body perceives and moves. In criticism of Dworkin’s and Locke’s views, I will offer a more practical conception of a person and its persistence over time. I have included the concept of an embodied person for completeness. The gist of this view is that since many features of cognition are embodied in that they are deeply dependent upon characteristics of the physical body of an agent, such that the agent’s beyond-the-brain body plays a significant causal role, or a physically constitutive role, in that agent’s cognitive processing, the judgment of personal identity should be based on embodied theory. From the perspective of the embodied person view, it cannot be said that a patient with dementia ceases to exist or changes into a different person once his psychological connectedness and his personal memories have been lost in the manner suggested by Locke-Parfit. Further, it follows that we cannot simply identify the person, as Dworkin does, with capacity for autonomy and critical interests as the products. This arguably justifies the authority of an advance directive but not necessarily as a device with absolute and binding authority since personal identity is persistent even in severe dementia cases. In addition, the absence of any “clear and confident” oral or written evidence of the patient’s wishes in present, leaves the decision of executing advance directives to a third party. In order to know what the best for the patient is, I have suggested that we need to become authors as well as a critic of his life. ;의사결정능력이 있는 성인 환자의 의료처치에 관한 자기결정권은 온전히 보호되며, 이는 생명의료윤리에 있어 기본적인 원칙으로 자리 잡고 있다. 또한, 자기결정권의 연장선에서, 본인에 대한 의료행위에 관한 결정을 내릴 수 없는 경우를 대비하여, “현재”는 의사결정능력이 있는 환자가 “미래”에 의사결정능력이 손상된 나를 위해 내리는 결정을 “사전의료지시”(advance directives)라고 한다. 이러한 사전의료지시는 윤리적 정당성뿐 아니라, 영국 정신능력법(Mental Capacity Act 2005)이나 미국의 환자 자기결정권법(Patient Self-Determination Act) 등을 통해, 그의 법적 정당성 또한 인정받고 있는 듯 보인다. 그러나 어디까지나 과거의 내가 현재의 나를 제약할 수 있다는 주장은 과거의 온전했던 나와 현재의 불완전한 내가 동일하다는 가정하에서만 가능하다. 본 연구는 알츠하이머병으로 인해 과거의 이익과 현재의 이익이 충돌하는 경우, 사전의료지시의 적용이 환자의 최선의 이익에 부합하는지를 인격(person)과 인격 동일성(personal identity)의 시각에서 탐구하는 것을 목적으로 한다. 이를 위하여, 향유적 이익(critical interests)은 온전한 삶의 전체적 평가나 우려의 대상이 될 수 없음을 지적하고, 비판적 이익의 우위를 설명한 Ronald Dworkin의 견해와, 인격의 동일성이 심리적 요인으로 환원할 수 있으며 신체가 동일하다고 할지라도, 강력한 심리적 연결관계가 있지 않는 한 동일한 인격이라고 할 수 없다는 주장을 한 John Locke와 Derek Parfit의 이론을 대립시켜, 사전의료지시의 정당화 근거에 대한 재규명을 시도하였다. 또한, 인격 동일성 상정을 위해 각 이론이 지닌 전제의 한계를 지적하고, 정신적 작용과 몸을 분리하여 이분법적으로 인격을 규율하는 이 이론들의 공통적 문제점을 논한다. 마지막으로, 이를 상쇄할 수 있는 대안으로 인간의 정신적 작용들은 몸과 분리되어 있지 않고, 오히려 구체적으로 몸을 가지고 환경에 구현, 내재되어 사회 문화 환경에 적응하는 존재로 인간을 보는 체화된 인격(embodied person)의 관점을 제시하였으며, 이를 바탕으로 알츠하이머병 환자의 최선의 이익에 부합하는 사전의료지시의 정당화 근거를 피력하고, 이에 수반되는 그 한계점을 수용하였다.