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Advance Directives for Dementia Can Survive Altered Preferences

Emily Walsh argues, correctly, that preference changes in progressive dementia attributable to “transformative experiences” can diminish the moral weight of advance directives (ADs). She also contends that an influential positive philosophical view about directives (to her, “the dominant view”) fails to account for transformative experiences, and that this failure explains why the view is at odds with clinicians’ typical and justified skepticism about ADs. Her analysis ends on a constructive note, suggesting important improvements to be made in ADs. Despite these notable strengths, Walsh’s analysis overplays the potential of transformative experience in dementia to constitute a relevant change of mind about a previous AD, misses a crucial element behind ADs’ moral weight, seems not to grasp what many people who write ADs about dementia are focusing on, and fails to examine carefully the subjective value of survival in precisely the dementia situations that many ADs address. After explaining these weaknesses, I, like Walsh, end on a positive note, refining one of Walsh’s important suggested improvements.