Dowrking - the importance of critical interests
2009: Advance directives and personhood
The evidentiary vs. the integrity view of autonomy
In “Life’s Dominion: an argument about abortion, euthanasia and individual freedom”, Dworkin (1994) considers the right of people lacking capacity to autonomy. He acknowledges that competent individuals have the right to make decisions which might not necessarily seem logical, wise or in their best interests but that adults with incapacity do not have this same right. Dworkin puts forward the evidentiary view as a possible explanation, which basically supposes that people do in fact know what is in their best interests, and that consequently, other people should not interfere. In the case of people with incapacity, it would be presumed that they do not know what is in their best interests but that other people, for example specialists like doctors, do. However, he acknowledges that this is clearly not the case, as competent adults regularly and freely make decisions in full knowledge that they are not in their best interests e.g. continuing to smoke despite repeated health warnings about the dangers.
With regard to advance statements, Dworkin points out, “People are not the best judges of what their own best interests would be under circumstances they have never encountered and in which their preferences and desires may drastically have changed” (p.226). Another theory of autonomy is therefore needed to justify respecting wishes contained in an advance directive.
Dworkin proposes the integrity view of autonomy. This approach considers autonomy as a reflection of a person’s integrity as opposed to being based on concerns for their welfare. Taking the previous example of smoking, an autonomous adult may be fully aware that it is not in their best medical interests to smoke but may feel that the personal benefit they gain from smoking outweighs any possible negative effects on their health. In this sense, it derives from the capacity to express one’s character through the life that one leads – based on values, commitments, convictions and critical as well as experiential interests:
Experiential interests: the things that people do just because they like the experience of doing them e.g. cooking or eating out, going out with friends, doing sport, going to the cinema etc. The value of such things depends on the fact that people find them pleasurable or exciting as experiences. It is not important if other people like them and their lives are unlikely to be any less valid for not liking them. Other experiences are often avoided as they are painful or unpleasant but if another person enjoys them or doesn’t mind them (e.g. going to the dentist’s), it is generally no problem.
Critical interests: interests, which if not satisfied, people would think they were worse off in some way or that their life had been wasted. These are convictions about what helps to make a life good on the whole. They represent critical judgments rather than experiential preferences. They are the kind of things that make a person think, had it not been so, their life would have been worse or wasted e.g. having a close relationship, accomplishing a particular task or fulfilling a duty.
Such a theory of autonomy should recognise the right to make choices that seem irrational or may be based on weakness, indecision or caprice. It supports people’s right to lead their lives as they see fit based on what is important to them provided that their lives reflect a general, overall integrity and authenticity.
According to Dworkin, “if his (the person with dementia) choices and demands, no matter how firmly expressed, systematically or randomly contradict one another, reflecting no coherent sense of self and no discernable even short-term aims, then he has presumably lost the capacity that it is the point of autonomy to protect”. Dworkin goes on to suggest that in such cases, people only have the right to beneficence (the right that decisions be made in his/her best interests) but that their preferences may, for different reasons, be important in deciding what their best interests are.
Clearly, conflict may arise when doctors try to balance respect for the principle of beneficence with respect for a person’s right to autonomy. One might ask whether the former can be considered as a reason to ignore a person’s precedent autonomy. In other words, if a person seems to be enjoying life in some way, would it be justifiable to withhold life-supporting treatment on the basis of a previously made request? Maintaining life-supporting treatment would violate rather than respect their autonomy.
Dworkin claims that people with dementia in the later stages have no sense of a whole life with a past joined to a future and that they cannot have the projects or plans of the kind that leading a critical life requires. Furthermore, they are no longer able to act in a way that would make life more or less valuable. Consequently, although there may be a conflict between a person’s precedent autonomy and contemporary experiential interests (if they are clearly enjoying life or some aspect of it), there is no conflict with their critical interests as they perceived them whilst still competent.
Dworkin gives the example of a woman who asked not to be given medical care for life-threatening illnesses contracted after she had acquired dementia. Dworkin states that neither her right to autonomy nor her right to beneficence would give grounds for denying that request, even if she seemed to be enjoying life, as it would constitute a lack of compassion “toward the whole person, the person who tragically became demented”. He points out that even though experiential interests seem to take precedence over critical interests in advanced dementia, it is no reason to ignore the critical interests they had when competent.
Dworkin’s position on dementia and personal identity
Dworkin’s view of a person with dementia seems to be one in which the person at a particular stage of their life has dementia, but this is just one stage in their complete life which has already involved different stages. As such, the stage they are now in, is affected by interests and concerns which transcend that stage and are important for their life as a whole. As such, the competent and incompetent selves are one and the same person. The critical interests, which previously gave meaning and coherence to life, are still important, even if at this particular moment in time, the experiential interests seem to be more in the foreground. Dworkin’s account would seem to suggest that advance directives should be respected because they are to be viewed as expressions of the critical interests a person has, which are relevant to their whole life and which should take precedence over current experiential interests. Failure to respect them would, in his view, constitute “an unacceptable form of moral paternalism”.
Last Updated: Friday 09 October 2009