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Kuhse – existence over time

2009: Advance directives and personhood

Whilst Kuhse (1999) accepts the argument by Robertson and Dresser that advance directives are conceptually confused because they rely on inapplicable notions of self-determination and personal identity, she believes that this does not justify overriding refusals of life-sustaining treatment.

Kuhse agrees with Buchanan who describes people suffering from advanced Alzheimer’s disease as having only very truncated interests and mental capacities that “are much less sophisticated than those of a small child or nonhuman animal such as a dog”. She adds that people with severe dementia lack the capacity for self-consciousness, rationality and purposive agency, and have no conception of themselves existing over time, even though they are capable of experiencing pain and pleasure - basically, they lack a vision of their lives as extending into the future. She quotes Tooley (1983) who argues that the ability to see oneself as existing over time is a necessary condition for being a person and for having a “right to life”.

On the basis of this argument, Kuhse concludes “it would thus not be directly wrong to allow a human individual who is not a person to die painlessly………… and to argue that the advance refusal of life-sustaining treatment by a person should be honored if the individual that succeeds her is not a person, that is, does not have an interest in her own continued existence.”

Kuhse acknowledges that even in the most advanced stage of dementia, people have an interest in avoiding pain and discomfort and therefore does not condone withholding pain and symptom relief even if the person refused this in advance of receiving palliative care to alleviate pain and suffering.



Last Updated: Friday 09 October 2009


  • Acknowledgements

    Alzheimer Europe gratefully acknowledges the support of the German Ministry of Health for the implementation of the Dementia Ethics Network.
  • Bundesministerium für Gesundheit