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Advance decisions in dementia: when the past conflicts with the present
  1. George Gillett
  1. Correspondence to George Gillett, Medical Sciences Division, University of Oxford, Oxford OX1 2JD, UK; george.gillett{at}


As the prevalence of dementia increases across the Western world, there is a growing interest in advance care planning, by which patients may make decisions on behalf of their future selves. Under which ethical principles is this practice justified? I assess the justification for advance care planning put forward by the philosopher Ronald Dworkin, which he rationalises through an integrity-based conception of autonomy. I suggest his judgement is misguided by arguing in favour of two claims. First, that patients with dementia qualify for some right to contemporary autonomy conceptualised under the ‘sense of liberty’ it provides. Second, that respecting precedent autonomy, such as an advance care plan, is not essential to Dworkin’s integrity-based account of autonomy. Together, my claims problematise the practice of using advance decisions in the context of dementia.

  • autonomy
  • dementia
  • elderly and terminally ill
  • living wills/advance directives
  • psychiatry

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  • Contributors I take responsibility for the content of this manuscript, wrote it and decided to submit it for publication. The manuscript represents original work undertaken entirely by the proposed author.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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