Dworkin on Dementia: Elegant Theory, Questionable Policy

In his most recent book, Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom,[1] Ronald Dworkin offers a new way of interpreting disagreements over abortion and euthanasia. In doing so, he enriches and refines our understanding of three fundamental bioethical concepts: autonomy, beneficence, and sanctity of life. It is exciting that this eminent legal philosopher has turned his attention to bioethical issues. Life's Dominion is beautifully and persuasively written; its clear language and well-constructed arguments are especially welcome in this age of inaccessible, jargon-laden academic writing. Life's Dominion also is full of rich and provocative ideas; in this article, I address only Dworkin's remarks on euthanasia, although I will refer to his views on abortion when they are relevant to my analysis. Professor Dworkin considers decisions to hasten death with respect to three groups: (1) competent and seriously in people; (2) permanently unconscious people; and (3) conscious, but incompetent people, specifically, those with progressive and incurable dementia. My remarks focus on the third group, which I have addressed in previous work,[2] and which in my view poses the most difficult challenge for policymakers. I present Dworkin's and my views as a debate over how we should think about Margo. Margo is described by Andrew Firlik, a medical student, in a Journal of the American Medical Association column called A Piece of My Mind."[3] Firlik met Margo, who has Alzheimer disease, when he was enrolled in a gerontology elective. He began visiting her each day, and came to know something about her life with dementia. Upon arriving at Margo's apartment (she lived at home with the help of an attendant), Firlik often found Margo reading; she told him she especially enjoyed mysteries, but he noticed that "her place in the book jump[ed] randomly from day to day." "For Margo," Firlik wonders "is reading always a mystery?" Margo never cared her new friend by name though she claimed she knew who he was and always seemed pleased see him. She liked listening to music and was happy listening to the same song repeatedly, apparently relishing it as if hearing it for the first time Whenever she heard a certain song however, she smiled and told Firlik that it reminded her of her decease husband. She painted, too, but I the other Alzheimer patients in he art therapy class, she created the same image day after day: a drawing o four circles, in soft rosy colors, on inside the other." The drawing enabled Firlik to understand something that previous had mystified him: Despite her illness, or maybe somehow because of it, Margo is undeniably one of the happiest people I have known. There is something graceful about the degeneration her mind is undergoing, leaving her carefree, always cheerful. Do her problems, whatever she may perceive them to be, simply fail to make it to the worry centers of her brain? How does Margo maintain her sense of self? When a person can no longer accumulate new memories as the old rapidly fade, what remains? Who is Margo? Firlik surmises that the drawing represented Margo's expression of her mind, her identity, and that by repeating the drawing, she was reminding herself and others of that identity. The painting was Margo, plain and contained, smiling in her peaceful, demented state." In Life's Dominion, Dworkin considers Margo as a potential subject of his approach. In one variation, he asks us to suppose that years ago, when fully competent, Margo had executed a formal document directing that if she should develop Alzheimer's disease ... she should not receive treatment for any other serious, life-threatening disease she might contract. Or even that in that event she should be killed as soon and as painlessly as possible. …