Advance decisions in dementia: when the past conflicts with the present.

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. © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.