Medicine, Health Care and Philosophy (2020) 23:705–715
https://doi.org/10.1007/s11019-020-09965-0
SCIENTIFIC CONTRIBUTION
Indeterminacy of identity and advance directives for death
after dementia
Andrew Sneddon1
Published online: 14 July 2020
© Springer Nature B.V. 2020
Abstract
A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through
deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue
that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are dis-
tinguished. Two of these—epistemic indeterminacy and metaphysical indeterminacy—should be addressed in laws/policies
regarding advance directives for euthanasia.
Keywords Dementia · Personal identity · Medical assistance in dying · Derek Parfit · Ronald Dworkin
Introduction
An enduring 1 question in discussions of the ethics of
advance directives for euthanasia is whether patients who
go through deep psychological changes retain their iden-
tity. Rather than seek an account of identity that answers
this question, I argue that responsible policy should directly
address indeterminacy about identity. Three sorts of inde-
terminacy are distinguished. Two of these—epistemic-
indeterminacy and metaphysical-indeterminacy—should
be addressed in laws/policies regarding advance directives
for euthanasia.
Dementia and medical assistance in dying
The last few decades have been marked by increased official
acceptance of assisted suicide and active euthanasia (hereaf-
ter glossed, in the Canadian fashion, as MAID, for “medical
assistance in dying”). For example, the Netherlands made
MAID legal in 2001, Belgium in 2002, and Canada in 2016.
Generally, MAID is restricted to patients able to form and
express rational preferences about themselves, their condi-
tion, and what they want to happen to them. One practical
* Andrew Sneddon
asneddon@uottawa.ca
1
University of Ottawa, Ottawa, Canada
issue is whether to extend MAID services to dementia
patients. For instance. Belgium is currently going through
social and governmental consideration of such a change to
their Euthanasia Act (Cohen-Almagor 2016, pp. 76–77;
Crisp 2019). As another example, when Canada enacted its
MAID law in 2016, it simultaneously commissioned several
reports from the Council of Canadian Academies (CCA) on
tricky cases and the question of whether to extend MAID to
them. One of these reports, which was delivered in late 2018,
is entitled The State of Knowledge on Advance Requests for
Medical Assistance in Dying (CCA 2018). The panel therein
reports that interest in being able to make such requests is
driven to a significant extent by “capacity-limiting condi-
tions” such as dementia (2018, pp. 39–41). Dementia is
marked by deep, often irreversible changes to memory, per-
sonality, and reasoning that interfere with the kind of prefer-
ence formation and expression recognized as important in
MAID policy. In many cases, dementia is symptomatic of a
fatal condition. In these cases, the underlying cause of the
dementia eventually makes the person who has it a prima
facie candidate for MAID, but in such places as Belgium
and Canada the dementia disbars them from legal access
to MAID. Advance directives (AD-MAID) are the obvious
1
Academic discussion of this issue begins with Rebecca Dresser’s
criticism of Ronald Dworkin’s position in Life’s Dominion (Dworkin
1993; Dresser 1986). Subsequent debate ensued and continues today.
Eva Constance Alida Asscher and Suzanne van de Vathorst (2020)
and Jonathan Hughes (2020) discuss it in connection with a high-
profile case going through the courts in the Netherlands, showing the
relevance to this issue to matters beyond the academy.
13
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general means to facilitate access to MAID. People could
make such requests for MAID for the future before succumb-
ing to dementia, or even being diagnosed with it.
Other countries have more liberal policies concern-
ing AD-MAID and dementia. In April 2020, the Hoge
Raad der Nederlanden—the Supreme Court of the Neth-
erlands—upheld the acquittal of a physician who had per-
formed MAID on a dementia patient. In so doing, the Court
enshrined the legal admissibility of such advance directives
more generally.2 That this decision has been made in 2020
demonstrates that legal and practical considerations of
dementia and AD-MAID are only now being settled in the
jurisdictions that have legalized euthanasia.
Dementia, AD‑MAID, and personal identity
Since the 1980s, one theme in the philosophical and legal
literature about AD-MAID has concerned personal identity.3
The question is whether people who have gone through the
deep psychological changes characteristic of dementia are
literally the same persons that existed prior to these changes.
If they are, then advance directives made before dementia
apply, prima facie, to these people after dementia. But if
identity changes in dementia, such that people with dementia
are different persons from those who existed before demen-
tia, then it is not at all clear why advance directives made
by one person should be thought to have authority over the
treatment of a subsequent distinct person.
One might think that personal identity is a uniquely philo-
sophical and academic concern. However, the concern about
identity comes up for ordinary people dealing with demen-
tia. Julian Hughes writes of his experience with this issue
as (at least in part) a Consultant in Old-Age Psychiatry at
Newcastle General Hospital: “A patient with dementia tells
me she can no longer feel, it’s as if she is not real. A spouse
tells me his wife with dementia is a different person from
the one he married. Some say that in severe dementia the
person is lost.” (2001, p. 86) Surely Hughes’ experience is
2 life is not worth living any longer.” (Schüklenk et al. 2011,
On this court case, see (1) ECLI: NL: HR: 2020: 712; online at
https ​ : //uitsp ​ r aken ​ . recht ​ s praa ​ k .nl/inzie ​ n docu ​ m ent?id=ECLI:NL
:HR:2020:712; (2) “Dutch court approves euthanasia in cases of
advanced dementia”: https​://www.thegu​ardia​n.com/world​/2020/
apr/21/dutch​-court​-appro​ves-eutha​nasia​-in-cases​-of-advan​ced-demen​
tia; (3) “Dutch Supreme Court Expands Euthanasia Laws for Demen-
tia Patients”: https​://www.nytim​es.com/reute​rs/2020/04/21/world​/
europ​e/21reu​ters-healt​h-eutha​nasia​-nethe​rland​s.html. For history and
academic discussion, see Asscher and van de Vathorst (2020) Hughes
(2020).
3
There are various philosophical problems of personal identity. The
present concern is one of these—the question of persistence of per-
sons through time—but others might well be implicated by it. See
Olson (2017) for an overview.
13
A. Sneddon
typical: ordinary people outside of the academy worry about
personal identity when either observing or going through
the psychological changes characteristic of dementia.4 Allen
Buchanan and Dan Brock (1989, p. 106), followed by Mark
Kuczewski (1994, p. 32), emphasize that clinical cases
involving deep psychological change resulting in a dementia
patient who enjoys her current life are particularly important
for feeling the importance of this issue.
Some authors argue that the personal identity issue is
not necessarily relevant to AD-MAID, and hence may be
avoidable after all. Elisabeth Furberg (2012) claims that the
relevance of personal identity turns on the normative frame-
work that one adopts: it won’t be particularly relevant by the
standards of a utilitarian framework, but it will be by the
standards of some versions of a rights-based framework. The
present question then is just what framework(s) is relevant to
AD-MAID policy. The answer is that policy discussions, at
least in the sorts of broadly liberal democracy that currently
allow MAID, tend to be pluralistic, including acknowledge-
ment of the value of personal autonomy. For instance, the
Dutch euthanasia law exhibits sensitivity to the value of
both suffering and voluntariness, the latter of which is part
of what is valued under the general rubric of “autonomy”.
The same pluralism is found in Belgium’s Euthanasia Act,
which goes so far as to define “euthanasia” as voluntar-
ily chosen by patients (Cohen-Almagor 2016, pp. 74–76).
In Canada, before the government pursued legalization of
MAID, it commissioned a study from the Royal Society of
Canada. Entitled End-of-Life Decision-Making in Canada:
The Report by the Royal Society of Canada Expert Panel on
End-of-Life Decision-Making (Schüklenk et al. 2011), the
study addressed practical, cultural, legal and ethical dimen-
sions of MAID (with special attention to medicine and death
in Canada). Its authors give particular prominence to the
value of autonomy, or, equivalently for them, self-determi-
nation. They call this value “paramount” but not exclusively
important (Schüklenk et al. 2011, p. 31) and, with regard to
MAID specifically, they write, “If autonomy is, as we claim
that it is, a central constitutional value, then it quite clearly
grounds the right to request assistance in dying according
to one’s considered and stable views about when one’s own
p. 34). Autonomy is routinely understood as a psychologi-
cal state/capability/achievement of persons specifically: see,
e.g., Buss and Westlund (2018). If autonomy is specifically
4
This does not imply that they do not also worry about other things.
Of course they do. Interpretation is needed to figure out just what
concerns ordinary people have about these complex issues. Such
interpretation will sometimes preserve the initial appearances, and in
the present case this will mean that some ordinary people are worried
about the persistence of persons through time across deep changes in
psychology.
Indeterminacy of identity and advance directives for death after dementia 707
personal autonomy, then since concerns about autonomy are
central to the ethical frameworks in which MAID is ordi-
narily understood and valued, questions about the nature,
significance, and, crucially, identity of persons cannot be
evaded within these frameworks.
Another argument is that bioethicists should address
what we essentially are, and that this is not persons. David
DeGrazia (1999) ties this claim to a specific account of what
matters and does persist here, namely organisms rather than
persons. I shall return to this specifically in the next section;
for now, let’s consider the more general argument. We have
already seen two reasons to think that we cannot turn away
from persons in connection with AD-MAID. One is practi-
cal, the other theoretical. The practical issue is that there
is reason to think that ordinary people dealing with these
issues for themselves and others conceive of the issue in
terms of sameness/difference of persons. Recall the observa-
tions of Hughes, Buchanan & Brock, and Kuczewski. Any-
one who claims that we should think about something else
risks being received as either changing the topic or miss-
ing the real issue. The second reason is, again, the role of
autonomy in the frameworks surrounding MAID. We can
assume that the personal identity issue pertains to any medi-
cal/legislative frameworks that give a role to the value of
personal autonomy, regardless of the evitability of this issue
in other contexts.
Finally, much the same thought applies to the position
of David Shoemaker (2010). Shoemaker argues that when
considering the issue of the legitimacy of advance directives
for dementia patients, the focal point is not whether some
prior person continues to exist as a dementia patient, but the
grounds of authority of the preferences of the pre-dementia
person. Depending on the nature of these grounds, iden-
tity might or might not be a relevant issue. If earlier prefer-
ences do not trump later ones, then it seems that identity
is beside the point: that one person has persisted through
time and across changes does not indicate that prior prefer-
ences are still relevant. But in discussions of AD-MAID,
and specifically in contexts that acknowledge the centrality
of patient autonomy to both medicine and MAID, personal
autonomy is already officially on the table as at least part of
the grounds of the authority of one’s prior preferences for
one’s current treatment. The context need not be character-
ized by a document as explicit as the report by Schüklenk
et al.; wherever MAID is justified or conceived of in terms
of giving patients more control over their lives (or bodies,
or treatment), the issue of the extent of the domain of such
5
This does not imply that there are not other problems as well. For
instance, hard questions arise when third party medical decisions
must be made for persons whose interests have changed through time,
even when the identity of the persons in question is taken for granted.
control is found. Hence, again, questions of personal identity
cannot here be avoided after all.5
Dementia and the psychology of identity
The unavoidability of the personal identity issue should not
be surprising. Reidentifying persons is an important thing
for us to be able to do, social animals that we are. To do this
successfully will require attention, probably quite automatic,
to changes in persons, and similarly automatic assessment
of whether the person being observed is the same or differ-
ent from a person we have met previously. Philosophers and
psychologists have studied both this skill and the correlative
pretheoretical concept of personal identity. Psychological
features loom large—i.e., we judge selves to remain the same
despite undergoing lots of physical changes, but detection of
certain psychological changes leads us to say that the person
in front of us is no longer the same as some prior person.
Unsurprisingly, changes in personality matter to such judg-
ments. Perhaps more surprisingly, features of our moral psy-
chology are particularly important to assessments of same-
ness of persons through time. There is some reason to think
that these are the most important aspect of personal identity
by lay standards. For instance, Nina Strohminger and Shaun
Nichols performed five experiments about folk concepts of
personal identity. Their conclusion: “... we find strong and
unequivocal support for the essential moral self hypothesis.
Moral traits are considered more important to personal iden-
tity than any other part of the mind.” (2014, p. 168) Sarah
Molouki and Daniel M. Bartels have found much the same
phenomenon specifically for judgments about the persistence
of oneself through time and across various changes (2017).
Particularly important for present purposes, Strohminger
and Nichols extended this framework to a study of three
kinds of neurodegenerative disease: frontotemporal demen-
tia, Alzheimer’s disease, and amyotrophic lateral sclerosis
(ALS). They found that change in features of moral psy-
chology was most closely tied to judgments that a patient’s
identity had changed (2015, p. 1477). Equally importantly
for present purposes, this means that identity is more likely
to change due to some conditions rather than others. The rea-
son is that they affect different parts of the brain and hence
different capacities. Frontotemporal dementia is more likely
to result in identity change by folk standards than ALS is.
These findings provide an important perspective on the
academic debate about dementia and AD-MAID. The roots
of this debate lie in criticism of Ronald Dworkin’s position
on AD-MAID in Life’s Dominion (1993). Put very briefly,
Dworkin argues in favour of AD-MAID on the basis of
autonomy and what he calls “critical interests”. Such inter-
ests concern whether our lives are characterized by good or
bad things/actions, regardless of the experiences connected
13
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to them (Dworkin puts aside “experiential” interests as less
important than critical ones). Dworkin’s notion of a critical
interest is explicitly moralized: it is an interest in a life being
characterized by the good/bad, regardless of experience. In
cases of dementia where moral personality changes to a
greater rather than a lesser degree, we will find changes in
assessment of what counts as good/bad from those endorsed
by the pre-dementia patient. In these cases, it seems that
ordinary people will tend to think that identity has changed
along with critical interests. Contra Dworkin, this would
lend prima facie credence to the idea that the autonomy of
the person without dementia does not have authority over
the life of the person with dementia.
Dworkin presupposed that people retain their identity
before and after development of dementia. This was con-
tested by Rebecca Dresser (1995 most directly; see also
Dresser 1986; Dresser and Robertson 1989). If dementia
sometimes/often/always comes with a change in person,
then Dworkin’s position loses its foundation (for some range
of cases): the person choosing before dementia is a differ-
ent person from the dementia patient, so considerations of
autonomy do not apply. Dresser contends that such decisions
as ones about MAID for dementia patients should be made
on the basis of consideration of their current interests, so
AD-MAID should not be used (1986, pp. 390–393; 1995,
pp. 37–39; Dresser and Robertson 1989, pp. 290–291).
Dresser uses a more common notion of “interest” than
Dworkin; it amounts to whatever makes life worth living
from a person’s own standpoint (see, e.g., Dresser 1986, pp.
379–388; Dresser and Robertson 1989, p. 236). This will
typically involve moral considerations, in the spirit of Dwor-
kin’s notion, although it need not. To the extent that it does,
then, again, changes in moral personality will bring about
changes in interest, along with changes in personal identity
by the standards of the folk conception.
Three kinds of indeterminacy of identity
None of this implies that we should judge, once and for all,
that dementia brings with it changes in personal identity.
There are various reasons to hesitate in drawing this conclu-
sion. One is, as already noted, that different forms of demen-
tia will have different effects on identity by the standards of
the folk notion: presumably in some cases we will want to
say that the person has changed, but not in other cases. Sec-
ond, the reticence of policy makers (and, I assume, medical
professionals) to declare this to be the situation indicates
both lay and more experienced awareness of the vagaries
of identity change and persistence found in neurodegenera-
tive conditions. Third, there is the (at least apparent) wide-
spread support among the public for AD-MAID. For exam-
ple, the Council of Canadian Academies report The State of
13
A. Sneddon
Knowledge on Advance Requests for Medical Assistance in
Dying cites several polls that put Canadian support for AD-
MAID in the range of 62–80% (CCA 2018, p. 41). People in
general seem to think that they will be judging and preparing
for their own future state and treatment via AD-MAID. That
is, they assume continuity of person across the psychological
changes undergone in dementia. While some members of the
public have no close experience of such changes, many will
have watched family members succumb to dementia, so we
cannot assume that the public opinion reflects mere igno-
rance about dementia and identity. Fourth, that this is (or
might be) how the folk concept of personal identity works
does not imply that it is how personal identity works: prethe-
oretical concepts can be incorrect. What the most defensible
view of personal identity is might diverge from the standards
of judgment that we deploy in lay assessments of identity
persistence and change across changes.
There is a fifth reason for caution about tying policy and
practice closely to the folk standards of personal identity.
It is not clear that our folk practices are coherent; indeed,
why should we expect them to be so? We should not assume
that our pretheoretical concept, including our standards for
applying it, will yield determinate assessments of either per-
sistence or change in a self across changes.
Consider a hypothetical example: suppose that someone
undergoes a large psychological change affecting moral per-
sonality in a very short period of time. This could be due
to stroke, for instance, or to accident, such as in the famous
case of Phineas Gage who suffered a brain injury due to a
metal rod being driven through his skull because of an explo-
sion (Macmillan 2000, cited by Strohminger and Nichols
2014, p. 159; 2015, p. 1469).6 Let’s say that this person goes
from psychological state A, characterized by various values,
action tendencies, personality traits, and more, to psycholog-
ical state Z, characterized by different values, etc. Suppose
that in this case, we (and/or ordinary people) are inclined to
say that the person post-change, in psychological state Z, is a
different person from the prior person in psychological state
A. (M. Macmillan reports that Gage’s friends said that he
was “no longer Gage” after his accident: 2000, p. 13). Now
consider someone who goes through the same change, from
psychological state A to Z, but very slowly, perhaps across
years. Alzheimer’s, for instance, can develop very quickly,
within a year, or take decades (CCA 2018, p. 62). Here is an
empirical conjecture: the longer the process of change from
A to Z, the more likely ordinary people will be to say that
the person has not changed. Consider our experience of such
a person day-to-day: we will be inclined to judge that the
person on Tuesday is the same as the person Monday, that
6
Gage’s changes seem to have been of features of his “moral person-
ality”, so his case is particularly apt in the present context.
Indeterminacy of identity and advance directives for death after dementia 709
the person on Wednesday is the same as the person Tuesday,
and so on through the slow process of change over years (I
predict). Since identity is a transitive relation, this implies
that, by normal standards, the person we find in state Z is
the same as the person in state A, as the people at all adjoin-
ing moments between A and Z are the same. To the extent
that my assessments of these two cases are correct, then our
ordinary concept of personal identity can yield judgments
both of persistence of person and change of person for any
given psychological change. That is, our ordinary concept
leaves it to some degree indeterminate about just what we
should say about personal identity in such situations as we
find in cases of dementia.7
My empirical guess can be challenged. One might claim
that the ordinary standards of “identity” of persons are
loose rather than strict. So, when ordinary people assess
that someone is the same as they were before, they don’t
mean this in a strict sense of “same”. Rather, it is meant
roughly, in a way consistent with there being differences in
psychological characteristics between earlier and later times.
While the day-to-day assessments are of loose persistence of
a person through time, the accumulated tiny changes amount
to a change in person over the long run. Imagine two people
observing the person who goes through the slow change
from A to Z. One observer sees the person every day, while
the other observer sees the person only on the first and last
day. Presumably the first observer will be inclined to say
that the person is the same and the second will be inclined
to think that the person has changed. One has attended to
the tiny changes, the other sees only the big picture. This
is indeed plausible, but it concedes my point about the
indeterminacy of our folk notion of personal identity. If the
standards of application of this (or any) concept are loose,
then there will cases where it is indeterminate about how
it applies. This is what is implied by the comparison of the
two observers: they are both competent with the folk concept
of personal identity, but such competence leaves it indeter-
minate whether the person who has gone from A to Z has
persisted or not.
These reflections apply to the folk concept of personal
identity, including its standards of application to cases of
change through time. It’s specifically this concept, and our
skills in its application, that leaves it unspecified what we
should think about personal identity for dementia patients.
Accordingly, for a label, let’s say that our situation is “folk-
indeterminate”. A natural response to such folk-indetermi-
nacy is to turn to more formal study of personal identity.
7
Andrea Ott makes a similar point in a similar way. She analyzes
two hypothetical cases (one very realistic, the other much less so)
from Jeff McMahan (2002) to trace a “tension within some of our
basic intuitions” concerning personal identity, medical treatment,
advance directives, and moral standing (2009, Sect. 1).
The hope would be that explicit study of personal identity
would resolve our folk-indeterminacy by giving us a more
refined, technical, theoretical concept of personal identity.
The standards of application of this more formal concept
would (so the hope would be) show us what we should say
about the hard cases left unresolved by the folk concept. The
more formal concept would provide tools to legislators and
medical professionals for saying whether patients with one
or other form of neurodegenerative condition are the same
as some person(s) who existed prior to the onset of these
conditions.
To a certain extent, commentators on this issue have taken
this approach. The work is impressive, but hard for legisla-
tors to use, as it is spread across many books and articles.8
A more realistically useful resource would be a report on the
scale of CCA 2018 or Schüklenk et al. (2011). However, it
is also unrealistic to think that this issue could be resolved
at all; classic philosophical problems tend to be long-lived,
and this certainly counts as a classic philosophical prob-
lem. It is commonplace to claim that study of such famous
philosophical topics exhibits a familiar pattern marked by
the continuing development of arguments for and against
various positions without a final consensus (see, e.g., Over-
gaard et al. 2013, Chap. 2; Kekes 2014, pp. 1–6). Hence even
if we turned to formal study out of hopes of alleviating our
folk-indeterminacy, we should still expect not to know what
to make of personal identity both in general and especially
in the specific difficult cases of dementia patients. Instead of
folk-indeterminacy, we should expect to find ourselves in a
state of “epistemic-indeterminacy”: i.e., we still would not
know what to say about identity, dementia, and AD-MAID.
This is only part of the problem. We have two hopes if
we turn to academic study of personal identity to resolve
our folk-indeterminacy. The first is that hard work will pin
down criteria of personal identity (or some other grounds
of identity, such as our animal nature). The remarks above
express doubt about achieving this. The second hope is that
with such criteria in hand, we will be able to figure out deter-
minate answers about change or persistence of identity in all
8
Some details about a few examples: Julian Hughes endorses a
“situated embodied agent” view of personal identity for the purposes
of understanding what’s going on when we go through the psycho-
logical change involved in dementia (2001, pp. 87–89). Paul Menzel
and Bonnie Steinbock endorse a “narrative identity” view (2013, p.
489) for much the same reason, with more attention than Hughes to
AD-MAID. Mark Kuczewski chooses a socially embedded narra-
tive approach (1994, pp. 42–43). Andrea Ott endorses Lynne Rudder
Baker’s “constitution without identity” position for resolving such
issues (2009, Sect. 2; see Baker 2000), focusing particularly on its
metaphysical aspect. David DeGrazia argues for the centrality of our
nature as animals rather than persons to questions of what we are and
what persists across such changes as those found in dementia (1999).
There is more: McMahan 2002, DeGrazia 2005, Lizza 2005. I hope
that this suffices to make the problems for legislative use clear.
13
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cases. But this second hope might be disappointed even with
a satisfactory account of personal identity, for it is possible
that the best account of the nature of persons will leave it
indeterminate whether earlier and later people are the same
or not across certain changes.
There are at least two ways in which this might occur,
both via the criteria of some putatively true account of per-
sonal identity. The first way is via recapitulation of the inde-
terminacy found in our pretheoretical concept of identity.
Consider Mark Kuczewski’s position (1994) as an example.
He takes identity to be a matter of a socially developed and
supported narrative. Who we are, and hence whether we
are the same or not at two different times, is in part due
to our contexts and what others are inclined to say about
who we are and whether we are still the same as before.
As Kuczewski puts it, “The answer to the question of the
same person is that it is the same person at tl and t2 mainly
because the society recognizes and helps constitute this as
the case.” (1994, p. 46). Such a position includes an official
role for our folk practices of assessing personal (dis)conti-
nuity across changes. Suppose that our studies into personal
identity vindicate a view that endorses this idea. Now recall
that our ordinary understanding of ourselves seems to rec-
ognize dementia patients as sometimes different from prior
persons, sometimes the same. Familiarity with cases can
both lead people to think that their loved ones are no longer
the same and to want AD-MAID so that they can put in
place treatment options, including MAID, for themselves in
the event of such change, which seems to assume continu-
ity of person through dementia. Where social context and
folk understanding are indeterminate regarding the persis-
tence of persons across changes, any theoretical view that
builds in such context and understanding will also inherit
this indeterminacy.
Alternatively, an account of personal identity might
deliver indeterminacy independently of folk-indeterminacy.
This is the case with the position of Derek Parfit in Reasons
and Persons (1984), one of the landmark achievements of
recent work on personal identity in the last few generations
and one already invoked in connection with identity, demen-
tia, and AD-MAID (Dresser 1986, p. 380; 1995, p. 35—note
14; Dresser and Roberston 1989, p. 236; Buchanan (1988,
p. 294) discusses the same point from Parfit that is raised
here, but draws a different lesson from it). Parfit argues
for a “reductionist” view of personal identity, according
to which (to put it roughly) identity is secured by physi-
cal and psychological continuity between earlier and later
persons. One consequence of this is that there is no deeper,
or even necessarily deep, fact to which we might appeal to
settle cases where we do not know what to say, but where we
have the facts about physical and psychological continuity
in hand. Where these physical and psychological facts do
not settle the issue, there is literally nothing else to say. As
13
A. Sneddon
Parfit puts it, “There is sometimes a real difference between
some future person’s being me, and his being someone else.
But there is no such real difference [in other cases].” (1986,
p. 277). Parfit follows David Hume in likening persons to
nations and clubs: at a certain point, questions about same-
ness or difference of such groups through time are empty
(1986, pp. 277–278). There is no fact about such matters
to be found. So, if such a view is correct, then even figur-
ing out the criteria of personal identity might not provide
determinate answers about whether and when people change
or remain the same when they develop dementia. The truth
about personal identity might retain significant indetermi-
nacy about certain cases at its very core.
The indeterminacy addressed here is found in accounts
of the nature of persons and of their identity across changes,
rather than in our knowledge of such things, so let’s call it
“metaphysical-indeterminacy”. Metaphysical-indeterminacy
is not just of academic appeal. Recall the folk-indeterminacy
found regarding dementia patients and how to design policy.
One diagnosis of the fact that we seem drawn both to recog-
nize changes in identity in some such patients and to insist
that there’s wide-enough continuity of identity across the
psychological changes found in dementia to support AD-
MAID is that our folk skills of person identification are sen-
sitive to metaphysical-indeterminacy, perhaps especially of
the kind for which Parfit argues. If we had skills of track-
ing such metaphysically-indeterminate entities, yet lacked
reflective awareness of what these skills tracked and of the
metaphysical-indeterminacy found in this domain, then our
present folk-indeterminacy is what we would expect to find
(or so it seems to me). In addition, a judgment of such met-
aphysical-indeterminacy may be additionally apt in cases of
dementia patients who go through regular variation of state
from lucidity to incoherence.
Medical policy in the face of indeterminacy
about personal identity
I have identified three sorts of indeterminacy about personal
identity relevant to AD-MAID:
(a) Folk-indeterminacy: our ordinary standards of think-
ing about personal identity leave it unspecified what
we should think about personal identity in the face of
the deep psychological changes characteristic of the
process of developing dementia.
(b) Epistemic-indeterminacy: since the question of the per-
sistence of persons through time is a live and classic
philosophical problem, academic study of this topic
should not be expected to resolve this problem in a way
that provides uncontroversial criteria of such identity.
Indeterminacy of identity and advance directives for death after dementia 711
(c) Metaphysical-indeterminacy: more than one live option
regarding the nature of persons implies that there may
be no determinate fact to be found in certain cases
about whether the same person exists before and after
certain psychological changes.
It is not reasonable to wait for all three of these sorts of
indeterminacy to be resolved before designing policy
about dementia and AD-MAID. Endless inquiry might
never resolve them. Accordingly, the responsible thing to
do is to design policy about dementia and AD-MAID in
the face of such indeterminacy. Since folk-indeterminacy
allows of both epistemic and metaphysical interpretations, I
shall put it aside and focus on epistemic-indeterminacy and
metaphysical-indeterminacy.
So far, I have framed the relationship between medical
practice and policy regarding personal identity and MAID
in a specific way: the issue has been one of an issue raised by
the experiences of medical practitioners, along with patients
and family members, for the sorts of theoretical and abstract
consideration apt for academic and policy-level discussion.
That is, the question of whether identity is preserved through
the sorts of psychological changes characteristic of dementia
is due to what patients, third parties, and medical practi-
tioners experience on the ground (so to speak). Law/policy
should address this, but this raises a different issue of the
relationship between this and medical practice: how much
can or should law/policy spell out for medical practition-
ers? Should the law/policy be as determinate as possible,
or should it instead provide abstract parameters that leave
ample leeway for medical practitioners to shape into deter-
minate form? As we shall see, the practical and conceptual
nuances raised by indeterminacy of identity require abstain-
ing from giving medical practice a univocal role.
Epistemic‑indeterminacy
Suppose that we are designing policy about AD-MAID and
dementia explicitly in connection with epistemic-indeter-
minacy. This means that we do not know whether dementia
patients (or some specific subset of these patients) are the
same persons as people who existed before the onset of
dementia. Whether we allow AD-MAID, thereby prima
facie giving the autonomy of pre-dementia people author-
ity over the treatment and continued existence of people
with dementia, or whether we disallow AD-MAID and
thereby prima facie insist that the people pre- and post-
dementia are different, we are making a wager. Policy
should be made with open admission of this guess. The
additional grounds for the particular policy that is chosen
should be made clear. Although a wager must be made to
deal with epistemic-indeterminacy, it need not be made
blindly, nor need it be represented as blind. If there are
reasons that can be found and offered for preferring one
position on the identity of pre- and post-dementia patients
over the other, then they should be used and offered
openly. At the same time, the degree of warrant provided
by these reasons should not be overstated. Committing
oneself (and one’s government) to a position, being clear
about the grounds for it, all while acknowledging the pos-
sibility of error, is admirably humble and fair-minded.
Since law/policy would be explicitly gambling regard-
ing the (non-)identity of pre- and post-dementia patients,
it would be appropriate for legislators or policy-makers to
lay out a formal procedure for revisiting the question of
personal identity in the future. A bet is by its very nature
made on the basis of lack of certainty about the subject in
question. Being open to refining the wager that is being
made on the basis of better information about the medical,
psychological and philosophical issues is all but demanded
by openness about such uncertainty.
One bet that might be made is that identity is wholly
preserved through the psychological changes found in
dementia. This would remove an obstacle to the extension
of MAID to dementia patients on the basis of pre-dementia
advance directives, but it would not require AD-MAID for
dementia patients. The additional grounds for allowing
AD-MAID should be made clear. In this case they have
to do primarily with respecting the autonomy of patients,
as in the basic case for MAID (Schüklenk et al. 2011, p.
34). This wager would close the door to subsequent inter-
pretation of the question of personal identity by medical
practitioners: all dementia patients would be handled as
if continuous in identity with some pre-dementia person.
But even if there is no role for the exercise of discretion by
medical practitioners in particular clinical cases, there is
room for subsequent “upstream” contribution of the expe-
riences of practitioners (and patients and other parties) to
the formal procedures for revisiting the law/policy that
has been made as a bet about epistemic-indeterminacy of
personal identity of pre- and post-dementia patients.
Under epistemic-indeterminacy, it is important to regis-
ter and acknowledge the preferences of pre-dementia peo-
ple with extra care. This is particularly important if we are
going allow AD-MAID for dementia patients. The reason
is that we have good evidence for what these preferences
are, while lacking good evidence about the persistence of
persons across the psychological changes characteristic of
dementia. Policy should be in touch with the best available
information, I presume. These preferences, along with the
related anxieties, can be both about death and about living
with dementia at the very least. To the extent that people
experiencing dementia have clear preferences, they should
also be carefully registered and given prominent standing
in both policy and clinical decisions. Whether there are
13
712
such clear preferences will depend on the nature and extent
of the dementia in question.
The other wager that might be made is that, for some
range of cases, personal identity is not preserved through
the psychological changes characteristic of dementia. This
coheres more naturally with denying AD-MAID to such
patients, but it does not require such denial. If we choose to
restrict MAID and AD-MAID to competent patients, then
we should be clear that we are choosing this way of proceed-
ing to avoid killing people who have not expressed a will
about this (in many cases, anyway) and who are not compe-
tent to do so, on the basis of an assumption that these peo-
ple are not the same as any people who existed prior to the
dementia of the patients in question. Such a policy should
be coupled with extra urgency for dementia research and
support, as well as provision of MAID to people who have
been diagnosed with dementia but who are still competent
and clearly the same person as before the diagnosis. Such
measures mitigate the concern that a precautionary policy
regarding the life of vulnerable people who have dementia
will impose an unjustifiably high burden on others.
As with the prior gamble, medical practitioners should
have an upstream role in the formal process of revisiting
the personal identity question. However, in this case there
should also be “downstream” allowance for leeway on the
part of medical practitioners. The reason is the conceptual
nuance surrounding such law/policy. The ideal scenario
requires precise spelling out by lawmakers of just what cases
count as involving changes in identity. The gold standard
would be a checklist of symptoms jointly sufficient for such
change, such that practitioners could run through it with
patients and ensure that the answer chosen to the identity
question was in compliance with the law. One problem is
just how difficult making such a checklist is for legislators
to do, but suppose that this could be overcome. The deeper
issue is that the law is openly, and appropriately, framed as
a wager. This renders any specific criteria of identity change
essentially contestable, in that reasonable people with the
same information could, in principle, disagree about whether
identity really has changed without either party necessarily
being in an epistemically preferable position (although one
might be: the wager in question need not have been made
on even odds). Such inherent uncertainty is conceptually
appropriate, but it will be practically frustrating for legisla-
tors, medical practitioners, patients and family-members.
One way of mitigating the contestability of any policy
built within the framework of a wager is for legislators to
turn over the challenge of coming up with operationaliz-
able criteria of identity change to medical practitioners.
This would most appropriately be done by the professional
bodies responsible for the standards that will govern medi-
cal practice in a given jurisdiction. This will not eliminate
the contestability of any checklist—such lists would still be
13
A. Sneddon
designed within the context of a bet about personal iden-
tity. However, since doctors are better positioned through
their experiences with patients to understand and respect
the nuances of the psychological changes that come with
dementia than legislators are, they ought to be able to miti-
gate the practical significance of the essential contestability
found in this territory.
Leaving the choice completely to the discretion of indi-
vidual medical practitioners would mitigate this contestabil-
ity even more, in one way. In principle, doctors could try to
get as particular a sense of the psychological change that
their patients have undergone as possible, and then assess
identity continuity on this particularized basis. However, as
much as the attention to the situations of particular patients
is desirable, such an arrangement would also reintroduce
a significant degree of practical uncertainty into the medi-
cal landscape. The reason is that, in the absence of profes-
sional standards, different doctors could be expected to give
different assessments of continuity/change of identity for
dementia patients even when they have the same information
about these patients. This would render the practical situa-
tion regarding AD-MAID for these patients unpredictable,
subject to the contingencies of the views of the doctors with
whom patients happen to deal.
Three things should be done by professional medical bod-
ies, in connection with the relevant legal procedures, with
regard to the professional standards devised in the face of
epistemic-indeterminacy regarding identity in cases where
the bet is made that some patients change identity through
time. First, the relevant expertise should not be narrowly
construed. Besides physicians, both psychologists and phi-
losophers should be included, for the reasons seen through-
out this paper. Second, the fact that the relevant legal frame-
work involves a gamble about changes in identity of a certain
range of patients should be preserved as part of the medical
policy. Both practitioners and patients (and family members)
should be aware of the legal and conceptual issue at the
foundation of the medical policy. Third, and related to the
second point, the policy should be represented as itself to
be revisited as part of the eventual reconsidering of the epis-
temic-indeterminacy of identity issue by legislators. In part
this is called for in the spirit of ensuring that patients and
family members are well informed, but this is also desirable
as a way of facilitating upstream contributions from medical
practitioners to the relevant policy processes. Such official
inclusion is more likely to happen, and to happen well, if
everyone expects it to happen throughout the period of time
from the initial legislative wager to its eventual revisiting.
Metaphysical‑indeterminacy
Let’s consider designing policy about AD-MAID and demen-
tia explicitly in connection with metaphysical-indeterminacy.
Indeterminacy of identity and advance directives for death after dementia 713
If we design policy to address metaphysical-indeterminacy,
then we have to admit that, for some range of dementia
patients, there is literally no fact of the matter about whether
they are the same persons as certain people who existed
before the dementia in question. To frame the debate as if
there must be such a fact would be a mistake. It’s important
to be clear that the policy that is chosen is not just made in
the absence of information about whether the people are the
same or different; that’s epistemic-indeterminacy. Rather,
the policy has to be designed acknowledging that there is
no fact here. Since there are no determinate facts about per-
sistence of identity for these patients, it is legitimate just to
decide the matter on other grounds while being open about
the metaphysical-indeterminacy. The preferences and anxi-
eties of people without dementia can be allowed consider-
able weight in such a decision (regarding both death and
continued existence, as above). So can the condition and
prospects of the dementia patients themselves. The better we
can treat such people—not just interpersonally, but formally,
through medical, social, and political resources—the less
general clamour there will be for AD-MAID, even though
such measures might still retain considerable support.
Suppose that the decision is taken that identity is continu-
ous through the psychological changes found in dementia.
This is most consistent with allowing AD-MAID, but it does
not itself require such a practice. This decision provides no
particular reason to allow for the exercise of discretion of
medical practitioners either in the application of its implica-
tion to MAID or to subsequent reconsideration of the deci-
sion. It allows no specific room for the exercise of discretion
by medical practitioners in following the law because there
is nothing further to be decided: dementia patients are to be
treated as having the identity of pre-dementia patients. All
that is needed is attention to the specifics of a patient’s case
regarding the provision of death and other details concern-
ing care, as with non-dementia patients. Such a decision
provides no special reason to consult medical practitioners
in revisiting the law because it provides no special reason to
revisit the law itself. Here a decision is made, not a wager,
and as such it need not be represented as conditional and
subject to uncertainty. The decision is made on the basis of
absence of a deep fact about personal identity, not on a lack
of information about such facts, and hence there is no reason
to design a procedure that would be sensitive to improve-
ments in information.
The other decision that could be made would be that,
for some range of cases, identity is discontinuous for pre-
and post-dementia patients. This would prima facie count
against allowing AD-MAID for these patients. As with a
wager made in the face of epistemic-indeterminacy, here
it is desirable for these cases to be delineated precisely. A
checklist that ensures the compliance of practitioners with
the law would be best, but looser standards might be the best
that can be provided. If the standards are inescapably loose,
then the law should allow room for responsible exercise of
professional discretion by medical practitioners. It strikes
me as desirable that the burden of designing such standards
should fall to professional bodies, as with the situation under
epistemic-indeterminacy. Legislators are distanced from
appreciation of the relevant information; leaving the deci-
sion open purely to individual practitioners leaves medical
practice unprincipled and hence unpredictable.
A third option?
Is there any way for law/policy to proceed other than through
making a wager or a decision about the identity of patients
who go through the psychological changes that attend
dementia? In one sense “yes”, in another “no”. In principle,
legislators could eschew betting and deciding and instead
acquiesce in indeterminacy. However, choosing such a way
of proceeding comes with its own challenges, and it might
end up being self-defeating.
One thing that might be done is to address dementia,
MAID, and AD-MAID with a very fine-grained focus. In
principle the territory could be sub-divided, resulting in a
carving off of a group of issues where identity does not mat-
ter, leaving the recalcitrant ones in a circumscribed group of
their own. However, we have already seen the importance
of considerations of personal autonomy to MAID and AD-
MAID. Since this brings the issue of personal identity with
it, I am skeptical about the prospects for progress through
sub-division.
Another thing that might be done would be to articulate
alternative grounds on which to base consideration of MAID
and AD-MAID. Instead of personal identity, perhaps some-
thing such as organismic continuity through time could be
used. However, there are two problems with this. One is that
patients and family-members seem to think of this in terms
of personal identity; trying to use something else as the foun-
dation for treatment options risks seeming like avoidance of
the real issue. Second, there is the significance of personal
autonomy again. If something other than consideration of
the nature and identity of persons is used as the foundation
for considerations of MAID and AD-MAID, then these con-
siderations are severed from the conceptual background at
work in so much theoretical, practical, and legislative work
on MAID, as this background gives personal autonomy a
significant, indeed central place.
Finally, legislators could pass the buck, so to speak. They
could acknowledge that the issue is either epistemic- or met-
aphysical-indeterminacy, then leave it to medical practition-
ers to navigate the indeterminacy. While this would indeed
relieve legislators from betting or deciding, these are still
the options that medical practitioners would face, so they are
not really avoided after all. If such an approach were taken
13
714
by legislators, then, as with the above scenarios, it would be
best for the medical establishment in general to make the
wager or take the decision, rather than leaving this to indi-
vidual clinicians. Also, in the event that policy is designed to
address epistemic-indeterminacy, it should be accompanied
at least by a procedure for the relevant medical bodies to
revisit the wager that is made, if not also with a request for
legislators to reconsider the issue at some point.
Consider the Dutch April 2020 Supreme Court decision
in the light of these considerations. The Netherlands has
developed a legal context in which both AD-MAID and liv-
ing wills have force for patients who can no longer express
their will concerning continued existence. This force is not
necessarily definitive; the condition of the patient at the time
of consideration of MAID is relevant, as are, potentially,
other things. The Court upheld the acquittal of a physician
who had performed MAID on a dementia patient on the
basis of an advance directive. The Court did not directly
address the question of the identity of the people before and
after dementia. Instead, the Court speaks as if it presumes
that it is just one person in these two conditions. Strikingly,
the Court held that the wish made in writing before dementia
was held to deliver authority for euthanasia for a dementia
patient for whom confirmation of the wish was impossible,
as the capacity for understanding had been lost, and who
physically resisted the procedure at the time of death—fam-
ily members held her down. Given the lack of capacity for
understanding, such resistance cannot be taken straightfor-
wardly as signifying rejection of either death or the advance
directive.
Let’s note two things about this case. First, we should
think that the Court has made an assumption about the con-
tinued identity of persons before and after dementia. This
position has not been taken deliberately, judging from the
Court transcript, so we should say that a rather casual guess
is being made, rather than a decision. Asscher and van de
Vathorst claim that a lower court decision amounted to a set-
tling of this issue in the manner seen in the Supreme Court
decision for the purposes of Dutch law (2020, pp. 73–74).9
Perhaps the Court’s hands are tied by the content of the laws
with which they are working, but there should be no doubt
that both judges and legislators could address the relevant
metaphysical and epistemological issues if they chose.10
That the judges’ assumption on this issue is a casual one is
shown mostly by their silence about the issue, but also by the
9
Jonathan Hughes (2020) contests Asscher and van de Vathorst on
this issue in his examination of the Hoge Raad decision. I’m inclined
to agree with Hughes that this is too broad an issue for a single case
to settle.
10
This goes for policy makers in Canada and Belgium as well, of
course. The Dutch decision will undoubtedly be noted by participants
in the on-going Belgian considerations.
13
A. Sneddon
alternative positions considered in publicly available thought
about this issue. For instance, in a skeptical rumination about
euthanasia in general and specifically in the Netherlands,
Christopher de Bellaigue contends that AD-MAID effectively
treats pre- and post-dementia patients as two different people,
at odds with each other (2019). This is diametrically opposite
to the assumption of the Hoge Raad. Putting decades of aca-
demic discussion aside, that international public discussion
of the issues at stake in Dutch euthanasia practices and law
includes views of the personal identity issue other than the
one adopted by the Dutch Supreme Court is ample evidence
that the position assumed by the Hoge Raad on this topic is
not self-evident. It thus deserves explicit attention and choice,
rather than being passed off as something that can go without
saying. Since the wager has been made implicitly, no specific
reason or procedure for revisiting it is laid out by the court.
Second, the Court appropriately considers both the con-
tent of the advance directive and the patient’s condition and
situation at the time of dying. Since a wager is being made,
however, reasonable people could disagree with the decision to
uphold the acquittal. The patient’s physical resistance to MAID
can reasonably (but not definitively) be taken to be so impor-
tant as to render MAID in this case at least morally suspect,
and perhaps legally problematic too. The emphasis that the
Court gives to the advance directive in this case, and for future
like cases, would be more defensible if the Court had faced
the personal identity issue directly and explicitly defended the
assumption of continuity of identity through dementia. Even
better would be if Dutch legislators or medical profession-
als had assessed and taken a position on the identity issue in
advance of the case coming before the courts at any level.
One might think that independent considerations sup-
port the rejection of AD-MAID regardless of the personal
identity issue. Legislators and policy-makers tempted by
rejection of AD-MAID (either in general or specifically
for dementia patients) while allowing MAID should make
their case clearly and openly, in explicit connection with the
identity issue. The reason is that the pro-AD-MAID case
based on autonomy and the identity of the people pre- and
post-dementia is quite powerful. An anti-AD-MAID position
regardless of identity amounts to saying to people who want
AD-MAID that your autonomy does not have authority over
here, despite it supporting MAID and other post-person,
post-competence practices (such as wills and donation of
organs), and despite the incompetent person whose life is in
question still being (at least for the purposes of argument)
you. Without careful defense, such a position is open to a
charge of incoherence.11
11
Such a blanket anti-AD-MAID position is unlikely in such juris-
dictions in Canada, I surmise, given that the CCA report recognizes
pro-AD-MAID considerations (2018, Chap. 3).
Indeterminacy of identity and advance directives for death after dementia 715
There is no realistic third option other than wager or deci-
sion regarding the persistence of persons across the psycho-
logical changes that come with dementia. To design policy
without facing this issue squarely is, arguably, both a bet
and a choice. Such measures are best taken in full awareness
of their nuances and difficulties. The evidence from such
reports as CCA 2018, which notes the issue but does not
give it a role in its more focused examination of the ethical
and practical issues raised by AD-MAID (CCA 2018, p. 51),
and from the April 2020 Dutch Supreme Court decision is
that too often these issues are handled only with eyes closed
and fingers crossed.
References
Asscher, Eva Constance Alida, and Suzanne van de Vathorst. 2020.
First Prosecution of a Dutch Doctor Since the Euthanasia Act of
2002: What Does the Verdict Mean? Journal of Medical Ethics
46: 71–75.
Baker, Lynne Rudder. 2000. Persons and Bodies: A Constitution View.
Cambridge, UK: Cambridge University Press.
Buchanan, Allen. 1988. Advance Directives and the Personal Identity
Problem. Philosophy & Public Affairs 17 (4): 277–302.
Buchanan Allen, and Dan Brock. 1989. Deciding for Others: The Eth-
ics of Surrogate Decision Making. New York: Cambridge Uni-
versity Press.
Buss, Sarah and Westlund, Andrea. 2018. Personal Autonomy. In:
Edward N. Zalta, ed., The Stanford Encyclopedia of Philosophy
(Spring 2018 Edition). https​://plato​.stanf​ord.edu/archi​ves/spr20​
18/entri​es/perso​nal-auton​omy/.
Cohen-Almagor, Raphael. 2016. First Do No Harm: Euthanasia of
Patients with Dementia in Belgium. Journal of Medicine and
Philosophy 41: 74–89.
Council of Canadian Academies. 2018. The State of Knowledge on
Advance Requests for Medical Assistance in Dying. Ottawa
(ON): The Expert Panel Working Group on Advance Requests
for MAID, Council of Canadian Academies.
Crisp, James. 2019. Euthanasia Discussion Over Dementia Patients.
The Independent (Dec 31). https​://www.indep​enden​t.ie/world​
-news/europ​e/eutha​nasia​-discu​ssion​-over-demen​tia-patie​nts-
38824​128.html.
de Bellaigue, Christopher. 2019. Death on Demand: Has Euthanasia
Gone Too Far? The Guardian (Jan 18). https​://www.thegu​ardia​
n.com/news/2019/jan/18/death​-on-deman​d-has-eutha​nasia​-gone-
too-far-nethe​rland​s-assis​ted-dying​.
Degrazia, David. 1999. Advance Directives, Dementia, and ‘The Some-
one Else Problem’. Bioethics 13 (5): 373–391.
Degrazia, David. 2005. Human Identity and Bioethics. Cambridge, UK:
Cambridge University Press.
Dresser, Rebecca. 1986. Life, Death, and Incompetent Patients: Con-
ceptual Infirmities and Hidden Values in the Law. Arizona Law
Review 28 (3): 373–405.
Dresser, Rebecca. 1995. Dworkin on Dementia: Elegant Theory, Ques-
tionable Policy. The Hastings Center Report 25 (6): 32–38.
Dresser, Rebecca, and John Robertson. 1989. Quality of Life and Non-
treatment Decisions for Incompetent Patients: A Critique of the
Orthodox Approach. The Journal of Law, Medicine, and Ethics
17 (3): 234–244.
Dworkin, Ronald. 1993. Life’s Dominion: An Argument About Abor-
tion, Euthanasia, and Individual Freedom. New York: Alfred A.
Knopf.
The Guardian (April 21, 2020): Dutch court approves euthanasia in
cases of advanced dementia. https​://www.thegu​ardia​n.com/world​
/2020/apr/21/dutch​-court​-appro​ves-eutha​nasia​-in-cases​-of-advan​
ced-demen​tia.
Hoge Raad der Nederlanden: The Netherlands Supreme Court Decision
April 2020: ECLI: NL: HR: 2020: 712. https​://uitsp​raken​.recht​
spraa​k.nl/inzie​ndocu​ment?id=ECLI:NL:HR:2020:712.
Hughes, Jonathan A. 2020. Advance Euthanasia Directives and the
Dutch Prosecution. Journal of Medical Ethics. https​: //doi.
org/10.1136/medet​hics-2020-10613​1.
Hughes, Julian. 2001. Views of the Person with Dementia. Journal of
Medical Ethics 27 (2): 86–91.
Kekes, John. 2014. The Nature of Philosophical Problems: Their
Causes and Implications. Oxford: Oxford University Press.
Kuczewski, Mark. 1994. Whose Will Is It, Anyway? A Discussion of
Advance Directives, Personal Identity, and Consensus in Medical
Ethics. Bioethics 10 (1): 27–48.
Kuhse, Helga. 1999. Some Reflections on the Problem of Advance
Directives, Personhood, and Personal Identity. Kennedy Institute
of Ethics Journal 9 (4): 347–364.
Lizza, John. 2005. Persons, Humanity, and the Definition of Death.
Baltimore: Johns Hopkins University Press.
Macmillan, M. 2000. Restoring Phineas Gage: A 150th retrospective.
Journal of the History of the Neurosciences 9: 46–66.
McMahan, Jeff. 2002. The Ethics of Killing: Problems at the Margins
of Life. New York: Oxford University Press.
Menzel, Paul, and Bonnie Steinbock. 2013. Advance Directives,
Dementia, and Physician-Assisted Death. Journal of Law, Medi-
cine, and Ethics 41 (2): 484–500.
Molouki, Sarah, and Daniel M. Bartels. 2017. Personal Change and the
Continuity of the Self. Cognitive Psychology 93: 1–17.
Olson, Eric T. 2017. Personal Identity. In: Edward N. Zalta, ed., The
Stanford Encyclopedia of Philosophy. https​://plato​.stanf​ord.edu/
archi​ves/sum20​17/entri​es/ident​ity-perso​nal/.
Ott, Andrea. 2009. Personal Identity and the Moral Authority of
Advance Directives. The Pluralist 4 (2): 38–54.
Overgaard, Søren, Paul Gilbert, and Stephen Burwood. 2013. An Intro-
duction to Metaphilosophy. Cambridge: Cambridge University
Press.
Parfit, Derek. 1984. Reasons and Persons. Oxford: Oxford University
Press.
Schüklenk, Udo, Johannes J.M. Van Delden, Jocelyn Downie, Sheila
A.M. McLean, Ross Upshur, and Daniel Weinstock. 2011. End-
of-Life Decision-Making in Canada: The Report by the Royal
Society of Canada Expert Panel on End-of-Life Decision-Making.
Bioethics 25 (S1): 1–73.
Shoemaker, David. 2010. The Insignificance of Personal Identity for
Bioethics. Bioethics 24 (9): 481–489.
Strohminger, Nina, and Shaun Nichols. 2014. The Essential Moral Self.
Cognition 131: 159–171.
Strohminger, Nina, and Shaun Nichols. 2015. Neurodegeneration and
Identity. Psychological Science 26 (9): 1469–1479.
The New York Times (April 21, 2020): Dutch Supreme Court Expands
Euthanasia Laws for Dementia Patients. https​: //www.nytim​
es.com/reute​rs/2020/04/21/world​/europ​e/21reu​ters-healt​h-eutha​
nasia​-nethe​rland​s.html.
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