Alzheimer and dementia: am I still the same person?

Since its tabling on November 29, the Filion-Maclure experts report has been widely talked about. Not enough, it seems, since the proposal the report is putting forward raises a major moral issue: the possibility for someone to put an end to his life in advance. A person should be able to receive euthanasia, the report says, even if he or she is unable to consent at the time of receiving the lethal injection, in the case when consent is given in advance, following a diagnosis of an incurable disease.

To justify this measure, the report tackles in chapter 5 a properly philosophical problem (one of the co-chairs of the committee, Jocelyn Maclure, is professor of philosophy): do you remain the same person if you lose your mental capacities? We must commend the effort and intellectual transparency of this section of the report, which has been very little discussed. It sets out the philosophical positions justifying advance demands of euthanasia as well as the most relevant objections. However, the experts’ conclusion is far from going in the direction of their justification. We even believe that it represents a philosophical mistake.

The main objection to the possibility of coercing one’s “future self” goes as follows, as presented in the report: one cannot coerce oneself in advance, since the person with dementia or Alzheimer is not the same. In this perspective, the sick person no longer has “psychological connections” with the different periods of his life. His current identity is at odds with his past identity (p. 99-100 of the report). It is therefore morally problematic to allow a “past self” to make decisions for a completely different person, a “future self”.

Paradoxically, the argument of “rupture” (my future self is distinct from my current self) is rather used in the public space to justify advance directives for euthanasia. While some fear that they will no longer be “recognizable” at the end of their life, they disown their future selves in advance, who is said to no longer be their true selves.

However, according to the authors of the report, this argument does not hold. First, empirical studies do not allow this conclusion of a rupture in identity. Cognitive diseases indeed do not affect all regions of the brain that define identity (p. 100).

That said, without neglecting these biological aspects, the report is based rather on what is called a “narrative conception of personal identity”. This concept, it is said, is “centered on the values and the narrative that we use to interpret our experience” (p. 100). The question then arises: is the disease part of the “life story” of a person, even if he or she is no longer able to “update” this story?

To this question, the authors of the report answer no. The illness is not part of the identity, because then the person is no longer the narrator of his identity. It is then the identity prior to cognitive loss that prevails. In this way, someone could decide in advance to receive medical assistance in dying without doing violence to another “self”. His identity is kind of frozen in time.

This position is based on a distinction between a person’s “critical interests” and their “experiential interests”. The former are interests that guide the most important choices in our lives; they are a person’s “priority values”. The second refers to “the interests that allow us to lead a pleasant and comfortable life, to live positive experiences and emotions, to improve our immediate well-being”. According to the authors of the report, although an incapacitated person still has experiential interests, the criticizing interests disappear. As these are most important in determining a person’s identity, the person is no longer able to live “fully”.

So, our experts rule out the possibility of a break in identity, but affirms the possibility of a freeze, of a petrification of identity at a stage X of a disease.

However, this is at odds with a narrative conception of identity, as put forward by the most notorious philosophers, from Paul Ricoeur to Charles Taylor. A narrative conception of identity does not imply an “omniscient narrator” who would be completely transparent to himself. On the contrary, our identities are formed in dialogue with others and the world around us. Paul Ricoeur sums up human identity thus: yourself like another.

You, self and other. It means that our self is constantly changing through relationships and experiences. In other words, “experiential interests” are also decisive for the choice of priority values, for the construction of the self. That these experiences are less conscious does not mean that they are not decisive. And when adequate support is provided, human relationships can even be enriched.

On the other hand, a person also remains the same (“you”, “me”), since their whole being does not change over time. We can illustrate this difference and this complementarity between the “same” and the “self” by the most common example: are you the same person as when you were a baby? Obviously. However, everything in you has changed: the matter of your body has been renewed at 100%, your cognitive capacities are no longer the same and your personality has greatly evolved. Despite this, when you see a photo of you as a child, you say “it’s me!”.

In short, if a person suffering from dementia or Alzheimer’s indeed has limited possibilities of identity building, the fact remains that he or she not only remains the same, but that his or her “self” continues to transform and determine personal identity . Forcing yourself to commit suicide in advance (through someone else) is a serious violence against a future self that you cannot know, violence that should not be allowed.

it is now no more only a matter of taking sides for or against medical aid in dying, but we are now simply dealing with the possibility of legally executing someone.

Maxime Huot Couture