Chapter

Dilemmas in dementia: a framework and philosophical approach

Julian C. Hughes

in Thinking Through Dementia

Published on behalf of Oxford University Press

Published in print February 2011 | ISBN: 9780199570669
Published online February 2013 | e-ISBN: 9780191754654 | DOI: http://dx.doi.org/10.1093/med/9780199570669.003.0009

Series: International Perspectives in Philosophy & Psychiatry

Dilemmas in dementia: a framework and philosophical approach

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What we have found in discussing these cases is that judgements are made against a particular background or surround. Not only is there a great variety of facts to be taken into consideration, and not only do the facts alter in each case, but there are also numerous evaluative judgements to be made, which are partly connected with the facts, but which also reflect broader considerations in the background of particular cases.

The inner subjectivity of persons is embodied. Just as intentionality is played out in the world in terms of practices, where normativity is a constitutive, immanent, and irreducible feature of those practices, so too our sense of right and wrong in particular cases is often determined by judgements about behaviours and histories, as recorded in discourse, which can be taken to reflect the person's sense of what is significant, meaningful, or important to them in their lives. The necessary interpretation that must occur will not always be easy and sometimes judgements will have to be made on the basis of partial understanding. None the less, in each case it is the broad view that is required: the human-person-perspective. So, we must act on the basis of seeing the world from a perspective that makes sense of our decisions. Once the surround is seen clearly—once we have a surview—the right decision is likely to be made.

What we see in these stories is that dementia is always dementia-in-the-world. Decisions must always, therefore, take into account everything that makes up the person's world. If this can be done then it is more likely that the right decisions will be made. But often, in situations of uncertainty, which will frequently obtain where there is acquired diffuse neurocognitive dysfunction, the important thing will be the nature of the communications that have occurred. In the end, good decisions will be made when those involved have had the courage to look with some intensity at the face of the Other; when encounters, however brief, are at the level of the soul. At this point, reflecting the mutual engagement of beings of this kind, there may be some sense of the ground for the possibility of knowing what might be right or wrong under the particular circumstances. But this ground is likely to be beyond our ability to enunciate, because at this level judgements are aesthetic. We are in the area of Keats’ ‘negative capability’, … when man is capable of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact & reason … (Keats, 1990: 370)

Our moral dilemmas, therefore, are solved by judgements that are akin to aesthetic judgements, where the key ingredient is that we should see things aright, and we shall do this if we can adopt the human-person-perspective. Aesthetic judgements involve reason. But they also involve a sense of normativity, which is based on our ways of being-in-the-world. In the end, we do not make these judgements on the basis of pure reason, but on the basis of our mutual participation in a form of life that sees things in this way and not that.

Chapter.  7939 words. 

Subjects: Psychiatry

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