Living wills in dementia
Dementia can result in a conflict between the living will written in the past, in which the autonomous will of a person is expressed, and the so-called "natural will" of the person now suffering from dementia. The decisive factor in this conflict is that a person suffering from dementia can only express his or her current will without having the ability to form an autonomous will. Practice shows that "natural will" is often attributed a high value, as the well-being of the patient is the central focus, while from a legal point of view, autonomous expression of will is attributed a higher instructive value. Whether more weight should be given to the former autonomous expression of will or the natural current will is subject of controversial discussion in ethics.
On the concept of natural will:
Jox, Ralf (2006): Der „natürliche Wille” als Entscheidungskriterium: rechtliche, handlungstheoretische und ethische Aspekte. In: Schildmann, Jan / Fahr, Uwe / Vollmann, Jochen (Hg.): Entscheidungen am Lebensende: Ethik, Recht Ökonomie und Klinik. Berlin: LIT, 69-86. (German)
Cf. for an overview of the central arguments, see, for example:
Schmidhuber, Martina (2013): Überlegungen zu den Grenzen der Patientenverfügung für die Selbstbestimmung von Demenzbetroffenen im Anschluss die Dworkin-Dresser-Debatte. In: Ach, Johann S. (Hg.): Grenzen der Selbstbestimmung in der Medizin. Münster: mentis, 317-334, especially section 5. (German)
Cf. on the Dworkin-Dresser debate:
Dworkin, Ronald (1986): Autonomy and the Demented Self. In: The Milbank Quarterly 64(2), 4-16. doi: 10.2307/3349959.
Dworkin, Ronald (1993): Life’s Dominion. An Argument about Abortion, Euthanasia, and Individual Freedom. New York: Randomhouse, hier 218-241.
Dresser, Rebecca (2006): Dworkin on Dementia. Elegant Theory, Questionable Policy. In: Green, Stephen / Bloch, Sidney (Hg.): An Anthology of Psychiatric Ethics. New York: Oxford University Press, 297-301.
Volhard, Theresia (2015): Demenz. In: Sturma, Dieter / Heinrichs, Bert (Hg.): Handbuch Bioethik. Stuttgart: Metzler, 231-239, especially 268f. (German)
Cf. on the statement of the German Ethics Council and the recommendation contained therein to give priority to life-affirming statements:
Deutscher Ethikrat (2012): Demenz und Selbstbestimmung. Stellungnahme. Online Version, especially 100. (German)
Cf. also:
Dabrock, Peter (2007): Formen der Selbstbestimmung. Theologisch-ethische Perspektiven zu Patientenverfügungen im Demenzfall. In: Zeitschrift für medizinische Ethik 53, 127–144. Online Version (German)
For further details, see the detailed presentation in the In Focus Advanced Decisions.