This article addresses the question: How should caregivers ethically respond when a person with dementia expresses present preferences that conflict with their past values? In this article, I argue the claim that when caring for people with dementia, one should balance considerations from the past with more weight than considerations from the present. This view draws from the works of Ronald Dworkin and Agnieszka Jaworska. I side more with Dworkin. I claim that even if there is a possibility that people with dementia can form new values, the ability to have an integrated view of one’s life as a whole gives past values more weight than present. My argument for ethically caring for people with dementia follows three guidelines: uphold advance directives, maintain past valued commitments, and allow compromise when past values conflict with current comfort​​. 

Dworkin identifies two crucial kinds of ethical concerns that arise in caring for someone with dementia: beneficence and autonomy. Within beneficence, he establishes two types of interests: experiential and critical. Experiential interests are those that one feels, such as those causing feelings of excitement or relaxation. Critical interests are those that one believes improve one’s life and build more value, whether the experience is felt or not. Dworkin claims that critical interests should be given more weight than experiential interests. Dworkin argues that a person with dementia cannot form new critical interests, though the person still maintains the critical interests formed before developing the disease. Thus, he explains that it does not make sense to act as if a person with dementia has the right to choose for themselves after their diagnosis. He instead thinks that their earlier choices, reflective of critical interests, such as advance directives and living wills, can contribute to this person living a “self-authored” life. 

Jaworska believes that in order to live a self-authored life, one must have the ability to value. She defines the ability to value as being able to sustainably care about something in a meaningful way. While Dworkin emphasizes the importance of a person’s ability to understand and shape their life as a whole, especially through long-term critical interests, Jaworska does not see this as necessary for autonomy. She puts more weight on a person’s current experiential life. Jaworska raises evidence that people with dementia have the ability to maintain and create new values even without full life comprehension. For Jaworska, as long as a person retains the capacity to value, their autonomy and well-being are not threatened by respecting their current interests. She argues that instead of viewing autonomy as the ability to shape one’s entire life, one should view it as the ability to self-govern based on the values one holds.

My first guideline for ethically caring for people with dementia holds that if a person’s current new values conflict with their advance directives, their advance directives should be upheld. Even if Jaworska is correct in her assertion that people with dementia can have the capacity to value, the very purpose of a legally binding directive is to ensure that newly formed values do not override earlier, reflective commitments. Jaworska might argue that individuals signing such directives should understand they may later develop conflicting values. Her essay attempts to correct the misconception that people with dementia are incapable of forming new values. Recognizing this might change how people approach such directives. Still, this view remains consistent with the idea that once signed, directives can remain legally enforceable, even if they override later-formed values. I agree with Dworkin’s claim that values depend on a person’s capacity to understand their life as a whole. Values are not innate but formed and refined over time through experience and reflection. Dementia disrupts this process. A person without short-term memory cannot retain or process new experiences in a way that builds toward a coherent, evolving self. While Jaworska emphasizes that consistent desires may signal new values, this places responsibility on caretakers to interpret those behaviors, inviting personal judgments to override clearly expressed, competent directives. In contrast, Dworkin’s view avoids this danger by grounding respect for autonomy in the values a person constructs based on a lifetime of knowledge. This is also why some people may choose to create directives in the first place. They do not want others to make decisions for them based on a compromised version of themselves: a version whose values may no longer align with their thoughtful, pre-dementia self. Even in cases where no formal directive exists, they may prefer that others not default to prioritizing those later-formed values. Creating a directive can be a way of protecting against that possibility and ensuring that one’s autonomy is respected, even when one can no longer defend it personally. 

Consider a person who, while fully competent, created an advance directive to be denied life-saving care if they later developed dementia. Jaworska might argue that if, after developing dementia, the person consistently expresses a desire to live, this should be taken seriously. Still, she does not necessarily conclude that the directive should be ignored. Her view highlights the moral complexity of such cases. Dworkin would insist that the directive be followed, since the person no longer has the capacity to assess their life as a whole. I believe that present preferences, however sincere, cannot express true autonomy once critical reflection is lost. To act otherwise is to assume one knows better than the person did when they were fully capable of self-reflection.

My second guideline holds that in the absence of legal directives, a caretaker should continue to prioritize past interests over current conflicting interests. Consider a Jewish woman with dementia who once strictly adhered to Kosher laws but now exhibits a strong desire to eat bacon. This desire extends beyond pure want and even manifests as what seems to be a genuine value. Perhaps the woman feels as though it is incredibly important that she tries bacon before she dies. Allowing the woman to eat bacon may seem compassionate to her current experiential interests, but it threatens her broader critical interest. Her lifelong commitment to keeping kosher represented more than a dietary preference. It reflected a deeply held moral and religious identity that should be upheld despite current wants. 

According to Jaworska, the emergence of new values in dementia should be taken seriously, as they may reflect genuine aspects of the person’s evolving identity. Still, Dworkin would argue that respecting autonomy requires grounding decisions in the values that shaped a person’s life as a whole. Even without a formal directive, the enduring significance of long-standing commitments like religious practice should carry moral weight. To honor those values is not to ignore the person she is now, but to take seriously the person she spent a lifetime becoming. It also sets a stable standard for caretakers, reducing the risk of projecting their own assumptions onto the patient’s shifting preferences. In cases where cognitive decline makes it difficult to determine whether a new desire reflects a true value or a surface-level interest, grounding care in the person’s critical interests provides a clearer and more respectful guide. 

​​My third guideline argues that if past values no longer make sense to a person and now conflict with their comfort, they should be weighed against present needs through compromise. ​​Jaworska acknowledges that individuals with dementia may desire certain actions while losing the ability to appreciate how specific choices affect their broader values. In such cases, Jaworska does not advocate ignoring past values entirely, but instead seeks compromises that respect both past and present selves. This flexibility offers an advantage over Dworkin’s more rigid approach. 

The following hypothetical scenario presents an example of how a compromise could be implemented. Consider a woman who deeply valued a polished lady-like appearance, expensive dresses and makeup who, after developing dementia, insisted such clothes meant nothing to her. She now values the comfort of sweatpants. Dworkin’s framework may suggest that her prior commitment to appearance was how she lived a self-authored life, and as such, a caretaker should continue to dress her in such a way. Jaworska, on the other hand, would try to find a compromise — perhaps dressing the woman in high-quality leisure suits. Jaworska’s approach better honors both her enduring commitment to appearance and her present experiential interests towards comfort. In such cases, one must acknowledge that the way the woman derived value from these clothes has become closed off to her. The value in the clothing, making her feel confident in herself and secure in her dignity, no longer exists for her. The dignity of the woman must continue to be maintained, but one can also see that the value of specific clothing has been lost. The value of physical well-being and comfort prevails more strongly and thus must be prioritized.

To conclude, I will restate the qualities I find essential for ethically caring for an individual with dementia: honoring advance directives, maintaining past commitments and values and compromising on past values that threaten current comfort. With dementia patients, prioritizing past values over new values in cases of conflict is the most secure method of preventing misinterpretation and ensuring one’s whole self is respected.