Dementia, Authenticity, and the Moral Weight of Preferences

The moral weight of preferences expressed by people with advanced dementia remains a persistent challenge for clinical ethics, in part because healthcare professionals (HCPs) often treat some such preferences as still deserving respect even while acknowledging that decision-making capacity is compromised. Drawing on dilemmas discussed in a 2023 ethics workshop in a Danish nursing home, we argue that HCPs differential responses are plausibly tracking a distinction between disorder-driven prefer- ences and authentic preferences that remain genuinely expressive of the person. We defend a thin, procedure- externalist conception of authenticity on which pref- erences can be authentic even without higher-order critical reflection, and we argue that such authenticity can ground defeasible normative reasons for compli- ance even without autonomy. We address three chal- lenges and note converging experimental-bioethics findings suggesting that stakeholders’ judgments in dementia cases are sensitive to authenticity consider- ations. Given persistent uncertainty, we propose three defeasible, clinically usable indicators for presuming authenticity: (i) stability and minimal prioritisation in preference patterns, (ii) domain-specific mini- mal ("spherical") comprehension, and (iii) absence of salient distortion or undue influence. We apply these indicators to the workshop cases and illustrate how the framework can guide practice while leaving room for justified override in high-stakes or distorted cases. Overall, the framework extends current debates in neuroethics both rationalises a common source of clinical hesitation about capacity-based decision rules and offers a principled, action-guiding approach to care decisions.