Psychiatric Advance Directives and the someone else problem: A question of practical identity

Anson Fehross1

1University Of Sydney, Sydney Health Ethics, Camperdown, Australia

In Life’s Dominion, Ronald Dworkin provides the example of Margo. In the early stages of dementia, Margo arranged an advance directive instructing no intervention beyond comfort care once the disease has rendered her permanently incompetent. When her dementia progressed to this stage, however, Margo seemed to be happy—blissful, even. She seemed to have lost the drives, memories, values and capacities that made Margo Margo: in other words, she had lost continuity of personal identity. Given this reality, how are we to respond to the advance directive? Dworkin’s example illustrates what DeGrazia dubs the ‘someone else problem’: if advance directives can only apply to the person who completed them, then in cases like advanced dementia they offer no guidance, precisely because we are now dealing with someone other than the person who prepared the directive.

In psychiatric contexts, personal identity changes like Margo’s are relatively few and far between. For this reason, it might be assumed that psychiatric advance directives are rarely beleaguered by the someone else problem. I will show that this assumption is ill-founded. While most psychiatric patients will maintain their personal identity, changes in their practical identity (i.e. profound shifts in their key values, commitments and beliefs), can also render their prior directives invalid. I will argue, furthermore, that in cases where practical identity changes are likely to be permanent, respect for patient autonomy requires us to heed the patient’s current values, even in cases where they lack decisional capacity.


Anson Fehross is a PhD student at Sydney Health Ethics at the University of Sydney. He joined the centre in 2015, after completing a MSc in the Unit for History and Philosophy of Science. Much of his research focuses on the interface of metaphysics and applied ethics. His thesis sets out a new model for substituted decision making in both general medicine and psychiatry.