My aim in this section is to challenge the Conditionality View. Its first interpretation, according to which children lack duties to visit parents who cannot recognise them because people cannot benefit from being visited by those whom they are unable to recognise, is most easily shown to be false. Whereas I will suggest shortly that such visits might serve several parental interests, my focus here is on hedonic or well-being interests. The reason for this is that, on most axiological theories,Footnote 3 well-being—by which I mean the absence of pain and the presence of contentment and pleasure—is a morally significant good even if it is not the only thing that matters as some utilitarians contend.
When we focus on the hedonic effects of filial visits, it soon becomes clear that the first interpretation must be incorrect. Though it is sometimes frightening and distressing for people with advanced dementia to be visited by those whose identity is unknown to them—as it would be for many of us were a stranger to appear in our home—there is ample evidence that such visits can be, and frequently are enjoyable for these individuals (e.g. Lucero 2004, p. 174), as well as that the heighted feelings of well-being that they induce might persist for some time after the visit and even after the memory of the visit has been lost (Guzmán-Vélez et al. 2014).Footnote 4 In fact, in many cases, the hedonic interests of people with severe dementia in being visited appear to be stronger than those of most other individuals. The reason for this is that this group is especially vulnerable to chronic loneliness,Footnote 5 which has been found to contribute to a range of adverse outcomes, including depression (Cacioppo et al. 2010), poorer physical health (Aanes et al. 2010), and suicidal thinking (Stravynski and Boyer 2001).
One reason why people with (severe) dementia are particularly prone to chronic loneliness is to do with the social losses that older adults tend to experience. Not only does people’s social network shrink substantially as they reach old age,Footnote 6 a large proportion of older adults loses their primary confidants due to the death of friends, partners/spouses, and siblings. Another reason is that compensating for these losses is often difficult for those with (severe) dementia. Apart from the fact that they might have age-related physical disabilities that reduce their ability to socialise, such as deafness and diminished mobility (cf. Moyle et al. 2011, p. 1449), their disease imposes various hurdles to maintaining existing relationships and forging new ones. Besides a progressively diminishing capacity to form memories and to retain existing memories, these might include an impaired ability to recognise faces,Footnote 7 as well as various disease-related behaviours that make it less enjoyable for others to spend time with them, such as repeated questioning, shouting, and swearing.Footnote 8 A final noteworthy hurdle concerns the stigma on dementia. Whilst this stigma has abated within many Western societies over the past decades (Hope 2010, p. 96), there continue to be reports of people being shunned by friends, relatives and other individuals upon revealing their dementia diagnosis (e.g. Moyle et al. 2011).Footnote 9
Special interests in filial visits
So far, I have suggested that the first interpretation of the Conditionality View must be false. But what about its second interpretation? As may be recalled, this interpretation concedes that many parents retain interests in being visited by their children after they lose the ability to recognise them. However, it maintains that, because of this loss, the parents lose any special interests in being visited by their children, i.e. any interests in being visited by their children rather than by (equally socially-skilled) strangers that derive from goods that their children can provide but most other individuals cannot, or simply not to the same degree. To the extent that parents need to have special interests in filial visits in order for their children to have duties to visit them, it follows on this view that children cannot be duty-bound to visit parents who have lost the ability to recognise them.
I believe that there are two problems with this argument. The first concerns its minor premise, according to which parents cease to have special interests in being visited by their children once they lose the ability to recognise them. As I argue below, even when this ability is lost, there are different ways in which filial visits might promote parental interests that visits by most other individuals cannot, or simply not to the same extent.
To start with, some parents retain special interests in filial visits because their children are especially well-placed to promote their well-being, which I have defined as the absence of pain and the presence of contentment and pleasure. This will often be the case when their children are already visiting them on a regular basis. To see why, it should be noted that even when parents do not recognise them as their children, it is not uncommon for them to remember that they are the same individuals who visit them regularly, which may have the effect that they will miss them once they stop visiting or simply reduce the frequency of their visits (cf. Marley 2013).Footnote 10
But that is not all; many children also have epistemic privileges that allow them to promote their parents’ well-being better than most other individuals with the possible exception of the parents’ romantic partners, siblings, friends, and a few other select individuals. To see this, it ought to be observed that, over the course of their lives, children tend to accumulate a considerable amount of information about their parents’ beliefs, preferences, and character traits, as well as about various episodes of the parents’ lives. This matters because such insider knowledge can be highly useful in deciding how to approach and interact with their parents so that their meet-ups become more enjoyable for the latter (and would expect in many cases themselves). For example, they might use this information to decide what topics to raise when talking to their parents; what kinds of gestures to make; when to be silent; and when to show affection and how. Especially when the parents have difficult personalities, getting these things right can have a big impact on their well-being.
When people reach a level of cognitive impairment whereby they no longer recognise their children, they will have lost the capacity for autonomy understood as the ability to independently endorse a conception of the good life and live in accordance with it more or less successfully (cf. Colburn 2010). That does not necessarily mean, however, that they will have lost autonomy-interests in filial visits given that such visits might still honour their past autonomy. By this, I mean that such visits help to fulfil certain future-oriented preferences that the parents had when they were still autonomous, namely preferences to continue to receive filial visits if they were to lose the ability to recognise their children.
Though I am unaware of any survey data on this, such preferences appear to be widespread. Because of the love and affection that many parents have for their children, one may safely assume that a substantial share wants their children to remain part of their lives even if they were to lose the ability to recognise them. There might be exceptions to this; for example, some parents might not want to be visited by their children because they hold grievances against them, or because they do not want to be seen by their children in such an indigent state. Still another group may not wish to receive filial visits because of the burdens this places on their children or perhaps on other individuals who rely on their children’s care and support, such as their partners or own children. Nonetheless, especially when parents had minimally decent relationships with their children before they developed (severe) dementia and when their children do not live too far apart, one might expect that many would have wanted to continue to be visited by their children. When this is the case, filial visits fulfil a special parental interest given that no one else can honour these past autonomous preferences. (Of course, all this presupposes that individuals who have irretrievably lost the capacity for autonomy do indeed have interests in having their past autonomy honoured. Whereas any attempt to vindicate this view is beyond this article’s scope, I will just note here that other authors have offered compelling arguments for it,Footnote 11 as well as that its moral significance is presupposed within many real-life contexts, including by the practice of letting advanced directives bear on decisions about end-of-life care and by the practice of allocating a diseased person’s property based on their final will.)
Thus far, I have suggested that for children to simply visit parents who have lost the capacity to identify them as their children might honour the parents’ past autonomy. Yet there are ways in which many children can interact with their parents during such visits that few others can that might honour further future-oriented preferences of the parents’ past autonomous selves. Prominent amongst these will be preferences to retain various memories for as long as possible. Such retention does not only matter to most people because they cherish specific memories (e.g. memories of their marriage, graduation, the birth of their children), but also because most of us regard memory-retention as a major part of identity-preservation, i.e. of remaining the same person.
Now although accessing memories becomes increasingly difficult for those who suffer from dementia, there is evidence that providing individuals with dementia with cues from their past can help many to access memories that would have otherwise remained inaccessible to them (Holton 2016).Footnote 12 Such priming might occur, for instance, by showing them family pictures; playing music from their youth; or simply by recounting events from their lives. What is important for our purposes is that since children generally have greater knowledge about their parents’ lives than most other people and are more likely to have access to various personal objects from the parents’ lives, they will often be especially well-placed to provide such memory-inducing cues. When this is the case, the parents will have special interests in filial visits that are conditional upon their children helping them to remember their past during such visits.
At this point, some might say that retaining precious memories and preserving one’s identity through memory-retention are valuable independently of whether these things honour the preferences of our (past) autonomous selves. For example, in discussing the roles that friends and relatives can play in buttressing people’s identities through the provision of memory-inducing cues, authors such as Cowley (2018), Holton (2016), and Lindemann (2009) suggest that preserving one’s identity matters in its own right. Though I am sympathetic to such views, trying to vindicate them here would take us too far afield.
The same is true, mutatis mutandis, of views on which filial duties to visit parents who have lost the ability to recognise their children derive from the parents’ dignity interests. Such views are predicated on the assumption that even when parents no longer remember who their children are, it generally remains a greater affront to their dignity when their children refuse to visit them than when most other individuals refuse to do so, which is thought to be case even when the parents lack past autonomous wishes for their children to continue to visit them. Whilst I suspect that this is correct, a critic might argue that as long such parents receive enough social and emotional support from individuals other than their children, the notion that their dignity is undermined by their children’s refusal to (regularly) visit them simply reflects a social or cultural bias. (Which, of course, does not preclude the critic from holding the view that such dignity-harms might be incurred when the parents do recognise their children, as well as the view that there are ways in which children could harm the dignity of parents who no longer recognise them; all that she is committed to is that, under the conditions described, for children to refrain from visiting their parents does not cause such harm). Since a discussion of this topic is well outside this article’s purview, I will just note that, because dignity is such an abstract value,Footnote 13 it is not clear whether defenders of the dignity-argument can answer our critic in a non-question-begging way. This is why despite being drawn to the conclusion of this argument, I do not wish to put much weight here on dignity-interests either.
Generic duties of sociability
My criticism of the second interpretation of the Conditionality View has hitherto challenged the notion that when parents lose the ability to recognise their children, they cease to have any special interests in being visited by their children (i.e. any interests in being visited by them as opposed to strangers). Against this view, I argued that, in many cases, filial visits can still make contributions to the well-being and past autonomy of such parents that few, if any, other individuals can make. The aim of this subsection is to challenge the major premise of the second interpretation of the Conditionality View. According to this premise, children can only have duties to visit parents who cannot recognise them when, and because, their parents have special interests in being visited by them.
My objection to this premise proceeds on the assumption that we have what I call ‘generic duties of sociability’. These are duties to help ensure that others are provided with adequate opportunities for social contact when this can be done at reasonable cost,Footnote 14 which are not just lacking when people are kept in isolation cells or in quarantine (to mention two extreme cases), but also when they are unable to visit other people as a result of severe dementia. What makes such duties generic is that they are owed to humanity as a whole, which distinguishes them from any duties of sociability that we have towards our friends and relatives specifically. Whilst the latter are based on our shared relationships, generic duties of sociability derive from the serious physical, psychological, and developmental harms that chronic loneliness has been found to engender (see the outset of this section). Such harms are not only problematic because they prevent lonely people from living minimally decent lives, although this is clearly a serious problem. They might also compromise people’s ability to provide (adequate) care to others, as well as adversely affect members of society more broadly when feelings of social exclusion give rise to anti-social behaviour (cf. Brownlee 2016a, b).
Whereas a lot more is to be said in defence of generic duties of sociability, I will not do so here as Collins (2013) and Brownlee (2013) have already offered elaborate and compelling defences. What is pertinent for us is that, inasmuch as we have generic duties of sociability, one may reasonably expect that the best way for many people to discharge these duties will involve providing company to any parents with severe dementia that they might have. There are at least two reasons for this.
The first is that individuals with (severe) dementia are especially vulnerable to chronic loneliness. As was noted, this is due to the social losses that people tend to experience in old age along with the distinct difficulties that those with dementia face in maintaining social contacts and forging new ones (see the outset of this section). Since any plausible account of generic duties of sociability will require people to make greater efforts to address the social needs of those who are at higher risk of (continued) loneliness than to address the social needs of those who are at lower risk, all other things being equal, it seems that the social needs of individuals with (severe) dementia will often need to be prioritised. (Notice that in this respect, generic duties of sociability are relevantly similar to moral duties to alleviate global poverty; all other things being equal, we have stronger reasons for giving money to those who are poorest and who need our resources the most than to those whose financial needs are weaker.) The second reason is that many children have a level of affection for their parents that they do not have for most other individuals with the possible exception of any partners, friends, and other close relatives that they might have. When such ties exist, it will typically be easier for people to establish or maintain a habit of visiting specific individuals, including those with severe dementia, compared to cases where these emotional connections are absent or simply not as strong. This is relevant because it means that by seeking to protect their parents from loneliness rather than individuals who are at equal risk of (continued) loneliness but towards whom they feel less affection, if any, children will be more likely comply with their generic duties of sociability, all other things being equal. (Notice that whilst most children will not reflect upon these issues and, consequently, not visit their parents with the aim of discharging generic duties of sociability, this does not undermine the point that I am trying to make, which is simply that generic duties of sociability can, and often will, give rise to duties to visit any parents with severe dementia that we might have.)
If the foregoing is correct, then even if parents generally ceased to have any special interests in being visited by their children once they lose the ability to recognise them (as I have denied within the previous subsection), it does not follow that their children cannot have duties to visit them. For as I have shown here, there are good grounds for thinking that we have generic duties of sociability and that for a large proportion of children, the most reliable way to discharge these duties involves visiting any parents with severe dementia that they might have.
This brings us to a final possible ground of filial duties to visit parents who cannot recognise their children. Some will argue that children have duties to show gratitude towards their parents, at least when the parents have not done anything that would render displays of gratitude inappropriate such as physically abused their children (cf. Welch 2012), and that complying with these duties will often require that they (regularly) visit their parents even if the latter have lost the capacity to remember who they are.
Those who hold this view need to vindicate three assumptions. The first is that children can incur duties to show gratitude towards their parents as a result of the sacrifices that their parents have made for them and sometimes continue to make.Footnote 15 The second assumption is that, for at least some children, such gratitude can only be duly displayed by protecting their parents from loneliness (among other possible ways in which they might have to express their gratitude that do not offer such protection, at least not in any straightforward sense; for example, they might be duty-bound to send packages to their parents with the latter’s favourite food or music.)Footnote 16 The third assumption is that, for at least some of these children, protecting their parents from loneliness is possible only if they (regularly) visit them.
Can these assumptions be vindicated? Insofar as there are children who are duty-bound to show gratitude towards their parents, I think it is plausible that, in many cases, for them to discharge these duties will require that they help to protect their parents from loneliness, whatever else they might be required to do. This follows from the twin facts that (i) appropriate displays of gratitude will take into account the interests of the benefactors, and that (ii) many parents with severe dementia have stronger interests in being protected from loneliness than in receiving other goods from their children, including gifts. Given that (iii) a large share of children can only realistically protect their parents from loneliness by visiting them—even when there is the possibility of paying others to provide (regular) company on their behalf, doing so will be prohibitively expensively for many, apart from the fact that it might contravene the parents’ past autonomous preferences (see the penultimate subsection)—this would suggest that many children with parents who cannot recognise them have gratitude-based duties to visit their parents.
If I am right that (i)–(iii) are correct, then the success of gratitude-based arguments for filial duties to visit parents who have lost the ability to recognise their children turns on whether it is possible for children to owe their parents displays of gratitude. Whereas several authors subscribe to this view (e.g. Berger 1975; Blustein 1982; Wicclair 1990), it should be noted that it is not uncontroversial. For example, Wellman (1999) has argued that gratitude is a virtue and that this precludes it from being something that can be owed. Yet even when duties of gratitude are not considered to be incoherent, my experience is that a significant proportion of scholars believes that filial duties of gratitude are rare.Footnote 17 One common reason for this is that they believe that only extraordinary sacrifices—whether supererogatory or not—can give rise to duties of gratitude, and that most parents do not make such sacrifices for their children. Another is that they think that we can only owe gratitude for acts to which we have meaningfully consented. Since many of the sacrifices that parents make for their children are ones to which the children never (meaningfully) consent as they are made during the latter’s (early) childhood, this too would substantially reduce the scope of filial duties of gratitude.
I believe that there are some promising responses to these objections (see e.g. Jeske 2017, pp. 373–375; and Schinkel 2012, pp. 400–403). As a discussion of these is beyond this article’s remit, however, I will just end by noting that if one believes that at least some children have duties to show gratitude towards their parents, then it is even more likely than I have suggested here that children can, and oftentimes do, have duties to visit parents who no longer recognise them. In an age where many societies are ageing rapidly and where a cure for Alzheimer and other forms of dementia remains to be found, these are important conclusions.