The Principle of Autonomy and Behavioural Variant Frontotemporal Dementia

Abstract

Behavioural variant frontotemporal dementia (bvFTD) is characterized by an absence of obvious cognitive impairment and presence of symptoms such as disinhibition, social inappropriateness, personality changes, hyper-sexuality, and hyper-orality. Affected individuals do not feel concerned enough about their actions to be deterred from violating social norms, and their antisocial behaviours are most likely caused by the neurodegenerative processes in the frontal and anterior temporal lobes. BvFTD patients present a challenge for the traditional notion of autonomy and the medical and criminal justice systems. Antisocial behaviour is often the earliest recognized manifestation of bvFTD. Given that the symptoms are not specific and that atrophy of the frontal lobes is only observable with structural neuroimaging in the later stages of the disease, it is hard to ascertain their autonomy. Recently proposed re-conceptualizations of autonomy (Dworkin’s, Jaworska’s, and Dubljević’s) can, however, be sufficiently redefined to provide explicit rules and offer nuanced guidance in such cases. A combination of notions of autonomy gives the most nuanced guidance with three modifications: 1) including socio-moral judgement in the notion of “normal cognitive competence,” 2) excluding in-principle un-endorsable ideals from the notion of “capacity to value,” and 3) redefining ideal-typical degrees of compulsion (mild, severe, and total).

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Notes

  1. 1.

    This “default” approach is shared by many jurisdictions in the West, most notably in countries with the common law tradition. As succinctly formulated by Hardcastle “Western law assumes that all adults are rational beings who act for specific reasons … In other words, courts do not care about issues of impulse control, impaired executive functioning, and the like” (Hardcastle 2018, 325).

  2. 2.

    An argument could possibly be made (by strong supporters) to salvage the usefulness of the Frankfurtian concept of autonomy in bvFTD. However, that would take a strong supporter actually doing the work of re-conceptualizing, which may or may not be fruitful. Either way, there is a strong presumption that re-conceptualizations (some of which draw on Frankfurt) may be more appropriate in application (see discussion below). In fact, Dworkin’s view may be seen as an extension of Frankfurtian autonomy, informed by neurology and neuroscience and applied in the context of dementia. As such it avoids some of the unfortunate language that is traditionally used, while better aligning the principle of autonomy with relevant scientific findings and intuitions in the specific case of dementia.

  3. 3.

    Even though Alzheimer’s disease (AD) and FTD share certain symptoms, the onset and progression are different. Thus, socio-moral decision-making deficits do occur in AD but at a much later stage. I am grateful to an anonymous reviewer for prompting me to make this clear.

  4. 4.

    This is very clear in the example of Tommy McHugh: “ … a heroin addict incarcerated for violent offenses … addiction has persisted until a cerebral hemorrhage altered his personality. After suffering damage to frontal and temporal lobes, he was effectively cured of his addiction but he developed a compulsive interest in painting, sculpting, and writing. Unlike his previous condition (addiction), he is committed to his current compulsions, and claims that life is 100% better’. [ … ] [T]he idea of a rational life-plan clarifies the difference in these two compulsions. Namely, addiction to heroin cannot be incorporated into a long-term rational life-plan whereas compulsive artistic interest can” (Dubljević 2013, 48). Unlike addicts, however, bvFTD patients usually don’t see any issues with their anti-social behaviour, and feel that their lack of inhibition is basically liberating and good. In the words of one bvFTD patient “I’ve never felt better in my life” (see Dubljević 2019).

  5. 5.

    Such guidance is familiar in the philosophical literature. For instance, Kitcher contends that “[d]esires are endorsable just in case there are possible environments in which they could be satisfied for all our fellows” and “ … the desire to have adequate food is endorsable, whereas the desire to monopolize reproduction is not” (Kitcher 2011, 223).

  6. 6.

    As people with Alzheimer’s disease (AD) also exhibit failures of socio-moral judgement and commit crimes, and for reasons of expedience, I am not arguing for establishing a diversion court specifically for bvFTD. I presume that most of the cases will be from the bvFTD population, specifically because criminal behaviour is recurrent in bvFTD. For instance, a Swedish study reported instances of criminal behaviour in 14.9 per cent of AD patients and 42 per cent of FTD patients, whereas the criminal behaviour was recurrent in 56.4 per cent of AD patients and 89 per cent of FTD patients (see Liljegren et al. 2019). I am grateful to an anonymous reviewer whose constructive comments prompted me to consider socio-moral deficits in AD and generalization of findings of this article to how autonomy is embedded in the legal system.

References

  1. Baez, S., B. Couto, T. Torralva, et al. 2014. Comparing moral judgments of patients with frontotemporal dementia and frontal stroke. The Journal of the American Medical Association Neurology 71(9): 1172-1176.

    PubMed  Google Scholar 

  2. Birkhoff, J.M., C. Garberi, and L. Re. 2016. The behavioral variant frontotemporal dementia: An analysis of the literature and a case report. International Journal of Law and Psychiatry 47: 157-163.

    Article  Google Scholar 

  3. Chare, L., J.R. Hodges, C.E. Leyton, et al. 2014. New criteria for frontotemporal dementia syndromes: Clinical and pathological diagnostic implications. Journal of Neurology, Neurosurgery, and Psychiatry 85(8): 866-871.

    Article  Google Scholar 

  4. Christman, J. 2015. Autonomy in moral and political philosophy. In The Stanford Encyclopedia of Philosophy (Spring 2015 Edition), edited by E.N. Zalta, https://plato.stanford.edu/archives/spr2015/entries/autonomy-moral/. Accessed 27 Feb, 2020.

  5. Daniels, N. 2018. Reflective equilibrium. In The Stanford Encyclopedia of Philosophy (Fall 2018 Edition), edited by E.N. Zalta, https://plato.stanford.edu/archives/fall2018/entries/reflective-equilibrium/. Accessed 27 Feb, 2020.

  6. Diehl-Schmid, J.K., R. Perneczky, J. Koch, N. Nedopil, and A. Kurz. 2013. Guilty by suspicion? Criminal behavior in frontotemporal lobar degeneration. Cognitive and Behavioral Neurology 26(2): 73-77.

    Article  Google Scholar 

  7. Dryden, J. 2017. Autonomy. The Internet Encyclopedia of Philosophy. http://www.iep.utm.edu/autonomy/#SH2b. Accessed 27 February, 2020.

  8. Dubljević, V. 2013. Autonomy in neuroethics: Political and not metaphysical. American Journal of Bioethics Neuroscience 4(3): 44-51.

    Google Scholar 

  9. ———. 2015. Lost in interpretation: Autonomy and what patients tell vs. what is inferred. American Journal of Bioethics 15(9): 28-30.

    Article  Google Scholar 

  10. ———. 2016. Autonomy is political, pragmatic and post-metaphysical: A reply to open peer commentaries on ‘Autonomy in neuroethics.’ American Journal of Bioethics Neuroscience 7(4): W1-W3.

    Google Scholar 

  11. ———. 2019. Disease and wellness across the lifespan: A global perspective on mental health burden of dementia. In Global mental health and neuroethics, edited by D. Stein and I. Singh, 225-235. Amsterdam: Elsevier.

    Google Scholar 

  12. Dworkin, R. 1993. Life’s dominion: An argument about abortion, euthanasia and individual freedom. New York: Alfred A. Knopf.

    Google Scholar 

  13. Felsen, G., and P.B. Reiner. 2011. How the neuroscience of decision making informs our conception of autonomy. American Journal of Bioethics Neuroscience 2(3): 3-14.

    Google Scholar 

  14. Frankfurt, H. 1971. Freedom of the will and the concept of a person. The Journal of Philosophy 68(1): 5-20.

    Article  Google Scholar 

  15. ———. 1988. The importance of what we care about. Cambridge: Cambridge University Press.

    Google Scholar 

  16. Hardcastle, V. 2018. The neuroscience of criminality and our sense of justice. In Neuroexistentialism: Meaning, morals, and purpose in the age of neuroscience, edited by G.D. Caruso and O. Flanagan, 311-332. New York: Oxford University Press.

    Google Scholar 

  17. Jaworska, A. 1999. Respecting the margins of agency: Alzheimer’s patients and the capacity to value. Philosophy and Public Affairs 28(2): 105-138.

    Article  Google Scholar 

  18. ———. 2006. Ethical dilemmas in neurodegenerative disease: Respecting patients at the twilight of agency. In Neuroethics: Defining the issues in theory, practice and policy, edited by J. Illes, 87-101. New York: Oxford University Press.

    Google Scholar 

  19. Kitcher, P. 2011. The ethical project. Cambridge: Harvard University Press.

    Google Scholar 

  20. Lanata, S.C., and B.C. Miller. 2016. The behavioral variant frontotemporal dementia (bvFTD) syndrome in psychiatry. Journal of Neurology, Neurosurgery, and Psychiatry 87(5): 501-511.

    Article  Google Scholar 

  21. Libet, B. 1985. Unconscious cerebral initiative and the role of conscious will in voluntary action. Behavioral and Brain Sciences 8(4): 529–566.

    Article  Google Scholar 

  22. Liljegren, M., M.L. Waldo, A.F. Santillo, et al. 2019. Association of neuropathologically confirmed frontotemporal dementia and Alzheimer disease with criminal and socially inappropriate behavior in a Swedish cohort. JAMA Network Open 2(3): e190261.

    Article  Google Scholar 

  23. Manes, F., T. Torralva, A. Ibáñez, M. Roca, T. Bekinschtein, and E. Gleichgerrcht. 2011. Decision-making in frontotemporal dementia: Clinical, theoretical and legal implications. Dementia and Geriatric Cognitive Disorders 32(1): 11-17.

    Article  Google Scholar 

  24. Mendez, M.F. 2010. The unique predisposition to criminal violations in frontotemporal dementia. The Journal of the American Academy of Psychiatry and the Law 38(3): 318-323.

    PubMed  PubMed Central  Google Scholar 

  25. Mendez, M.F., E. Anderson, and J.S. Shapira. 2005. An investigation of moral judgments in frontotemporal dementia. Cognitive and Behavioral Neurology 18(4): 193-197.

    Article  Google Scholar 

  26. Menzel, P.T., and B. Steinbock. 2013. Advanced directives, dementia, and physician-assisted death. The Journal of Law, Medicine, and Ethics 41(2): 484-500.

    Article  Google Scholar 

  27. Mischel, W., and O. Ayduk. 2004. Willpower in a cognitive-affective processing system: The dynamics of delay of gratification. In Handbook of self-regulation: Research, theory and applications, edited by R. Baumeister and K. Vohs, 99-129. New York: Guilford.

    Google Scholar 

  28. Mitchell, O., D.B. Wilson, A. Eggers and D.L. MacKenzie. 2012. Assessing the effectiveness of drug courts on recidivism: A meta-analytic review of traditional and non-traditional drug courts. Journal of Criminal Justice 40: 60-71.

    Article  Google Scholar 

  29. Racine, E., and V. Dubljević. 2017. Neuroscience and socio-environmental determinants of moral agency: Threat or empowerment? In Neuroethics: Anticipating the future, edited by J. Illnes, 388-410. Oxford: Oxford University Press.

    Google Scholar 

  30. Racine, E., V. Ngyen, V. Saigle, and V. Dubljević. 2016. Media portrayal of a landmark neuroscience experiment on free will. Science and Engineering Ethics 23(4): 989-1007.

    Article  Google Scholar 

  31. Rascovsky, K., J.R. Hodges, D. Knopman, et al. 2011. Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain 134(9): 2456-2477.

    Article  Google Scholar 

  32. Rawls, J. 1971. A theory of justice. Cambridge: Belknap/ Harvard University Press.

    Google Scholar 

  33. U.S. Congress, Office of Technology Assessment [OTA]. 1987. Losing a million minds: Confronting the tragedy of Alzheimer’s Disease and other dementias. OTA-BA-323. Washington, DC: U.S. Government Printing Office; 1987.

  34. Wolff, N., N. Fabrikant, and S. Belenko. 2011. Mental health courts and their selection processes: Modeling variation for consistency. Law and Human Behaviour 35(5): 402-412.

    Article  Google Scholar 

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Correspondence to Veljko Dubljević.

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Dubljević, V. The Principle of Autonomy and Behavioural Variant Frontotemporal Dementia. Bioethical Inquiry 17, 271–282 (2020). https://doi.org/10.1007/s11673-020-09972-z

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Keywords

  • Autonomy
  • Behavioural variant frontotemporal dementia
  • Moral responsibility
  • Legal issues
  • Informed consent