Tuesday, 4 November 2014

Dementia and the Truth

The Mental Health Foundation has made available on its website a literature review on truth-telling in dementia that I found really interesting to read. The review is part of an inquiry into distressing symptoms of dementia funded by the Joseph Rowntree Foundation. The reviewer is Yulia Kartalova-O'Doherty.

The upshot of the inquiry is supposed to consist in practical recommendations for carers and healthcare professionals who find themselves in a dilemma: on the one hand, challenging the patient's beliefs when they are delusional (e.g., the belief that a loved one is still alive when she has been dead for some time, or the belief that the spouse is a deceitful impostor) causes considerable distress to the patient; on the other hand, not challenging the beliefs seems wrong as it involves lying or implies disrespect towards the patient.

One of the findings of the literature review is that current guidelines to healthcare professionals do not justify lying, but in practice people with dementia are not often confronted about their delusional beliefs. Further, there seem to be some tension between the recommendations currently offered by charities and other organisations: the Alzheimer's Society, for instance, warns against letting people live in a delusional reality but then suggests that ignoring a mistake can be the right thing to do, in order not to undermine the patient's confidence.

This is not the place to summarise the contents of the literature review -- it is short, engaging and I invite you all to read it. I just want to comment on something that happens to be very relevant to our new project, Pragmatic and Epistemic Role of Factually Erroneous Cognitions and Thoughts (PERFECT), which started last month. When the reviewer lists the main reasons why carers and healthcare professionals lie or "collude with the delusional beliefs" we find that they do so because they want to act in the best pragmatic interests of the patients (e.g., avoid distress, aid communication, enhance quality of life).

If the core idea behind our project is right, though, and some beliefs can be both false and epistemically beneficial, then we should also take into account the epistemic benefits of patients' delusional beliefs before we decide whether and how to challenge them. Delusions are usually false beliefs that are not well supported by the evidence, so they are obviously epistemically costly. But can they also have benefits in the context of dementia? Can a delusion be the only way to help patients reconnect with a fading autobiographical past or make sense of an increasing confusing present? Would the patient be epistemically better off without that delusion? Avoiding false beliefs is not the only legitimate epistemic goal and, in circumstances in which one's capacity for self-correction and the access to one's autobiographical memories are both compromised, not challenging the delusion may be justified on epistemic grounds.

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