Dignity, Dementia and Death

Abstract According to Kant’s ethics, at least on one common interpretation, persons have a special worth or dignity that demands respect. But personhood is not coextensive with human life; for example, individuals can live in severe dementia after losing the capacities constitutive of personhood. Some philosophers, including David Velleman and Dennis Cooley, have suggested that individuals living after the loss of their personhood might offend against the Kantian dignity the individuals once possessed. Cooley has even argued that it is morally required on Kantian grounds for those who realize that they will lose their personhood as a result of dementia (e.g. Alzheimer’s) to hasten their deaths (e.g. commit suicide). This article specifies circumstances in which post-personhood living might indeed involve an affront to the Kantian dignity of a person who once was. However, the article contends, Kant implies that it is neither morally required nor even morally permissible for someone in an early stage of Alzheimer’s to hasten their death to avoid such an affront, even if they have autonomously chosen to do so. The article adds an ethical perspective to debate on physician-assisted dying, in particular on the moral permissibility of the soon-to-be-demented ending their lives.


Introduction
Over 6 million people in the United States have Alzheimer's disease, including approximately one in nine people of age 65 or older. Alzheimer's patients over 65 live on average four to eight years after diagnosis. As the disease progresses, they typically experience difficulty completing daily tasks, such as driving to a familiar place, following or participating in conversations and locating their personal belongings. They often exhibit poor judgement (e.g. in dealing with money), withdraw from social activities and become confused, suspicious, anxious or depressed. Approximately 40 per cent of the time that patients between 70 and 80 years of age spend with the disease is in its final, most severe stage. Symptoms at that stage typically include incontinence, loss of speech, difficulty eating or swallowing and loss of awareness of recent experience and of surroundings. Alzheimer's was the nation's sixth-leading cause of death in 2019 (Alzheimer's Association 2022: 700). Over 55 million people worldwide are living with dementia, including Alzheimer's; by 2030, the number is expected to reach 78 million (Gauthier et al. 2021: 19).
In the Netherlands, it is legal for people diagnosed with dementia to participate in euthanasia or physician-assisted suicide (EAS). Dutch law specifies that a doctor must deem a patient's request for EAS to be informed and voluntary and the patient to be suffering unbearably, with no prospect of improvement (de Beaufort andvan de Vathorst 2016: 1464). The law even allows for advance euthanasia directives for dementia patients (Miller et al. 2019: 85). 1 In the US, while euthanasia is illegal, physician-assisted suicide is legally permitted in several states. However, Alzheimer's patients tend to be excluded from participating in it (Menzel and Steinbock 2013: 484). In Oregon, for example, before writing patients prescriptions for lethal doses of medication, doctors need to certify both that the patients have six months or less to live and that they are 'capable', that is, able to make and communicate health care decisions. But Alzheimer's patients who, as a result of that disease, can be certified to have six months or less to live are rarely capable in this sense.
Whether EAS for Alzheimer's patients should be legal depends at least in part on whether it is ethical. If it is morally wrong for an Alzheimer's patient to partake in EAS, then there is reason to be concerned that physician participation might be wrong as well. 2 Some ethicists, inspired by Immanuel Kant, have argued against the moral permissibility of self-interested suicide (Velleman 1999: 608, 614). According to David Velleman's interpretation (1999: 614), Kant holds that an action is morally permissible if and only if it respects the value or dignity of personhood. In Kant's view, Velleman suggests, it is wrong for someone to sacrifice her personhood solely to have a life better overall for herself than she would have if she lived longer. Hastening one's death just to promote one's own well-being fails to respect one's dignity. 3 For example, it is morally impermissible for someone to kill herself simply to avoid an ending to her life in which she maintains her personhood, but suffers from pain, anxiety and disappointment. Or, especially pertinent to our purposes, suppose that someone has Mild Cognitive Impairment, a diagnosis that often precedes that of dementia (Petersen et al. 2018: 127); this person has mental lapses, but ones that do not significantly interfere with her daily activities. She would act wrongly if she killed herself to avoid any suffering she, while still a rational agent, might encounter in the future.
Although he does not focus on the idea, Velleman claims that Kantians leave open the possibility that suicide might 'constitute an appropriate expression of respect for one's person' (Velleman 1999: 616), if undertaken for a reason different from that of promoting one's own well-being. According to Velleman: When a person cannot sustain both life and dignity, his death may indeed be morally justified. One is sometimes permitted, even obligated, to destroy objects of dignity if they would otherwise deteriorate in ways that would offend against that value. The moral obligation to bury or burn a corpse, for example, is an obligation not to let it become an affront to what it once was. (p. 617) Velleman goes on to say that '[r]espect for an object of dignity can sometimes require its destruction' (p. 617).
Velleman's rejection of the moral legitimacy of self-interested suicide does not depend on these claims. However, the claims prompt questions. Does the course of an individual's Alzheimer's disease sometimes result in deterioration that offends against his dignity? If so, might it, according to Kantian ethics, be morally permissible or even morally required for an individual diagnosed with Alzheimer's, say at a very early stage, to hasten his death? This article addresses these questions. To do so, it considers arguments developed by philosopher Dennis Cooley who maintains that, according to Kantian ethics, if someone knows she will become demented, thereby permanently losing her Kantian personhood, she has a moral duty to terminate her life before this happens (Cooley 2007: 40). She has this duty apparently because if she did not hasten her death, she would go on living in a state that would be demeaning to the dignity she once possessed.

Preliminary points and plan
To avoid misunderstanding, let us fix from the outset the way we will use some terms. In a Kantian vein, let us use the term 'person' in a quasi-technical sense. A being is a person or, equivalently, has 'humanity' or 'rational nature' only if it has certain capacities. It must be able to set and pursue ends; strive for coherence among its ends; be self-aware; conform its actions to practical rules that specify means to ends; and act in accordance with moral imperatives, even when it believes that it would gain more satisfaction by acting contrary to them.
Let us call 'post-personhood' the existence of an individual who was a person or the existence of the remains of such an individual. Philosophers defend various views regarding personal identity, that is, regarding what makes an individual one and the same over time (Shoemaker 2019). A human being who falls into a non-reversible vegetative state is not one and the same individual he was before falling into it, some say. These philosophers might hold that personal identity is based on psychological continuity (e.g. having the same or overlapping beliefs or desires over time), which continuity does not obtain between a person and a being in a non-reversible vegetative state because the latter lacks sentience. They might refer to a being in this state as the remains, albeit living, of the person. Other philosophers disagree, arguing that personal identity is grounded in the continuing existence of one human organism. On this view, one and the same individual exists before and after he enters the vegetative state. In this article, I hope to avoid controversy regarding personal identity. For our purposes, what matters is that post-personhood existence, whether as the same individual one once was or as the remains of such an individual, might reflect in some way on the worth the person once possessed.
Philosophers, including Cooley's critics, invoke the idea of post-personhood existence sometimes being an affront to the dignity an individual possessed. Yet when is it such an affront? The article addresses this largely neglected question (section 5). It argues that post-personhood living might indeed sometimes offend against dignity according to Kant's understanding (section 5). However, Kant's notion of dignity implies that it is neither morally required nor even morally permissible for someone in an early stage of Alzheimer's to hasten her death to avoid such an affront, even if she has made an informed, voluntary choice to do so (section 6). Let us begin by examining Cooley's attempt to show the contrary, namely, that, according to Kant's view, if a person knows that she will become severely demented, then she has a moral duty to prevent that from occurring by hastening her death (sections 3 and 4).

Cooley's conditions
Cooley claims that, according to Kant's ethics, if one knows he will become demented, thereby permanently losing his Kantian personhood, then he has a duty to terminate his life before this happens (Cooley 2007: 40). Cooley's defence of this claim is based on his analysis of cases Kant discusses in lectures. In one such case, central to Cooley's argument (p. 38), an honourable man unjustly accused of treason has to choose between being executed for his supposed crime or living as a galley slave. Kant suggests that as a man of inner worth, he would, and morally must, choose execution 155;27: 376). 4 In opting to be executed, the honourable man would avoid living on without the aspect of personhood that gave him dignity: his capacity to act from duty, Cooley takes Kant to hold (Cholbi 2015: 608). Living on devoid of this capacity would amount to living in a way that is unworthy of the value the honourable man once possessed, thus giving him a status lower than that of non-rational animals, according to Cooley's interpretation of Kant.
Based largely on consideration of this case, Cooley claims that, according to Kant, an individual has a duty to kill himself or to allow himself to be killed if three conditions are met (Cooley 2007: 40-1). First, the individual has a 'moral life', that is, the capacity to act from duty or moral agency (pp. 39-40). Cooley interprets Kant to hold that some individuals possess aspects of rational agency, but have 'sacrificed' this capacity. These individuals include 'galley slaves and those committing sexual crimes against nature' (p. 40). I discuss and reject this interpretation below. Second, the agent is in a situation in which he must choose between either taking his physical life or continuing to live devoid of moral agency (p. 40). Of course, the honourable man described above is, according to Cooley, in this situation.
The last of the three allegedly jointly sufficient conditions sketched by Cooley for an individual's being morally obligated to end his life is that he be capable of doing so with good intentions or motives (Cooley 2007: 40). If there is someone able to end his life but only out of a motive of avoiding future suffering, this individual would be unable to fulfil this condition, Cooley seems to imply. In contrast, the honourable man is capable of fulfilling it, in his view. Although Cooley does not rely on this point, Kant clearly implies the following: upon reflection, we must conclude that every person (i.e. in the quasi-technical sense explicated above), no matter how strong his inclination to contravene his duty, is capable of abiding by it, from duty, that is, out of respect for the moral law (CPrR, 5: 30-7). If Cooley is correct that we have a Kantian duty to hasten our deaths rather than to lead degrading lives as former persons, then we must agree that respect for the moral law, which is clearly a good motive for Kant, provides us with sufficient incentive to hasten our deaths, according to Kantian thinking.
Cooley holds that competent individuals diagnosed with impending and irreversible dementia typically fulfil these three conditions and so typically have a 'rational duty to die physically before dying morally' (Cooley 2007: 40). Why would a person's fulfilling all three conditions, namely, having a 'moral life', facing either hastening her death now or living on devoid of a moral life, and being able to hasten her death for morally appropriate reasons, entail that a person has a duty to hasten her death? According to Cooley, 'the moral agent should select self-inflicted death before she becomes incompetent because she owes it to herself as a moral agent. Her action would show that if she could not be a person, then she would not settle for a lower moral status she could prevent ' (p. 40). But what would be wrong with 'settling' for lower moral status, such as would, according to Cooley's take on Kant, accrue to an individual with advanced dementia or the falsely accused individual if he chooses to be a galley slave rather than to be executed? In the context of Cooley's discussion, only one answer makes sense: Cooley holds that an individual's existing with advanced dementia or as a galley slave (i.e. in Cooley's view, devoid of moral agency) amounts to his living in a way that is unworthy of the dignity the individual once possessed by virtue of having moral agency (cf. Cholbi 2015: 608). Cooley suggests that choosing to go on living devoid of Kantian personhood, at least in severe dementia, amounts to choosing a mode of existence that will dishonour the worth of the personhood he once possessed. 5 A central question for us is whether this suggestion is plausible.

Forfeiture of dignity?
Before turning to that question, let me make some points connected to the first of the conditions Cooley claims to be jointly sufficient for an individual's having a duty to hasten her death. This condition is fulfilled if she has moral agency, which involves having the capacity to conform, from duty, one's actions to the moral law. According to Cooley's interpretation, some individuals who have what he calls 'rational agency', which presumably includes the capacities to set and to rationally pursue ends, have, through their actions, forfeited their 'moral lives' or moral agency and so their worth as persons (i.e. their dignity). Among these individuals are galley slaves.
This interpretation is salient to our purposes. Cooley suggests that someone can forfeit his moral life by choosing to live on as a slave rather than to die. He suggests that the person's choice itself, independent of its consequences, including his being treated as a slave, suffices for him to lose his worth as a person (Cooley 2007: 38, 43). Against the background of this suggestion, Cooley, or those sympathetic to his views, might hold that someone forfeits his moral agency simply by making the choice to live on in severe dementia rather than to die before reaching that state. They might hold Kant to be committed to the view that individuals diagnosed with early-stage Alzheimer's who are able to, but choose not to, take steps to ensure that they will die before becoming severely demented thereby throw away their moral agency. Yet in my view Cooley's interpretation of Kant is unsustainable, especially as it applies to Kant's major works in ethics from the Groundwork of the Metaphysics of Morals (1785) to the Metaphysics of Morals (1797). I now explain briefly why, without pretence to providing the scope and depth of textual analysis necessary for a definitive refutation.
Since an individual cannot have dignity without having rational nature, according to Kant, there is clearly a way in which the individual is able to forfeit his dignity through his action; he can commit suicide simply to avoid suffering. Moreover, at least in his lectures as recounted by students, Kant does sometimes imply that a person can lose his inner worth or dignity through actions that do not eliminate his rational nature. For example, '[I]f a person, for the sake of profit, lets himself be used in everything, like a ball, by someone else, he is throwing away his worth as a person', Georg Collins recounts Kant as saying (Eth-C, 27: 341; see also 391). In his published writings, Kant himself also sometimes seems to suggest that dignity is forfeitable by deed. 'By a lie a human being throws away and, as it were, annihilates his dignity as a human being' (MM, 6: 429), he says. It is understandable that Cooley would claim to find a basis for his interpretation in Kant's text.
However, we should not take such passages to mean that in acting in these ways a person literally forfeits his dignity. Kant's use of 'as it were' in the latter passage signals that he is speaking figuratively. In lying, a person is acting as if he had no dignity, I take Kant to be saying. Kant views lying as a violation of a duty to oneself (MM, 6: 429). According to him, the liar acts in a way that would be appropriate only if he did not have a dignity that demands respect. In a similar way, a person who for profit permits himself to be used like a ball by others behaves in a way that would be warranted only if he were a mere thing, rather than a person. This reading coheres with Kant's repeated suggestions that, as long as one has rational nature, including the capacity to conform one's actions, from duty, to the moral law, one has dignity (6: 434-5, 462). Kant characterizes dignity as 'inalienable' from personhood (6: 436). That one has lied or violated one's duty in some other way, for example through servile behaviour (6: 435-6), is, according to him, consistent with maintaining rational nature, including moral agency, or so I interpret him.
Of course, it is open to those who reject this interpretation to reply that an individual who, for example, has lied has thereby relinquished his personhood, according to Kant. I doubt whether that reading is permitted by the text, but if it is, it has jarring implications. First, Kant ultimately seems to recognize just two levels of moral status, namely, that of persons and that of things (G, 4: 428) (cf. Wood 1999: 122-4, 143-4). Since those of us who have lied are not persons (i.e. beings who possess morally practical reason) according to the reply, we are things. Second, as a result, the reply implies that no individual, whether a person or a non-person, wrongs those of us who have lied in treating us merely as means. An assailant would not count as wronging us by promoting his own happiness through mugging or even killing us. Let me hasten to point out that many philosophers with Kantian leanings find unacceptable Kant's stark bifurcation of moral status, arguing, for example, that he should and, indeed, could have made room for a moral status higher than that of things but below that of persons (Kerstein 2013: 22-3).
In any case, Cooley himself suggests that, according to Kant, an individual forfeits his personhood, conceived of as including the capacity to act from duty, only for certain, particularly egregious, violations of the moral law, which Cooley calls 'moral agency-crushing' actions (Cooley 2007: 38, 40;2015: 283-4), such as bestiality. Yet neither does Cooley highlight nor do I find a basis in Kant's major ethical writings for a distinction between violations of the moral law that result in an individual going on living devoid of personhood and violations that have no such result. Indeed, if it were Kant's view that some violations of the moral law had this result, then he would likely include lying among them. He calls lying 'the greatest violation of a human being's duty to himself regarded merely as a moral being' (MM,6: 429). This brief discussion has, I hope, highlighted some significant reasons for rejecting Cooley's reading of Kant's views regarding one's forfeiture of personhood through one's deeds.
As is already apparent, if Cooley's interpretation of Kant were correct, Kant's view would have implications that many of us would judge to be morally repugnant (Powell and Asch 2007). The interpretation implies the following, for example: an individual who chooses to live as a slave with the hope of someday gaining her freedom rather than to die immediately in rebellion at the hand of her master thereby makes herself a mere thing. As a mere thing, the master would not wrong her in using her in whatever way he chose. 6 To many of us, this kind of implication is unacceptable, to say the least. Of course, that it is suggests that it would be uncharitable to attribute a view with such an implication to Kant, especially since there are textual grounds for refraining from doing so. For interpretative as well as philosophical reasons, I will assume that, on Kant's considered view, those who act contrary to duty, except in rare cases such as when the immoral action is suicide, do not thereby forfeit their personhood and thus their dignity.

Post-personhood existence as an affront to Kantian dignity
Both Velleman and Cooley suggest that it is sometimes morally permissible or even morally required to destroy a being with dignity if, in enduring, it would lose or be without its dignity in a way that would 'offend against' this value. However, neither Cooley nor Velleman explains when an affront or insult to dignity occurs. Without pretence to being exhaustive, let us explore when post-personhood existence might constitute an affront, insult or degradation of dignity on Kant's understanding of dignity, at least on one well-entrenched interpretation. This interpretation seems to cohere with that of Velleman (Velleman 1999: 611, 613), and it has adherents among Kant scholars (Wood 1999). Cooley does not say much about how he interprets the concept of dignity, but I am aware of no other understanding of it that would put his claims regarding dignity in a more favourable light.
Kant suggests that a being has dignity if and only if it has the capacities constitutive of personhood, that is, rational nature. Several points surrounding this suggestion warrant attention. To have dignity is to have unconditional and incomparable worth. To say that the worth of a person is unconditional is to imply that she would have positive worth in every context in which she existed. Moreover, this worth would not increase or decrease no matter what happened to the individual, as long as she maintained her personhood. A person who loses her zest for life, her fortune or her sight does not thereby forfeit any of her worth as a person. Kant explains incomparable worth by contrasting it with price: 'What has a price can be replaced by something else as its equivalent; what on the other hand is raised above all price and therefore admits of no equivalent has a dignity' (G, 4: 434; see also MM, 6: 462). The value of something with dignity, then, is incomparable in the sense that it has no equivalent for which it can legitimately be exchanged. That it has no such equivalent seems to have two implications (Hill 1992: 47-9). First, something with dignity can never be legitimately sacrificed for or replaced by something with price. Not even all the gold in Fort Knox would truly compensate for the killing of one rational agent. Second, something with dignity cannot be legitimately sacrificed for or replaced by something else with dignity. This view seems to imply that if it is legitimate to kill one person, thereby saving several others, it is not because the value of the several outweighs that of the one. Kant holds that, if something has mere price, it lacks dignity. Finally, according to Kant, persons have a worth to be respected, as 'independently existing ends' (G, 4: 437), not a value to be realized, say, by bringing as many persons into being as possible.
It is important for our purposes to note that, in Kant's view, human beings having unconditional, incomparable worth derives from our ability to act from duty. Kant implies that we have dignity insofar as we are 'capable of morality' (G, 4: 435). He calls autonomy 'the ground of the dignity of a human and of every rational nature' (4: 436). Autonomy in Kant's sense is roughly the capacity to represent the moral law (i.e. Kant's Formula of Universal Law or its equivalent) to oneself and to abide by it, no matter what one is inclined to do. Having autonomy involves being able to act from duty. In calling autonomy the ground of dignity, Kant is, therefore, implying that if a being has it, then it has unconditional, incomparable worth. Kant also apparently holds that having autonomy implies having the other capacities constitutive of rational nature, including the capacities to reflectively set and rationally pursue all sorts of ends.
This notion of dignity is not coextensive with conceptions of dignity commonly employed in bioethics. For example, some bioethicists write of a patient losing dignity if he experiences a diminished sense of self-worth, say, because he can no longer feed himself (Chochinov 2002). But a diminished (or augmented) sense of self-worth would not itself affect one's worth as a person; that worth depends on one's possession of rational nature. In what follows, I invoke solely the Kantian understanding of dignity specified above.
Some ways in which a severely demented individual might live would, it seems, be degrading to the dignity that he once possessed. Perhaps in any society with a consensus that persons have dignity but lose it when they become severely demented, some treatment of severely demented individuals would be an affront to the worth they once had. Ridiculing, neglecting or assaulting these individuals might qualify as such treatment.
Of course, in contemporary US culture, to cite one example, there is no consensus that persons have dignity as Kant conceives of it. Some contemporary Americans think, more in line with Hobbes than Kant, that a person's worth is simply a function of his wealth and what others are willing to pay for his services. On this view, no one has unconditional worth. Others hold that all human beings, no matter the state of their cognitive capacities, have (something like) unconditional, incomparable value.
Yet let us assume for a moment that there is in the contemporary US a consensus embracing the dignity of persons, as we have defined it. Would contemporary US customs or mores dictate that individuals who are living with severe dementia are thereby existing in a way that is degrading or insulting to the dignity they formerly possessed? It seems not. That an individual has moved downward from a higher moral status (personhood) to a lower moral status (life without personhood) does not entail that the latter status is an insult to the former. The diminished status might be unfortunate or even sad, but that does not mean that it constitutes an affront. In a roughly analogous way, suppose that someone who was an Olympic sprinter at 25 years of age is unable to run at 65. His lack of running ability at 65 is unfortunate and, perhaps, sad, but it does not constitute an insult to his status as a great runner at 25, at least according to contemporary American mores as I can discern them.
As we noted in section 3, Cooley implausibly suggests that an individual disrespects her worth as a person and, indeed, thereby forfeits her moral agency simply by making the choice to live on when she becomes severely demented rather than to die before reaching that state. But Cooley's reflections might help to generate a less radical position. According to it, in choosing to live on rather than to die before severe dementia occurs, a person would not be throwing away her moral agency. Yet in some unfortunate circumstances, a person would be choosing a course of life during which the worth she once had as a person would in all likelihood be disrespected. She might have good reason to believe that (unfortunately unavoidable) treatment of her, once she lost her personhood, would constitute an affront to what she once was. For example, as suggested above, she might reasonably expect that her fate if she becomes severely senile would be to be mocked or neglected, which would be an insult to the worth she once had. To return to our rough analogy, a lack of running ability at 65 does not itself amount to an insult to someone's status as a great runner at 25. But mocking him at sixty-five, by forcing him to wear spikes, start from blocks and limp around a track, would be an insult to his former status as a great runner. In some contexts, it would be reasonable for someone with her rational nature intact to expect that, unless she hastens her death, she will develop severe dementia, losing her dignity, and be treated in a way that degrades the dignity she once possessed. 7 Is there another, distinct way that post-personhood existence as an individual with advanced Alzheimer's might offend against the dignity one once possessed? One might suspect that such an existence may constitute an affront against such dignity by representing a kind of failure of will.
Suppose that an individual, Theodore, has willed not to spend the last chapter of his life devoid of rational agency because, in his view, his doing so would render his life less good for him overall than it otherwise would be. Ronald Dworkin suggests that how we die plays a significant role in the narrative of our lives, 'like the final scene of a play, with everything about it intensified, under a special spotlight' (Dworkin 1993: 209). In accordance with Dworkin's suggestion, Theodore sees his life having a fitting ending, an ending that coheres with his deepest values, to contribute to his life's overall goodness. In particular, he sees the goodness of his life for him as deriving largely from his development and use of his cognitive powers, especially in his research and writing on the history of Central American migration. He judges that a life ending in advanced Alzheimer's, with months or years devoid of the cognitive abilities he cherishes, to be less good overall than one that ends abruptly, without such deterioration. Against the background of his conviction regarding how his life would go best for him, he strives to have it end before he lapses into severe dementia.
But suppose further that, through lack of prudence, Theodore fails to avoid life with severe dementia. Once he learns that he is in an early stage of Alzheimer's, he ceases part, but not all, of his treatment for a form of cancer that, left untreated, is typically lethal within a few months. He fails to make inquiries that would have revealed that the medication he continues to take will likely not only relieve his pain, but also extend his life. Theodore survives for several years, including in the final stage of Alzheimer's. The enduring manifestation of this failure (e.g. his continuing existence with advanced dementia) would, according to the view we are examining, be an affront to the dignity Theodore possessed as a person. It would be such an affront presumably because his worth as a person lies in his rational nature, and his continuing existence as a severely demented individual would manifest a crucial failure in the exercise of his rational nature. The failure would be crucial because, echoing Dworkin, in Theodore's view how he dies plays an especially impactful role in the overall goodness for him of his life.
One might reply by arguing that, when Theodore loses his rational nature, his personal identity changes. Before he has advanced Alzheimer's, Theodore is a different individual than he is when he becomes severely demented. Severe dementia breaks the psychological connections between beliefs, desires, projects, narratives and so forth requisite for an individual to be one and the same through time. Since severely demented Theodore is a different individual than Theodore with rational nature, whatever the former undergoes, it cannot amount to a disparagement of the latter's worth.
There is reason to doubt whether this is an adequate reply. First, as suggested above, some people do not subscribe to psychological accounts of personal identity. Some hold that even if psychological connections between pre-dementia Theodore and severely demented Theodore fail to hold, he is the same individual. He is the same individual in that the same organism exists in an earlier competent phase and in a later incompetent phase. 8 Therefore, contrary to the argument, the fate of the postpersonhood entity existing after the demise of Theodore the person can constitute an affront to his worth. Moreover, even if Theodore dead is not one and the same individual as Theodore alive, with his personhood intact, many believe that the treatment of his body could constitute an affront to the dignity he once possessed. Dismembering a body and throwing the pieces in a dumpster might, many think, constitute an affront to the dignity the individual once possessed. In a similar vein, even if there is a gap in identity between a person, Theodore, and the severely demented individual succeeding him, also called Theodore, the latter's existence might, it seems, contribute to an affront to the dignity the former possessed, if the latter's existence exemplifies a failure of the former's will.
However, there is, in my view, a different and successful reply to the position that post-personhood existence as an individual with advanced Alzheimer's offends against the dignity one possessed as a person because it represents a failed exercise of rational agency. As noted, according to Kant, human beings' unconditional, incomparable worth derives from our ability to act from duty. Against this background, a point crucial for our purposes emerges. Given that the capacity to act from duty is the source of dignity, it is implausible to say that a failure to realize an ultimate aim of maximizing one's wellbeing constitutes an affront to dignity. In trying to secure his death before becoming severely demented, Theodore was not acting from duty, but rather, as Kant would say it, from inclination. He was trying ultimately to ensure that he would have the best (e.g. happiest) life possible for himself. His failure to secure his death before becoming severely demented would not constitute an affront to his capacity to act on a self-given moral principle; it is hard to see how it would reflect on it at all. Of course, it would be otiose to object that the failure would constitute such an affront if it prevented him from having moral capacity or at least interfered with this capacity. It did neither; his going on to live in severe dementia rather than dying before he got there did not affect his ability to act from duty before he got there.
6. The wrongness of eliminating rational nature to prevent post-personhood affronts to dignity Even when an individual's living with severe dementia represents a failure on her part to realize a key element of what she takes to be a flourishing life, it does not thereby amount to an insult to the dignity she once possessed, we have found. However, someone's existence with severe dementia can, as a result of others' treatment of her, amount to such an insult. If someone reasonably expects a future life for her with dementia to be an affront to the worth she once possessed, is it morally permissible or required for her to commit suicide before she becomes demented, according to a Kantian view? To make this question concrete, suppose that someone, call her Julia, has received a diagnosis of Alzheimer's disease. She still possesses rational nature, but believes reasonably that, in as little as a year or as long as a few years, she will become severely demented, thereby forfeiting it. Moreover, Julia reasonably believes that once she becomes demented, her mode of continuing existence will involve an affront to the worth she once possessed. She will, unfortunately, be mocked and derided by her nephew who is the only one able to take charge of her care. Julia is not inclined to commit suicide. But if she believes it to be morally required for her to kill herself now, she is for that reason able to do so. Suppose that Julia reasonably believes that, if she does not kill herself now, she will be unable to do so (e.g. due to lack of means). Is Julia morally required, according to Kant, to kill herself to avoid a fate that is an affront to the dignity she now possesses? Cooley, of course, believes that she is. I will argue that she is not. Indeed, there is good reason to doubt that it is even morally permissible for her to do so, in Kant's view.
Kant holds that there are various formulations of the supreme principle of morality. One of them is often labelled the Formula of Humanity: 'So act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means' (G, 4: 429). On one interpretation, this imperative amounts to a command always to treat persons as ends in themselves, that is, as having unconditional, incomparable worth (i.e. dignity). As I have said, this interpretation seems to underlie Velleman's work on Kant and hastening death, and it seems just as compatible with Cooley's invocations of dignity as any other interpretation of the Formula of Humanity I am aware of. If Julia is morally required to kill herself, then it would be morally impermissible for her to refrain from doing so, of course. Her refraining would violate the Formula of Humanity because it would involve a failure on her part to treat her rational nature as having unconditional, incomparable worth.
I now argue that her choice to live on would not involve such a failure. First, treating something as having a special value often involves trying to preserve that thing. Suppose, for example, that we deem a certain painting to have remarkable aesthetic value. Treating it as such might involve protecting it against destruction from mould, excessive heat and so forth. Or suppose that we hold the last grove of Wollemi pines, a species in existence alongside dinosaurs, to have special worth. Preserving it, say, by preventing the trees from being destroyed in order to make way for a mine, would harmonize with our evaluation. In refraining from killing herself, thereby preserving her rational nature, Julia would be doing something that harmonizes with the idea that her rational nature has unconditional, incomparable worth. That gives us significant reason to hold that it would be morally permissible, according to the Formula of Humanity, for her not to hasten her death.
Here someone might object that while it is true that we honour the high aesthetic value some things possess by trying to preserve them, that is not always the case. We do not honour the value of a performance of an organ sonata by, say, requiring the organist to hold the last note so the piece does not end. We honour it, in part, by focusing on the performance while it lasts and refraining from interfering with its fitting end. We honour the dignity of a person, the objection continues, only if we treat this value like that of the performance of the sonata. We must respect the person's dignity as something that has a 'fitting' end, even when that end comes about sooner than a less fitting one might.
In reply, reflection reveals that one way we honour the value of musical performances is to try to preserve them, for example, by recording them. Therefore, even if the case of honouring the worth of musical performances were precisely analogous to that of honouring the worth of persons, it would not follow that we fail to honour the worth of persons unless we treat them as having a fitting end that might significantly truncate how long they endure as persons. Preservation is also a mode of honouring.
Moreover, according to the Kantian view we are considering, honouring musical performances is not precisely analogous to honouring dignity. That is because the value of persons is of a different order than that of musical performances. Persons have unconditional, incomparable worth; musical performances have mere price, according to the view. This difference matters. For example, we would not fail to honour the worth of musical performances, even great ones, if we cancelled one simply to ensure that two others would take place, reasoning that two great performances are more valuable than one. But we would fail to honour the worth of persons if we killed one simply in order to ensure that two others would remain alive, reasoning that two persons have more value than one. This action would fail to treat the worth of persons as incomparable.
My point in bringing up the honouring of things of special worth such as paintings and Wollemi pines is not to suggest that they have the same value as persons. It is, rather, to emphasize that honouring beings of special worth often involves trying to preserve them. That mode of honouring seems particularly appropriate when the value is as lofty as that of persons, according to the Kantian view. There is significant reason to believe that preserving rational nature would not amount to dishonouring it and that Julia is not required to refrain from extending her life as a person.
A couple of cases, the second of which is directly parallel to that of Julia, will show that we also have good reason to believe that Julia's killing herself would fail to respect the worth of her personhood and so be morally wrong, according to Kant. Before examining the first case, let us recall that, according to Velleman, we are sometimes permitted or obligated to destroy objects of dignity, including corpses, if they would otherwise decay in ways that would offend against the worth they once had. It seems reasonable to hold that the disposition of a corpse is sometimes an affront to the worth the individual had as a person. Judgement regarding when it is seems to vary according to time and place. Zoroastrians deem burial as well as cremation to be polluting to the earth. Yet the Zoroastrian practice of exposing a body so that vultures will consume it would to some constitute an affront to the dignity of the person who died. Those who have that view might hold that the prolonged exposure of a dead human body and the sights and smells associated with its decay suggest falsely that the deceased person was a mere animal, devoid of special worth.
In the first case, suppose you have a choice. If you refrain from killing yourself, you will have from one to three additional years, with your rational nature intact, after which you will die and the disposition of your corpse (e.g. as a result of its being neglected and not buried properly) will be an affront to the dignity you once possessed. Or you can kill yourself now, thereby preventing any such affront from occurring. If you do not kill yourself now, you will be unable to do so (e.g. because you will lack the means), you reasonably believe. There are no other salient effectsfor example, the fate of your corpse would not trigger death-precipitating shock and outrage in anyone.
We are supposing that the supreme principle of morality commands you to respect the dignity of rational nature. Destroying a being of special worth is not typically a way of honouring it, of course. Would this case be an exception? It seems not. Committing suicide would amount to your forgoing one to three years of life as a person for the sake of avoiding an affront to your dignity that would pose no threat to the existence of anyone's personhood and not at all diminish the worth your personhood possessed while it existed. Now suppose, in the second case, that you must choose between the following options, as does Julia. The first is to refrain from killing yourself. If you do this, you will have from one to three additional years with your rational nature intact, after which you will become severely demented and treated in a way that is an affront to the dignity you once possessed. Your second option is to kill yourself now, thereby preventing any such affront from occurring. Again, if you do not kill yourself now, you will be unable to do so, you reasonably believe. Moreover, there are no other salient effectsfor example, your living with severe dementia will not trigger homicidal or suicidal behaviour in other persons. For Kant, this case is essentially the same as the one, just discussed, which invokes an affront to (lost) dignity through the treatment of a corpse. As noted above, Kant divides beings into persons and things, with the former having dignity and the latter having value merely as means. In both cases, committing suicide would amount to your forgoing one to three years of life as a person for the sake of avoiding an affront to your dignity that would pose no threat to the existence of anyone's personhood and not at all diminish the worth your personhood possessed while it existed. If it would be a failure to respect the dignity of persons and thus wrong for the person in the first case to forgo one to three years of life as a person to avoid an affront to her corpse, then it would also be a failure to respect the dignity of persons and thus wrong for the person in the second case to forgo one to three years of life as a person to avoid an affront to the severely demented individual who succeeds her, according to Kant. In my view, on a charitable interpretation, Kant would join many of us in holding that it would indeed be a failure to respect one's own dignity to forgo one to three years of life as a person to avoid an insult to one's dignity that occurs through the treatment of one's corpse.
As I mentioned above, some of us reject Kant's division of beings into persons and things, insisting that beings devoid of personhood, such as some severely demented yet sentient human beings, have intrinsic wortha worth not reducible to their service to the ends of persons. But this rejection does not entail a rejection of the idea that a person would be acting wrongly in choosing to sacrifice significant time as a person in order to prevent an affront to her dignity that would occur in connection to her existence in severe dementia. It is possible to hold both that some individuals with severe dementia have intrinsic worth and that persons have a higher, incomparable worth, respect for which would, in the second case described above, require refraining from committing suicide. Maintaining in existence a being with dignity, one might reason, takes moral precedence over preventing an affront to the value of a being of lesser worth.
Against the background of assuming the Formula of Humanity, as interpreted, to be the supreme principle of morality, our brief reflections have revealed two points. First, since Julia's refraining from killing herself would not involve a failure on her part to treat her rational nature as having unconditional, incomparable worth, it would be morally permissible. Contrary to Cooley, Julia is not morally required to commit suicide. Second, if Julia committed suicide to avoid an affront to her dignity occurring during her post-personhood existence, she would be failing to demonstrate sufficient respect for the worth of her personhood, and so would be acting wrongly.
Let us return to Cooley's purportedly jointly sufficient conditions for those who know they will become demented to commit suicide. Julia obviously fulfils all three. She has moral agency; she faces a choice between hastening her death or continuing to live devoid of dignity; and she is capable of hastening her death from duty: a good motive. Despite her fulfilling these conditions, Julia does not have a moral obligation to terminate her life. Julia, we have been assuming, has good grounds to believe that her post-personhood existence would be demeaning to her dignity. Yet her refraining from terminating it would not fail to respect her worth as a person. Indeed, her terminating her life to avoid such degradation would fail to respect this worth. Of course, the case of Julia illustrates a general point. Cooley has failed to identify jointly sufficient conditions, licensed by a Kantian notion of dignity, for persons expected eventually to lose their personhood to dementia to be morally required or even morally permitted to terminate their lives.

Conclusion
Velleman may be correct that one is sometimes permitted or obligated to destroy some 'objects of dignity', corpses, for example, if they would otherwise deteriorate in ways that would offend against that value. However, according to our interpretation of Kant's notion of the dignity of persons (which is an interpretation Velleman himself seems to employ), a person in an early stage of Alzheimer's would be acting wrongly in hastening his death to avoid a post-personhood affront to his dignity. Moreover, we can now see, a physician helping the person to hasten it so that he avoids such an affront would be acting wrongly. Both would be failing to honour the dignity of a person.
At the article's outset, I mentioned the possibility of legally permissible advance directives permitting physicians to terminate the lives of patients who have become incompetent. Let me close with some brief remarks on the morality, from a Kantian perspective, of such directives. The remarks aim to raise questions and sketch preliminary positions, rather than to defend theses.
Suppose that an undoubtedly competent patient with Mild Cognitive Impairment specifies that he is to receive a lethal injection if the following conditions are fulfilled: he has been diagnosed with advanced Alzheimer's, is incontinent, cannot speak, has difficulty eating and manifests no awareness of his recent experience. The patient wants to die under these circumstances because he believes that a final chapter like that would diminish the goodness of his life as a whole. To keep attention on the moral matters at stake, suppose further that the patient's advance directive is legal. If the conditions specified in the directive are fulfilled, then, since the patient lacks Kantian personhood, a physician's giving him a lethal injection would not disrespect any Kantian dignity he currently possesses. Moreover, many of us believe that we can act wrongly vis-à-vis a person who is deceased. 9 It can be disrespectful of the person who once was to fail to dispose of his remains as we have promised, for example. Similarly, it seems, it can be disrespectful of the person who once was to fail to terminate his post-personhood life. Suppose that, as the patient's doctor knows, the conditions specified in the (legal) advance euthanasia directive are realized, and the doctor both promised the patient to abide by this directive and is able to do so. From the Kantian perspective we have been taking, it seems that it would be disrespectful of the dignity the patient once possessed for the physician to refrain from administering the lethal injection. Other things being equal, it seems that to refrain would be to act wrongly.
Yet let us imagine that the individual with advanced Alzheimer's appears content; he seems to enjoy watching television, sitting outdoors, and so forth, and he seldom gives any indication of being in pain. Some of us are attracted to the view that the patient's contentment gives the physician significant reason not to give him a lethal injection. As we noted, however, Kant seems to divide beings into persons and things, with the former having dignity and the latter mere price. Since the patient has lost his personhood, he would count as a thing, according to this classification. The positive value, if any, of keeping him in existence would be a function of its furthering the ends of persons or, perhaps, minimizing some bad effect on them (e.g. that of damaging the doctor's capacity to sympathize with her patients). If that is correct, then there would, it seems, be many cases where the doctor's honouring a promise to the person the patient once was, as she would do by giving him a lethal injection, would be morally required by the Formula of Humanity, as interpreted here, even when the patient seems content. 10 Such cases would include those in which the severely demented patient's staying alive would not further any person's ends, and in which a doctor's honouring her promise would not diminish anyone's capacity for sympathy.
But suppose we reject the idea that only Kantian persons have a value other than that of mere things. Breaking with orthodox Kantianism, suppose we hold, for example, that although severely demented human beings lack incomparable worth, their living pleasurable lives has value in itself, value not exhausted by its serving as means to persons' ends. Our discussion thus far has proceeded on the assumption that a person has a legitimate claim on how his post-personhood existence unfolds. For example, an individual has a moral prerogative to designate the disposition of his ashes. But that assumption might seem particularly questionable if an individual, after losing personhood, leads a life with intrinsically valuable experiences. Is it morally permissible for the person who preceded him to truncate such a life? Does the patient with Mild Cognitive Impairment who signed the advance directive act rightly in willing the death of an individual when the individual's experiences would have value in themselves? Does the answer to this question depend in part on whether the severely demented individual has the same personal identity as the person who preceded him? If the patient with Mild Cognitive Impairment would be acting wrongly in willing the death of the severely demented individual in question, would his doctor be morally permitted to give this individual a lethal injection? These questions are important, in my view, but they go beyond the scope of our inquiry.
If the main argument of this article is sound, then the Formula of Humanity, on one well-entrenched interpretation, implies that a certain kind of non-self-interested suicide is morally impermissible. The Formula of Humanity deems wrong an individual's killing himself and thereby significantly shortening his existence as a person to avoid post-personhood affronts to his dignity. But the article leaves open the possibility that advance euthanasia directives are consistent with Kantian moral principle.