In medical ethics, there is a well‐established debate about the authority of advance directives over people living with dementia, a dispute often cast as a clash between two principles: respecting autonomy and beneficence toward patients. In this article, I argue that there need be only one principle in substitute decision‐making: determining authenticity. This principle favors a substituted judgment standard in all cases and instructs decision‐makers to determine what the patient would authentically prefer to happen—based not merely on the patient’s decisions but also on their present settled dispositions. Adhering to this principle entails that, in a significant range of cases, an advance directive can (and indeed ought to) be overruled.

Across care settings, the practice of lying to or withholding the truth from people living with dementia is common, yet it is objected to by many. Contrary to this common discomfort, I have argued in previous work that respecting members of this group as moral equals sometimes requires deceiving them. In this paper, I test my proposed practice against complex, controversial cases, demonstrating both its theoretical strength and its practical value for those working in social care.

Many caregivers feel that they need to lie or withhold the truth from people living with dementia, but worry that, in doing so, they are violating a duty to tell the truth. In this article, I argue that withholding the truth from and, in limited circumstances, lying to people living with dementia is not only morally permissible, but morally required by a more general requirement that we treat each other as persons worthy of respect. I do so through an analysis of the groundings of the duty to tell the truth, and a critical reflection on its cognitively ableist construction.

This article takes as its starting point the moral requirement to include persons with serious cognitive impairments in democratic decision-making. That said, including such persons poses particular practical challenges to effective democratic participation. Nussbaum has set out the most extensive proposals for inclusion based on a model of guardianship, but we find they fall short due to not suitably respecting and facilitating the subjective decisionmaking of impaired persons. Instead, we argue for a model of co-constitution, whereby aides work within a supported decision-making paradigm to arrive at political choices in collaboration with impaired persons. To flesh out this model, we propose collaboration be based on three ideal types of interactionexpert, Socratic, and deliberativedesigned to accommodate differing degrees and types of cognitive impairments. We further argue that the aide should have a relationship of detached professionalism with the impaired person and therefore should not be the person's carer. Finally, we conclude that this separation be combined with transparent and regular invigilation of the aide's decision-making process to best safeguard the process from abuse or error.

Carers often interfere with the choices of people living with dementia. On neorepublican and (most) relational egalitarian views, interference can be justified if it tracks a person's interests: if it does not lead to a relationship of domination. However, the kind of environment-shaping interventions carers often pursue would be considered infantilising or objectionably paternalistic in other cases. In this paper, I defend this indirect approach and argue that it offers the best prospects of dementia care without domination.