In my classes, I like making students ponder the pros and cons of knowledge. We talk about Plato’s parable, in which people imprisoned in a cave mistake shadows projected on a wall for reality. I ask, “Assuming we’re in the cave, how many of you want to escape?” Most students dutifully raise their hands, because of course truth is good and ignorance is bad. Then I ask, “What if the cave is pleasant and the outside world painful?” That usually stumps them.
Many people face an agonizing, real-life version of this dilemma, according to a recent New Yorker article about treatment of people with dementia. Journalist Larissa MacFarquhar notes that decades ago many nursing homes practiced “reality orientation,” in which patients were constantly reminded of their circumstances, no matter how upsetting. “The core of the program,” MacFarquhar writes, “was not giving up hope that even the most bewildered, isolated patient could, with enough training, return to the world.”
Many caregivers have abandoned this program as impractical and even cruel. They play along with and even encourage the delusions of demented patients, because this strategy makes them calmer and happier. Some nursing homes are designed to resemble cute American towns with fake storefronts and bus stops. “When a person asks to go home,” MacFarquhar writes, “an aide takes them to the bus stop, where they sit and wait for a bus that never comes.” Eventually they forget why they’re waiting. MacFarquhar adds:
“To lie is to violate the respect that one person owes another; but lying to a person with dementia can protect them from awful truths that they have no power to alter. If a woman asks for her dead husband, having forgotten that he is dead, should you tell her the truth and cause her terrible grief, knowing that this fresh bereavement will likely repeat itself, over and over, day after day? Or should you just tell her that he is at the office?”
Critics denounce these practices as degrading. They point out that patients might be distressed if they realize, in lucid moments, that they are being deceived. “Even lying for benevolent reasons,” MacFarquhar acknowledges, “risks a coercive kind of paternalism, and can be corrupting, like any other unchecked exercise of power.”
Advanced directives represent a solution to this dilemma. While still lucid, you can specify how you want to be treated if you succumb to dementia. “Someone who most values happiness,” MacFarquhar explains, “however simple, might choose lies and medicine; someone who feels that life with late-stage dementia, without a certain degree of awareness, is not worth living might choose truth and death.”
But advanced directives pose problems too. What if someone who has chosen truth and death seems to enjoy life with dementia? “Should his directive be respected,” MacFarquhar asks, “ending his life?
So how would I choose? Pleasant delusion is tempting. After all, many non-demented people engage in denial, repression, and self-deception. That is, they exclude certain things from their minds. Lately I’ve been trying to avoid political news, because it makes me feel crappy and there’s little I can do about it.
Moreover, those who insist they would always choose reality over illusion assume reality is knowable. But what if it isn’t? What if ultimate reality is unknowable, as certain philosophers and mystics suggest? What if life is but a dream, and everything is an illusion? What if, when break your shackles and escape the cave, you just end up in another cave? In that case, wouldn’t you be a fool for choosing a miserable illusion over a pleasant one?
I can’t bear the thought of loved ones suffering. If choosing for them, I’d probably go with pleasant delusion. But in spite of my recent aversion to political news, I care about truth, even if I’m not sure what it is. So I like to think I’d choose reality for myself — even if it’s painful, and even if I’m not sure it’s real.
John Horgan directs the Center for Science Writings, which is part of the College of Arts & Letters. This column is adapted from one published on his Scientific American blog, “Cross-check.”
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