The case
Fifteen years ago Mr R retired as a senior partner from a highly successful legal practice. Mr R was involved in high profile legal cases during his career. He was a well respected person who was known to be strong willed and forthright in his arguments. After witnessing both his parents develop dementia, he was horrified by their illness and confided to those close to him: “I would rather be dead than be in this awful state”. In consultation with his doctor, he drafted an advance directive instructing medical staff not to take any measures to save his life if he were ever to become severely demented and lose capacity to refuse treatment for himself.
He remained active in the community and local politics throughout his retirement. However, people noticed that at times he rambled and was incoherent. Subsequently, he developed severe dementia and was unable to recall much about his professional or personal life. His previous forcefulness gave way to a gentle and agreeable person. While in hospital, he contracted a serious infection. The decision had to be made as to whether he should be treated for this. He was asked about it but did not understand the question. His family gave the medical staff his advance directive. There was no consensus. Some of the family and staff supported the advance directive. Others said that as he was a different person then, and, as he seems contented with his life now, he should be treated for the infection.

Key issues to be addressed:

  1. Identify the ethical issues involved in this case. Think broadly about personal identity in the context of dementia.
  2. Is Mr R the same person who made the advance directive?
  3. Is the issue of personal identity relevant to what should be done?
  4. How would you address the ethical issues identified? Specifically, what ethical criteria should be used in determining whether or not to treat Mr R?
  5. Consider weaknesses in your position and address potential challenges to your arguments.

Submission guidelines
Please construct a lucid, structured and well-presented discourse for the issues raised by this case. Please ensure that you have addressed all the questions highlighted and discuss these ethical issues academically, making sure to reference when necessary.

Your paper should not exceed 2,000 words.

Your essay will be evaluated on three major criteria:

  1. Ability to identify the ethical issues raised by the case.
  2. Fluency of your arguments.
  3. Academic quality with regard to depth of research, appropriateness of references and quality of sources.

Good luck!

This is the fourth instalment of the RCSIsmj Ethics Challenge. The editorial staff would like to congratulate Simon Clifford on his winning essay in the 2011/2012 Ethics Challenge. Please see here for his submission.

We invite all students to submit an essay discussing the ethical questions raised in the case study presented. Medical ethics is an essential aspect of the medical curriculum and we hope to encourage RCSI students to think critically about ethical situations that arise during their education and subsequent careers.

All essays will be reviewed by a faculty panel of experts and the winning essay will be published in the 2013 print edition of the RCSIsmj.

The deadline for submission of entries will be the same as the general submission deadline for the 2013 edition of the RCSIsmj. Please visit our website at for specific dates. Please contact us at for any questions or concerns.