C. S. Lewis poses a nasty dilemma for the Narnian children in his book, The Silver Chair. Jill Pole (a newcomer to Narnia) and Eustace Scrubb (from The Voyage of the Dawn Treader) come across the prince just before the hour when, every day, he is released from his enchantment. During that hour of freedom, he is able to tell the truth.

In the fictional setting Lewis has provided, we can say that Rilian is his true self (I*)during this brief time. He tells the children that he is under an enchantment and that all the things he has told them before are false. Furthermore, all the things he will tell them when this hour has passed are also false. Only during this time can he be believed.

Keeping the dilemma in mind and changing settings, let’s look at a person’s right to specify what medical procedures will and will not be performed on him as he nears death. The Prince Rilian scenario has three time periods. He has before (when he is enchanted) during (when he is free to tell the truth) and after (when he is, again enchanted.) The patient I have in mind is suffering a progressive dementia. The more severe depths of the dementia are his “enchantment.” But there is a time, before the enchantment, when he is free to assess his preferences and to say clearly what he wants.

The reduction of the three periods Prince Rilian has to the two of the demented patient makes all kinds of trouble for us. For the impaired patient, there is only NOW and LATER. Now, I know who I am and what I* want. Then, I will still want something, but it will not be connected to who I* am right now; to the continuing self who has lived a life and has reflected on it.

OK, I cheated a little bit. I invented the I* (with the asterisk) to mean the continuing person, the essential person. In dementia, that is what goes away or, more exactly, I* don’t have unimpaired access to that person’s mind. Functionally, I* is Prince Rilian during the hour he is freed from the spell and is free to be himself. And “I” (without the asterisk) is Prince Rilian under the spell. In the example, it is the person who is under the “spell” of dementia.

I have heard of a court ruling—I haven’t bothered to find out if it actually occurred—in which the court accepted the decision of a patient at an earlier time to be binding on the patient at a later time. The decision and intention of the I* patient is accepted over the later statements of the person who no longer has regular access to the I* person. This later, impaired, person has “intentions,” but they are momentary and they have no relationship to all the other things that make up his life.

I like that distinction. It is, of course, clearer in the case of Prince Rilian. Once we accept the premise—he is under an enchantment except for this one hour—we know to accept the words of Rilian during this hour and to resist what “Prince Rilian” says during the other times. It is clear because there is a will behind the enchantment and it is an evil will. We know that when “Prince Rilian” speaks when he is under the enchantment he is expressing the views of the evil witch who cast the spell.

The patient is “under the spell” of distorted brain function. We know that the patient does not have access to the I* as he once did. We reject the idea that the spell he is under has been “cast” by anyone, but that does not mean it is not there and functioning. It means only that it has not been “cast.”

This brings us to the cusp of a dilemma and that is where I want to leave us for today. Dementia offers us a kind of Prince Rilian situation in which I am Prince Rilian and I want to be believed sometimes and not other times. I need to say ahead of time when the “accepted times”—I am right on the edge of calling them “canonical times”—will be. Then I need to empower others to refuse to accept what I say (the I without the asterisk) at other times, no matter what it is.

Do I really want that? Yes, I think I do.