Dementia – Mind, Meaning and the Person. Edited by J. C. Hughes, S.J. Louw & S. R. Sabat. Oxford University Press. 2006. 326 pp. £29.95 (pb). ISBN 0 198566158

Wonder… is the first principle which prompts mankind to the study of philosophy

(Adam Smith,1795)

The best College meeting I have attended was the joint conference between the Philosophy Special Interest Group and the Faculty of Old Age Psychiatry in New-castle, in the autumn of 2002. I am not a philosopher but the ‘wonder’ generated by this meeting has remained with me. I was a naïve but entirely interested reader of Dementia – Mind, Meaning and the Person, pleased that contributors to the conference, clinicians and philosophers, had written chapters.

Inevitably in a multi-author book some chapters are more appealing and accessible than others. Being an orderly person I began at the beginning, but chapter 1 is by far the most difficult for the philosophy initiate – it does introduce the feast to come but as a hard-going menu in a foreign language, not as an aperitif. I returned to the first chapter having finished the book and at that point found it more digestible.

The book covers not only the philosophical but also social, spiritual, ethical and practical perspectives and the negative, soul-destroying attitudes about dementia in modern society. Dementia, with its progressive inevitable deterioration in memory, language and skills, causes us to consider the meaning of personhood and identity. Hughes had previously enlarged on the Locke–Hume reductive view that a person is no more than connected mental states, seeing the patient as a ‘situated-embodied-agent’. The person with dementia has to be understood in terms of relationships, not because that is all that is left to them but because that is characteristic of all our lives. ‘He is not the man I married, Doctor’, is commonly heard and needs to be taken seriously. In his quiddity he is the same, not a vegetable nor in second childhood, but the same man with a dementing illness. However, from a social constructionist viewpoint the usual mutual task of holding and preserving identity is now a solitary and heartbreaking one for the partner. There is a need to guard against using a purely social constructivist approach in order not to deny the patient's personal human agency and meaningful intersubjectivity. To be semiotic requires some capacity to express genuine intentions and meanings. We need to search for rational patterns which reveal the mind at work. Dementia threatens the process of meaning-making, the hermeneutics of life.

The book only occasionally entertains Doctor Scholasticus with angels dancing on pinheads. Ordinary clinicians need to suspend criticism of the way some philosophical arguments are constructed or supposed syntactical sentences put into the mouth of someone with severe dementia.

The chapter for all in old age psychiatry entitled ‘Respectare: moral respect for the lives of the deeply forgetful’ looks again and more carefully at the experience of persons with dementia. ‘Hypercognitive’ snobbery is moral blindness, an elitism which asserts that some are less worthy of moral concern than others, ‘them’ and ‘us’. The book affirms a common humanity. Our job as staff is to preserve identity.

This is a good book. It will not change base metal into gold but via a mosaic of ideas introduces a way of thinking. Ostensibly it is about dementia, actually it is about what it is to be human. The view that the person may survive into severe dementia is now also receiving attention from psychodynamic psychotherapists who recognise that even into the late stages of the disease the ability to forge a relationship is retained. The only way to come anywhere near an understanding of what it may feel like to have a dementia is by close and empathic listening, fusing the horizons of physician and patient even when speech is failing. We underestimate the complexity of the inner life of the patient with dementia. Language is not the whole of the emotional experience. Personhood is retained and to this we should relate.