Autonomy, Risk and Decision-Making in Dementia: Reconciling Personal Freedom, Capacity and Protection

Decision-making in dementia presents ethical, clinical, legal and social challenges, particularly where personal autonomy, perceived risk and protective intervention come into conflict. A diagnosis of dementia is sometimes treated as evidence of diminished decision-making capacity, potentially contributing to unnecessary restrictions on choice, independence and self-determination. Yet an unwise decision, refusal of assistance, disagreement with family members or professionals, and impaired capacity are distinct circumstances and should not be treated as interchangeable. This conceptual paper examines the relationship between autonomy, decision-making capacity, dignity of risk and protection in dementia. It draws on interdisciplinary scholarship, international human rights principles, Australian aged-care policy and relevant legal frameworks, with Western Australia used as a jurisdictional example. It considers the importance of presuming capacity, providing decision-making support, recognising changing preferences, and ensuring that protective and substitute decision-making arrangements are legally authorised, proportionate and appropriately safeguarded. The paper develops a preliminary framework for reconciling autonomy and protection. It argues that dementia care should preserve individual agency, identity and participation wherever possible, while responding appropriately to serious harm, coercion and exploitation. The framework is intended to inform clinical practice, aged-care policy, legal decision-making and future empirical research.