(2021). Truthfulness and the person living with dementia: Embedded intentions, speech acts and conforming to the reality. Bioethics, 35(

Highly reputable bodies have said that lying is to be avoided when speaking with people living with dementia, unless it cannot be. And yet, the evidence is that many professionals looking after people who live with dementia have been lying to them. I wish to consider an underlying philosophical justification for the moral position that allows lying under some circumstances whilst still condemning it generally. It can seem difficult to ignore the immorality of lying, but thinkers have developed arguments to get around the absolute prohibition. I shall argue that in concrete circum-stances the object and the intended end of an action are not as clearly distinct as has been presumed. Further, looking at how language functions allows us to appeal to speech acts and to see the illocutionary force of a statement as way to broaden its purview. We need not think that the only options are between lying and not lying; there is also the possibility, in exigent circumstances, of ‘conforming to the reality’, which would allow a more nuanced account of moral acts, where the intentional nature of the act is no longer to lie. There are, thus, extreme concrete circumstances where not to speak the truth may be excusable, even if regrettable.

similar conclusions. 2Both reports, therefore, suggested that if at all possible you should tell the truth; but you should minimize distress by lying or by some other deception if (and only if) necessary to avoid distress.
In this paper, I wish to sketch an underlying justification for this moral stance.My argument will run as follows: 1.1.Lying to people with dementia is wrong and is mostly unnecessary.
1.2.However, there are circumstances where lying is excused and tolerated.(For the sake of clarity, I should say here that there is obviously a variety of ways in which it is possible to be untruthful, e.g. by not saying something, but my focus is specifically on lying rather than other forms of deception.)2. A variety of ways around the absolute prohibition of lying have been sought.Yet, inasmuch as the prohibition depends upon the act of lying having an overriding immoral object, namely to deceive or be untruthful, it can seem difficult to ignore.
3.1.However, first, in concrete circumstances the object and the intended end of an action are not as clearly distinct as is presumed, as shown by (a) a particular reading of Aquinas and (b)   considering the intentional nature of actions.
3.2.Secondly, looking at how language functions allows us to appeal to speech acts and to see the illocutionary force of a statement as a means to broaden its purview.
4. In addition, we need not think that the only options are lying or not lying; there is also the possibility of 'conforming to the reality', as long as this is only pursued in exigent circumstances.4.1.'Conforming to the reality' allows a more nuanced account of moral acts, where the intentional nature of the act is no longer deception.
4.2.And the speech act, when 'conforming to the reality', has a different illocutionary force given the different circumstances. 5. Hence, there are concrete circumstances where not to speak the truth may be excusable, even if ceteris paribus it should only be used as an extreme option.

| Lying is wrong but is excused
The prohibition of lying has deep cultural roots.According to Aristotle, 'falsehood is in itself mean and culpable, and the truth noble and worthy of praise'. 3Whether it be a matter of religious teaching, or of giving testimony under oath in a court of law or to a government committee, or of statements to a legislature (think of the consequences of a UK minister of the Crown misleading Parliament), or of claimed academic work (where plagiarism or falsified research can spell ruin to a career), dishonesty-specifically, telling lies-is condemned and can be harshly sanctioned.Lying is regarded as anything from a criminal act to a gross subversion of personal or institutional integrity.
On the one hand, therefore, in a variety of situations there seems to be an accepted absolute prohibition of lying, even if this seems to be whittled away by the behaviour of some politicians and others.On the other hand, it seems to be accepted that we all lie from time to time and that small or 'white' lies can be tolerated and might be for the best.The inevitability and permissibility of lying to people living with dementia seem to be accepted and tolerated.
In any case, the empirical evidence is that lies are told quite commonly to people living with dementia.James and colleagues carried out a survey of nurses and care staff in UK settings looking after people living with dementia and found that 96% had resorted to lies. 4 In a survey of 76 psychiatrists in north-east England, albeit with only a 38% response rate, 69% had resorted to lying in looking after someone who lacked capacity if it were thought to be in the person's best interests and 66% had sanctioned the use of lies. 5In a study in Italy, roughly 90% of nurses involved in dementia care found it acceptable to use lies, especially 'to prevent or reduce aggressive behaviors'. 6Further, the use of (so-called) therapeutic lies seems legitimized by a study that shows that some people living with dementia themselves would agree to lies if in the person's best interests. 7ch is the support for lying to people with dementia under certain circumstances that, having accepted such lies are sometimes necessary, the literature has moved on to consider how lies might practically be put into effect, especially where behaviour is thought to be challenging. 8At the same time, the language has moved from talk of 'lying' to talk of 'untruths', which in part signals that some deceit is not stated (whereas, according to Bok's seminal work, a lie is 'any intentionally deceptive message which is stated' 9 ), but which might also be seen as a way to side-step the inclination to regard lying as wrong; indeed, in related literature the talk is of 'therapeutic untruths' and 'non-therapeutic lying'. 10 My concern is that lying to people living with dementia has become too easy and too easy to justify.The reality should be the other way around: that mostly carers (of whatever kind) tell the truth and only exceptionally deceive or lie.To be clear, my aim is to gesture at a justification for not telling the truth under particular extreme circumstances, where under these circumstances we do not have to think in terms of lying as such.Though informed by clinical practice, this is a philosophical discussion.How the conclusions of the discussion are put into effect is another matter.But the tendency to resort to lies too readily is to be regretted, not encouraged.

| The ubiquitous case
There is a paradigm case that is used to justify lying.It is that of the woman living with a diagnosis of dementia who has a terribly distressed reaction when told of her husband's death.She subsequently forgets that he has died.When told again that he has died she undergoes the same very distressed reaction.Her repeated marked distress leads to the very reasonable thought that perhaps it would be kinder not to upset her and to tell her a lie, e.g. that he will be in later, in the knowledge that she will forget this but will not then be distressed, which is seen as a better and more ethical outcome.
I have to say that, in the course of 25 years of practice in the field of dementia, I do not recall such a case exactly.Of course, I do recall distressing cases where a person living with dementia had to be told repeatedly that someone they loved had died.Naturally enough, carers would dissemble, avoid and even lie.But what I do not remember is a case where such tactics had to be pursued as a policy over a long period of time.I do remember three difficult cases very well (I have changed some details below for the sake of confidentiality), which could be taken as offering different paradigms.

| Case 1: the benefit of truth-telling
A man living with a moderate to severe dementia was persuaded by his family to go into a care home because his wife (his main carer) was ill.She was admitted to hospital and after about a week she died.The family were adamant that the husband should not be told this news on the grounds that he would forget to ask about his wife.
However, he became increasingly agitated and then positively violent enough to warrant the use of psychotropic medication.The next move would have been to detain him under compulsory powers in a psychiatric unit for assessment.In his best interests, his sons persisted in saying that staff were not to tell their father of their mother's death.However, a member of staff went ahead and explained to the resident that sadly his wife had died.He was very upset, but his agitation dissipated.His sons were initially furious, but they were amazed to see his improvement and graciously accepted that telling the truth was the right course of action.They were able to arrange a small memorial ceremony, which their father attended.He came off psychotropic medication.This would be a paradigm case of the benefit and justice of telling the truth.

| Case 2: different ways of grieving
A lady living with advanced dementia was admitted to a home.Her very attentive husband visited every day.But he suddenly fell ill and died.Their son was most concerned about whether and how to tell his mother of the death.He was given support and decided to tell her.After he had done so she was fine and any subsequent allusions to her husband or to his death were simply ignored.She would happily look at photograph albums in which there were pictures of him, but made no comment and showed no adverse reactions.This is a different paradigm, partly showing that telling the truth can be harder for those who have to do so than for the person hearing the information.We do not know whether the lady simply did not recall the news that her husband had died and had forgotten him; or whether her reaction was a form of denial as part of a defence mechanism.Either way, the paradigm teaches us that there is no need to batter someone's defences.We grieve, even in dementia, in different ways.

| Case 3: extended grief
In this case, which was very close to the ubiquitous paradigm, a lady living with dementia in a care home had suffered the loss of both her husband and her son in quick succession.Her daughter continued to visit.The mother had a dense amnesia affecting recall.Whenever she was told of the deaths of her husband and son, she would become very upset as if being told for the first time.It was very difficult for all concerned, but the agreed approach was to be straightforward with her.It could be extremely uncomfortable and upsetting to tell her the truth.But she was grateful and it became easier over time.
Having seen her for several years, during which her cognitive impairment generally was worsening, the last time I saw her was with a social worker.When the lady mentioned her husband she seemed to sense something was wrong and said, 'Oh no, wait, something happened to him'.She then spontaneously recalled his death and the death of her son.She was sad, but not overwhelmed.
She is a paradigm of someone who was able to grieve successfully, albeit in an extended manner, despite her worsening cognitive function.It would have been easier to lie to her, but this seems like a paradigm case where to do so would have undermined her standing as a person of dignity, worthy of respect.

| Summary
These three paradigms, unlike the ubiquitous paradigm, suggest that honesty is the best policy: lying to people with is mostly wrong and unnecessary.Yet, there are circumstances where lies can be excused and tolerated.For example, I recall an instance where, but for the use of a lie, a man would certainly have had to be given an intramuscular injection of a psychotropic drug.The lie seemed preferable.

| The absolute prohibition
The aim of this section is to present some definitions of lying (very briefly) and then to give examples of those who have favoured an absolute prohibition of lying, with some of their reasoning.Although I move on to look at suggested exceptions to the prohibition, in the first place it seems important to see the strength of the reasoning in support of an absolute prohibition.
A sustained account and defence of the absolute prohibition of lying from a Christian perspective is provided by Christopher Tollefsen, according to whom, '…the absolute view holds… that false assertion is always wrong, and thus should always be ruled out as a possible object of choice'. 11Later he says: 'Lying always involves intentional damage to the goods of personal integrity and community, and it is always incompatible with a virtuous orientation toward the goods of truth and religion'. 12llefsen puts forward a raft of cogent arguments in favour of absolutism.One such argument draws heavily on Christian, and in particular Catholic, tradition, '… that there are acts which ought never to be chosen…' and that '… judging acts only from the standpoint of their intention, or the good sought overall, is radically misguided'. 13e cogency of many of his arguments encourages me to think that departing from the truth should be exceptional.One of the arguments in favour of allowing veracity to slip, however, concerns this view that the object of a human act can determine it to be evil and, therefore, absolutely to be avoided.To this I shall return.
Having already in passing given Bok's definition of lying ('any intentionally deceptive message which is stated' 14 ), we can find very similar definitions elsewhere; for example, Bernard Williams takes 'a lie to be an assertion, the content of which the speaker believes to be false, which is made with the intention to deceive the hearer with respect to that content'. 15cordingly, a lie involves a statement made with the intention to deceive someone.In large measure, it is the definition of a lie that shows why it is so universally considered to be morally wrong or bad, even if it allows exceptions: 'the wrongfulness of lying is… built into the definition of the term'. 16That is, lying can be seen as a thick con-cept.If I say that I've told a lie, generally speaking it will be understood that I've done something reprehensible.
In discussing lying in the context of people living with dementia, it seems right to hang onto this fundamental point.As Bok states: …I believe that we must at the very least accept as an initial premise Aristotle's view that lying is 'mean and culpable' and that truthful statements are preferable to lies in the absence of special considerations.This premise gives an initial negative weight to lies.It holds that they are not neutral from the point of view of our choices; that lying requires explanation, whereas truth ordinarily does not. 17 early and often cited argument against lying comes from On the law of war and peace by Hugo Grotius (1583-1645), who stated that a lie involves: … a conflict with the existing and continuing right of him to whom the speech or sign is addressed… [and]   that right is nothing else than the liberty of judgement which, as if by some tacit agreement, men who speak are understood to owe to those with whom they converse. 18very similar argument, in effect that social discourse and society itself depend on people being able to trust what others say to them, can be found in Immanuel Kant (1724-1804), who saw truthfulness as an 'unconditional duty'. 19In what can be regarded, as far as absolutism and lying are concerned, as a locus classicus Kant writes: … truthfulness is a duty that must be regarded as the basis of all duties founded on contract, and the laws of such duties would be rendered uncertain and useless if even the slightest exception to them were admitted.
To be truthful (honest) in all declarations is, therefore, a sacred and unconditionally commanding law of reason that admits of no expediency whatsoever. 20 lie is to offend against the foundations of what is right: 'For a lie always harms another; if not some other human being, then it nevertheless does harm to humanity in general, inasmuch as it vitiates the very source of right'.Since man is by nature a social being, there is a natural indebtedness of one person to another in regard to those things without which life in society could not be maintained.People could not live with one another were there not a mutual trust that they were being truthful to one another. 22ter he was to state: 'it is clear that lying is directly … contrary to the virtue of truth'. 23 more needs to be said to make the point that lying has been condemned for many centuries in Western culture, as it has elsewhere.Instead, I wish to look briefly at some of the exceptions that have been proposed to the absolute prohibition of lying.

| Exceptions to the prohibition
As we have seen, according to Grotius, lying is always wrong.But he held it is not possible to lie to children or the insane (sic): 'since infants and insane persons do not have liberty of judgement'. 24Hence, it is not possible to infringe a person's freedom to judge matters if they lack the ability to judge properly in the first place, as might be the case with people who have impaired decision-making capacity because of dementia.Furthermore, Grotius held that beneficent lies can be tolerated: … whenever it is certain that he to whom the conversation is addressed will not be annoyed at the infringement of his liberty in judging, or rather will be grateful therefore, because of some advantage which will follow, in this case also a falsehood in the strict sense, that is a harmful falsehood, is not perpetrated. 25 this basis, he was inclined to allow lies for medical reasons, saying that a person does not lie when she 'comforts a sick friend by persuading him of what is not true'. 26milar thoughts have been expressed in modern times.In holding that lying always involves free communication between people who are fully responsible and rational, Donagan felt it would not be possible to lie to 'children, madmen, or those whose minds have been impaired by age or illness', since they are not fully responsible and rational. 27llefsen gives an account of the thought of John Cassian (roughly 360-435 AD), who is cited as an authority for the belief that 'a physician may, and sometimes must, lie to his patients'. 28Tollefsen summarizes three ideas to be found in Cassian: '… that lying can only be permitted for good, and not evil; that it can only be permitted of necessity; and that it must be regarded as "medicinal"'. 29llefsen moves on to consider the work of Dietrich Bonhoeffer   (1906-1945).Like Cassian, Bonhoeffer also talks about emergencies and necessity.Interestingly, he was acutely aware of the inevitability of guilt in situations where someone might feel impelled to lie.He recognized that lying is disordered, but cautioned against dealing in the abstract with problems to do with lying in a good cause.The abstract approach, …fails to bring about the authentic decision in which the whole man [sic], complete with his knowledge and his will, seeks and finds the good in the equivocal complexity of a historical situation solely through the venture of the deed. 30at emerges from these thinkers, again over a considerable timeframe, is that lies might be tolerated in emergencies, for therapeutic reasons, to help people who would find it difficult to make decisions for themselves.Moreover, Bonhoeffer alerts us to the 'equivocal complexity of a historical situation'.Let me park these ideas for a moment.

| Objects and embedded intentions
I shall now argue that in concrete circumstances the object and the intended end of an action are not as clearly distinct as was presumed in Tollefsen's arguments about traditional Catholic teaching. 31 We find in Aquinas the understanding of human moral actions split into three determinants: objects, intentions and circumstances (which includes consequences). 32Now, according to this understanding, the goodness of moral acts is mainly determined by the object of the act. 33(Whilst the objectum of an act is normally referred to as its 'object', the Dominican theologian Thomas Gilby   (1902-1975) refers instead to the 'objective' of an activity-as will be seen in the quotes from his translation and from his comments below.)The object or objective is, according to Gilby, '… what is 22 Aquinas, T. (2006).Summa theologiae.Volume 41 (2a2ae.101-122): Virtues of justice in aimed at, consciously or unconsciously, from the beginning; it is the "why" of activity and causally shapes its meaning'. 34However, in his appendix to the relevant passages, Gilby suggests that this abstract generalization about moral acts, where the object tells us what kind of act something is, is not enough when it comes to passing judgement on a particular act.We learn of the act's specific character from its object, but 'A more rounded judgment calls for appreciation of its circumstances, and some assessment of the intentions behind it'. 35ter, Gilby suggests that these determinants of the morality of acts are not 'sealed off from one another in real life': '… a single act is not to be pulled apart into three acts because it is scrutinized according to three mental categories.… when applied in the concrete they are over-lapping and their relations are criss-cross and complex.' 36 The object of an act is what it aims at (which tells us what kind of act it is), but intentions aim at ends.Gilby recognizes that ends and objects may become entwined: 'what starts as an end may finish up as an objective'. 37Thus we find Aquinas writing: '… the end intended has the force of an objective'. 38And, '… since the goodness of an act of will depends on its objective … it accordingly depends on the end intended'. 39uinas is clear that, 'You cannot call an act of will good if its cause be an evil intention'. 40Still, Davies comments that Aquinas, … denies that the goodness of an action can be determined by the goodness of its intention, even though he accepts that good intentions can be commended and that their goodness can, as it were, overflow into the action thereby preserving it in goodness insofar as it springs from a desire for what is objectively good. 41e relevance of these medieval distinctions should be clear.We may wish to say that lying is wrong objectively: its object is always deception, to move away from truthfulness.But the intention might be good and the circumstances (including the consequences) might make the lie praiseworthy (e.g.therapeutic).An alternative would be to say the object is not actually a deception; instead, the act is aiming at bringing about relief, at calming and so forth.
But just to highlight the complexity, deciding on my intention is not straightforward.I can fool myself.As the philosopher Elizabeth Anscombe (1919-2001) wrote: 'The idea that one can determine one's intentions by making … a little speech to oneself is obvious bosh'. 42She was more inclined to say 'what a man actually does' is important in understanding someone's intentions. 43Anscombe suggested that inten-tional actions are those 'to which a certain sense of the question "Why?" is given application'; 44 and she continued (albeit she recognized this was an insufficient statement): 'the sense is of course that in which the answer, if positive, gives a reason for acting'. 45One can also speak of the intentional nature of an action-the intention embodied in the action-which will need to make reference to all its surrounding circumstances.Again, the relevance should be clear: my intention (to calm the person), as shown by my action (telling a lie), aims at an end, also the object of the act, which can be a human good, inspired by the virtues of compassion and prudence, namely to bring solace and comfort to a person who otherwise would be in a miserable and desperate state.

| Speech acts
As we have seen, an aspect on which the definitions of lying tend to agree is that a lie is stated.A lie is an act of speech.It may be, therefore, that we can make some headway in discussing lies in the context of dementia by considering J. L. Austin's work on speech acts.This will provide a broader understanding of how language functions.
According to Harrison, 'Austin's primary target was the verificationist presumption that the only meaningful sentences are those which express true or false statements'. 46What we say is not just a description of some thing, which can either be true or false, but is also performative.Performative utterances do something.In saying that I promise to post the letter, I am not describing something-a commitment-that is going on in my mind, I am making a promise.I am performing an act.Such a performative utterance is neither true nor false, whereas pointing to the inner commitment (which could, for instance, not be there) might well be.
Inevitably, philosophers argue about these things.For present purposes it seems reasonable to say that speech is not just words that may or may not correspond to the reality of the world.For when I speak, I might be doing a variety of things.So, speaking is acting.Moreover, it is acting in a particular situation.As Austin says: Once we realise that what we have to study is not the sentence but the issuing of an utterance in a speech situation, there can hardly be any longer a possibility of not seeing that stating is performing an act. 47stin also made the now classic distinctions between locutionary, illocutionary and perlocutionary acts.
The locutionary act is just the act of saying something, albeit this can be understood in a variety of ways, from its sounds (phonetics), to its grammar, to its meaning.The illocutionary act is the function of the 21

| 5 HUGHES
Some centuries before, Thomas Aquinas (1225-1274) had made a similar point about truthfulness: I shall show this by (a) a particular reading of Aquinas and (b) considering the intentional nature of an action.