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Research | Should a person with dementia be allowed to vote? Caregivers, judges, and poll workers lack fair, consistent guidelines to make that decision, says Dr. Jason Karlawish, assistant professor of medicine and associate director of the Memory Disorders Clinic at Penn’s Alzheimer’s Disease Center. 

He researched this issue as part of a multidisciplinary Dementia Voting Panel whose findings were published in the September 15 Journal of 
the American Medical Association
. The group calls for the repeal of unconstitutional laws and the use of an objective standard to assess voting competency. “There should be a high threshold for declaring someone no longer competent,” says Karlawish, who is also director of the ADC’s education and information transfer core as well as a senior fellow at the Center for Bioethics. He notes that some states bar people from voting simply because they’ve been placed under a guardianship order.

On the other end of the spectrum, he points to anecdotal evidence of people voting on behalf of their cognitively impaired spouses. 

For a better standard the researchers looked to Doe vs. Roe, in which a federal district court in Maine found that a mentally ill person is competent to vote if he or she understands “the nature and effect of voting and can make a choice.” Though Karlawish’s research does not deal with mental illness, he says, “We find that [ruling] appealing because it removes the issue of whyyou made your choice and gets to the heart of the matter of, ‘Do you know what voting is?’”

As their paper points out, “Many individuals who are entirely competent may base their votes on what others may regard as ‘irrational’ considerations, but their choices are respected nonetheless.”

Karlawish believes that voting competence can be determined by administering a simple test:

“Imagine it’s election day for governor in (your state). How will the people of (your state) pick the next governor?”

“How will it be decided who wins?”

Next, the person is given a brief description of two candidates and asked to choose one. It doesn’t matter who is chosen; the point is to see that the individual can make a choice.

This standard could be used by family members struggling with concerns about their loved one voting, by judges ruling on guardianships for patients with dementia, and by election workers in the unusual event of a challenge at the polls.

The other use would be in long-term care facilities. “Currently, a lot of voting is in the hands of activity directors or social workers of nursing homes,” says Karlawish; to avoid abuses, poll workers should handle most of these duties. 

Beyond the issue of whether people with dementia should vote is whether they should receive assistance in doing so. Though voting has become more accessible for people with physical disabilities, little attention has been given to assisting voters with cognitive impairment, Karlawish says. “I think the [visually complex] butterfly ballot in Florida is a good example of that. It does no good to say this ballot is easy for a 30 year old to fill out. I want to know if the ballot works on an average 80 year old.” 

A third area their research addresses is proxy voting. “We feel quite clearly that the constitutional laws do not support [voting for another] person, even if they think they know how [that person would] vote,” he says. “We can’t delegate our citizenship to another person.”

For more information see ( —S.F.

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