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The goal of this project is to identify and address the ethical, legal, political, medical and practical issues regarding the rights and abilities of individuals with dementia and other causes of cognitive impairment to vote.

This project is made possible by a grant from the Greenwall Foundation and the Virginia Brown Fellowship for Aging and Stroke Research.


Project Members

Project team leaders:
Jason Karlawish, M.D., University of Pennsylvania
Richard Bonnie, J.D., University of Virginia
Paul Appelbaum, M.D., Columbia University

Legal experts:
Richard Bonnie, J.D., University of Virginia
Pamela S. Karlan, J.D., Stanford University
Charles Sabatino, J.D., American Bar Association

Government and Voting Policy expert:
Christopher Patusky, J.D., University of Pennsylvania

Capacity experts:
Paul Appelbaum, M.D., Columbia University
Jason Karlawish, M.D., University of Pennsylvania

Ethics and Long Term Care experts:
Rosalie A. Kane, Ph.D., University of Minnesota
Thomas Lawrence, M.D., University of Pennsylvania
Kenneth F. Schaffner, M.D., Ph.D., George Washington University

Dementia experts:
Constantine Lyketsos, M.D., Johns Hopkins University
David Knopman, M.D., Mayo Clinic

Project Goal and Aims

Voting is a fundamental civil right of all adult citizens of the United States. But adults with progressive cognitive impairment caused by dementia may lose the ability to exercise this right. This presents a problem to family members and health care professionals who are responsible for the well-being of persons with dementia: operationalizing the right to vote when capacity may be, at least to some extent, impaired.

The goal of this project is to identify and address the legal, ethical, constitutional, political, medical, and practical issues regarding the rights and abilities of individuals with dementia to vote.

To achieve this goal, with the support from the Greenwall Foundation, we have assembled a multidisciplinary working group of experts in law, ethics, government, neurology, geriatrics, and psychiatry, including persons with expertise in the assessment of capacity and long term care, to define the dimensions of the issue, and develop consensus guidelines for policy and for future research. The expert panel uses the following questions as a springboard for our work: How should we understand the construct of "the capacity to vote"?

  1. How can a person assess another person's "capacity to vote?"
  2. What kind of assistance in voting is appropriate to provide to a person with cognitive impairment who retains sufficient residual capacity to cast a meaningful vote?
  3. What role should long-term care staff have in providing voting assistance to residents?
  4. What are the political consequences of voting by persons who lack the capacity to vote?
  5. What procedural, regulatory or statutory changes are necessary to implement the policies suggested by the answers to questions 1-5?

What are the political and ethical consequences of both the current status quo and any regulatory or statutory changes suggested by the answers to questions 1-5?

Publications Showing Progress Toward Achieving Those Goals and Aims

  • Addressing the Ethical, Legal and Social Issues Raised by Voting Persons with Dementia

Jason H. Karlawish, MD; Richard J. Bonnie, JD; Paul S. Appelbaum, MD; Constantine Lyketsos, MD; Bryan James, MBioethics; David Knopman, MD; Christopher Patusky, JD; Rosalie A. Kane, PhD; Pamela S. Karlan, JD JAMA. 2004;292:1345-1350.

Read abstract

  • The Capacity to Vote of Persons with Alzheimer's Disease

Paul S. Appelbaum, Richard J. Bonnie, and Jason H. Karlawish
Am J Psychiatry, Nov 2005; 162: 2094 – 2100

Read abstract

  • Voting by Elderly Persons with Cognitive Impairment: Lessons from Other Democratic Nations

Jason H. Karlawish, MD; Richard J. Bonnie, JD. McGeorge Law Review 2007;38(4):879-916.

Read abstract

  • Identifying the barriers and challenges to voting by residents of long-term care facilities: A study of the 2003 Philadelphia mayor’s race.

Jason H. Karlawish, MD; Richard J. Bonnie, JD; Paul S. Appelbaum, MD; Constantine Lyketsos, MD; ; Pamela S. Karlan, JD; Bryan James, MBioethics; Charles Sabatino, JD; Thomas Lawrence, MD; David Knopman, MD; Rosalie A. Kane, PhD. J Aging and Soc Policy. 2008; 20(1):65-80.

Read abstract

Are you interested in helping move this project forward?
To continue this important effort, we hope to gather an even larger group of experts, and seek additional support. Please contact us if you are interested in participating in that effort. Tell us who you are, why you are interested, and how you can help.

Symposium - Facilitating Voting as People Age: Implications of Cognitive Impairment

The planning for this symposium came as a collaboration between the Borchard Foundation Center on Law and Aging, the American Bar Association Commission on Law and Aging, and the Capital Center for Government Law and Policy, University of the Pacific, McGeorge School of Law. The group commissioned a series of scholarly articles to examine key legal, social, and technical issues relevant to voting in persons with cognitive impairment. Fifty national experts in law and aging, disability, medicine, long term care, voting technology, and election administration met in a three day symposium at the University of the Pacific to debate issues and adopt a series of recommendations. The symposium members were separated into five groups for this task:

  1. The big picture group: how aging and cognitive impairment fit into the broader issues of access to voting
  2. Capacity group: defining and assessing capacity to vote
  3. Absentee balloting group
  4. Long term care group
  5. Technology group

The McGeorge Law Review has published the scholarly output of this Symposium (Volume 38, issue 4), which includes the following articles:

  1. Introduction by Charles P Sabatino and Edward D Spurgeon
  2. Recommendations of the symposium
  3. Voting and cognitive impairments: an election administrator’s perspective by Deborah Markowitz, Vermont Secretary of State
  4. Voting by elderly persons with cognitive impairment: lessons from other democratic nations by Jason H Karlawish and Richard J Bonnie
  5. Framing the voting rights claims of cognitively impaired individuals, by Pamela S Karlan
  6. Defining and assessing capacity to vote: the effect of mental impairment on the rights of voters by Sally Balch Hurme and Paul S Appelbaum
  7. Absentee voting by people with disabilities: promoting access and integrity by Daniel P Tokaji and Ruth Colker


ABA Adopts Voting Rights and Cognitive Impairment Policy Submitted by Commission on Law and Aging

The ABA House of Delegates adopted a voting rights and cognitive impairment policy submitted by the Commission on Law and Aging, at its annual meeting on August 13.
The policy is based upon the joint effort of the ABA Commission on Law and Aging, the Borchard Foundation Center on Law and Aging, and the Capital Government Center on Law and Policy at the Pacific McGeorge School of Law in Sacramento, California. The groups hosted a working symposium of national experts in law and aging, medicine, long-term care, voting technology, and elections administration entitled Facilitating Voting As People Age: Implications of Cognitive Impairment, which convened in March 2007 at the Pacific McGeorge School of Law.

Click here to read a .pdf of the final report (8 pages)

Other Items of Interest

  • Report Looks at Voting and Cognitive Impairment

The National Research Commission on Elections and Voting, formed by The Social Science Research Council( http://www.ssrc.org/ ) released its assessment of electoral reform themes in a March 1, 2005 report entitled, Challenges Facing the American Electoral System: Research Priorities for the Social Sciences. Among the issues discussed in the report is "The voting rights of persons with cognitive impairments."

Read more

  • Voting capacity and voting age

One of the goals of the Dementia Voting Project is to critique the assumptions that underlie concepts of what it means to be competency to vote. One assumption is that a person’s status is ethically relevant to deciding whether they have adequate capacity, i.e. are competent, to vote. “Status” describes membership in a group, such as persons with cognitive impairment secondary to dementia, persons who are mentally ill, or – using language from several State’s laws – persons who are insane. To label such persons as lacking the capacity to vote disregards that they have varying degrees of decision making ability.

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  • Voting capacity and voting rights issues and the 2004 general election

Most states do not provide coherent guidelines for what it means to be competent to vote and in fact many states have registration laws that are unconstitutional and out of step with contemporary legal and ethical principles. These problems are not simply hypothetical ones. Recent news reports from the “swing states” of Ohio and Florida suggest they may impact the outcome of the upcoming national election.

Read more

  • Why Does This Matter? Voting and capacity, and long term care issues in the news ...

Following are summaries from news stories reporting on allegations of voting fraud related to issues of voting capacity, absentee ballots and voting in long-term care settings. We present them in order to illustrate that voting by the elderly, especially elderly in long term care facilities, is a lightning rod issue that losing candidates can use to contest an election. The Mobile Register article, “DA probes election complaints,” is a fascinating display of the lack of clear guidance on what the capacity to vote is and how to assess it, and the confusion between a diagnosis of dementia and the claim someone lacks capacity. Many of these articles were identified using web searches using the subject topics “dementia,” “Alzheimer’s disease” and “voting.”

Read more


Relevant Research and Articles

Read additonal article summaries of research relevant to the project.

Click here to read the articles.

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