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

This article addresses an emerging policy problem in the United States participation in the electoral process by citizens with dementia. At present, health care professionals, family caregivers, and long-term care staff lack adequate guidance to decide whether individuals with dementia should be precluded from or assisted in casting a ballot. Voting by persons with dementia raises a series of important questions about the autonomy of individuals with dementia, the integrity of the electoral process, and the prevention of fraud. Three subsidiary issues warrant special attention: development of a method to assess capacity to vote; identification of appropriate kinds of assistance to enable persons with cognitive impairment to vote; and formulation of uniform and workable policies for voting in long-term care settings. In some instances, extrapolation from existing policies and research permits reasonable recommendations to guide policy and practice. However, in other instances, additional research is necessary.

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The Capacity to Vote of Persons with Alzheimer’s Disease

OBJECTIVE: The right to vote can be abrogated when persons become incompetent to cast a ballot. This applies particularly to people with Alzheimer’s disease, who at some point will lose capacity. A 2001 federal court decision offered the first clear criteria ("Doe voting capacity standard") for determining voting competence, focused on understanding the nature and effect of voting and on the ability to choose. This article explores how persons with Alzheimer’s disease perform on these criteria.
METHOD: The Doe standard was operationalized in a brief questionnaire, along with measures of appreciation and reasoning about voting choices. Performance was assessed in 33 patients attending an Alzheimer’s disease clinic and was related to dementia severity and demographic characteristics.
RESULTS: The interview questions were scored with high reliability. Performance on the Doe questions, along with appreciation and reasoning, correlated strongly with Mini-Mental State Examination (MMSE) scores. Patients with very mild to mild Alzheimer’s disease generally retained adequate ability to vote, and most persons with severe Alzheimer’s disease did not. Performance was highly variable among persons with moderate Alzheimer’s disease. The desire to vote was a poor predictor of voting capacity.
The capacity to vote, as embodied in the Doe voting capacity standard, can be measured simply and reliably. Structured assessment is particularly likely to be useful for people with moderate Alzheimer’s disease, whose performance cannot be predicted from MMSE scores alone. This approach can ensure retention of voting rights by capable persons and exclusion of clearly impaired persons from the voting booth.

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

Modern democratic nations have designed electoral systems to achieve two fundamental goals: increasing enfranchisement and voting, and, assuring the integrity of the vote. Efforts to achieve these two objectives can generate a tension between them. As an example, postal voting (also called absentee balloting) has the benefit of allowing persons who cannot easily reach a polling place to vote from remote locations at some time prior to the day of the election. This is especially valuable to persons with disabilities that limit their ability to travel. But postal voting also increases the risk of fraud. Specifically, these ballots can be stolen and either cast by other people or destroyed. The magnitude of this problem can increase in congregate living settings where multiple voters cast absentee ballots. In short, there is a trade-off between an effort to enhance enfranchisement, in this case by postal voting, while at the same time assuring the integrity of the electoral process.
The purpose of this paper is to examine and compare various nations’ electoral systems in order to understand how they address this trade-off. Our focus on voting by elderly persons, particularly those with cognitive impairments, highlights how well the various approaches succeed in simultaneously facilitating voting by vulnerable elderly persons while reducing the opportunities for deception and fraud.

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

To ascertain the need for and inform development of guidelines for voting in long-term care settings, we conducted a telephone survey of Philadelphia nursing (n=31) and assisted living (n=20) settings following the 2003 election. Substantial variability existed in procedures used for registration and voting, in staff attitudes, and in the estimated proportion of residents who voted (29%+28, range 0 to 100%). Residents who wanted to vote were unable to do so at nearly one-third of sites, largely due to procedural problems. Nearly two-thirds of facilities indicated they assessed residents’ voting capacity before the election. However, methods differed and may have disenfranchised residents who were actually competent to vote. Current procedures in many facilities fail to protect voting rights. These data suggest that rights might be better protected if election officials took charge of registration, filing absentee ballot requests, ballot completion, and trained LTC facility staff on voters’ rights and reasonable accommodations.

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