Vol. 2 No. 2 Specials

Since the founding of the United States, social and political movements have substantially expanded the right to vote. However, efforts to extend the franchise as broadly as possible have largely overlooked an important policy problem – how to ensure meaningful access to the ballot box for people with cognitive disabilities.

Among the many conditions that cause cognitive impairments, dementia presents particularly concerning and time-sensitive issues. Patients with dementia have progressive cognitive defects that impair their abilities to perform activities and make decisions. However, no consistent state electoral guidelines currently exist that prescribe who has the authority to disenfranchise a person due to mental illness or under what conditions someone can execute such authority. Forty-five states have widely-varying laws that address whether people who are unable to look after their own finances or health are allowed to vote, while twenty-five automatically terminate the right to vote if a person is under the care of a guardian. The result is a pastiche of outmoded laws that do not reflect current science and are applied inconsistently and arbitrarily.

Three overarching problems arise as a result of this confused legislation: qualified voter denial, incompetent voting, and voter fraud. In the first case, a person with dementia who remains capable of voting and wants to do so may be denied this right because his caregiver incorrectly assumes that he lacks the capacity to vote, or because states lack voting technologies tailored to people with cognitive disabilities. In the second case, a person who has lost the capacity to vote meaningfully may be allowed to vote anyway. And in the third case, health care professionals, family members, or others may cast a ballot in the name of a person with dementia, raising legal and ethical questions about the integrity of the voting system.

Voting rates are highest among people aged 65 to 74, and age is the chief risk factor for dementia. Estimates suggest that by 2050, there will be 15 million people with dementia in the United States. Concern over voters with dementia is therefore a major issue, and it is particularly pronounced for local elections where a small number of votes is more likely to affect the outcome. However, as the 2000 US presidential election showed, in which 537 votes in Florida (the state with the highest proportion of elderly) determined the outcome, even national elections can turn on very few votes.

Society has not adequately addressed issues related to voting by people with dementia. Three critical issues that require attention are the development of a standardized method to assess the capacity to vote, identification of appropriate kinds of assistance to enable people with cognitive impairment to vote, and the legal and ethical questions raised by balancing mechanisms that selectively deny the franchise with constitutional equal rights protections.