This November, millions of Americans may have been deprived of their right to vote or they may have been victims of voter fraud. This potential disenfranchisement of basic civil rights cuts across all party lines, income levels, and racial identities. Every citizen with Alzheimer's disease or other forms of dementia, regardless of his or her functional level, may be at risk during an election. Who should decide if these vulnerable citizens have the capacity to vote? How should that assessment be made? And how can electoral fraud be prevented?

A multi-disciplinary, multi-institutional group of 11 experts in law, ethics, government, neurology, geriatrics, and psychiatry investigated these questions and published their findings in the 15 September 2004 issue of The Journal of the American Medical Association. One of the group's leaders was Jason H. Karlawish, M.D., assistant professor of medicine at Penn and director of the Education and Information Core of Penn's Alzheimer's Disease Center. The 18-month study reveals an alarming inconsistency in voting policy regarding citizens with dementia. Said Karlawish, "We found that judges, family caregivers, and long-term care staff do not have adequate guidance to determine whether individuals with dementia have the capacity to vote."

By 2050, an estimated 15 million Americans will have dementia. Because age is the chief risk factor for the disease and voter turnout is highest I the 65 to 74 age bracket, the needs defined in this study will have an impact on the electoral process for generations to come.

The research group looked at existing voting laws and discovered an inadequate set of state, federal, and local legislation. Only eight states exclude voters on the basis of the specific "capacity to vote"—but none of these states provides a standard to assess such a capacity. As a result, the current laws of most states probably violate the Constitution of the United States, as well as the Americans with Disabilities Act (ADA).

According to the researchers, state laws should be changed to conform to modern constitutional principles, incorporating a test to assess competence to vote; ballots should be simplified to eliminate voter confusion; the public should be educated regarding appropriate assistance for voters with dementia; policies should be formulated for voting in long-term care settings; and additional studies should be conducted to develop more effective voting policies.

Karlawish, whose scholarship focuses on the ethics of research and care of people with dementia, stressed the importance of objectivity, simplicity, and clarity in assessing capacity to vote. "For example, ask the person with dementia how people will choose the next president and when the voting is over how will it be decided who is the winner. If they understand these concepts and they want to vote and can make a choice, that is all that is necessary. They do not need to comprehend the details of each candidate's platform."

The findings of the multi-institutional group were reported in The New York Times, The Washington Post, The Philadelphia Inquirer, and several other news outlets. Arthur L. Caplan, Ph.D., chair of Penn's Department of Medical Ethics and director of the Center for Bioethics, wrote an editorial for the Inquirer, advocating careful and sensitive reform: "While there are obviously many people who are too mentally ill to vote, the lingering stigma of mental illness and retardation—as well as stereotypes about the elderly—may still be denying many people their right to participate in elections….In the decade to come, millions more Americans will join the ranks of the elderly as the baby boomers age. Not only will many end up in nursing homes, but just like anyone else who's getting older, they will be at an increased risk for depression and dementia. Given the large numbers of people involved—and the fundamental individual rights at stake—it is not too soon to tackle the problem of voting for the elderly and mentally impaired. (September 16, 2004).