(Last of two parts)
Nowhere is the clash of these philosophies more ethically fraught and practically challenging than in contemporary approaches to dementia. If an aging parent, like Quijano, begins to inhabit a different reality, calling a nursing home a castle or a caregiver a long-dead spouse, the biomedical model presents an unyielding truth: this is a neurodegenerative disease, a cascade of amyloid plaques and tau tangles that is obliterating the person’s authentic self.
The primary goal of care, in this model, is often “reality orientation,” a cognitive therapy designed to continually pull the person back to the objective present: “No, Mother, you are not waiting for the school bus; you are 85 years old and your husband has passed.” It is a therapeutic corollary of the prison’s jeering, a well-intentioned but brutal insistence on a reality the person cannot and may not want to inhabit.
Yet, a different paradigm in addressing dementia has emerged, one that would look upon Quixote with profound recognition: validation therapy and the broader person-centered care movement described by Tom Kitwood. This approach radically reframes the “madness” of dementia not as a purely neurological deficit to be corrected, but as a meaningful expression of deep-seated emotional need and a final, desperate attempt to communicate when the cognitive tools for “normal” dialogue have disintegrated.
When an elderly woman calls out for her mother, the validation therapist does not tell her the “truth” of her mother’s death decades ago. Instead, they enter her world, asking, “You miss your mother a great deal? Tell me about her.” This approach implicitly understands that the emotion – a child’s desperate need for safety in a world that has become terrifyingly unfamiliar – is a deeper truth than the cold fact of a death certificate. It is the Quixotic approach. It looks at the shaving basin of the present moment and, by prioritizing the person’s emotional and experiential reality, dignifies it as the golden helmet of Mambrino.
Here, “health” is redefined not as cognitive restoration to a statistical norm, but as a state of relative well-being, emotional peace and maintained personhood within one’s own subjective reality. It is a philosophy that argues the person is not “sick” for chasing their personal windmills of memory; the sickness is in a system of care that would yank them back by the collar, bruising their soul in the name of a consensual reality they are already leaving.
Societies manage dementia based on their own overarching, often unspoken, philosophies of the self. In many Western cultures, heavily invested in an atomized, cognitive and hyper-cognizant self, the dissolution of memory is the ultimate tragedy, a “loss of self,” the windmills that are often met with grief, aggressive medicalization and institutionalization aimed at safety and bodily management. These windmills are the enemy.
However, societies with different philosophical underpinnings of personhood offer alternative scripts. In Japan for instance, while biomedical models are prevalent, a traditional relational selfhood, where the individual is defined by a web of interdependence and generational bonds rather than pure cognitive independence, can lead to different caregiving ethics. A family might find deep meaning in caring for an elder with dementia, seeing their vulnerability not as a monstrous erosion of identity but as a return to a childlike state that inspires reciprocal, tender obligation – a concept known as on and amae.
While not romanticizing the immense burden of care, this relational philosophy can sometimes allow families to hold the person within the family’s narrative identity even when their individual autobiography is fragmented. The person with dementia might no longer know their daughter, but the daughter knows them, and in that knowing, the person remains a mother, anchored in the relationship rather than in the neuronal map. It is a shift from asking “Who are you?” to stating “You are mine, and I am yours” – a profoundly Quixotic act of faith in the unseen reality of a lifelong bond.
As I walked out of the theater into the humid Manila night, the philosophical weight of the musical settled into a insistent, echoing question: who is actually chasing windmills? The immediate answer offered by Cervantes is Alonso Quijano, the man whose brain has “dried up.” But, in its heart-stopping final scene, the musical subverts this completely.
Quijano is now “sane,” and although cured of his delusions by a chest-puffed Dr. Carrasco (Alfredo Reyes) who, eerily, I as a physician somehow drew some parallels with, lies dying. Aldonza barges in despite protestations by the household. She has been transformed not by being oriented to reality, but by being seen by Quixote’s delusion. She refuses his new, healthy and hopeless reality. She reaches into Quijano’s failing mind and forces him to remember the impossible dream. “My Lord, you are not well,” she cries, but it is not the sickness of madness she laments; it is the sickness of surrender, the giving up of the quest.
For that final, fleeting moment, he rises, grasping his rusted sword, singing his credo with his final breath and dies, not as the sane Alonso Quijano, but as the gallant, utterly mad and utterly whole Don Quixote de La Mancha.
In that moment, the man secure in his reality is profoundly sick; he is dying of a crushed spirit. The societal ideals that deemed him mad and forced him into a “healthy” conformity are exposed as the true, life-destroying delusion. A society that imposes its rigid, often brutal, consensus about what is normal, healthy and sane can be a society of soul-killing pragmatists, a collective that has forgotten how to see Dulcinea in the mud.
The chase after windmills – the absurd, the asymptotic, the unattainable ideal – is not the project of a sick mind. It is the fundamental project of being fully human. Whether it is the impossible dream of justice, the unending chase for a cure to a protean disease or the dignifying of a fading consciousness that no longer remembers our name, the act of tilting at windmills is an act of defiant health. It is the refusal to live in a world narrowed only to what is empirically verifiable and immediately useful.
Perhaps the true pathology lies in a society so addicted to its own definition of a well-ordered reality that it can no longer hear the empowering music that turns a prison yard into a quest. The man chasing giants is not lost. The society that sees only windmills is.
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Ricardo Quintos, MD, DSc is a vascular surgeon and scientist, with post-doctoral credentials in Philosophy of Science.