This paper argues that one’s authority to issue advance directives governing one’s medical care is limited in ways that have not been appreciated. It focuses on advance directives issued by people who go on to suffer from dementia. An adequate account of decision-making for those with dementia should be able to do justice to two related aspects of that condition. First, for practical purposes, sufferers of dementia both are and are not the same people they were before. Second, (...) the “otherness” of the demented self reflects an unraveling rather than a becoming. The demented self is not a new self but rather the same old self in the process of disintegrating. The paper suggests that Christine Korsgaard’s treatment of personal identity provides a helpful framework for understanding these aspects of dementia. It also gives an account of decision-making for those with dementia that is sensitive to these aspects of dementia. (shrink)

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directives or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the (...) liberty or agency of one’s future incompetent self by issuing an advance directive? -/- In this paper, I use a virtue-ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self’s life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self-dictatorship, which is the vice of trying to control one’s life to an excessive degree, and that a self-dictator fails to give due moral consideration to the future self’s liberty or agency. I then introduce the Daoist idea of wu-wei, which recommends embracement of what happens in one’s life, as one of the possible remedies for the overemphasis on the value of autonomy and control. (shrink)

The increasing number of dementia cases has led to renewed interest in philosophical theories of personal identity, because these patients seem to “drop out” of their own identities in some ways. Philosophical positions that try to account for the phenomenon of identity loss include numerical theories of identity which argue for a psychological or a biological continuity criterion, narrative theories of identity, as well as reflections about different forms of memory, some of which have had influence in (...) modern psychology and in the neurosciences. This special issue brings together current articles by experts in these areas. ------ Die zunehmende Verbreitung von Demenzerkrankungen hat zu einem erhöhten Interesse an philosophischen Theorien der personalen Identität geführt, da diese Patienten in manchen Hinsichten aus ihrer eigenen Identität „herauszufallen“ scheinen. Zu den philosophischen Ansätzen, die sich hiermit beschäftigen, gehören Theorien der numerischen Identität, wie etwa das psychologische oder das biologische Kontinuitätskriterium, narrative Theorien der Identität, aber auch Refl exionen über verschiedene Formen des Erinnerns, die sich zum Teil in der modernen Psychologie und in den Neurowissenschaften niederschlagen. Dieses Schwerpunktheft enthält aktuelle Beiträge von Experten aus den genannten Bereichen. ​The increasing number of dementia cases has led to renewed interest in philosophical theories of personal identity, because these patients seem to “drop out” of their own identities in some ways. Philosophical positions that try to account for the phenomenon of identity loss include numerical theories of identity which argue for a psychological or a biological continuity criterion, narrative theories of identity, as well as reflections about different forms of memory, some of which have had influence in modern psychology and in the neurosciences. This special issue brings together current articles by experts in these areas. (shrink)

Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially (...) appear to provide a sound basis for extending the moral autonomy of an individual - and hence their autonomous wishes expressed through an advance directive - past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient’s best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interest judgements concerning an individual’s care or treatment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Personal Identity and the Moral Authority of Advance DirectivesAndrea OttSection 1What is the metaphysical basis for respecting an advance directive first drawn up by an individual who is competent but who is at present rendered incapacitated?1 What are the roles of autonomy, personal values, integrity, and beneficence contained within said respect? In this section the positions of two prominent philosophers, Ronald Dworkin and Jeff McMahan, (...) will be analyzed with regard to the above questions. While the two thinkers have different scholastic orientations—with Dworkin primarily a philosopher of law and McMahan an ethicist and metaphysician—their conclusions regarding the respect of the wishes of the competent-turned-demented are remarkably similar. Namely, they both argue that the values and desires held by the previously competent agent trump any current (contrary) wishes. What this amounts to for Dworkin involves respecting the autonomy of the dominant, competent part of the life where countermanding such autonomy would be worse for the life as a whole. For McMahan this means respecting the precedent autonomy generated by the deep prudential unity relations which form the basis for egoistic concern; this concern is often the basis for drafting a directive regarding future care in the first place.I will argue in this paper that if McMahan is to be consistent with his position regarding prudential unity relations then he will, in fact, not arrive at the same conclusion as Dworkin.2 Consistency will demand that the demented patient’s directive should not be followed because the demented individual will, at best, be only weakly connected to the previously autonomous, decision-capable agent. Therefore, I will argue, the moral authority [End Page 38] of the advance directive will be similarly weakened. According to McMahan, Dworkin maintains that the precedent autonomous decision has moral authority, for he assumes that the individual in question is understood to be one “temporally extended individual,” so that what is best for her life now will, in fact, be what is best for her life as a whole (501). McMahan claims to support Dworkin’s conclusion, albeit for different reasons. McMahan supports the execution of the directive out of some sort of respect for the earlier “reasonably full and complete life with its own deep prudential unity” (502). I argue that McMahan, though ostensibly in agreement with Dworkin, will have to acknowledge that the weakened prudential unity relations which make the life as a whole matter less will also undercut the moral authority of the directive. In other words, the moral authority of an advance directive weakens as the prudential unity relations weaken.Ultimately, I believe, Lynne Baker and her metaphysics of constitution can provide the best direction when faced with dilemmas such as The Advance Directive. Baker can do this and avoid the charge of positing a “post-person” (the basis for McMahan’s criticism of other versions of psychological accounts of personal identity). I use her metaphysics of constitution and derivative properties within a novel explanation of prudential concern for the organism without positing identity. I argue, in section 2, that the organism made the decision for advance care when it was derivatively (in Baker’s sense) a person. We can thus avoid the charges of (1) new entities “popping” into existence and (2) a person binding a nonperson. Such a metaphysics of constitution may thus offer some hope of adjudication within debate concerning these matters.Now I shall turn to the thought experiment in The Ethics of Killing that forms the basis of this discussion. True to the general style of his work, Jeff McMahan asks the reader to consider a thought experiment. To avoid any misinterpretation of the facts, I reproduce The Advance Directive in full below:A woman whose life has been devoted to creative intellectual work finds herself in the very early stages of Alzheimer’s disease. Given her nature, her values, and the character of her previous life, she believes that for her to continue to live in a demented state would be horribly degrading, worse than simply ceasing to exist. She accepts, however, that her life will continue to be worth living as long as she remains competent; therefore to commit... (shrink)

When talking about personal identity in the context of medical ethics, ethicists tend to borrow haphazardly from different philosophical notions of personal identity, or to abjure these abstract metaphysical concerns as having nothing to do with practical questions in medical ethics. In fact, however, part of the moral authority for respecting a patient’s self-regarding decisions can only be made sense of if we make certain assumptions that are central to a particular, psychological picture of personal identity, (...) namely, that patients will remain psychologically connected to a certain degree with their future selves. I draw this out, show problems with approaches in medical ethics based on alternate theories of personal identity that do not recognise this, and explore some important implications. Namely, I show how this recognition can better explain the circumstances under which we should respect advance directives and why, and how it can better make sense of patient fears that they will not "survive" personality-altering deep brain stimulation procedures, and provide guidance on approaching patient decisions concerning this type of procedure in a manner that captures and addresses such concerns. (shrink)

Advance directives (ADs) have for some time been championed by ethicists and patient associations alike as a tool that people newly diagnosed with dementia, or prior to onset, may use to ensure that their future care and treatment are organized in accordance with their interests. The idea is that autonomous people, not yet neurologically affected by dementia, can design directives for their future care that caregivers are morally obligated to respect because they have been designed by autonomous individuals. In (...) this paper, we first criticize the idea that ADs can retain moral authority in severe dementia by arguing that it is paradoxical. Second, we consider two arguments that initially seem to refute this critique of ADs, but we eventually dismiss them. The first argument states that ADs retain moral authority in severe dementia because autonomously formed interests, for example, ADs, can only be appropriately discarded by autonomous persons. This we term the historical autonomy argument. We dismiss it by demonstrating how we, in analog cases, are not obligated to continue to respect autonomously formed interests even though they have been discarded under nonappropriate conditions. The second argument is that ADs can be justified by what we term external interests. While we agree that people with severe dementia plausible can be said to have external interests, we show that ADs cannot express such interests and hence cannot be justified by them. We conclude that none of the discussed arguments support the use of ADs and because of this, the idea of ADs should be reassigned. (shrink)

Ronald Dworkin argued that Advance Directives informed by a principle of autonomy ought to guide decisions in relation to the treatment of those in care for dementia. The principle of autonomy in play presupposes a form of competence that is tied to the individual person making the Directive. This paper challenges this individualist assumption. It does so by pointing out that the competence of a patient is inherently relational, and the key illustrative case to make this point is the (...) case of music therapy. In music therapy, a relatively recent treatment modality in aged care, patients previously thought to be permanently unresponsive are shown on the contrary to be capable of significant levels of social agency. The conclusion to draw is that Advance Directives that fail to acknowledge the real possibility of such relational competence are misapplied. (shrink)

The moral authority of advance directives (ADs) in the context of persons living with dementia (PLWD) has sparked a multifaceted debate, encompassing concerns such as authenticity and the appropriate involvement of caregivers. Dresser critiques ADs based on Parfit's account of numeric personal identity, using the often‐discussed case of a PLWD called Margo. She claims that dementia leads to a new manifestation of Margo emerging, which then contracts pneumonia. Dworkin proposes that critical interests, concerning one's higher moral values, trump (...) experiential interests (things or activities one enjoys because they are pleasurable). Dresser argues that Margo's current experiential interests override her self's critical ones, as they contribute significantly to her quality of life (QoL). To render the argument more realistic, I introduce a variation in which Margo develops delirium, a common and severe comorbidity in PLWD. I argue that delirium could precipitate a sudden decline in experiential interests and, consequently, a deterioration in QoL. Given the uncertain trajectory of Margo's illness, I contend that her competent self's critical interests, as reflected in her AD, along with her right to self‐ownership, should take precedence over current experiential interests. Thus, the AD possesses moral authority. However, it is imperative for healthcare professionals to offer consultations for PLWD, facilitating an understanding of ADs and enabling a shared decision‐making process. Such consultations are essential for honouring the autonomy and dignity of PLWD, ensuring that their values and preferences guide ethical decision‐making amidst the complexities of dementia care. (shrink)

Currently, in the United States, there is no legal obligation for medical professionals or civil courts to uphold patients’ Advance Directives (ADs) regarding end-of-life care. The applicability and standing of ADs prepared by Alzheimer’s patients is a persistent issue in bioethics. Those who argue against giving ADs full status take two main approaches: (1) appealing to beneficence on behalf of the Alzheimer’s patient and (2) claiming that there is no longer any personal equivalence between the AD’s creator and (...) the subject of the AD. In this paper, I present profound arguments against both approaches. Firstly, I argue that the principle of beneficence cannot apply in the case of Alzheimer’s patients, and, secondly, that the moral and legal authority of the AD need not depend on strict equivalence of personal identity. I conclude by arguing that valid ADs protect the dignity and autonomy of Alzheimer’s patients and that, therefore, there are moral obligations to uphold ADs which should be reflected in public policy and legislation. (shrink)

Next SectionThe personal identity problem expresses the worry that due to disrupted psychological continuity, one person’s advance directive could be used to determine the care of a different person. Even ethicists, who strongly question the possibility of the scenario depicted by the proponents of the personal identity problem, often consider it to be a very potent objection to the use of advance directives. Aiming to question this assumption, I, in this paper, discuss the (...) class='Hi'>personal identity problem’s relevance to the moral force of advance directives. By putting the personal identity argument in relation to two different normative frameworks, I aim to show that whether or not the personal identity problem is relevant to the moral force of advance directives, and further, in what way it is relevant, depends entirely on what normative reasons we have for respecting advance directives in the first place. (shrink)

A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these—epistemic indeterminacy and metaphysical indeterminacy—should be addressed in laws/policies regarding advance directives for euthanasia.

: Debates on precedent autonomy and some forms of paternalistic interventions, which are related to questions of personal identity, are analyzed. The discussion is based on the distinction between personal identity as persistence and as biographical identity. It first is shown that categorical objections to advance directives and "Ulysses contracts" are based on false assumptions about personal identity that conflate persistence and biographical identity. Therefore, advance directives and "Ulysses contracts" are ethically acceptable tools for prolonging (...) one's autonomy. The notions of personality and biographical identity are used to analyze the ethically relevant features. Thereby, it is shown that these concepts are operative in and useful for thinking in biomedical ethics. The overall conclusion is that categorical arguments against precedent autonomy or "Ulysses contracts" are based on misleading theories of personal identity and that advance directives are an ethically respectable tool for prolonging individuals' autonomy in cases of dementia and mental illness. (shrink)

A high level of confidence in the identity of individuals is required to let them die as ordered by an advance directive. Thus, if we are animalists, then we should lack the confidence required to apply lethal advance directives to the cheerfully demented, or so I argue. In short, there is consensus among animalists that the best way to avoid serious objections to their account is to adopt an ontology that denies the existence of brains, hands, tables, chairs, (...) iced-tea, and lemonade. The adoption of such an ontology reduces the justificatory force of commonsense, which is key in arguing that we are animals and that we persist as long as we are biologically alive. With this loss of justification comes the loss of a high level of confidence that Quinn-pre-dementia’s lethal advanced directive applies to Quinn-post-dementia, via identity. If we do not have a high level of confidence that Quinn-pre-dementia’s advanced directive applies to Quinn-post- dementia, then it is not enough (on its own) to let Quinn-post-dementia die. (shrink)

This paper takes a novel approach to the active bioethical debate over whether advance medical directives have moral authority in dementia cases. Many have assumed that advance directives would lack moral authority if dementia truly produced a complete discontinuity in personal identity, such that the predementia individual is a separate individual from the postdementia individual. I argue that even if dementia were to undermine personal identity, the continuity of the body and the predementia individual’s rights (...) over that body can support the moral authority of advance directives. I propose that the predementia individual retains posthumous rights over her body that she acquired through historical embodiment in that body, and further argue that claims grounded in historical embodiment can sometimes override or exclude moral claims grounded in current embodiment. I close by considering how advance directives grounded in historical embodiment might be employed in practice and what they would and would not justify. (shrink)

Loss of personal identity in dementia can raise a number of ethical considerations, including the applicability of advance directives and the validity of patient preferences that seem incongruous with a previous history of values. In this chapter, we first endorse the self-concept view as the most appropriate approach to personal continuity in healthcare. We briefly describe two different types of dementia, Alzheimer’s dementia (AD) and behavioral-variant frontotemporal dementia (bv-FTD). We identify elements considered important for the continuation (...) of a self-concept, including continuation of memories, consistency in personality traits and personal preferences, and continued endorsement of certain moral tenets. We show that, depending on which element is considered most important for personal identity, continuity of a self-concept for individuals with distinct types of dementia will be affected and assessed differently. Utilizing a variety of empirical evidence, we argue that persistence of memory, personality traits, and preferences are not the most important for the maintenance of personal identity. Instead, as studies aimed to capture the folk-psychological view of personal continuity demonstrate, judgements about continuity depend primarily on the persistent commitment to widely shared moral beliefs. Because of that, we argue that individuals with bv-FTD are more likely to lose their sense of self than individuals whose dementia primarily affects memory, such as Alzheimer’s disease. We end the chapter by showing how the importance of moral beliefs for continuity of self can be used to provide guidance to health-care professionals when considering changes in preference by individuals with dementia. (shrink)

Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if (...) the purpose of a theory of personal identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular set of actions, experiences, and characteristics is that of a given person rather than someone else. (shrink)

Technologies are being developed for significantly altering the traits of existing persons (or fetuses or embryos) and of future persons via germ line modification. The availability of such technologies may affect our philosophical, legal, and everyday understandings of several important concepts, including that of personal identity. I consider whether the idea of personal identity requires reconstruction, revision or abandonment in the face of such possibilities of technological intervention into the nature and form of an individual's attributes. This requires (...) an account of the work done by the concept of personal identity, and an explanation of what “conceptual impacts of technology” and “conceptual reconstruction” might mean. Our existing notions of personal identity and related ideas such as personhood and autonomy may seem unable to comfortably accommodate the possibilities of technologically directed trait formation and development. This is a matter of moral and legal importance because the idea of personal identity embeds major values and reflects value-laden beliefs and attitudes. The assumed endurance of identity underlies interpersonal relationships, the assignment of rewards and punishments, and the very idea of what constitutes an autonomous person. Perhaps radical restructuring or even abandonment of concepts are sometimes called for when the world changes drastically, but I suggest that conceptual modification is not “compelled” for personal identity except under extreme circumstances—the remote possibility of rapid human “shape shifting” where physical and mentational attributes can be transformed quickly and continuously. Efforts to enhance human traits, including merit attributes and other resource-attractive characteristics (e.g., intellectual and athletic aptitudes, physical size and appearance), may generate legal problems wherever the persistence of identity is presupposed. Some advance speculation is thus warranted on how trait change generally will be managed within our legal and socioeconomic systems, and more particularly on rights of access to trait-altering technologies. I mention the possible distributive effects of enhancing highly-resource attractive traits, including the strengthening individual powers to acquire still more increments in such traits in a self-reinforcing cycle. A brief review of some constitutional issues bearing on trait change completes the discussion. I conclude that existing and projected technologies do not impel the abandonment or remodeling of the idea of personal identity. We may, however, have to reconsider some uses of this concept in different settings, to rethink our understandings of ideas of merit and desert, and to deal with the distribution of resources that may enlarge and entrench the “distances” between social and economic groups. (shrink)

My contention is that considering a person to be co-located with an organism, or one of its\nspatial or temporal parts, gives rise to a host of problems as a result of there then being too many\nthinkers. These problems, which Olson has emphasized, can be mitigated (somewhat) by a\nNoonan-style pronoun revisionism. But doing so will have very unwelcome consequences for\nbioethics as autonomy, informed consent, advance directives and substituted judgment will be\nimpossible for the human animal. I count it as a point (...) in favor of Olson’s answer to the\nmetaphysical question “What are we?” that it avoids such ethical quandaries. But his animalism -\nwith its Parfit-inspired claim that it is not identity that matters in survival but the continuation of\nour psychology even if someone else is its subject - appears to be at odds with our self-conception\nand practical concerns. And if the only argument for this thesis is the fission scenario, then the\nthesis is further undermined as Parfit’s account of fission runs afoul of Wiggins’s Only a and b\nrule. What I will very tentatively suggest is that we explore two (incompatible) accounts of\nanimalism which deny that being identical to a future being is only of derivative importance to us. (shrink)

The questions of whether there is a shared nature common to all human beings and, if so, what essential qualities define this nature are among the most widely discussed topics in the history of philosophy and remain the subject of perennial interest and controversy. This book offers a metaphysical investigation of the composition of the human essence-that is, with what is a human being identical or what types of parts are necessary for a human being to exist: an immaterial mind, (...) a physical body, a functioning brain, a soul? It also considers the criterion of identity for a human being across time and change-that is, what is required for a human being to continue existing as a person despite undergoing physical and psychological changes over time? Jason Eberl's investigation presents and defends a theoretical perspective from the thirteenth-century philosopher and theologian Thomas Aquinas. Advancing beyond descriptive historical analysis, this book places Aquinas's account of human nature into direct comparison with several prominent contemporary theories: substance dualism, emergentism, animalism, constitutionalism, four-dimensionalism, and embodied mind theory. There are practical implications of exploring these theories as they inform various conclusions regarding when human beings first come into existence-at conception, during gestation, or after birth-and how we ought to define death for human beings. Finally, each of these viewpoints offers a distinctive rationale as to whether, and if so how, human beings may survive death. This book's central argument is that the Thomistic account of human nature includes several desirable features that other theories lack and offers a cohesive portrait of one's continued existence from conception through life to death and beyond. (shrink)

The concept of a relational self has been prominent in feminism, communitarianism, narrative self theories, and social network theories, and has been important to theorizing about practical dimensions of selfhood. However, it has been largely ignored in traditional philosophical theories of personal identity, which have been dominated by psychological and animal theories of the self. This book offers a systematic treatment of the notion of the self as constituted by social, cultural, political, and biological relations. The author's account (...) incorporates practical concerns and addresses how a relational self has agency, autonomy, responsibility, and continuity through time in the face of change and impairments. This cumulative network model of the self incorporates concepts from work in the American pragmatist and naturalist tradition. The ultimate aim of the book is to bridge traditions that are often disconnected from one another--feminism, personal identity theory, and pragmatism--to develop a unified theory of the self. (shrink)

Agency and identity -- Necessitation -- Acts and actions -- Aristotle and Kant -- Agency and practical identity -- The metaphysics of normativity -- Constitutive standards -- The constitution of life -- In defense of teleology -- The paradox of self-constitution -- Formal and substantive principles of reason -- Formal versus substantive -- Testing versus weighing -- Maximizing and prudence -- Practical reason and the unity of the will -- The empiricist account of normativity -- The rationalist account of normativity (...) -- Kant on the hypothetical imperative -- Against particularistic willing -- Deciding and predicting -- Autonomy and efficacy -- The function of action -- The possibility of agency -- Non-rational action -- Action -- Attribution -- The psychology of action -- Expulsion from the garden : the transition to humanity -- Instinct, emotion, intelligence, and reason -- The parts of the soul -- Inside or outside -- Pull yourself together -- The constitutional model -- Models of the soul -- The city and the soul -- Platonic virtues -- Justice : substantive, procedural, and platonic -- Kant and the constitutional model -- Defective action -- The problem of bad action -- Being governed by the wrong law -- Or five bad constitutions -- Conceptions of evil -- Degrees of action -- Integrity and interaction -- Deciding to be bad -- The ordinary cases -- Dealing with the disunified -- Kant's theory of interaction -- My reasons -- Deciding to treat someone as an end in himself -- Interacting with yourself -- How to be a person -- What's left of me? (shrink)

개인동일성은 우리가 사람으로서 시간을 가로질러 지속하는 조건에 관한 형이상학의 오랜 논제이다. 개인동일성에 대한 지속 조건들의 문제는 ‘시간이 지남에 따른 개인동일성 문제’, 혹은 ‘지속성 질문(the Persistence question)’이라 불린다. 지속성 질문에 답하기 위한 몇 가지 시도들이 있다. 개인동일성과 관련한 지속성 질문에 대한 가장 인기 있는 답변은 심리적 연속성 견해(psychological-continuity views)이다. 이 견해는 심리주의로 알려져 있다. 이 견해에 따르면 개인의 지속은 어떤 심리적 속성들로 구성된다. 또 다른 영향력 있는 답변은 동물적-신체적 견해(brute-physical views)이다. 인간 존재를 생물학적 유기체로 보고 동물적-신체적 조건들이 인간의 (...) 지속 조건이라고 보는 이러한 입장은 우리에게 ‘애니멀리즘(animalism)’으로 알려져 있다. 본 논문은 심리적 연속성과 연결성이 우리의 지속 조건이라고 보는 심리주의와 동물적-신체적 연속성을 지속의 우선순위에 두는 애니멀리즘 혹은 생체주의의 논증들의 핵심 쟁점들을 검토하고, ‘무-사실 논제’를 통해 사실 지속성의 조건에 문제가 되는 사실이 없음을 보일 것이다. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:REID' S CRITICISM OF HUME'S THEORY OF PERSONAL IDENTITY One of the most interesting philosophical controversies is that between Reid and Hume, considered as representatives of two different sorts of empiricism. Hume, for these purposes, represents 'radical' empiricism, and the attempt to base knowledge solely on experience and what can be validly inferred from it, regardless of how far this leads one from everyday notions and beliefs. Reid, (...) in contrast, represents 'common sense' empiricism, and the view that the. results of experience and deduction must conform to a number of 'first principles or intuitive judgments' (Essays on the intellectual powers of man, VI, 4), which aie unprovable, but which no one can avoid accepting. It is important to be clear about the status of Reid' s 'intuitive judgments', or 'principles of common sense'. They are not merely the general beliefs of a particular culture, which could be 'vulgar errors or preJUdICeS''. Nor are they merely beliefs generally held by people uncorrupted by philosophy. They are assumptions which have to be made if theoretical or practical activity is to be possible at all, principles which are always accepted in practice even by those who deny them in theory. For example, although the uniformity of nature is not a logically necessary truth, everybody always thinks and acts in ways that presuppose that it is true: 'Nature is governed by fixed laws, and if it were not so, there could be no such thing as prudence in human conduct.... the whole fabric of natural philosophy is built upon this principle.' (Essays, VI, 5) Again, everyone, even a theoretical determinist, makes moral judgments and deliberates what to do; and these activities presuppose a belief in human free will. (Essays, ibid.) Hume himself, as Reid was aware, accepted the validity of some principles of this sort, notably of the 42. uniformity of nature. But Reid was dissatisfied with Hume's account, partly because he thought Hume had rejected far too much, and partly because of the grounds Hume gives for accepting, for example, the validity of induction, and the existence of the external physical world. Hume regards these beliefs as non-rational, and deriving from our psychological make-up; it is nature and not reason which causes the belief in an ordered physical reality. In Hume's eyes this is a sufficient justification: if our nature compels us to believe something, this is as good a ground for believing it as any other. Reid, on the other hand, believed, first, that there were many more principles of this sort than Hume had acknowledged, and secondly, that the justification of them was rational, and not merely psychologically determined, since it was based on the impossibility of thinking and acting coherently without them. Hence, even though Hume builds up with one hand what he pulls 'down with the other, and destroys the rational basis for belief only to replace it by one based on human nature and psychology, Reid continues to treat him as the archsceptic. In constructing his list of first principles in Essays, VI, 5, Reid explicitly or implicitly attacks Hume's 'scepticism' on five points - the existence of the mind; the existence of the physical world and the reliability of our senses; the reliability of memory; the reliability of reason; and the uniformity of nature. Against this scepticism he deploys three types of argument. The first is the argument from the universal beliefs of mankind, particular!/ as displayed in the structural features supposedly common to all languages. The second is the argument that the position of the sceptic is, when its consequences are worked out, either self-contradictory or incoherent. And the third is the argument already mentioned, that this position is inconsistent with other beliefs which the sceptic inevitably holds, since he thinks and acts in ways which are 43. inconsistent with their falsity, and cannot avoid doing so. To assess the force of Reid' s attacks, we have to consider both the strength of arguments of this sort in general and whether they apply in all these five cases. In this article, I want to concentrate on the first issue of the five, that of personal identity. Apart from displaying Reid... (shrink)

Advance directives permit competent adult patients to provide guidance regarding their care in the event that they lose the capacity to make medical decisions. One concern about the use of advance directives is the possibility that, in certain cases in which a patient undergoes massive psychological change, the individual who exists after such change is literally a (numerically) distinct individual from the person who completed the directive. If this is true, there is good reason to question the (...) authority of the directive Ð which is supposed to apply to the individual who completed it, not to someone else. This is `the someone else problem'. After briefly introducing advance directives as a basis for medical decision-making, this paper elaborates `the someone else problem' in the context of severe dementia. The paper then reconstructs the reasoning that leads to this putative problem and exposes the important underlying assumption that we are essentially persons. An alternative view of what we are, one that regards personhood as inessential, is then considered, before several arguments are advanced in favor of that alternative view. The paper next explores implications for advance directives: `The someone else problem' is effectively dissolved, while it is noted that a related problem (one beyond the paper's scope) may persist. A few implications beyond advance directives are also identified. (shrink)

This letter responds to the article “On the Authority of Advance Euthanasia Directives for People with Severe Dementia: Reflections on a Dutch Case,” by Henri Wijsbek and Thomas Nys, in the September‐October 2022 issue of the Hastings Center Report.

In many industrialized countries ethicists and lawyers favour advance directives as a tool to guarantee patient autonomy in end-of-life-decisions. However, most citizens seem reluctant to adopt the practice; the number of patients who have an advance directive is low across most countries. The article discusses the key argument for seeing such documents as an instrument of self-interpretation and life-planning, which ultimately have to be interpreted by third parties as well. Interpretation by third parties and the process of self-reflection (...) are conceptually linked by a qualitative concept of identity. Identity is conceived here as constructed in a processual dialogue between a personal and a cultural perspective. How the cultural dimension comes into play in understanding the motivation, rejection or content of wished for end-of-life-decisions, is shown by a brief review of empirical and cultural studies. Understanding advance directives as a culturally embedded tool of self-interpretation should help to overcome urgent moral problems in clinical settings: how to interpret such documents, how to deliberate on the content and on the best form. (shrink)

Theories of personal identity in the tradition of John Locke and Derek Parfit emphasize the importance of psychological continuity and the abilities to think, to remember and to make rational choices as a basic criterion for personhood. As a consequence, persons with severe dementia are threatened to lose the status of persons. Such concepts, however, are situated within a dualistic framework, in which the body is regarded as a mere vehicle of the person, or a carrier of (...) the brain as the organ of mental faculties. Based on the phenomenology of embodiment, this paper elaborates a different approach to personal identity in dementia. In this perspective, selfhood is primarily constituted by pre-reflective self-awareness and the body memory of an individual, which consists in the embodiment and enactment of familiar habits, practices and preferences. After describing the different types of body memory, the paper develops a phenomenology of dementia as a loss of reflexivity and meta-perspective. This is contrasted with the preservation of individual forms of body memory even in the later stages of the illness. The ethical consequences of an embodied approach to dementia are outlined. A final look is given to narrativistic and constructionist concepts of the self in dementia. (shrink)

Brain implants, such as Deep Brain Stimulation (DBS), which are designed to improve motor, mood and behavioural pathology, present unique challenges to our understanding of identity, agency and free will. This is because these devices can have visible effects on persons' physical and psychological properties yet are essentially undetectable when operating correctly. They can supplement and compensate for one's inherent abilities and faculties when they are compromised by neuropsychiatric disorders. Further, unlike talk therapy or pharmacological treatments, patients need (...) not ‘do’ anything for the treatment to take effect. If one accepts, as we argue here, that brain implants are unique among implantable types of devices, then this can have significant implications for what it means to persist as the same person and be the source of one's thoughts and actions. By examining two of the most common indications for DBS in current use, namely in the motor (Parkinson's Disease) and psychiatric (Major Depression) domains, we further argue that although DBS, as it is currently applied, does not necessarily represent a unique threat to personal identity and agency per se, it introduces an unprecedented ‘third party’ into the debate on these concepts. In this way, DBS can be used as a tool to begin probing, both conceptually and empirically, some of philosophy's most perennial metaphysical questions. (shrink)

Background: Caregivers and administrators in long-term facilities have fragile moral work in caring for residents with dementia. Residents are susceptible to barriers and vulnerabilities associated with the most intimate aspects of their lives, including how they express themselves sexually. The conditions for sexual agency are directly affected by caregivers’ perceptions and attitudes, as well as facility policies. Objective: This article aims to clarify how to approach capacity determinations as it relates to sexual activity, propose how to theorize about patient autonomy (...) in this context, and suggest some considerations for finding an ethically responsible and practically feasible way to respect the sexual rights of this population. Research Design: The focus is on residents with early to moderate dementia in states of daily dependency on professional caregivers. The article critically examines existing empirical research on sexuality among persons with dementia, caregivers’ attitudes, and institutional roadblocks to enabling residents’ sexuality. A relational lens and insights from disability studies are used in the philosophical analysis. Participants and Research Context: No research participants were part of this analysis. Ethical Considerations: This article offers a conceptual analysis and normative framework only. Findings: The analysis highlights the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. Sexual agency features into an ongoing sense of self for many individuals with dementia, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity. Discussion: Recommendations include developing clear and inclusive institutional policies and practices of care, providing education for caregivers on how to discuss and document residents’ sexual preferences over time, and taking advantage of ethics consultation services. Conclusion: This analysis establishes the need for more research and discussion on this sensitive topic. Future research should investigate the specific responsibilities of caregivers in furthering the sexual interests of residents, how exactly to modify existing capacity instruments, and how best to support historically marginalized patients in their sexual identities. (shrink)

The Palgrave Handbook of Practical Animal Ethics is a recent addition to anthologies in the field, joining The Oxford Handbook of Animal Ethics, and The Routledge Handbook of Animal Ethics. Edited by Andrew Linzey and Clair Linzey of the Oxford Centre for Animal Ethics, the book boasts more than 30 contributors, many of them philosophers, but also including sociologists, scientists, theologians, lawyers, psychologists, and animal advocates. The editors were intentionally multidisciplinary in their approach, noting that “there is currently no book (...) series that is a focus for multidisciplinary research in the field,” and calling attention to the need not only for philosophical inquiry into what we owe animals, but also into the “social, legal, cultural, religious and political” influences that “legitimate animal abuse” (p. viii).The book is divided up into four sections: “The Ethics of Control,” “The Ethics of Captivity,” “The Ethics of Killing,” and “The Ethics of Causing Suffering.” Each of these sections includes an editorial introduction and multiple entries spanning diverse issues, including animal research, animal agriculture, hunting, fishing, zoos, the role of animals in religion, the role of language in structuring thought about nonhuman animals, and others. Similarly, the chapters span issues affecting many species, including farmed animals, fish, deer, elephants, whales and dolphins, rodents, companion animals (e.g., dogs and cats), and others.While the book is billed as a “practical” handbook of animal ethics, it does wade into some conceptual territory, tackling such issues as the ethical permissibility of confining and controlling animals, the question of whether (painless) death harms nonhuman animals, and the comparative wrongness of killing humans and nonhuman animals. This said, it largely stays away from more detailed discussion of normative ethical theory and the moral standing of nonhuman animals, focusing instead on the specific ways that humans treat nonhuman animals. In focusing more on practical than theoretical ethics, the Palgrave Handbook of Practical Animal Ethics both complements and differentiates itself from some other anthologies in the field.The book has several strengths to recommend it, the first being the logic of its organization. The ethically problematic aspects of humans’ treatment of nonhuman animals frequently map onto one or more of the categories of causing suffering, killing, and confining. The organization of chapters under these section headings helps to provide a rational structure to the text, as well as an easy way for the reader to navigate which sections they would like to tackle first (although there is some overlap between sections). With this, the explicit and sustained focus on the ethics of control (section 1) is a welcome and differentiating feature of the text. Much prior work in animal ethics has addressed questions of harming and killing animals, but the ethical permissibility of control per se has received comparatively lesser attention.The multidisciplinary nature of the book is also a selling point. In any anthology on animal ethics, the reader can expect entries from academic philosophers, but the book's inclusion of empirical scientific reviews, sociological and legal analyses, and work in discourse analysis are strengths. One danger in focusing exclusively on what we ought to think and do is that it ignores the influences on how we actually think and act. Many of the book's entries address these influences and thus round out the normative analysis.The middle two sections of the book seem most successful to this reviewer. The section on the ethics of killing contains two well-argued conceptual chapters, coupled with practical analyses of fishing, deer hunting, and religious perspectives on killing nonhuman animals. While animal research and animal agriculture are not directly addressed in this section, the conceptual arguments can be applied to the killing of nonhuman animals in these contexts. The section on the ethics of captivity is not as conceptually strong but contains excellent empirical chapters on the welfare of elephants, whales, and dolphins in captivity. Prior work in normative ethics has established how confinement can be harmful to nonhuman animals by directly causing suffering or depriving them of opportunities for satisfaction (see, e.g., DeGrazia, 2002). However, it is important to complement such theoretical frameworks with substantiation of how captivity actually is harmful to nonhuman animals in virtue of the interests they have and how captivity infringes upon such interests. These chapters argue that captivity is fundamentally (and not conditionally) incompatible with the welfare of elephants, whales, and dolphins.If I have one criticism of the book, it is that it could be stronger on certain conceptual issues. Acknowledging its practical and not theoretical focus, it is nonetheless true that if controlling, confining, killing, and causing suffering to nonhuman animals is wrong, then it is important to say something about why it is wrong—even if that explanation amounts to a short synopsis of more theoretical work done elsewhere. While the question of killing is addressed well, the section on the ethics of causing suffering does not address directly why (or under what conditions) causing suffering is wrong. The chapters in this section are worthwhile reading and review practices causing animal suffering in a variety of contexts. Nonetheless, some additional conceptual front matter would have strengthened the section overall.From a conceptual standpoint, the sections on the ethics of control and captivity seem to hang together. Confinement is a form of control and might be argued against on the grounds that it deprives nonhuman animals of opportunities for satisfaction, directly causes physical injury, or causes psychological distress, anxiety, or boredom. These kinds of arguments fit into interest-based accounts of animal welfare, which in turn can be subsumed under a principle of nonmaleficence: We should not cause harm to animals under some specified set of conditions; confinement harms animals in ways x, y, or z; therefore, we should not confine animals in this way.While such interest-based arguments do make an appearance in the text, several of the book's authors also elaborate an autonomy-based argument against control and confinement: Nonhuman animals have their own kind of autonomy, and just as infringing upon the autonomy of paradigmatic persons is wrong, infringing upon nonhuman animals’ autonomy is also wrong. The problem with this argument is that different kinds of autonomy are likely to be at stake. The wrongness of infringing upon paradigmatic persons’ autonomy is often explained by the facts that we are self-conscious, capable of abstract thought (including language use), and capable of intentionally choosing the kind of life that we want to live (e.g., relating to long-term projects or schemes of personal ethics). It could be argued that because nonhuman animals are not capable of exercising this kind of autonomy, they therefore cannot be harmed by its infringement.Some of the book's authors chip away at this presumption, noting (inter alia) that nonhuman animals have desires to move around and do things that are thwarted by confinement or control, that these desires constitute a form of agency, and that (following previous scholarship) nonhuman animals possess some forms of self-awareness. Specifically, the chapters from Valéry Giroux and Carl Saucier-Bouffard, Lori Gruen, and Carlos Naconecy consider such arguments. Naconecy draws upon David DeGrazia's (2009) analysis of animal self-awareness in making his argument. Though the issue deserves more treatment than I can give it here, it seems that nonhuman animals’ autonomy and self-awareness, even if granted, are of a different sort than that possessed by paradigmatic persons. Specifically, (most) nonhuman animals cannot feel wronged by having their preferences overridden because they are not the kinds of beings who are capable of abstractly considering themselves as autonomous and worthy of self-direction. They may desire things, and thwarting these desires might sometimes harm them, but that is a different kind of argument.Infringing upon nonhuman animals’ (more limited kind of) autonomy might nonetheless be wrong, but if different sorts of autonomy are at stake, then moral arguments relating to paradigmatic persons cannot be directly transposed to nonhuman animals. Some additional argument(s) must be supplied, but (on my reading) the book's contributors stop short of this. Nonetheless, as stated above, the ethics of control and questions of nonhuman animals’ autonomy are not as well trod as other issues in animal ethics. Despite my taking issue with some of the details, the discussions contained in the book's first two sections are worthy reading and help to advance the field.Overall, the book's chapters are well written and cogently argued, and given its breadth, different readers will find different things to value in it. The Palgrave Handbook of Practical Animal Ethics is a welcome addition to the literature. (shrink)

As the prevalence of dementia rises, it is increasingly important to determine how to best respect incapable individuals' autonomy during end‐of‐life decisions. Many philosophers advocate for the use of advance directives in these situations to allow capable individuals to outline preferences for their future incapable selves. In this paper, however, I consider whether advance directives lack moral authority in instances of dementia. First, I introduce several scholars who have argued that changes in peoplewith dementia's values throughout disease progression (...) reduce the validity of their advanced wishes. I then outline Karin Jongsma's rejection of this claim, which she calls the “losing and choosing” distinction. Jongsma argues that changes in people with dementia's values should not be respected, because they are unchosen and dictated by the disease. I critique her claim that the process of value change is morally relevant when determining which values we respect. I argue that if individuals with dementia are capable of valuing, their contemporary values should be respected, even when they conflict with past preferences outlined in an advance directive. As such, situations of value change diminish the moral authority of advance directives for individuals with dementia. (shrink)

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. (...) Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications. (shrink)

In “On Avoiding Deep Dementia,” Norman Cantor astutely notes that, for some individuals, the concept of “protracted maintenance during progressive cognitive dysfunction and helplessness is an intolerably degrading prospect.” This cannot be argued with. Cantor's solution, however—that in the wake of a dementia diagnosis, patients should have the option to direct, in advance, instructions for voluntary stopping of eating and drinking should they develop a state of deep dementia—is more ethically challenging than it may first appear.Respect for autonomy is (...) one of the most fundamental principles of bioethics, and it requires that we allow patients with capacity to refuse life‐sustaining treatment, even when that treatment is something as seemingly innocuous as nutrition and hydration. If a capacitated person uses an advance directive to prospectively refuse artificial nutrition or hydration, then that treatment must be withheld if the person develops dementia and loses the ability or willingness to eat. Cantor is incorrect, however, in suggesting that an advance directive can require that nutrition and hydration be withheld from a patient with dementia who actively requests to eat or drink. Regardless of the language in an advance directive, caregivers cannot be compelled to abandon their duty to attend to the person's human dignity, nor can physicians be compelled to sedate a person with moderate or severe dementia because that person continues to be receptive to eating and drinking. (shrink)

When philosophers address personal identity, they usually explore numerical identity: what are the criteria for a person's continuing existence? When non-philosophers address personal identity, they often have in mind narrative identity: Which characteristics of a particular person are salient to her self-conception? This book develops accounts of both senses of identity, arguing that both are normatively important, and is unique in its exploration of a range of issues in bioethics through the lens of identity. Defending a biological view (...) of our numerical identity and a framework for understanding narrative identity, DeGrazia investigates various issues for which considerations of identity prove critical: the definition of death; the authority of advance directives in cases of severe dementia; the use of enhancement technologies; prenatal genetic interventions; and certain types of reproductive choices. He demonstrates the power of personal identity theory to illuminate issues in bioethics as they bring philosophical theory to life. (shrink)

Advance patient directives are various forms of anticipatory medical directives made by competent individuals for the eventuality of future incompetence. They are therefore appropriate instruments for competent patients in the early stage of Alzheimer's disease to document their self-determined will in the advanced stages of dementia. Theoretical objections have been expressed against the concept of advance patient directives (problems of authenticity and identity) which, however, cannot negate the fundamental moral authority of advance patient directives. Therefore, patients, family (...) members, and physicians should make use of the appropriate form of advance directive as part of common treatment and care planning. Advance directives, when utilized intelligently, represent appropriate instruments for shared decision-making by patient, family members and physician. They should be utilized to a greater extent, particularly for the treatment planning of demented patients. (shrink)

This paper explores the use of advance directives in clinical dementia research. The focus is on advance consent to participation of demented patients in non-therapeutic research involving more than minimal risks and/or burdens. First, morally relevant differences between advance directives for treatment and care, and advance directives for dementia research are discussed. Then attention is paid to the philosophical issue of dementia and personal identity, and the implications for the moral authority of research advance (...) directives. Thirdly, a number of practical shortcomings of advance directives for non-therapeutic dementia research are explored and attention is paid to the role of proxies. It is concluded that upon a closer look the initial attractiveness of advance directives for dementia research is lessened, and that it is doubtful whether these instruments can compensate for the lack of subject consent in case of non-therapeutic dementia research involving more than minimal risks and/or burdens for the incompetent demented subject. (shrink)

: In this paper, I consider objections to advance directives based on the claim that there is a discontinuity of interests, and of personal identity, between the time a person executes an advance directive and the time when the patient has become severely demented. Focusing narrowly on refusals of life-sustaining treatment for severely demented patients, I argue that acceptance of the psychological view of personal identity does not entail that treatment refusals should be overridden. Although (...) severely demented patients are morally considerable beings, and must be kept comfortable whilst alive, they no longer have an interest in receiving life-sustaining treatment. (shrink)

It has often been claimed that orthodox thinking about personal identity undermines the moral authority of advance directives in dementia by implying that the signer of the directive is numerically different from the severely demented patient. This is the ‘identity problem'. I introduce the problem, outline some well‐known solutions, and explain why they might be deemed unattractive. I then propose an alternative solution. It promises to be compatible with orthodox thinking about personal identity. I discuss three ways (...) in which it might be challenged and find that none is convincing. Personal identity is no bar to the moral authority of advance directives. (shrink)

Advance directives (ADs), which are also sometimes referred to as ‘living wills’, are statements made by a person that indicate what treatment she should not be given in the event that she is not competent to consent or refuse at the future moment in question. As such, ADs provide a way for patients to make decisions in advance about what treatments they do not want to receive, without doctors having to find proxy decision-makers or having recourse to the (...) doctrine of necessity. While patients can request particular treatments in an AD, only refusals are binding. This paper will examine whether ADs safeguard the autonomy and best interests of the incompetent patient, and whether legislating for the use of ADs is justified, using the specific context of the legal situation in the United Kingdom to illustrate the debate. The issue of whether the law should permit ADs is itself dependent on the issue of whether ADs are ethically justified; thus we must answer a normative question in order to answer the legislative one. It emerges that ADs suffer from two major problems, one related to autonomy and one to consent. First, ADs’ emphasis on precedent autonomy effectively sentences some people who want to live to death. Second, many ADs might not meet the standard criteria for informed refusal of treatment, because they fail on the crucial criterion of sufficient information. Ultimately, it transpires that ADs are typically only appropriate for patients who temporarily lose physical or mental capacity. (shrink)

In this article I revisit earlier stages of the discussion of personal identity, before Neo-Lockean psychological continuity views became prevalent. In particular, I am interested in Bernard Williams’ initial proposal of bodily identity as a necessary, although not sufficient, criterion of personal identity. It was at this point that psychological continuity views came to the fore arguing that bodily identity was not necessary because brain transplants were logically possible, even if physically impossible. Further proposals (...) by Shoemaker of causal relations between mental states in our memory and Parfit’s discussion of branching causal chains created additional complications. My contention in this paper is that psychological continuity views deflected our attention from what should have remained in the spotlight all the time: the intersubjective character (or not) of criteria proposed to decide personal identity in our language game, and ultimately our form of life concerning ourselves as persons. B. Williams’ emphasis on the body was not just common sense. It was also recognition of the importance of giving priority to criteria that could be kept under intersubjective control. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 161-167 [Access article in PDF] Social, Cognitive, and Neural Constraints on Subjectivity and Agency:Implications for Dissociative Identity Disorder Peter Q. Deeley In this commentary, I consider Matthew's argument after making some general observations about dissociative identity disorder (DID). In contrast to Matthew's statement that "cases of DID, although not science fiction, are extraordinary" (p. 148), I believe that there are natural analogs of (...) the disorder that, when considered, make it seem less puzzling and exotic. After discussing these examples, I examine the relations between social, cognitive, and neural processes supporting subjectivity and agency, to identify sources of personal identity in cases of DID that can be used as a basis for assessing Matthew's points against Behnke and Sinnott-Armstrong. I am not proposing a comprehensive theory, but rather identifying what I believe are components of such a theory. I then outline an approach to determining criminal responsibility in DID, drawing on analogies with other psychiatric disorders. Dissociative Identity Disorder DID is a disorder described in DSM-IV, which "is characterised by the presence of two or more distinct identities or personality states that recurrently take control of the individual's behaviour accompanied by an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness" (American Psychiatric Association, p. 519). Recognizing Personal Identity How is personal identity recognized in normal cognition? If we take personhood to involve recognition of continuity of social, psychological, and physical identity for a given individual, then such judgments are routinely made rapidly and automatically as an aspect of what has come to be termed social cognition (Adolphs 2003). There is likely to be considerable redundancy in [End Page 161] the types of information used to make judgments about whether a person is the same as one who was previously encountered, or perhaps heard about—for example, facial features, movement patterns, speech prosody, dress, speech content, gender, ethnicity, social role, among other features, all provide information about individual identity, and hence personhood. When uncertainty exists, it is likely to reflect a loss or alteration of cues that would ordinarily be used in a rapid, automatic, unexamined way (Adolphs 2003). In such extreme cases (for example, severe mental illness or disfigurement), the problem of identification becomes the subject of explicit reasoning (and hence of potential disagreement, because we then engage in post hoc rationalizations to establish criteria for determining personhood, whereas normally we rely on essentially automatic, implicit abilities that work in most circumstances, some of which make little use of linguistic representations and formal reasoning—for example, individual facial identity recognition, which may occur as quickly as 170 ms after stimulus onset [Adolphs 2003]). Nevertheless, examining our judgments and intuitions in cases that force us to explicitly consider whether personal identity is preserved may provide analogies and clues for how we should proceed with DID. Let us consider, then, some natural analogs of DID. Natural Analogs of DID Method Acting I suggest that method acting is an analog of DID (Manderino 1985). Method acting refers to an approach to acting training and performance in which emphasis is placed on intensely imagining and identifying with the mental life of the character being portrayed. Training courses and manuals list many techniques and practices that can be used to facilitate absorption in a role, drawing on different kinds of memory—for example, experiential memories, memories of others, general knowledge (semantic memory), and memories of sensations and feelings, to creative a vivid sense of the subjective experience and actions of the character. Manderino, a method acting teacher, comments: "it is important to investigate the way in which your own mental makeup can improperly influence a character. Insecurities, self-consciousness, shyness or self-doubts can maintain a strong hold, and permitting any of these feelings to enter a performance is to remain the actor and not enter into the mental life of the character. For some, acting allows personal problems to be left behind, and they are thankful for the complete escape that... (shrink)

Jeff McMahan's impressive recent defence of the embodied mind theory of personal identity in his highly acclaimed work The Ethics of Killing has undoubtedly reawakened belief that physical continuity is a necessary component of the relation that matters in our self-interested concern for the future. My aim in this paper is to resist this belief in a somewhat roundabout way. I want to address this belief in a somewhat roundabout way by revisiting a classic defence of the (...) belief that enormous changes in the contents of a person's psychology does not preclude justified fear of future pain. I have in mind Bernard Williams' The Self and the Future (1970) in which he argues, against the psychological view, that physical continuity is necessary for survival. I examine Williams' second thought experiment which ostensibly supports that intuition and afterwards defend two related claims. First, I argue that a close examination of the second thought experiment reveals that one's prior commitments to a particular criterion of personal identity can influence one's response to that thought experiment. Second, I argue that Williams' second thought experiment is set out in questionbegging terms. I do not claim, however, that the intuition under consideration lacks justification; I only claim that Williams' second thought experiment does not provide the needed support. (shrink)

If personal identity consists in non-branching psychological continuity, then the sharp breaks in psychological connectedness characteristic of Multiple Personality Disorder implicitly commit psychological continuity theories to a metaphysically extravagant reification of alters. Animalist theories of personal identity avoid the reification of alternate personalities by interpreting multiple personality as a failure to integrate alternative autobiographical memory schemata. In the normal case, autobiographical memory cross-classifies a human life, and in so doing provides access to a (...) variety of interpretative frameworks with their associated clusters of general event memory and episodic memory. Multiples exhibit erratic behavior because they cannot access reliably the intersecting autobiographical memory schemata that permit graceful transitions between social roles, behavioral repertoire and emotional dispositions. Selves, in both normal and certain pathological cases, are best understood as semi-fictional narratives created by human animals to serve their social, emotional and physical needs. (shrink)

This book relates work in neuroscience, psychology and psychiatry to questions about what a person is and the nature of a persons unity across a lifetime. The neuropsychiatry is now dated. The philosophy has three themes still perhaps of interest. The first is a response to Derek Parfits powerful and influential work on personal identity, which, like many other people, I discussed with him as he worked it out. I accept his view that there is no ego that owns (...) the stream of our experiences, and the unity of a person over time is constructed out of continuities in our mental life. But I argue against Parfits view that personal unity thereby becomes less deep or less morally important. The second theme is an emphasis on the importance of self-creation and an attempt to work out how far it is possible. The third theme is about the way self-creation is linked to recognition by other people, and the importance of this for understanding the role of tribalism in human life. "This book is about what it is to be a person, to think of oneself as an "I". It is about the ways people think of themselves, and how they use these ideas in shaping their own distinctive characteristics. It is about how far we create ourslves." "When a way of life does not fit with what you think you are really like, you can feel like a plant away from the light, distorted by having to twist and grope towards the sun. This analogy suggests that we might have a genetic programme to unfold, in the way plants do. But no doubt it is too simple to think that "the real me" is genetically laid down. These strong affinities we have for some kinds of life, and the sense of drowning that others give us, are likely to have been created by the interaction of our genetic make-up with thigs we have come across and responded to... We care a bit like trees would be, if they were conscious and could partly choose their direction of growth. Perhaps oaks could not become beeches, and stunted trees could not become giants, but they could influence the angle and direction of their branches. Trees thinking about determinism and free will might find it impossible to assess their own contribution to their final shape.". (shrink)

This article reassesses the notion of personal identity over time from a Heideggerian perspective, aiming to bridge the conceptual gap between concerns for personhood and continuity. Traditional approaches, including the psychological and moral approaches to the self, often inadequately address the relationship between personhood and temporal continuity. This article establishes an understanding of personhood as social agency, contending that this perspective encompasses both conceptual dimensions central to the question of personal identity over time. Following an (...) initial exploration of the problem (§ 2), a concept of social agency rooted in Heidegger’s notion of Dasein is developed in comparison with alternative conceptions of personhood (§ 3). Subsequently, drawing on Arthur Danto’s philosophy of history, Heidegger’s perspective on personal identity over time is examined with a focus on historicity (§ 4). Lastly, this account is compared with contemporary views on personhood and identity over time (§ 5). (shrink)

Some of the concerns that have been raised in connection to the use of advance directives are of the epistemic variety. Such concerns highlight the possibility that adhering to an advance directive may conflict with what the author of the directive actually wants at the time of treatment. However, at least one objection to the employment of advance directives is metaphysical in nature. The objection to be discussed here, first formulated by Rebecca Dresser and labeled by Allen (...) Buchanan as the slavery argument and David DeGrazia the someone else problem, aims to undermine the legitimacy of certain uses of advance directives by concluding that such uses rest upon an incorrect assumption about the identity over time of those ostensibly governed by the directives. There have been numerous attempts to respond to this objection. This paper aims to assess two strategies that have been pursued to cope with the problem. (shrink)

Advance directives for withholding life-saving treatment are controversial for dementia patients whose previously expressed wishes conflict with their currently expressed desires. To illustrate this ethical dilemma, McMahan conceives a hypothetical case in which an intellectually proud creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition with dementia. However, when she develops dementia and forgets this advance directive, she contracts pneumonia and now expresses a desire to live. In (...) response to such dilemmas, scholars like Norman Cantor have defended the moral authority of advance directives by giving credence to one’s prior competent wishes over one’s current incompetent preferences. I argue that their arguments, which are rooted in the principle of respect for autonomy, operate under ableist assumptions about incompetent persons and exclude other important features of respect. I propose an ethics of care model as an alternative moral approach that reconceptualises respect as a matter of caring about people’s contemporaneous interests, even if they are not competently conceived. It fosters the virtues of care by encouraging healthcare providers to recognise dementia patients as legitimate narrative agents capable of authoring their own evolving life story. I argue that the ethics of care model not only provides an ethical defence of the creative woman’s current incompetent desire to live despite her advance directive, but also vindicates our moral intuitions about what it means to demonstrate respect to dementia patients. (shrink)