Advance directives, dementia, and 'the someone else problem'

Bioethics

Volumn 13, Issue 5, 1999, Pages 373-391

  Degrazia, David ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

DEMENTIA; IDENTITY; MEDICAL CARE; MEDICAL DECISION MAKING; PATIENT ATTITUDE; PATIENT CARE; REVIEW; SELF CONCEPT;

EID: 0032853051     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/1467-8519.00166     Document Type: Review

References (53)

1. My thanks to David Wasserman and Robert Wachbroit for helpful discussions of some of the issues discussed in this paper. A draft was presented on May 12, 1998 at the Kennedy Institute of Ethics, Georgetown University, where the feedback of attendees, especially Madison Powers and John Hasnas, was quite helpful. I would also like to acknowledge the insightful comments of two reviewers for Bioethics, Julian Savulescu and another who remains anonymous.
2. I use the terms 'competence' and 'decision-making capacity' interchangeably, while recognizing that some may find it useful to distinguish the terms for certain purposes.
3. These instructions can either specify types of care to be provided or withheld, designate an individual to serve as a proxy decision-maker, or both. For simplicity, I will focus on the care-specifying aspect of advance directives.
4. While health care providers can educate patients about common medical conditions such as dementia, arguably no amount of education would have fully informed the man what it would be (or feel) like for him to be demented. Of course, such incomplete information - and therefore imperfect understanding - characterizes all medical decisions involving new conditions or experiences, not just those concerning future conditions of incompetence. Thus, someone who consents to chemotherapy, having never undergone it before, is not fully informed regarding the consequences of this treatment. Fortunately, what is needed for informed consent is substantial, not perfect, understanding of treatment options and their likely consequences (see Ruth R. Faden and Tom L. Beauchamp, A History and Theory of Informed Consent [New York: Oxford University Press, 1986], pp. 251-53). The present concern about advance directives is that even substantial understanding is often hard to come by.
5. This summary draws from the American Psychiatric Association, Diagnostic Criteria from DSM-IV (Washington, DC: APA, 1994), pp. 85-93.
6. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
7. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
8. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
9. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
10. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
11. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
12. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
13. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
14. The classic statement is found in John Locke, Essay Concerning Human Understanding, 2nd ed. (1694), Bk. II, ch. 27. An early twentieth-century effort to refine Locke's view that did not generate much discussion at the time is found in H.P. Grice, 'Personal Identity,' Mind 50 (1941): 330-50. More distinctively contemporary versions of this broadly Lockean approach - within which there is considerable variety of theoretical detail - appear, for example, in Sidney Shoemaker, 'Persons and Their Pasts,' American Philosophical Quarterly 7 (1970): 269-85; John Perry, 'Can the Self Divide?', Journal of Philosophy 69 (1972): 463-88; David Lewis, 'Survival and Identity,' in Amelie Rorty (ed.), The Identities of Persons (Berkeley: University of California Press, 1976): 17-40; Robert Nozick, Philosophical Explanations (Cambridge, MA: Harvard University Press, 1981), ch. 1; Derek Parfit, Reasons and Persons (Oxford: Clarendon, 1984); Harold W. Noonan, Personal Identity (London: Routledge, 1989); and Raymond Martin, Self-Concern (Cambridge: Cambridge University Press, 1998).
15. I defend my own view of what persons are in 'Great Apes, Dolphins, and the Concept of Personhood,' Southern Journal of Philosophy 35 (1997): 301-20.
16. A at one time is numerically identical with B at a later time if and only if they are one and the same entity; such identity is logically compatible with significant qualitative change in the entity over time. Thus a house may persist over a hundred years even if the old house is qualitatively very dissimilar from the house as it was originally. By contrast, pieces of paper may be qualitatively similar (in principle, even identical), but they are not numerically identical if they are different objects. Hereafter, 'identical' and 'the same' will be elliptical for 'numerically identical' and 'numerically the same,' respectively.
17. See the twentieth-century works cited in note 6 for some efforts to characterize psychological continuity.
18. See, e.g., Rebecca Dresser, 'Life, Death, and Incompetent Patients: Conceptual Infirmities and Hidden Values in the Law,' Arizona Law Review 28 (1986): 373-405.
19. Cf. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge: Cambridge University Press, 1989), pp. 157-58. Also, in real-life clinical scenarios, if A (who wrote the directive) and B (who is demented) both qualify as persons, it seems doubtful that they would fail to be the same person. For example, even if person B could not remember life as person A, B would probably have many overlapping chains of memory that extend bit by bit to that earlier time. Moreover, A probably had some plans and intentions (a few of which are stated in the advance directive) that extend into the future that B occupies. B is also likely to retain many beliefs and skill memories (e.g., regarding the meaning of words), and at least some desires and character traits, from the days of A.
20. I am strongly inclined to attribute this reasoning to Buchanan and Brock, who consider cases like Granny's, in which the severely demented individual is judged to be a nonperson (Deciding for Others, pp. 162-66). The authors, who hold that persons are beings with the capacity for complex forms of consciousness (pp. 159-60) and that psychological continuity is at least necessary for personal identity (pp. 155-56), refer repeatedly to the demented nonperson as a 'successor' to the agent of the directive (pp. 164, 166), which agent 'no longer exists' (p. 162). Whether or not this reasoning is correctly ascribed to Buchanan and Brock, they clearly hold that the fact that the severely demented individual is not the same person (because not a person at all) as the author of the directive raises an issue about the authority of the directive. And they never explicitly note either (1) the possibility that the person and demented nonperson might be the same individual, even if not the same person, or (2) the assumption, stated immediately below, that would justify the conclusion that they are not the same individual.
21. Interestingly, Locke's discussion of identity does not suggest that we are essentially persons - or anything else. Locke not only distinguishes personal identity from the identity of 'man' (humans) (Essay, Bk. II, ch. 27, sects. 6-10); he also distinguishes identity of substance, thinking it likely that our 'consciousness is annexed to, and the affection of, one individual immaterial substance,' (sect. 25; see also sect. 2). By contrast, E. J. Lowe accepts both the Lockean thesis of what persons are and the thesis that we are essentially persons, but takes personal identity to consist in identity of substance ('Real Selves: Persons as a Substantial Kind,' in David Cockburn [ed.], Human Beings [Cambridge: Cambridge University Press, 1991]: 87-107).
22. See, e.g., Nozick, Philosophical Explanations, pp. 78-79.
23. Consider, for example, Parfit's Reason and Persons. Throughout the book, Parfit discusses criteria for personal identity over time and criteria for our identity over time, generally treating the two issues as if they were the same. Thus he holds that our identity is a function of psychological continuity (p. 216). But, in discussing a view he rejects - that each of us is a Cartesian ego -he distinguishes our identity from that of a putative ego (pp. 227-28). Parfit never explicitly notes or discusses criteria of identity for any ontological category, other than persons, that he thinks we instantiate. (In one place, he notes the possibility of distinguishing a person and a human being, and implies different criteria of identity by stating that, arguably, the person comes into existence after the human being and can fade away before the human being dies (pp. 322-23). Even here he never claims that we exist as mere human beings; nor does he state that he endorses the distinction between human beings and persons.) So everything he says about our identity is consistent with person essentialism. The same tendency to treat our identity as personal identity, without noting any competition from other ontological categories that we instantiate, is found in the works of at least most of the other contemporary representatives of the Psychological View. Some of them also hold that, if one's mental contents were erased from one's (original) brain and then transferred in some reliable way to another brain, one would now be the person with the second brain even if the first body continued to live. On this view, then, if your continuing psychological and living body part ways, you go where your mind goes. (See, e.g., Sydney Shoemaker, 'Personal Identity: A Materialist's Account,' in Shoemaker and Richard Swinburne [eds.], Personal Identity [Oxford: Blackwell, 1984], pp. 108-9.) The last claim fits very comfortably with, and would be explained by, the thesis that we are essentially persons.
24. See, e.g., Edward T. Bartlett and Stuart J. Youngner, 'Human Death and the Destruction of the Neocortex,' in Richard M. Zaner (ed.), Death: Beyond Whole-Brain Criteria (Dordrecht, Netherlands: Kluwer, 1988), pp. 210-11; Roland Puccetti, 'Does Anyone Survive Neocortical Death?', in Zaner, Death, pp. 84-85, 87; Richard M. Zaner, 'Brains and Persons: A Critique of Veatch's View,' in Zaner, Death, pp. 190-1; H. Tristam Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), pp. 241-50; and Ben A. Rich, 'Postmodern Personhood: A Matter of consciousness,' Bioethics 11 (1997), p. 212.
25. See, e.g., Edward T. Bartlett and Stuart J. Youngner, 'Human Death and the Destruction of the Neocortex,' in Richard M. Zaner (ed.), Death: Beyond Whole-Brain Criteria (Dordrecht, Netherlands: Kluwer, 1988), pp. 210-11; Roland Puccetti, 'Does Anyone Survive Neocortical Death?', in Zaner, Death, pp. 84-85, 87; Richard M. Zaner, 'Brains and Persons: A Critique of Veatch's View,' in Zaner, Death, pp. 190-1; H. Tristam Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), pp. 241-50; and Ben A. Rich, 'Postmodern Personhood: A Matter of consciousness,' Bioethics 11 (1997), p. 212.
26. See, e.g., Edward T. Bartlett and Stuart J. Youngner, 'Human Death and the Destruction of the Neocortex,' in Richard M. Zaner (ed.), Death: Beyond Whole-Brain Criteria (Dordrecht, Netherlands: Kluwer, 1988), pp. 210-11; Roland Puccetti, 'Does Anyone Survive Neocortical Death?', in Zaner, Death, pp. 84-85, 87; Richard M. Zaner, 'Brains and Persons: A Critique of Veatch's View,' in Zaner, Death, pp. 190-1; H. Tristam Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), pp. 241-50; and Ben A. Rich, 'Postmodern Personhood: A Matter of consciousness,' Bioethics 11 (1997), p. 212.
27. See, e.g., Edward T. Bartlett and Stuart J. Youngner, 'Human Death and the Destruction of the Neocortex,' in Richard M. Zaner (ed.), Death: Beyond Whole-Brain Criteria (Dordrecht, Netherlands: Kluwer, 1988), pp. 210-11; Roland Puccetti, 'Does Anyone Survive Neocortical Death?', in Zaner, Death, pp. 84-85, 87; Richard M. Zaner, 'Brains and Persons: A Critique of Veatch's View,' in Zaner, Death, pp. 190-1; H. Tristam Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), pp. 241-50; and Ben A. Rich, 'Postmodern Personhood: A Matter of consciousness,' Bioethics 11 (1997), p. 212.
28. See, e.g., Edward T. Bartlett and Stuart J. Youngner, 'Human Death and the Destruction of the Neocortex,' in Richard M. Zaner (ed.), Death: Beyond Whole-Brain Criteria (Dordrecht, Netherlands: Kluwer, 1988), pp. 210-11; Roland Puccetti, 'Does Anyone Survive Neocortical Death?', in Zaner, Death, pp. 84-85, 87; Richard M. Zaner, 'Brains and Persons: A Critique of Veatch's View,' in Zaner, Death, pp. 190-1; H. Tristam Engelhardt, Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), pp. 241-50; and Ben A. Rich, 'Postmodern Personhood: A Matter of consciousness,' Bioethics 11 (1997), p. 212.
29. Here I find common cause with Eric T. Olson, who argues that defenders of a broadly Lockean view usually assume without question that person is a 'substance concept' - a fundamental answer to the question of what kind of thing something is (The Human Animal: Personal Identity Without Psychology [New York: Oxford University Press, 1997], p. 27).
30. I address this issue in Taking Animals Seriously: Mental Life and Moral Status (Cambridge: Cambridge University Press, 1996), pp. 129-83.
31. At least not during our known existence: an afterlife as something other than an animal, such as a spirit, seems logically possible (though I suspect it is contrary to the laws that govern the actual world). Presumably, we could not exist as dead animals or corpses. When we die, assuming there is no afterlife, we no longer exist.
32. Person essentialism can be accepted by one who rejects the Psychological View and holds that persons are beings with an immortal soul, a human genetic code, or some other distinguishing feature. But I restrict my discussion of person essentialism to the position that also embraces the Psychological View, because the latter dominates the literature on persons and their identity (and I find its two theses rather plausible).
33. Olson, The Human Animal. Another formidable, but very different, challenge to some aspects of the Psychological View - including the claim that psychological continuity is essential to the numerical identity of persons - may be found in Marya Schechtman, The Constitution of Selves (Ithica, NY: Cornell University Press, 1996).
34. I make this argument in 'Biology, Consciousness, and the Definition of Death,' Report from the Institute for Philosophy and Public Policy 18 (Winter/Spring 1998), p. 20; it is further developed in 'Persons, Organisms, and Death: A Philosophical Critique of the Higher-Brain Approach', Southern Journal of Philosophy 37 (forthcoming fall 1999)
35. I make this argument in 'Biology, Consciousness, and the Definition of Death,' Report from the Institute for Philosophy and Public Policy 18 (Winter/Spring 1998), p. 20; it is further developed in 'Persons, Organisms, and Death: A Philosophical Critique of the Higher-Brain Approach', Southern Journal of Philosophy 37 (forthcoming fall 1999)
36. It does not follow, by the way, that newborns lack moral status. That conclusion follows only if we assume that all nonpersons lack moral status. Elsewhere I have argued that that assumption, however traditional, is indefensible (Taking Animals Seriously, ch. 3).
37. See Olson, The Human Animal, pp. 79-81.
38. ibid, pp. 88-89. One might argue that this statement begs the question of the definition of death, since permanent loss of the capacity for consciousness is death according to the higher-brain standard of human death. But proponents of the higher-brain approach nearly always concede - rightly, I think - that organismic life continues in permanent coma or PVS; they distinguish personal death and human organismic death. (See, e.g., Richard M. Zaner, 'Introduction,' in Zaner [ed.], Death, p. 7; Bartlett and Youngner, 'Human Death and the Destruction of the Neocortex,' p. 211; and Engelhardt, The Foundations of Bioethics, p. 248.) Moreover, even higher-brain theorists do not claim that severely demented individuals are dead.
39. ibid, pp. 88-89. One might argue that this statement begs the question of the definition of death, since permanent loss of the capacity for consciousness is death according to the higher-brain standard of human death. But proponents of the higher-brain approach nearly always concede - rightly, I think - that organismic life continues in permanent coma or PVS; they distinguish personal death and human organismic death. (See, e.g., Richard M. Zaner, 'Introduction,' in Zaner [ed.], Death, p. 7; Bartlett and Youngner, 'Human Death and the Destruction of the Neocortex,' p. 211; and Engelhardt, The Foundations of Bioethics, p. 248.) Moreover, even higher-brain theorists do not claim that severely demented individuals are dead.
40. ibid, pp. 88-89. One might argue that this statement begs the question of the definition of death, since permanent loss of the capacity for consciousness is death according to the higher-brain standard of human death. But proponents of the higher-brain approach nearly always concede - rightly, I think - that organismic life continues in permanent coma or PVS; they distinguish personal death and human organismic death. (See, e.g., Richard M. Zaner, 'Introduction,' in Zaner [ed.], Death, p. 7; Bartlett and Youngner, 'Human Death and the Destruction of the Neocortex,' p. 211; and Engelhardt, The Foundations of Bioethics, p. 248.) Moreover, even higher-brain theorists do not claim that severely demented individuals are dead.
41. ibid, pp. 88-89. One might argue that this statement begs the question of the definition of death, since permanent loss of the capacity for consciousness is death according to the higher-brain standard of human death. But proponents of the higher-brain approach nearly always concede - rightly, I think - that organismic life continues in permanent coma or PVS; they distinguish personal death and human organismic death. (See, e.g., Richard M. Zaner, 'Introduction,' in Zaner [ed.], Death, p. 7; Bartlett and Youngner, 'Human Death and the Destruction of the Neocortex,' p. 211; and Engelhardt, The Foundations of Bioethics, p. 248.) Moreover, even higher-brain theorists do not claim that severely demented individuals are dead.
42. See Olson, The Human Animal, p. 94
43. If so, we are also essentially organisms, since animals are a kind of organism. That we are essentially animals receives some support from the intuition that I could not be transformed into a plant; if I entered some hightech machine and only a plant came out, presumably I would have died in the process. I am open to the possibility, however, that we are not essentially homo sapiens. If I entered a machine that caused just enough mutations to yield a member of the homo erectus species, I might be able to survive such changes and be that homo erectus (whether or not I would be proud of the changes).
44. Locke apparently thought so, although he also distinguishes the category of a substance (see note 13). Mark Thornton argues that Locke's view is 'a keen insight into our dual nature, as human beings and as persons,' ('Same Human Being, Same Person?', Philosophy 66 [1991], p. 118). The significance of this view is brought out by considering this question: If my cerebrum were successfully transplanted into a fresh corpse, which became animated, and the rest of my original body, including the brainstem, continued to breathe, maintain heartbeat, metabolize, and so on spontaneously, where would I be? There is a definite answer only if we have an essence. If not, then we might say that I-qua-person go with the functioning cerebrum (assuming psychological continuity is maintained), while I-qua-animal remain with the original body (since retention of a cerebrum is not necessary for a body to continue living). It is interesting to note that even I-qua-person continue to exist as an animal in this scenario, only not as the original animal. If there are no factually possible situations in which we continue to exist as something other than an animal, that would support the thesis that we are essentially animals (see immediately below).
45. Olson, who argues that we are essentially organisms, suggests this criterion of identity: 'For any organism x and any y, x = y if and only if x's life is y's life,' (The Human Animal, p. 138).
46. Jocelyn Downie points out that integrated functioning arguably occurs no sooner than the point of segmentation at the eight-cell stage; before then, the cells are functionally equivalent and do not work together in any real sense ('Brain Death and Brain Life: Rethinking the Connection,' Bioethics 4 [1990], pp. 219-20). Cf. Norman M. Ford, When Did I Begin? (Cambridge: Cambridge University Press, 1988), pp. 170-73.
47. Jocelyn Downie points out that integrated functioning arguably occurs no sooner than the point of segmentation at the eight-cell stage; before then, the cells are functionally equivalent and do not work together in any real sense ('Brain Death and Brain Life: Rethinking the Connection,' Bioethics 4 [1990], pp. 219-20). Cf. Norman M. Ford, When Did I Begin? (Cambridge: Cambridge University Press, 1988), pp. 170-73.
48. Although Parfit generally runs together the issues of personal identity and of our identity (see note 15), he ultimately argues that psychological continuity matters much more than identity (Reasons and Persons, ch. 13). He can distinguish the two, despite working within the Psychological View, because psychological continuity is not sufficient for identity; the continuity must take a non-branching form and have the right kind of cause (p. 207). In a highly original contribution, Schechtman urges us to refocus our attention away from numerical identity, a metaphysical relation she claims has little importance, to the sense of identity captured in the phrase 'identity crisis,' a sense close to that of 'self-concept' or 'sense of self' (The Constitution of Selves).
49. They may also be identical qua selves and qua subjects (see above) depending on how identity criteria for these categories are specified.
50. I make the point in 'Biology, Consciousness, and the Definition of Death' and further develop it in 'Persons, Organisms, and Death.' Of course, an anti-essentialist might argue that personhood is what matters, so that its loss justifies a declaration of death - though I doubt such an argument will be persuasive.
51. I defend this thesis - and the more specific claim that Great Apes, dolphins, and some humans are borderline persons - in 'Great Apes, Dolphins, and the Concept of Personhood.'
52. Cf. Olson, The Human Animal, pp. 71-72.
53. ibid, p. 83