Decisions about brain surgery pose existential challenges because they are often decisions about life or death, and sometimes about possible personality changes. Therefore they require rigorous neuroethical consideration. However, we doubt whether metaphysical interpretations of ambiguous statements of patients are useful for deriving ethical and legal conclusions. Particularly, we question the application of psychological theories of personal identity on neuroethical issues for several reasons. First, even the putative “standard view” on personal identity is contentious. Second, diverse accounts of personal identity (...) have been introduced into the neuroethical debate, which are incompatible. Third, the criteria for “diagnosing” the supposed changes in “identity” are ambiguous and indeterminate. Fourth, the metaphysical theories of personal identity imply highly questionable ethical and legal revisions, namely the denial of advance directives, particularly of Ulysses contracts, and, for patients with brain cancer, even therapeutic nihilism.We discuss three examples in which ideas from the personal identity debate in metaphysics are straightforwardly applied to discuss ethical issues of neurosurgery. We discuss revisions of the current medico-legal practice that have been proposed on grounds of psychological theories of personal identity. We argue that the established status quo in law and clinical practice is beneficial to the patients concerned. Furthermore, it is metaphysically neutral, which is an important principle of liberal, democratic, pluralistic societies.We recommend a pragmatic approach: empirical research on personality changes arising from brain disorders or interventions, comprehensive information about risks of personality changes, and advance directives, particularly Ulysses contracts. (shrink)

Although advance directives are widely believed to be a key way to safeguard the autonomy of incompetent medical patients, significant questions exist about their moral authority. The main philosophical concern involves cases in which an incompetent patient no longer possesses the desires on which her advance directive was based. The question is, does that entail that prior expressions of medical choices are no longer morally binding? I believe that the answer is “yes.” I argue that a patient’s autonomy is not (...) respected by honoring the desires she used to have but no longer does. I also consider and reject the view that honoring an advance directive that reflects the patient’s previous values must be in that patient’s best interests. If that is correct, then advance directives in the kind of case at issue are not morally binding. (shrink)

Implant ethics is defined here as the study of ethical aspects of the lasting introduction of technological devices into the human body. Whereas technological implants relieve us of some of the ethical problems connected with transplantation, other difficulties arise that are in need of careful analysis. A systematic approach to implant ethics is proposed. The major specific problems are identified as those concerning end of life issues (turning off devices), enhancement of human capabilities beyond normal levels, mental changes and personal (...) identity, and cultural effects. (shrink)

In a Ulysses contract, A gets B, at t1, to agree (i) to act at t2 in such a way that A is made to abide by her own earlier intentions and (ii) to ignore A’s later attempt to rescind the authorization. But why does A’s will at t2 lack the authority it had at t1? This article makes the case that a person has authority to enter a Ulysses contract only insofar as her expressed will at t1 is a (...) better expression of the values that remain attributable to her at t2 than is her expressed will at t2. (shrink)

Ulysses contracts are a method by which one person binds himself by agreeing to be bound by others. In medicine such contracts have primarily been discussed as ways of treating people with episodic mental illnesses, where the features of the illness are such that they now judge that they will refuse treatment at the time it is needed. Enforcing Ulysses contracts in these circumstances would require medical professionals to override the express refusal of the patient at the time treatment is (...) required, something that is generally problematic both ethically and legally. In this paper I will argue that despite appearances Ulysses contracts can make it the case that treating a patient in such circumstances is an instance of treating him with his consent, although safeguards are needed to ensure that this is the case. Given the potential benefits to patients I further argue that modified Ulysses contracts should be made legally enforceable. (shrink)

I examine current models of self-destructive addictive behaviour, and argue that there is an important place for Ulysses contracts in coping with addictive behaviour that stems from certain problematic preference structures. Given the relevant preference structures, interference based on a Ulysses contract need not involve questionably favouring an agent’s past preferences over her current preferences, but can actually be justified in terms of the agent’s current concerns and commitments.

A challenge has recently been levelled against the legal and/or moral legitimacy of some advance directives. It has been argued that in certain cases an advance directive carries no weight in a decision on whether to withhold treatment, since the individual in the debilitating state is not the same person as the person who created the advance directive. In the first section of this paper, I examine two formulations of the argument against the moral legitimacy of the advance directives under (...) review. The second section reviews, and criticizes, an objection to such arguments. In the penultimate section, possible models supporting the viability of the advance directives are considered. The final section makes good on an obligation incurred by the title of the paper. (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)

In this paper, I focus on a kind of medical intervention that is at the same time fascinating and disturbing: identity-changing interventions. My guiding question is how such interventions can be ethically justified within the bounds of contemporary bioethical mainstream that places great weight on the patient9s informed consent. The answer that is standardly given today is that patients should be informed about the identity effects, thus suggesting that changes in identity can be treated like ‘normal’ side effects. In the (...) paper, I argue that this approach is seriously lacking because it misses important complexities going along with decisions involving identity changes and consequently runs into mistakes. As a remedy I propose a new approach, the ‘perspective-sensitive account’, which avoids these mistakes and thus provides the conceptual resources to systematically reflect on and give a valid consent to identity-changing interventions. (shrink)

Ordinary Language Philosophy has largely fallen out of favour, and with it the belief in the primary importance of analyses of ordinary language for philosophical purposes. Still, in their various endeavours, philosophers not only from analytic but also from other backgrounds refer to the use and meaning of terms of interest in ordinary parlance. In doing so, they most commonly appeal to their own linguistic intuitions. Often, the appeal to individual intuitions is supplemented by reference to dictionaries. In recent times, (...) Internet search engine queries for expressions of interest have become quite popular. Apparently, philosophers attempt to surpass the limits of their own linguistic intuitions by appealing to experts or to factual uses of language. I argue that this attempt is commendable but that its execution is wanting. Instead of appealing to dictionaries or Internet queries, philosophers should employ computer-based linguistic corpora in order to confirm or falsify hypotheses about the factual use of language. This approach also has some advantages over methods employed by experimental philosophers. If the importance of ordinary language is stressed, the use of linguistic corpora is hardly avoidable. (shrink)

Is a theory of identity necessary for bioethics? In this paper I investigate that question starting from an empirical explication of identity based on post-genomics, in particular on epigenetics. After analysing whether the classic problems a theory of identity has to cope with also affect the proposed epigenetic account of identity, I deal with three topics to offer an insight on the relationship between that account and bioethics.

Advances in brain–brain interface technologies raise the possibility that two or more individuals could directly link their minds, sharing thoughts, emotions, and sensory experiences. This paper explores conceptual and ethical issues posed by such mind-merging technologies in the context of clinical neuroethics. Using hypothetical examples along a spectrum from loosely connected pairs to fully merged minds, the authors sketch out a range of factors relevant to identifying the degree of a merger. They then consider potential new harms like loss of (...) identity, psychological domination, loss of mental privacy, and challenges for notions of autonomy and patient benefit when applied to merged minds. While radical technologies may seem to necessitate new ethical paradigms, the authors suggest the individual-focus underpinning clinical ethics can largely accommodate varying degrees of mind mergers so long as individual patient interests remain identifiable. However, advanced decisionmaking and directives may have limitations in addressing the dilemmas posed. Overall, mind-merging possibilities amplify existing challenges around loss of identity, relating to others, autonomy, privacy, and the delineation of patient interests. This paper lays the groundwork for developing resources to address the novel issues raised, while suggesting the technologies reveal continuity with current healthcare ethics tensions. (shrink)

A ‘Ulysses arrangement’ (UA) is an agreement where a patient may arrange for psychiatric treatment or non-treatment to occur at a later stage when she expects to change her mind. In this article, I focus on ‘competence-insensitive’ UAs, which raise the question of the permissibility of overriding the patient’s subsequent decisionally competent change of mind on the authority of the patient’s own prior agreement. In “The Ethical Justification for Ulysses Arrangements”, I consider sceptical and supportive arguments concerning competence-insensitive UAs, and (...) argue that there are compelling reasons to give such UAs serious consideration. In “Decisional Competence and Legal Capacity in UAs”, I examine the nature of decisional competence and legal capacity as they arise in UAs, an issue neglected by previous research. Using the distinctions which emerge, I then identify the legal structure of a competence-insensitive UA in terms of the types of legal capacity it embodies and go on to explain how types of legal capacity might be shared between the patient and a trusted other to offer support to the patient in the creation and implementation of a competence-insensitive UA. This is significant because it suggests possibilities for building patient support mechanisms into models of legal UAs, which has not addressed in the literature to date. Drawing on this, in “Using Insights from the Competence/Capacity Distinction to Enhance Patient Support in UAs”, I offer two possible models to operationalize competence-insensitive UAs in law that allow for varying degrees of patient support through the involvement of a trusted other. Finally, I outline some potential obstacles implementing these models would face and highlight areas for further research. (shrink)

Advance Directives are under-utilized, both from the fact that few Americans have them and that health professionals don’t always rely on Advance Directives provided by patients. Many health professionals have philosophical objections to their use. Using a fictitious case as background, five different objections to the use of Advance Directives will be discussed and arguments against those objections will be posed along with suggestions to improve Advance Directives.

Distributive egalitarians believe that distributive justice is to be explained by the idea of distributive equality (DE) and that DE is of intrinsic value. The socio-relational critique argues that distributive egalitarianism does not account for the “true” value of equality, which rather lies in the idea of “equality as a substantive social value” (ESV). This paper examines the socio-relational critique and argues that it fails because – contrary to what the critique presupposes –, first, ESV is not conceptually distinct from (...) DE, and second, the idea of ESV cannot serve as a “foundation” or “root” of distributive egalitarianism. (shrink)

The widespread abandonment of frozen embryos by the gamete providers or intentional parents urgently demands a solution. Most centres react by requiring patients to enter a prior agreement governing the future disposition of their embryos in all foreseeable circumstances. These dispositional directives are inappropriate and self defeating in the event of contingencies in which the patients remain competent to execute an updated directive. Internal and external changes may invalidate the prior directive by altering the situation as represented by the couple (...) at the initiation of treatment to such an extent that it no longer corresponds with the actual situation at the time of the execution of the disposition. The prior agreement should only be considered binding if the agreement among the partners on a specific option was a material condition for one of the partners to start treatment. (shrink)

In this paper several meanings of ‘personal identity’ are distinguished. It is argued that the ontological questions of unity and persistence should not be analysed using the notion of a person but using the notion of a human organism. The notions of personhood and personality are used to describe the evaluative and normative aspects of being a person. Based on these conceptual distinctions the classical philosophical problem of personal identity is dissolved into four sets of problems. Then it is argued (...) that the ethical problems of intervening in the psyche of human beings should be discussed using the notions of personhood and personality, not unity or persistence. Finally, those ethical problems of interventions in the psyche of human beings directly related to personhood or personality are distinguished from more general ethical problems raised by these interventions. (shrink)

Only in recent years have the German bioethical and biopolitical debates begun to decline due to rationalization concerning stem cell research or the pre-implantation diagnosis related to the ethical status of the beginning of human life. This is due to the fact that in these contexts we have to ask whether quality of life assessment is ethically acceptable in principle. A fundamental premise in the current debate is that quality of life assessment and human dignity are incompatible. In this paper (...) four different standards of quality of life assessment are distinguished (the naturalistic, the social, the interpersonal and the personal standard). Then an interpretation of human dignity is developed which rests on the essential feature of human beings to develop the capacity for personal autonomy. Finally it is argued that human dignity in this sense is compatible with quality of life assessments based on the personal and the interpersonal standard. (shrink)