PERSONHOOD AND HEALTH CARE

INTERNATIONAL LIBRARY OF ETHICS, LAW, AND THE NEW MEDICINE

Editors

DAVID C. THOMASMA, Loyola University, Chicago, U.S.A. DAVID N. WEISSTUB, Universite de Montreal, Canada

THOMASINE KIMBROUGH KUSHNER, University ofCalifornia, Berkeley, U.S.A.

Editorial Board

SOLLY BENATAR, University ofCape Town, SouthAfrica JURRIT BERGSMA, Rijksuniversiteit Utrecht, The Netherlands

TERRY CARNEY, University of Sydney, Australia UFFE JUUL JEN SEN, Universitet Aarhus, Denmark

GERRIT K. KIMSMA, Vrije Universiteit, Amsterdam, The Netherlands EVERT VAN LEEUWEN, Vrije Universiteit, Amsterdam, The Netherlands

DAVID NOVAK, University ofToronto, Canada EDMUND D. PELLEGRINO, Georgetown University, Washington D.C., U.S.A. DOM RENZO PEGORARO, Fondazione Lanza and University of Padua, Italy

ROBYN SHAPIRO, Medical College ofWisconsin, Milwaukee, U.S.A.

VOLUME7

PERSONHOOD AND HEALTH CARE

by

DAVID C. THOMASMA Loyola University Chicago Medical Center; Maywood, IL, U.S.A.

and

DAVID N. WEISSTUB University of Montreal School of Medicine, Montreal, Quebec, Canada

and

CHRISTIAN HERVE Universite Paris Rene Descartes, Paris, France

... " SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.

A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN 978-90-481-5858-4 ISBN 978-94-017-2572-9 (eBook) DOI 10.1007/978-94-017-2572-9

Printed on acid-jree paper

All Rights Reserved © 2001 Springer Science+Business Media Dordrecht

Originally published by Kluwer Academic Publishers in 2001 No part of the material protected by this copyright notice may be reproduced or

utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and

retrieval system, without written permission from the copyright owner.

TABLE OF CONTENTS

DEDICATION

ACKNOWLEDGMENTS

CONTRIBUTORS

PREFACE ............................................................ 1 David C. Thomasma, David N. Weisstub, Christian Herve

HOMAGE TO YVES PELICIER .......................................... 9 Christian Herve

PART ONE: Concepts 0/ the Person

CHAPTER 1: The Development ofthe Concept ofPersonhood .................. 13 Jean Delumeau

CHAPTER 2: Persons .................................................. 19 Lenn E. Goodman

CHAPTER 3: The Human Person as The Image of God ....................... 43 DavidNovak

CHAPTER 4: The Person ............................................... 55 Jean Bernard

CHAPTER 5: The Failure ofTheories ofPersonhood .......................... 59 Tom L. Beauchamp

CHAPTER 6: Personhood: The Vain and Pointless Quest for aDefinition ......................................... 71

Edmund L. Erde

CHAPTER 7: Genetic Knowledge and Our Conception ofOurselves as Persons .................................. 91

Tuija Takala

CHAPTER 8: The Concept ofthe Person and the Value ofLife .................. 99 JohnHarris

vi

PART TWO: Theories of Personhood in Medicine and Bioethics

CHAPTER 9: The Just and Medical Ethics Paul Ricoeur

115

CHAPTER 10: The Concept ofPerson in Bioethics: Impasse and Beyond ......... 121 Hubert Doucet

CHAPTER 11: Towards a Social Concept ofPerson ......................... 129 Ruud H.J ter Meulen

CHAPTER 12: A Key Term in Ethics: Tbe Person and His Dignity .............. 137 Simonne Plourde

CHAPTER 13: The Confucian Relational Concept of the Person and Its Modem Predicament .............................. 149

Jiwei Ci

CHAPTER 14: Tbe Traditional African Perception ofa Person ................. 165 Godfrey B. Tangwa

CHAPTER 15: Tbe Anthropological Concept ofModem Medicine in the Perspective of Tbeological Ethics ..................... 173

Ulrike Kostka

PART THREE: Person and Identity

CHAPTER 16: The Pro ce dural Morphing ofthe Person: From Selfto Property ................................... 191

Judith Lee Kissell

CHAPTER 17: Personal Identity and Mental Health .......................... 203 Eric Matthews

CHAPTER 18: Tbe Person, Filiation, Possession: Conceming Dissociative Identity Disorder (DID) ....................... 213

Jean Guyotat

CHAPTER 19: Moral and Metaphysical Reflections on Multiple Personality Disorder ............................. 221

David C. Thomasma

vii

CHAPTER 20: Personhood and a Paradox About Capacity .................... 243 Jeffrey Spike

CHAPTER 21: Precedent Autonomy and Personal Identity .................... 253 Michael Quante

CHAPTER 22: Some Reflections on the Problem of Advance Directives, Personhood, and Personal Identity ......................... 265

HelgaKuhse

PART FOUR: Personhood and fts Relations

CHAPTER 23: Cloning, Naturalness and Personhood ........................ 281 Matti Häyry and Tuija Takala

CHAPTER 24: Vulnerable Persons ....................................... 299 Michel Silber/eid

CHAPTER 25: Human Dignity, Vulnerability, Personhood ., .................. 317 David N. Weisstub and David C. Thomasma

CHAPTER 26: Personhood and Relational Persons .......................... 333 Constance K. Perry

CHAPTER 27: Professionalism and Personhood ............................. 347 M Gregg Bloche and Kevin P. Quinn

CHAPTER 28: Autonomy and Dialogue: About the Patient-Doctor Relationship ............................... 355

JohnNessa

CHAPTER 29: The Medical Interpretation ofPain and the Concept ofPerson ................................ 363

Guillermo Diaz Pintos

CHAPTER 30: Suffering, Time, Narrative and the Self ....................... 373 Lazare Benaroyo

INDEX ............................................................. 383

DEDICATION

To our children and grandchildren, that they may be blessed by good friends and loves to grow in stature as human persons.

ACKNOWLEDGMENTS

We could not have assembled this book without the help of four essential people. Judith Lee KisseB, Ph.D., of Creighton University, aided us in editing key chapters while Diane Kondratowicz, M.A., Ph.D. (Cand.); at Loyola, helped edit the entire manuscript and formulated our Introduction. Of course, we remain responsible for any errors. George Tomossy, lD., of the International Academy of Law and Mental Health, assisted us by helping plan the International Preconference in Paris hosted by Professor Herve that led to the development ofthis book. Last, but not least, Robbin Hiller, senior secretary at Loyola, also helped copyedit and worked her magic to get the manuscript ready for publication. She was our principal agent in working with all our contributors and the Press.

We also want to thank our Universities and the donors of our respective Chairs for the support that makes our collaboration possible. We are grateful as weIl for our editor at the Press, Anne Ultee, and her assistant, Helen van der Stelt, who were so supportive of this book and the series itself.

Thank you to aB!

David C. Thomasma David N. Weisstub Christian Herve

Chicago, I1Iinois Montreal, Quebec Paris, France

CONTRIBUTORS

Tom L. Beauchamp, Ph.D. Senior Research Scholar Kennedy Institute ofEthics Professor of Philosophy Georgetown University Washington, DC., USA

Lazare Benaroyo, M.D. Charge de cours cl la Faculte de medecine Mectecine generale FMH Switzerland

Jean Bernard, M.D. Professeur de Medecine Membre de l' Academie Fran9aise France

M. Gregg Bloche, M.D., J.D. Professor of Law Georgetown University Adjunct Professor Department ofHealth Policy Johns Hopkins University Washington, D.C., USA

Jiwei Ci, Ph.D. Associate Professor Department ofPhilosophy University of Hong Kong Hong Kong

Jean Delumeau, Ph.D. Professeur au College de France France

Guillermo Diaz Pintos, J.D., Ph.D. Professor Titular de Filosofia deI Derechio Facultad de Perecho y Ciencia Sociales University ofCastilla-La Mancha La Mancha, Spain

Hubert Doucet, Ph.D. Director, Program in Bioethics Professor Faculty ofMedicine and Theology University ofMontreaI Canada

Edmund L. Ede, Ph.D. Professor Departrnent ofFamiIy Medicine University of Medicine & Dentistry ofNew Jersey School of Osteopathic Medicine New Jersey, USA

Jean Guyotat, M.D. Professeur honoraire de psychiatrie Universite LYON I France

John Harris, Ph.D. Sir David Alliance Professor of Bioethics Director Centre for Social Ethics and Policy Director Institute ofMedicine Law and Bioethics University of Manchester England

Matti Häyry, Ph.D. Professor Department of Philosophy University of Helsinki Senior Research Fellow Academy of Finland Helsinki, Finland

xiv

Christian Herve, M.n., Ph.n. Professeur de Mectecine Directeur de Laboratoire d'Ethique medicale et de sante publique Faculte Necker Universite Paris Rene Descartes Paris, France

Judith Lee Kissell, Ph.n. Assistant Professor Center for Health Policy and Ethics Creighton University Nebraska, USA

Ulrike Kostka, MPH, Ph.n. Senior Fellow NFP 46: Implants and Transplants Basel, Switzerland

Helga Kuhse, Ph.n. Professor of Bioethics Director of the Centre for Human Bioethics Monash University, Clayton Victoria, Australia

Eric Matthews, Ph.n. Professor Department of Philosophy University of Aberdeen Aberdeen, ScotIand

John Nessa, M.n., Ph.n. Department ofPublic Health University of Bergen Bergen, Norway

navid Novak, Ph.D. Director 1. Richard and Dorothy Shiff Chair of Jewish Studies University of Toronto Canada

Constance K. Perry, Ph.n. Assistant Professor School of HeaIth Professional Arts and Sciences Department MCP Hahnemann University Pennsylvania, USA

Simonne Plourde, Ph.n. Laboratory of Medical Ethics and Public HeaIth University of Quebec in Rirnouski Canada

Michael Quante, Ph.n. Assistant Professor Philosophisches Seminar Universität Münster Germany

Kevin Quinn, S.J., J.n., S.T.L., Ph.n. Professor of Law Georgetown University Law Center Senior Fellow Kennedy Institute of Ethics Georgetown Universite Washington, D.C., USA

Paul Ricoeur, Ph.n. Professeur honoraire de philosophie Universite Paris X France

Michel Silberfeld, M.n., M.Sc., C,R.c'P(C) Assistant Professor Department of Psychiatry Joint Centre for Bioethics University of Toronto Canada

Jeffrey Spike, Ph.D. Medical Humanities University ofRochester Medical Center New York, USA

Tuija Takala, Ph.D. Research Fellow Department of Philosophy University of Helsinki Helsinki, Finland

Godfrey B. Tangwa, Ph.D. Associate Professor of Philosophy University ofYaounde Cameroon

Ruud H.J. Ter Meulen, Ph.D. Institute for Bioethics University ofMaastricht Maastricht, The Netherlands

David C. Thomasma, Ph.D. Professor and Fr. English Chair ofBioethics Neiswanger Institute for Bioethics and Health Policy Loyola University Medical Center Illinois, USA

xv

David N. Weisstub, J.D., D.H.L. Philippe Pinel Professor of Legal Psychiatry and Biomedical Ethics Faculty of Medicine University ofMontreal Canada

PREFACE

PERSONHOOD AND HEALTH CARE

This book arose as a result of a pre-conference devoted to the topic held June 28, 1999 in Paris, France. The pre-conference preceded the Annual Congress of the International Academy ofLaw and Mental Health. Other chapters were solicited after the conference in order to more completely explore the relation of personhood to health care. The pre­conference was held in honor of Yves Pelicier who led so many of our French colleagues in medicine, philosophy, and ethics as Christian Herve notes in his Tribute.

As health care is aimed at healing persons, it is important to realize how difficult it is to construct a theory of personhood for health care, and thus, a theory of how healing in health care comes about or ought to occur. The book is divided into four parts, Concepts of the Person, Theories of Personhood in Relation to Health Care and Bioethics, Person and Identity, and Personhood and Hs Relations. Each section explores a critical arena in constructing the relation of personhood to health care. Although no exploration ofthis nature can be exhaustive, every effort was made to present both conflicting and complementary views of personhood from within similar and different philosophical and religious traditions.

PART ONE: CONCEPTS OF THE PERSON

Tracing the origins of the concept of person from antiquity through present day, Jean Delemeau provides an historical sketch of the development of a wide range of meanings. Although its meaning has changed over time, in general "person" demarked an individual with character and specificity. There has yet to be a consensus about a definition, however. Delemeau maintains that the concept remains at the core of our contemporary debates about health related matters such as aborti on, genetics, and euthanasia. Whether we regard persons as a bundle of neurons or as possessing inherent value and dignity will greatly inform and influence these debates.

Acknow ledging that ethics calls upon us to respect and treat persons in accord with their deserts, Lenn Goodman focuses upon the worth ofpersons. He argues that these deserts are objective claims that are based upon a person's subjecthood. Deserts include and exceed traditional human rights; they impart human dignity that it is protective ofthe name, honor, privacy, and intellectual as weIl as bodily integrity of persons, and they demand that persons be respected. Using a number of contemporary social and health-related issues as examples, (e.g., mental illness, self-mutilation, teen prostitution, suicide, pornography), Goodman ilIustrates the application ofthese deserts to therapeutic work related to the body and mind.

David Novak examines how the image of God can serve as the foundation of personhood and human rights, particularly within the context of Judaism. To this end, he raises the question of the ends of human action and recognizes that the term "telos" has altered its meaning from that of substance in ancient times (i.e., astate ofbeing, for example,

D.C. Thomasma. D.N. Weisstub anti C. Herve (eds.). Personhood and Health Care. 1-8. © 2001 Kluwer Academic Publishers.

2 David C. Thomasma, David N. Weisstub, Christian Herve

happiness) toward personhood in Modem times. Novak maintains that the image ofGod is of immediate ethical significance because it is teleological in that it identifies the proper ends for persons. Novak proposes that questions regarding personhood are best answered by an ontology and theological anthropology emerging from the doctrine of creation ofthe human person as the image 0/ God, and that God is therefore the ultimate source of ethics.

Drawing upon his extensive background in Natural Law Theory, Novak argues that the concept of the person derives from being an image of God as instilIed in both nature and in revelation. Using Levinas' insights about the need of the other person as revealing that person and ultimately revealing the way in which honor and dignity is due to that person, Novak continues to stress that naturallaw is revealed through human interaction.

J ean Bemard focuses upon the defining features of"personhood." Recounting scientific progress, he notes two definitions: one, based upon our genetic make-up and, two, based upon the nervous system involving brain function and capacity. Beyond these biological definitions, personhood has come to command "respect" that is based in a recognition ofthe liberties that all persons share. Bemard thinks, though, that this notion of respect ought to be supplemented with the concept of human "dignity" that is inherent in persons from the time of conception and endures long beyond physical death. Human dignity will be explored in later chapters in more detail.

After these more general reflections that accept a special moral place for persons and health care aimed at their good, the section continues with more skeptical concems ranging from those who still hold that a theory of personhood is important to those who hold that such a theory is a fruitless pursuit.

Thus, on a less accepting note, Tom Beauchamp examines why theories ofpersonhood seem to fail. He draws a distinction between "metaphysical" and "moral" conceptions of personhood that is ordinarily overlooked. For a number ofreasons, he finds each conception problematic, as he finds the vagueness ofthe concept of"person" itselfproblematic as weil. However flawed, though, Beauchamp stops short in discounting philosophical theories of metaphysical and moral persons; his intent, rather, is to expose their difficulties. He acknowledges the importance of such theories in the provision ofhealth care and in morality generally. Yet he is convinced that the best way to approach the problems is to stay focused on each moral problem as it arises.

By contrast, Edmund Erde focuses an "originating question " - specifically, what do we mean by "person." In vogue for several decades following WWII, Erde employs facets of ordinary language philosophy to explore, among other things, the meaning of the term "person," how the "originating question" figures in but goes wrong in bioethics and, ultimately, to dissolve the force ofthe question. Erde argues that we ought to reject a vain and pointless quest to define personhood and proposes, instead, that we focus upon what we value about persons - e.g., fetuses, pregnant women, brain dead patients - and why.

One way out ofthis conceptual impasse is to re-examine the question from the point of view of new knowledge gained in genetics. If, after all, persons are specific and unique individuals, much ofthat specificity comes from their genetic makeup. Yet Tuija Takala

Preface 3

notes that genetic knowledge holds great promise for medicine but also raises pressing ontological, epistemological, and moral questions that threaten our conception of ourselves as persons - e.g., Is everything pre-determined by our genetic make-up? Should we view ourselves as ill if we are genetically predisposed toward a certain illness? What about our free-will and action? Overall, what impact ought genetic knowledge have on us? Tuija Takala favors a conception of"personhood" that, although based in Enlightenment thinking, has application to and instills meaning in the very questions we face today.

Given that the concept of personhood has become intimately connected with fundamental ethical questions about the value oflife - e.g., killing versus letting die, John Harris attempts to define and examine this notion to determine why, among other things, the lives of persons, as distinguished from animals for example, make urgent moral claims upon uso He considers and evaluates a number of characteristics (e.g., potentiality, gradualism towards moral status) to arrive at a unique defining feature, notably, "a creature capable of valuing its own existence." His approach through the way we behave ethically leads then to the next section of the book.

PART TWO: THEORIES OF PERSONHOOD IN MEDICINE AND BIOETHICS

Paul Ricoeur analyzes medical ethics within the context ofthe judicial system. He advances that medical ethics is a treatment pact of trust between two people - the suffering patient who asks for help and the physician who has the knowledge and agrees to provide assistance. This pact is governed by a system of norms and regulations that comprise a professional code of ethics. Ricoeur draws a parallel between these two levels of medical ethics and that of the judicial system, specifically, between a particular judgment made by a court of law and the legal norms on which that judgment is based.

Hubert Doucet notes that respect for the person is the core ofthe bioethical enterprise in both the United States and in France, indeed in all ofWestern thought. Yet, usage ofthe concept creates difficulties and contradictions for discipline. Only recently have we begun to recognize personhood and, in some instances, it has come to be a means by wh ich medical care is excluded from some (e.g., human embryos, fetuses, anencephalic infants). In response, Doucet explores promising directions, proposed by Hans Jonas and Jean Ladriere, regarding how this might be overcome. Rejecting the strict methodological reductionism of contemporary biomedical science, the task ofbioethics ought to be enlarged to incorporate into its framework an anthropological understanding of persons.

Acknow ledging that the right to self-determination is a necessary condition for realizing one' s autonomy, Ruud H. J. ter Meulen considers whether this right is a sufficient condition. Arguing to the contrary, ter Meulen opts for a broad conception ofautonomy that is based, not upon a rationalistic and individualistic conception characteristic oftraditional bioethics. Rather, he envisions that persons conceive themselves within a broader social, cultural, and spiritual context that decreases fragmentation among persons within society and facilitates the growth of mutual ties.

4 David C. Thomasma, David N. Weisstub, Christian Herve

Complementing the other contributors in this section, Simonne Plourde focuses upon the concept of "personhood" within the context of medicine and bioethics. Beginning with an historical sketch, she traces the evolution ofthe concept from antiquity through present day and pays particular attention to its discussion in the works of contemporary theorists Emmanuel Mounier, Gabriel Marcel, Emmanuel Levinas, Paul Ricoeur, and Lucien Seve. Plourde argues that the concept of personhood is of central concern within the context of recent and emerging biotechnological advances that have transformed our lives, both positively and negatively. Yet traditional defmitions of personhood seem inadequate to provide answers to the fundamental questions these advances pose or resolution to the dilemmas that medical practitioners now routinely face and require re-examination.

Many previous reflections suggest a relational concept ofthe person. Jiwei Ci argues that uninformed appeal to the Confucian relational concept ofthe person can be helpful to its role in health care, but a more critical view of it shows that Confucianism suffers from both epistemic and ethical flaws (e.g., it assumes that relations among persons are hierarchical in their scope and quality). Ci considers whether Confucianism might be restructured to remove these flaws but reasons that doing so would no longer render it distinctively Confucian. Unfortunately, then, Confucianism does not represent an attractive alternative to liberal individualism that also has its own inherent flaws. In his view both represent first-order theories that rest on second-order theories (epistemic justifications) that are essentialist rather than constructivist. This means that both theories assume that their view of persons is grounded on Nature or the way things are, rather than on social construction and the relativity of social systems. Nevertheless, Ci advances that Confucianism does have something useful to contribute toward our understanding and resolution of contemporary bioethical problems, namely, a specific idea about the conduct ofhuman relations between physician, patient, and family.

Godfrey Tangwa discusses personhood within the context ofthe African and Western philosophical tradition. Despite recognition of stages in the maturation process, a hierarchal society, based upon title, age, experience, etc., and current physical, mental and socio­politico-economic changes that persons experience, Tangwa argues that the moral worth of a person within the African tradition remains constant and unchanging throughout his or her lifetime. Critical to his sketch ofthe differences between African views and Western views is the notion that Western philosophy has focused on the patient, on the moral worth ofthe individual or groups toward which agents act, and the victims ofagent's action. Instead, he argues, the African view focuses on the agency of all human beings as persons. While Africans recognize the development of human life from infancy to maturity, they would never agree with Engelhardt's description of fetuses and the retarded as being "outside" secular moral concern since they are not moral persons. Greatly influenced by science, technology, and commercialism (e.g., profit, materialism) and all too ready to classify persons, countries, and cultures as advanced versus backward, developed versus developing, etc., the Western tradition does not appear to hold personhood in the kind of reverence found in African thought and culture.

Preface 5

Tangwa speculates about how desirous it would be to infuse the technologically advanced and efficient Western medical tradition with the moral sensibility ofthe African tradition. Although there is no simple formula, Tangwa sketches an initial step about how this might be accomplished.

Emphasizing the climate offundamental change in modem medicine (e.g., technological advances, genome analysis, structural and fmancial crisis), Ulrike Kostka recognizes an opportunity and need for critical discussion about the scientific and technical rationality that has served as the basis and aims ofmedicine throughout history. This paradigm need not be entirely abandoned, she thinks, but it might be supplemented by additional concepts such as psychosomatic medicine, homeopathy, and the science ofpublic health. Kostka speculates that medical and theological ethics might serve weH to facilitate the necessary dialogue among the parties involved (e.g,. Healthcare providers and patients) aboutthe basis and aims of medicine. In making this claim, Kostka returns the reader to the earlier more theoretical examinations as well as preparing for the specific example of person and identity within health care.

PART THREE: PERSON AND IDENTITY

Judith Lee Kissell wams that biotechnologieal advances have radically altered or "morphed" our conception of persons, transforming persons from subjects of reverence whose inherent dignity requires protection to objects of economic worth and property value (e.g., ownership of eggs and sperm may be transferred, body parts may be sold, etc.,). To ensure regard for persons involved in technologieal interventions, Kissell advances that we have readily imposed the requirements of informed consent and sought justification of our actions from the value neutrality aspect ofliberal politieal philosophy. These measures, though, do little to cultivate critical reflection about personhood that is indicated by our new-found capabilities or restore meaning and value to persons involved with them.

Taking up the specific problem of identity for persons in health care, Eric Matthews examines personal identity within the context of mental health. He focuses upon a "disturbance ofpersonal identity," specifically, a condition in which persons have a fully formed identity albeit, due to neurologieal or social factors (e.g., interaction with other persons during childhood), it has disintegrated or has become flawed. Matthews then draws some ethical, legal, and therapeutic conclusions about our approach in treatment of such disorders. He argues, for example, that effective treatment will depend upon identifying what prompted the person' s disturbance of identity and, through therapeutic guidance, counseling them as to how it might be restored.

Recognizing that the concept ofpersonhood is central to psychiatric iIIness (Le., how persons destructure and reintegrate themselves), but that it tends to be overlooked in everyday practice (Le., patients are often classified and categorized by psychiatrie disorder, e.g., DSM III), Guyotat focuses upon personhood within the context ofDissociative Identity Disorder (DID). This ilIness is characterized as a problem ofidentity, wherein several beings co-exist within the same body. More fundamentally, Guyotat interprets it as a break in the

6 David C. Thomasma, David N. Weisstub, Christian Herve

tie of filiation among persons and generations. The person does not view themselves within the context ofhis or her genealogicallineage but, instead, feels displaced.

David Thomasma reflects on the disputes about Multiple Personality Disorder and whether there is such a diagnosis. He pays tribute to Dr. Robert DeVtio with whom he consulted for almost 20 years. Without solving the question itself, Thomasma wonders how "persons" of such widely varying ages and genders, not to mention divergent nationalities, linguistic abilities, dominant hands, handwriting, can "inhabit" a single body. The moral question arises in this disorder, as the therapist must aim at constructing a new integrated personality from multiple ones, and in so doing, musttackle the moral responsibilities ofthis interim person. Thus, multiple personality disorder contributes to both a metaphysical reflection on the nature of persons and a moral reflection on the nature of therapeutic responsibility and interim moral responsibility forthe individual suffering from the disorder.

On a more general note conceming ethical consultations in health care, Jeffrey Spike argues that the status of a patient's personhood is oftentimes at the coreof ethical consultations but may be lost with the use of traditional consultation models (e.g., deliberations of ethics committees with little, if any, meaningful input from patient). Drawing from his professional experience, Spike sketches an approach to ethics consultation that he uses to identify points of convergence and dissonance among the parties involved and, most importantly, to solicit the active engagement of the patient in decisionmaking conceming hislher Iife. He provides two case examples to illustrate how the input ofpatients in the consultation and decisionmaking process significantly altered their respective course oftreatment.

The use of advance directives today, as consistent with and an extension of patient autonomy, has become commonplace. Quante, however, considers contexts in which it is less clear whether these directives ought to be respected - e.g., progressive and irreversible dementia, Alzheimer's disease, cases in psychiatry. In such contexts, two conceptions of personal identity - a persistent sense and identity as personality or biographical identity -are oftentimes conflated that, Quante argues, ought not.

Acknowledging advantages and widespread ethical and legal acceptance, Kuhse focuses upon one specific, albeit formidable, criticism of advanced directives - namely, that relying upon inapplicable notions of self-determination and personal identity, directives are conceptually confused and, in some circumstances, ought to be overridden. Kuhse takes issue with this criticism, arguing that, even ifthese directives are conceptually confused, it does not follow that refusals, at least in the case of life-sustaining treatment, ought to be overridden. Directives relating to pain relief, though, may be another.

PART FOUR: PERSONHOOD AND ITS RELATIONS

In earlier sections, arguments were posed that would require examining the concept of Person as relational in itself, and then that the relations within health care would allow us to re-examine notions of personhood. In this final section we look at the importance of

Preface 7

personal relations themselves. The fIrst is that to oneself and the intriguing possibilities raised by cloning. The others are the vulnerability and dignity of persons, their relations their fetuses, to professionals, and to their bodies through illness and pain.

Mätti Häyry and Tuija Takala explore two intriguing arguments that have been articulated in opposition to the increasingly real prospect ofhuman cloning - one, that due to the unnaturalness oftheir origin, a clone produced would not be a person in the fuH sense and, two, that human clones are thought to lack certain characteristics integral to personhood. Despite their initial appeal, Häyry and Takala argue that these arguments cannot be used to absolutely reject the prospect ofhuman cloning, as there may be exceptional cases in which it might be indicated.

Given their ambiguous personhood and moral status, Michel Silberfeld focuses upon mentally incompetent or "vulnerable" persons. He defInes how mental incompetency is determined, discusses the vagaries and shortcomings of some ofthese determinations (e.g., self-determination) and considers using quality oflife as a criterion. Silberfeld conceives of personhood as inclusive and considerate of vulnerable persons. Drawing upon an evolutionary, aesthetic, and visionary conception of ethics, he sketches how this might be accomplished.

In their chapter, "Human Dignity, Vulnerability, Personhood, " Weisstub and Thomasma argue that the special vulnerability of persons gives rise to their dignity and from this, their personhood is to be respected. By becoming ill, diseased, or being in aecidents, the morality and fInitude ofthe human being evokes a response of other like beings, and that response is to come to their aid. Community cohesion is a natural prompt in this regard. The dignity ofthe person, most often proteeted in the laws ofliberal Western soeiety, should rest on the special vulnerability ofthe siek when it comes to health eare, and not so much on Western liberal politieal theory. The latter is widely assumed to have failed in the 20th Century.

Constance Perry examines an aspect ofpersonhood that is often overlooked, partieularly within the eontext of pregnaney, namely, the social and relational. Given that medieal technology has enabled us to treat the fetus as an entity separate from its mother, Perry contends that traditional, individualistic coneeptions ofpersonhood (e.g., the potential for moral agency, moral agency, autonomy, ete.,) are insuffIcient to fully respeet and proteet that ofpregnant women. Instead, given its complexities, pregnaney requires a richer, more eommunal sense of personhood that reeognizes and respects the value of the developing fetus and, likewise, that of the pregnant woman.

M. Gregg Bloche and Kevin Quinn maintain that physicians routinely treat their patients as physiological processes, organ systems, and lab values rather than whole persons. They traee the origins ofthis failing to the arduous proeess and formidable pressures ofmedical training, as well as to inereasingly routine diseussions coneerning the alloeation of scarce medieal resourees. Block and Quinn note that proposed remedies to this problem are prevalent but laeking. As remedy, they advoeate a realistic assessment ofthe tensions and eonstraints that physicians face. Simply put, cognitive requirements and emotional limitations (e.g., a eertain detachment from patients) preclude physicians from fully

8 David C. Thomasma, David N. Weisstub, Christian Herve

interacting with patients as persons but, to an extent, are necessary if physicians are to be clinically responsive to their patients' needs. Advocating pragmatic accommodation, physicians must strike a balance between providing technically appropriate care and engaging patients to win their trust and provide for their comfort.

lohn Nessa contends that the patient-doctor relationship is primarily an ethical encounter between two mutually autonomous subjects and, only secondarily, is a scientific and technological treatment relationship. Drawing upon elements of dialogue philosophy and expanding upon Kanfs theory ofautonomy, he advances that at its core the challenge and art of medicine is to balance the biomedical task with the dynamic process of communication and interaction between two persons within a situational and institutional· context. Nessa provides excerpts from a dialogue to iIIustrate how this might be accomplished, the inherent difficulties, and the interpretation to wh ich it might be subject.

Medicine is an art designed to relieve and, if possible, eliminate human pain and suffering. With this as its task and goal, however, medicine unfortunately tends to overlook the genuine condition of the afflicted person as weil as the deeper meaning and significance of pain and suffering. GuiIIermo Diaz Pintos maintains that the debilitating affects, vulnerability, and des pair that accompanies pain and suffering threatens a person's very identity, rendering them incapable of fully comprehending, appreciating, and actualizing their human existence. Meeting suffering patients' needs would restore their sense ofbeing.

Finally, Lazare Benaroyo examines the extent to which personal identity may be adversely affected by iIIness and human suffering. Drawing upon the works of Edmund Husserl and Martin Heidegger, he explores the linkage between the various modalities of time (having-been, coming-forth, and making-present) and personal identity. He also draws upon the work of Paul Ricoeur to iIIustrate how narrative is correlated with time and identity. Benaroyo advances that greater clinical attention to the patient's narrative ofhislher experience with suffering will do much to restore a patient' s wounded identity and, thereby, facilitate the process ofhealing.

Dur contributors have expressed a wide range of concems about personhood in health care, from more objective foundations ofpersonhood in creation and naturallaw theory, to relational origins in ethics and human conduct, to more subjective valuing, either by beings ofhuman genetic origin or by the community itself. Without doubt this debate will continue as long as there are ethical dilemmas in health care. At the very least, however, a theory of personhood, if it is to be valued in health care, must rest on the best scientific data we have available about human beings of genetic human origins, along with the values we associate with persons, whether they be human or extraterrestrial.

We want to thank Diane Kondratowicz for her special help in writing this Preface.

David C. Thomasma, Ph.D. David N. Weisstub, J.D. Christian Herve, M.D., Ph.D.

Chicago, II. Montreal, Quebec, Canada Paris, France