Theor Med Bioeth (2013) 34:479–498 DOI 10.1007/s11017-013-9273-1

Saving a life but losing the patient Mark Greene

Published online: 30 November 2013  Springer Science+Business Media Dordrecht 2013

Abstract Gregor Samsa awakes to find himself transformed into a gigantic bug. The creature’s inchoate flailing leads Gregor’s sister to conclude that Gregor is no more, having been replaced by a brute beast lacking any vestige of human understanding. Sadly, real cases of brain injury and disease can lead to psychological metamorphoses so profound that we cannot easily think that the survivor is the person we knew. I argue that there can be cases in which statements like, ‘‘It’s just not Gregor anymore,’’ are not merely figures of speech. With this in mind, I consider three possible results of saving a biological life: (1) ordinary cases where saving the life will save the person, with strong duties to save the life; (2) cases where the intervention needed to save the life will replace the person, with strong duties not to save the life; (3) cases in which it is indeterminate whether the person will be saved or replaced. How should we think about indeterminate cases? Impersonal ethical considerations miss the point, while standard person-affecting considerations are inapplicable. I suggest turning attention away from survival towards a richer focus on what I call ‘‘personal concern.’’ I show how considerations of personal concern, unlike those of self-interest, need not be tied to survival and how this allows personal concern to provide a basis for ethically substantive discussion of cases where saving a life might result in losing the patient. Keywords Identity
Survival
Replacement
Indeterminacy
Life-saving
Brain injury
Persons
Personal concern
Metamorphosis

M. Greene (&) Department of Philosophy, University of Delaware, 24 Kent Way, Newark, DE 19716, USA e-mail: [email protected]

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The problem of replacement Gregor Samsa awakes one morning to find himself transformed into a gigantic bug [1]. By the end of Kafka’s novella, Gregor’s sister, Greta, believes that her brother’s stark, overnight transformation has been mental as well as physical. Though she never questions that the creature is what Gregor has become, Greta concludes that the person she knew did not continue through the metamorphosis, in other words, that Gregor did not survive. Greta believes that the beast now occupying her brother’s room is not her brother but has replaced him. One of the tragedies of the tale is that we, as the readers, know that Gregor’s mind remains trapped in its new bug body because Kafka allows us into Gregor’s mental life. Though he is unable to communicate with his family, Gregor continues to recognize them, to understand them, and to worry about getting to work to provide for them. Though Gregor’s sister is mistaken about the facts of the case, her judgment is neither unreasonable nor incoherent: there are conceivable physical and/or mental transformations that are so sudden and so radical as to be reasonably judged incompatible with the continuation of the original person, despite the persistence of a biological life. Sadly, human metamorphosis is not confined to fiction. Brain injury and disease can lead to mental metamorphoses that parallel Gregor’s physical transformation [2]. Even though biological death has not yet occurred and even though some person emerges from the disease process, such events sometimes lead friends and family to talk in terms of having lost the person they knew. It can be hard to distinguish literal talk about individual survival from metaphor, hyperbole, or other figures of speech. One could insist that expressions of having lost someone to brain injury or disease must always be examples of such loose and popular usage; but this would be a mistake. I will argue that there are conceivable cases in which claims that the original individual has been replaced by someone else should be understood literally. If neuropathology can lead to replacement, then it may be possible to save a biological life while losing or even killing the original patient. Matters may be further complicated by the emergence of a new person in the same body from which the original person was lost. I need hardly say that such cases raise ethical puzzles: What are we to say of the original person’s prior relationships, property, and promises? I will not try to address all these questions here, but I will try to make some progress with puzzles concerning duties to save. I will begin by establishing a conceptual framework for discussion. One can describe continua of metamorphosis, from trivial to total. There are clear cases of survival at the trivial end of such continua and clear cases of replacement at the total end. I will show how intermediate cases are subject to at least two distinct kinds of indeterminacy as to whether the original person survived or was replaced. There are three kinds of cases to consider when thinking about duties to save: clear cases of survival, clear cases of replacement, and cases in which whether the original person survived or was replaced is indeterminate. I will argue that duties to save are most plausibly understood as duties to save persons rather than as duties to save lives. I will show how this understanding leads to clear obligations in clear cases of survival and in clear cases of replacement, but it leads to jarring results where the continuation of the original person is indeterminate. I will argue that we can make

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useful progress in such cases with a ‘‘personal concern’’ approach—one that recognizes ethical considerations that are personal and yet independent of personal survival.

Continua of metamorphosis and indeterminacy of survival I begin mapping the conceptual landscape by describing clear cases of continuation through trivial metamorphosis and clear cases of replacement due to radical metamorphosis. I then fill in the space of possibilities with a continuum of intermediate cases. The general question is whether the original individual survives through the metamorphosis and continues as the emergent individual, or is terminated by the transformation with the emergent individual being a replacement rather than a continuation of the original. Although, like many philosophers, I tend to think of myself, primarily, as a mental being, the metamorphoses I describe have both mental and physical aspects and my conceptual map is thus far neutral with respect to the metaphysical grounds for the survival of human persons. I also take no position on whether survival has the logical features of numerical identity. My neutrality does, however, have limits, and I will argue that there is an ethically significant distinction between survival of the original person and mere biological survival. When I have a cold, I may say, ‘‘I’m not myself,’’ but I do not mean it literally. I am not reporting my own death and I am not saying that the person with the cold did not previously exist. I am myself; I am just even grumpier than usual. A cold does alter my mental and physical states, but it does not come close to threatening my personal continuation. Whether I am viewed as a person or as an organism, surviving a cold is a clear case of ordinary continuation—if you think otherwise, this paper is not for you. What Greta thought had happened to her brother points to another easy case. Suppose that Gregory undergoes a metamorphosis that is even more extreme than Gregor’s. Gregory’s transformation is both physical and mental. Industrious gnomes with a passion for xenografting wait until Gregory is asleep and get to work swapping out his entire body, a chunk at a time, replacing each bit with bug parts purchased on EBay. Finally, they swap out Gregory’s brain (or, if you prefer, a larger chunk including Gregory’s brain). Clearly the resulting bug is not Gregory but has replaced him—if you think otherwise, this paper is not for you either. Because Gregory’s metamorphosis has both physical and mental aspects, nothing hangs on adopting any particular account of personal continuation or survival.1 As long as the gnomes accomplish their task while maintaining a living body throughout, and I see no reason to think they cannot, Gregory’s case also shows that personal and biological survival are distinct: Gregory was replaced despite the ongoing biological life. Real cases of permanent coma have already given us reason

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I have used similar continua of incremental differences to argue for the indeterminacy of identity in the context of the non-identity problem [3].

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to believe that personal continuation is not the same thing as continuation of a biological life. These easy cases lie at opposite ends of continua of metamorphosis. Progressing from a cold, one can imagine disease and injury of increasing severity. One can accompany one’s imagined ailment with increasingly heroic surgical replacement of failing parts. There are sequences of arbitrarily small increments such that minor surgery morphs into radical surgery, and radical surgery escalates from partial to total body replacement. Conversely, starting with the gnomes, one can imagine incrementally less obsessive nights of body replacement in which some of Gregory’s original parts remain—initially just a toe here, a dorsal root ganglion there, but more and more of Gregory lies undisturbed with each increment. Thus, there are various ways to progress, via arbitrarily small increments, between recovering from a cold and undergoing total body replacement. Each particular way of progressing between the extremes constitutes a continuum along which both physical and mental features gradually change. So, clear cases of survival and clear cases of replacement mark the extremes on continua of possibilities for bodily and mental metamorphosis. Continua of intermediate cases between personal continuation and replacement can always be used to generate sorites indeterminacies in which it is unclear whether the original person remains. To the extent that ethical questions turn on the survival of the original person, a sorites indeterminacy leads to ethical uncertainty. Sorites indeterminacies may provoke line-drawing disputes but they do not give rise to fundamental disagreement over the ordering of steps along the continua. However, continua of metamorphosis also give rise to another kind of indeterminacy—one that suggests that a more fundamental re-think is in order. George Frideric Ha¨ndel can help to elucidate the difference between a sorites indeterminacy and the more fundamental kind that I have in mind. It is open to debate whether Ha¨ndel (born 1685) was old when he composed the Messiah (1742) but it is not debatable whether, at that time, his friend and fellow composer Telemann (born 1681) was older. The old/not-old indeterminacy is a pure sorites indeterminacy; there is scope for dispute about where to draw the line but not about what determines the ordering of the age continuum. Now to another question: was Ha¨ndel a great composer? There is a sorites indeterminacy here too (one might wonder just how good is great), but there is a more fundamental indeterminacy to be found in the space that exists for disagreement over who was the better composer. Of course, Ha¨ndel suffers no lack of devotees but I incline to Telemann. I even have something to say in defense of my judgment—e.g., I might point to Ha¨ndel’s well documented plagiarism of his less famous friend [4]—but I will grudgingly confess that I have nothing decisive to say. There is no determinate fact about the relative importance of originality or other putative criteria for musical genius. Even full agreement on all the relevant facts may not bring us into agreement on the relative merits of Telemann and Ha¨ndel. To distinguish from a sorites indeterminacy, I call this a ‘‘rank indeterminacy.’’ Continua of metamorphosis give rise not only to a sorites indeterminacy but also to a rank indeterminacy. As I have argued, in the context of tracking persons across worlds, complete agreement on all the relevant facts of a case will not resolve

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questions of how to interpret, weigh, balance, and rank the many different aspects of a person that feed into determinations of personal continuation [3, pp. 644–645]. For example, discontinuities of memory, professional interests, and personal commitments might all be relevant to the discontinuation of a particular person. Presumably, a more radical discontinuity on any relevant axis presents a more radical challenge to personal continuation and this, of course, gives rise to a sorites indeterminacy. However, there is further indeterminacy concerning the relative significance of discontinuities on different axes. Is an atheist homebody pushed further in the direction of replacement by an abrupt attack of religion or by a sudden antipathy to close family? Since a determinate ordering of continua of metamorphosis requires determinate answers to such questions, lacking such determinate answers, one is faced with rank indeterminacy. Before proceeding, I should say something about why it is worth considering metamorphosis at all. Those who have never passed a night with surgically inclined gnomes might find Gregory’s case a tad fanciful, and might reasonably wonder whether highly theoretical questions about indeterminacy and replacement can be of any practical interest. My view is that it is well worthwhile to get one’s theoretical commitments right, or at least to identify mistaken commitments and then to stop relying on them. If an ethical theory gets theoretical cases wrong, so much the worse for the theory. That said, I do think that there are real cases that raise issues of indeterminacy and replacement. In the next section, I will sketch a few examples that have given me and others pause. Some readers may find such cases far clearer than I do, one way or the other, thereby exemplifying my contention that judgments of survival differ despite agreement on the determinate facts.

Indeterminacies of survival through brain injury and disease Like me, Michael Tooley distinguishes personal from biological survival: Suppose, for example, that by some technology of the future the brain of an adult human were to be completely reprogrammed, so that the organism wound up with memories (or rather, apparent memories), beliefs, attitudes, and personality traits completely different from those associated with it before it was subjected to reprogramming. In such a case one would surely say that an individual had been destroyed… even though no biological organism had been killed. [5, p. 46] Sadly, science fiction is not needed to raise questions about personal survival. Military technologies of the present are eminently capable of initiating extensive blunt reprograming. Although improvements in acute care have improved survival, at least biologically, the emerging person is likely to exhibit severe psychological disruption including memory loss, striking personality change, and markedly disrupted social behavior [2, 6]. Meanwhile, some have wondered whether the use of stem cells to treat brain injury and disease might raise questions about personal continuation [7, 8]. Thus, there already are cases that raise questions about the survival of the original person, despite continuation of the biological life.

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While the sharp discontinuities of traumatic brain injury are striking, experiences with neurodegenerative diseases suggest that even gradual transitions can give rise to doubts about whether the original person has survived. The narrative literature on Alzheimer’s disease is rich with expressions that are at least suggestive of a sense of having lost a loved one to something other than biological death: ‘‘That person that I knew is not really there anymore.’’ [9, p. 55] ‘‘This lady, she absolutely denies that her mother’s alive. ‘She’s not my mother. She’s not who I know her to be. She doesn’t know who she is.’ ’’ [10, p. 453] ‘‘It’s two people. The person that you met before, you married before, to someone who’s entirely different.’’ [10, p. 460] ‘‘With Alzheimer’s physically they’re well, but emotionally and mentally, he’s gone. With a cancer person, he’s still the same person: an Alzheimer’s isn’t. He has died a long time ago.’’ [11, p. 1254] ‘‘People say, ‘Oh, you know, you have to treat her like, you know, she has a disease. She’s not your mother anymore,’ they’ll say to me. No, what do you mean she’s not my mother? She’s still my mother.’’ [10, p. 460] This last exchange is suggestive of indeterminacy. The disagreement about whether the speaker’s mother has persisted through the descent into dementia could result from especially wide divergence on line-drawing questions, reflecting sorites indeterminacy. However, there may also be a more fundamental disagreement concerning how to think about different aspects of the mother’s transformation, reflecting rank indeterminacy. By highlighting the possibility of replacement in an ongoing biological life, Gregory’s metamorphosis suggests that we should not dismiss all statements like these as hyperbole or confusion; some such expressions may be meant, and can coherently be understood, literally. Nevertheless, one should not expect that the slowly growing sense of the original person having been lost will prompt carefree abandonment of the emerging person. Apart from the practical and legal barriers to abandonment, it can be hard to let go, especially when there is no particular time or event with which the loss can be identified. Also, even as the original is being lost, a new relationship is being established with an emergent person who is closely associated with, and maximally biologically related to, the original. Even in the clearest case of loss, ordinary death, the bereft often continue to do things as if for the person: they take on debt to pay for expensive funerals and visit the grave for months or years after the loss.

Duties to save as duties to save persons In the context of sorites and rank indeterminacies, how should we think about duties to save? First, a general point: although we routinely talk of saving lives, the precise content of the duty is more plausibly to save the person. This is easily missed in

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ordinary cases where to save the life is to save the person. However, the two considerations can come apart: a life-saving heart transplant is futile if it renders the patient permanently comatose and, if the donor organ could instead be used to restore someone else to reasonable health, it would be positively grotesque. These judgments imply that if there is any duty at all merely to save a biological life, it is so vanishingly weak that it stands in no comparison to the duty to save a person. This is so even on the view that we are essentially human organisms: being metaphysically essential is not the same as mattering. The substantive personal duty to save is a duty to save a person.

Three kinds of cases Continua of metamorphosis give us three kinds of outcome to consider. First, clear cases of personal continuation: cases of ordinary survival in which saving a person and saving that person’s biological life coincide. Second, clear cases of personal replacement: a biological life is saved and a person emerges, but the emergent person is so transformed as to be unidentifiable with the original person. Third, indeterminacy: between clear cases of continuation and clear cases of replacement, there are cases in which it is indeterminate whether the original person continues in the biological survivor. I will now consider each kind of case. I find that there are sharply contrasting imperatives in clear cases of continuation and in clear cases of replacement. These contrasting imperatives come into conflict where survival of the original person is indeterminate. I will consider some options for resolving the conflict: resolve the indeterminacy, live with the indeterminacy, or avoid the indeterminacy by breaking the link between personal continuation and personal duties to save. I will argue that the third option is the most promising.

Contrasting duties in clear cases Understanding duties to save as duties to save persons has unsurprising implications in cases of ordinary survival with personal continuation. Where a physician can save her patient, there is a strong prima facie obligation to do so. Since the duty to save the person is discharged by means of saving her biological life, the physician should save the patient’s life. In clear cases of replacement, by contrast, there will be such extensive mental and physical disruptions that the original patient will be lost: saving the biological life will not save the person. Since ought implies can, and the original person cannot be saved, there can be no duty to save the original person. The life can be saved, but the example of the comatose transplant patient illustrates the futility of mere lifesaving and the consequent implausibility of any significant duty arising from that consideration alone. Can any duty to save be claimed on behalf of the emergent person in a case of replacement? No. At the time that the life-saving action must be taken, the emergent

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person does not yet exist and, therefore, cannot be saved. Continuing to assume that ought implies can, any prior duty to the emergent person cannot be a duty to save. Might there be a duty to bring the emergent person into existence? Duties are all too easily claimed but this one has little appeal. Duties to procreate or otherwise to bring people into existence are very hard to motivate, even when the resulting person is expected to live a full, healthy, and happy life [12, p. 391]. Cases of replacement due to brain injury or disease cannot be assumed to warrant such rosy expectations. There is a subset of replacement cases in which a personal ethical approach gives an even more striking result. The following is one such story. Having been given six months to live by completely reliable physicians (play along with me here), a patient with a brain tumor seeks the help of technically proficient but metaphysically challenged gnomes. The gnomes are confident that their ailing client can be saved by dint of an immediate brain transplant. If the patient is desperate enough to agree, this would be an example of iatrogenic replacement; the treatment itself will cause the replacement of the original person. Worse, the gnomes’ plan will cause the termination of their patient by replacement before she would otherwise have died. If anything, the intuitive strength of the duty not to terminate one’s patient is even greater than that of the duty to save. It is most implausible that any claimed duty of mere biological life-saving or any alleged imperative to bring a new person into existence would have much force against the strong duty not to terminate an already existing person. Since the gnomes’ course of action would prematurely terminate a person in the process of extending biological life, there is a strong presumption that it should not be undertaken. In clear cases of ordinary life-saving and in clear cases of replacement, understanding duties to save as duties to save persons gives clear ethical guidance. There is ordinarily a substantive duty to save a life when that is the means to save the person. In a subset of replacement cases, there would appear to be a strong duty not to save the life because doing so would terminate the person by replacement earlier than she would otherwise have been lost to ordinary death.

Confounding indeterminate cases I have just shown how the difference between personal continuation and replacement can make the difference between there being a strong duty to save a life and a strong duty not to do so. These contrasting duties threaten to come into conflict in intermediate cases, where the original person’s continuation is indeterminate. The obvious thing to say in such cases is that the indeterminacy is inherited: if the survival of the original person is indeterminate, it is also indeterminate whether that person is owed a strong personal duty to be saved or a strong personal duty not to be terminated. Failure to deliver determinate guidance in all cases is not a fatal defect. On the contrary, one should expect the messiness of the real world to throw up indeterminacies, and view with more suspicion than admiration any theory that manages to carve sharp ethical distinctions across all of unruly reality. To illustrate the point, consider the shifting balance between duties to be paternalistic and duties

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to respect autonomy as children mature into adulthood. Although the law draws bright lines as a matter of practical necessity, there is no pretense that such lines carve our moral nature at the joints. A child’s emergence into adulthood is replete with both sorites and rank indeterminacies. Sorites indeterminacies arise because the capacities that constitute autonomy are matters of degree: when do akratic children become enkratic adults? Rank indeterminacies arise because overall autonomy depends on the relative importance of distinct capacities: is someone with an abundance of enkrateia but little nous more or less autonomous than someone whose sagacity is undermined by akrasia? Perhaps ways of balancing autonomy and paternalism in the context of child rearing can inform our thinking about indeterminacies of replacement in the context of life saving. Unfortunately, there are significant differences between the two contexts. In the context of child rearing, the question is not whether the child is or is not autonomous but to what degree she is autonomous; and the choice for action is not between paternalism and respect for autonomy but between different ways to calibrate one’s paternalism from, ‘‘Turn that TV off and do your homework!’’ via, ‘‘Before you glue yourself to the idiot’s lantern, did you remember your homework?’’ to, ‘‘I can’t believe they’re showing re-runs of ‘American Idol.’’’ There is no such scope for nuance or calibration in the context of life saving: the question is whether the patient will or will not be replaced, and the options for action are to save or not to save the patient’s life. Differences between indeterminacies of autonomy and indeterminacies of replacement also show up when we consider the consequences of error. Miscalibrated paternalism may impede development of a child’s enkrateia to some degree, but a neurosurgeon whose life saving intervention triggers replacement has not only failed to discharge a duty to save but has actually terminated the patient. One lesson to draw from child rearing is not to expect an ethical theory to deliver bright lines in the face of indeterminacy. However, the lack of a bright line does not mean that decisions must be arbitrary. Especially when choosing between such starkly contrasting duties as a duty to save and a duty not to terminate, it would be nice to have something of ethical substance to say, something to help guide action in the face of indeterminacy.

Three responses to indeterminacies of replacement The first step in responding to indeterminacies of replacement is to understand what one is looking for. I am considering the possibility that the process of saving a biological life might be so disruptive as to trigger replacement of the original patient with a new emergent person. On a straightforward understanding of duties to save as duties to the person, there are cases in which the question of whether one faces a duty to save or a duty not to terminate depends on whether the life-saving intervention will trigger replacement. Because of this dependence, the evaluation of these contrasting duties inherits the indeterminacy of replacement. Given the basic structure of the challenge, there is a very short list of options for response: resolve

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the indeterminacy of replacement, live with indeterminacy of duties to save, or break the dependence between replacement and duties to save. With the indeterminacies of replacement firmly ingrained in the underlying continua of metamorphosis, a struggle to resolve the indeterminacy has poor prospects. Relaxing and learning to live with indeterminacy is far more promising. One might hope to achieve de´tente with indeterminacy on reasonable terms if it can be handled as just another example of having to make ethical decisions with imperfect knowledge. Unfortunately, this is not an apt model for addressing indeterminacies of replacement. When there is no other hope, an intervention offering a one in a hundred chance of survival might be the best bet. But how is a patient to view the prospect of indeterminate survival? Even if the patient can make sense of survival that is indeterminate to the hundredth degree, there is no obvious reason for her to view this as being equivalent to a one in a hundred chance of survival. That being the case, ethical decision-making under conditions of imperfect knowledge does not provide a template for learning to live with indeterminacies of replacement. There may be other ways to come to terms with indeterminacy, but I am reluctant to accept that life and death ethical questions remain undecided even when all the relevant determinate facts are known. This gives reason to consider the third option for responding to indeterminacies of replacement: weakening or breaking the link between the patient’s continuation or replacement and the question of whether we face a duty to save or a duty not to terminate. I have already distinguished biological from personal survival. I am now wondering whether the moral substance of the duty to save persons can be pulled apart from questions of personal survival or continuation. No one since Buddha has done more than Derek Parfit to weaken the link between ordinary survival and what really matters, prudentially and morally [12, pp. 245–280; 13]. In Parfit’s view, the realization that personal identity reduces to un-branching chains of psychological continuity supports a more impersonal ethical outlook than we typically hold [12, p. 445]. Parfit himself endorses somewhat moderate impersonal claims [12, p. 446], but a purely impersonal outlook would be able to finesse issues of indeterminacy by dint of indifference to whether the emergent person is a continuation of the original or a replacement. However, few of us can achieve the required level of indifference as to whether our loved ones continue or are replaced. It seems, then, that we are stuck between standard personal ethical considerations that run into the indeterminacies of replacement, and purely impersonal considerations that wholly miss the point when we consider the irreplaceability of those we love. Can we find personal ethical considerations that do not turn on the indeterminacies of personal continuation? Yes, we can. The idea might seem oxymoronic but I will argue that it does make sense. I will then apply the idea to duties to save.

Personal concern Many people’s lives contain pivotal misfortunes. Even as misfortunes reduce our welfare, they also affect the course of our lives going forward. The projects we

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adopt, the people we meet, and the relationships we form are changed as a result of the misfortunes we suffer. If a young person loses a spouse it will be agonizing—a source of lasting pain. But suppose that re-marriage eventually follows, and children. Even if the survivor’s life, from a welfare point of view, would have gone better overall had her first husband not died, it does not follow that she should personally regret the tragedy, all things considered. Reflecting that her actual children would never have existed but for her earlier loss, it would be hard for her to wish, with a whole heart, that it had never happened. Thus, while we would not choose tragedy looking forward, when viewed in retrospect our commitment to the projects and relationships that we have actually come to cherish most deeply can trump sober assessments of lost opportunities for greater wellbeing. I call the projects and relationships about which we actually care our ‘‘personal concerns’’ [3, p. 655]. When one frames ethical discussion in terms of personal welfare (or the even more misleading shorthand of rational self-interest), one is employing notions that require personal continuation. However, personal continuation is neither necessary nor sufficient for people’s actual personal concerns. There are obvious examples of personal concerns that do not depend on survival: the personal concern that many parents have for their children easily eclipses that for their own wellbeing, it even eclipses concern for their own survival. However, the fact that some personal concerns are not purely egoistic does not show that personal ethical considerations in general can be independent of survival. To sustain the stronger claim, I need to show both that survival is not sufficient and that it is not necessary for anything of personal concern. I will address each direction in turn.

Survival is not sufficient for anything of personal concern Thinking about the prospect of permanent coma makes it clear that mere continuation of the organism is not sufficient for the preservation of anything of personal concern. Coma cases, however, involve the end of the person and therefore leave open the question of whether personal survival might suffice to preserve at least something of personal concern. To show that personal continuation is not sufficient for personal concern, I need a case in which nothing of personal concern is preserved despite continuation of the original person. Jeff McMahan’s deification example fits the bill: [I]magine the prospect of becoming like a god. Imagine the prospect of becoming vastly more intelligent and developing a vastly richer and deeper range of emotions of which one cannot now form any conception. One would be as different from oneself now, in terms of psychological capacities, as one is now from a dog (or, more to the point, as different from oneself now as a dog would be from itself if it were to become a person). One would be, in short, so utterly psychologically remote from oneself as one is now that one may have little or no egoistic reason to want to become that way. Even if the transformation would be identity-preserving and would lead to a state that would be clearly superior to one’s present state, it would be too much like

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becoming someone else—and, of course, losing oneself in the process—to be very desirable from an egotistic point of view. [14, pp. 321–322] In terms of personal concerns, the problem with deification is that it improves away the stuff we actually care about. I care very deeply about my closest relationships. I do not want to have a god’s eye view of my parents, siblings, spouse, or child; I prefer the intimate human view and the actual relationships to which that view is essential. Deification would tear all that from me: the emergent deity might not mind but, if one were to ask this human original, consent to deification would not be forthcoming.

Survival is not necessary for anything of personal concern In a previous paper, I used a fictional teletransportation device to argue that survival is never necessary for personal concern [3]. Standard teletransportation devices work by scanning a person (who disintegrates in the process) and then transmitting the information to a remote receiver where the original person is exactly duplicated. My medical teletransportation device works by transporting a sick patient while, in the process, making whatever minimal modifications are required for the reconstructed person to be disease free [3, pp. 656–657]. If I suffered a debilitating disease, medical teletransportation would be an appealing option. But suppose I look more closely into the process and discover that the disintegration of the original actually takes place a little moment after the reconstruction of the disease free copy. In that case, both the original and the copy coexist, briefly, as distinct human persons. The period of coexistence ends when the post-reconstruction original suffers ordinary death by disintegration.2 I have discovered that I die in the process of medical teletransportation. Prior to scanning, I can comfort myself with the thought that I will, in some sense, continue as the copy but, after scanning, no such comfort is available to the scanned original awaiting disintegration; there is no sense in which he continues or survives. Despite these sobering realizations, it is far from obvious that this quirk of timing has any bearing on the benefits that I was personally concerned to enjoy when I signed up. I daresay my outlook would change if the period of coexistence were extended so that original and copy started to amass significantly diverging experiences during the time between duplication and disintegration, but if medical transportation were quick and reliable I would happily use it to get rid of cancer or cardiac disease; if it were cheap I would bid adieu to the common cold; if it were convenient I would turn off the medical circuitry and use it for my commute. Those who have qualms may find reassurance in a pair of cases described by Derek Parfit: All of my brain cells have a defect which, in time, would be fatal. But a surgeon can replace all these cells. He can insert new cells that are exact replicas of the existing cells except that they have no defect. We can 2

This is a branch line case [12, pp. 200–201].

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distinguish two cases. In Case One, the surgeon performs a hundred operations. In each of these, he removes a hundredth part of my brain, and inserts a replica of this part. In Case Two, the surgeon … first removes all of the parts of my brain, and then inserts all of their replicas. [12, p. 474] Parfit, here, focuses on the brain, but the same idea can be applied to total body replacement. Case One is a reminder that we already accept that our bodies, our brains, and what matters in our survival can all be preserved through progressive change and replacement with new matter. The fact that the process of replacement is not progressive in Case Two makes a metaphysical difference in that, instead of being repaired, the original brain is destroyed and replaced. Despite the metaphysical differences, the surgeon achieves exactly the same end result in both cases and Parfit finds it hard to imagine that the differences in the details of timing could make any substantive difference to what matters. Medical teletransportation, of course, is just an elegant means of realizing Case Two. There are, however, those who balk at the prospect of being scanned and disintegrated, even if they are also copied. In a PhilPapers survey, a plurality of professional philosophers (36.2 %) accepted or leaned toward ‘‘survival’’ in response to the question, ‘‘Teletransporter (new matter): survival or death?’’ but those accepting or leaning toward ‘‘death’’ were not far behind with 31.1 % [15].3 It would be nice to dismiss those with scruples about teletransportation as having suffered a lack of Star Trek in their metaphysically formative years, but many of those who would shun teletransportation in favor of chemotherapy, colds, and tedious commutes actually seem sane enough in other respects. Jeff McMahan’s intuition is that physical continuity is necessary for what matters in survival and that something of genuine concern is lost in the transition to Case Two [14, p. 70]. He observes that, as long as the sequence of replacements in Case One is sufficiently gradual, ‘‘there would be physical continuity, despite the replacements,’’ but as things speed up towards Case Two there comes a point where ‘‘turnover would be too rapid for there to be physical continuity’’ [14, p. 71]. Of course, since there is nothing aphysical about the replication and replacement process, McMahan’s concern must be that there is the wrong kind of physical continuity in Case Two. Despite his qualms, McMahan does find Parfit’s view defensible and acknowledges that it looks odd to suppose that there is anything that matters in the difference between cases One and Two. It looks very odd to me. Suppose that the defect will not only be fatal, but is also painful until the replacement of defective brain cells is complete. Both luddites and technophiles endorse treatment if the only option is very gradual replacement. Take for example McMahan’s number and say that one hundredth part of the brain (or body-brain if preferred) is replaced every six months for fifty years [14, p. 71].4 The cost of this slow process will be nearly fifty years of pain until the treatment is complete. If surgical refinements get the replacement 3

I would note that the survey might be understating the appeal of teletransportation in that one might well think that teletransportation is just as good as survival even though it is in fact death. Parfit rejected both options for this reason [16]. (The view that teletransportation, though in fact survival, is just as bad as death is too implausible to offer a balancing bias). 4

One can pick smaller chunks or longer intervals if preferred.

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interval down to five months that would save over eight years of pain: clearly a good thing! No? Well, at some point, McMahan has to say, ‘‘No.’’ At some point, it should strike him as bad news to hear that the technique has been further refined and now progresses to just the same physical and functional end-point even faster. At some point, one refinement too many will bring the surgical option close enough to medical teletransportation to flip McMahan into a state of metaphysical masochism in which he should be willing to pay more for a slower procedure that promises more pain. While I hesitate to claim that such a preference structure is outright incoherent, it strikes me as a highly unfortunate result of taking a stand against medical teletransportation. Much more needs to be said, but a full apology for teletransportation is beyond the scope of this paper. I hope to have shown that it is defensible, even appealing, to hold that teletransportation disrupts nothing of personal concern. That being the case, since we do not, as it turns out, survive teletransportation, it is at least a defensible view that survival is never necessary to personal concern.

Personal concern and duties (not) to save I have considered a deification case in which survival guarantees nothing that is actually of personal concern, and I have considered medical teletransportation and progressive transplant cases in which it is at least reasonable to believe that nothing of personal concern is undermined by the mere fact of replacement. Taken together, these cases support the claim that personal continuation is neither necessary nor sufficient for personal concern. Since considerations of personal concern are both ethically relevant and, of course, personal, the upshot is that there are personal ethical considerations that are not tied to personal survival. Thus, there does seem to be a way to break the dependence between questions of personal continuation or replacement and the assessment of personal duties (not) to save. A personal concern approach avoids the problems of indeterminacy in the same way as an impersonal approach, by looking only at ethically relevant considerations that are independent of continuation or replacement. However, because it attends to personal considerations, the personal concern approach does not share the impersonal approach’s inability to distinguish between ordinary survival and personal obliteration followed by replacement with an altogether new person. In this section, I will compare the approaches in a series of three cases. In the next section, I will ask if the personal concern approach is missing something crucial. The three cases are as follows. Dr. McCoy has bad news for Lucy, Hal, and Brian. Because all three patients feel perfectly well, they are shocked to learn that they have brain tumors. Each can expect to remain symptom free for the next six months but the tumors are progressing rapidly and, unless treated immediately, will be fatal in a year. All three tumors can be completely removed by immediate surgery, though the details of each case differ as follows: Lumpectomy: Lucy is told that her tumor will be easy to remove and that there will be no lasting effects.

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Hack and Hope: Hal’s tumor is more diffuse than Lucy’s. Surgery will unavoidably disrupt brain structures as yet untouched by the tumor. Dr. McCoy explains that the surgery itself will profoundly disrupt Hal’s autobiographical memory, his current attachments to friends and family, and his commitments to other personal and professional projects. (I am deliberately leaving the details vague to accommodate a range of intuitions about what would constitute profound disruption). However, Dr. McCoy assures Hal that the emergent person will ultimately be free of lasting disability and will be able to develop new relationships and life projects. Shiny New Brain: Brian needs even more radical surgery than Hal. But Dr. McCoy is very reassuring about the high success rate of the latest transplant techniques using off-the-shelf replacement brains. In Lumpectomy, Lucy’s treatment option promises ordinary biological and personal survival. Impersonal considerations, personal continuation, and personal concerns all align in favor of surgery in such a case. Even so, it is worth pausing to note contrasts between the rationales underlying the joint recommendation: impersonal rationales can recommend surgery, but not because it will save Lucy; personal preservation rationales recommend surgery precisely because it will save Lucy; and a personal concern approach recommends saving Lucy because that aligns best with what Lucy actually cares about. Turning to the other extreme case, Brian’s Shiny New Brain promises biological survival. However, immediate brain transplantation will bring personal obliteration six months earlier than if the tumor were left untreated. So the options are effectively, death now with later replacement, or death later with no replacement. It is a serious deficiency of a thoroughly impersonal view that it is unable to draw any ethical distinction between Brian and Lucy’s treatment options: replacement is as good as survival from an impersonal perspective. From a personal continuation perspective, the premature termination of a person’s existence is, prima facie, a serious wrong that is unmitigated by replacement. There would be a strong presumption that the surgeon should not perform the brain transplant even if, in a moment of metaphysical confusion, Brian requests it. The personal survival perspective’s handling of Shiny New Brain is far more plausible than that of a purely impersonal approach. By focusing on personal considerations that actually matter to Brian, a personal concern approach would be expected to align with the more plausible view. In general (exceptions will be discussed below), a brain transplant will promote Brian’s personal concerns no better than ordinary death, and the intervention will actually rob him of six months of continuing to enjoy the relationships and projects with which he is personally concerned. Since a brain transplant will not only fail to advance Brian’s personal concerns but will actually set them back, it would be a presumptive wrong to swap Brian’s diseased original for a shiny new brain. In Hack and Hope, a pure impersonal approach, once again, gives flat footed approval to disruptive surgery, utterly oblivious to serious ethical qualms about personal duties to the patient going under the knife. Meanwhile, a standard personal

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survival approach will require an answer to the question of whether the operation will save the patient, leading to the dead end of indeterminacy. My suggestion is that it would be a mistake for the surgeon to focus on survival during the process of informed consent. It will be more productive to consider to what extent the intervention will promote the patient’s substantive personal concerns, her most cherished projects and relationships. Instead of asking if the emergent person will be a continuation of the original, I ask to what extent the emergent person will promote the personal concerns of the original. This, of course, is a very complicated question and one that, unlike asking whether the patient will survive or not, admits of degrees. Some facing the prospect of disruptive brain surgery might wonder, principally, to what extent the emergent person will continue to be a participant in their closest relationships. Others might wonder more about whether the emergent person will be able to continue with business, charitable, or artistic projects to which the original is dedicated. Balancing the great variety of competing personal concerns is a tough struggle but, unlike bashing one’s head against indeterminacy, it is a productive struggle, and one should expect grappling with matters of fundamental moral substance to involve some head scratching. Indeed, it is interesting to reflect on such questions even in the absence of an existential threat. I find, for example, that there are work projects to which I devote considerable effort that I would drop without hesitation in favor of a better offer. Yet, and I am sure I am not alone in this, these same projects sometimes clash with commitments to spouse and child that I would never willingly give up. Others have suggested accounts of what matters that do not depend on ordinary survival. Parfit has suggested psychological continuity and, especially, connections as plausible sources of personal value [12, p. 262]. But suppose one could either throw oneself into some quixotic, make-work administrative project handed down by middle management or blow that off and spend the time on a potpourri of charitable projects about which one actually cares. Now, it could be that the endless strategic planning meetings would better promote continuity and connectedness across time than would the performance of a series of standalone good deeds, but it would be very odd to think that the promise of strong continuity of tedium provides a reason to forego more disjointed endeavors about which one actually cares. I do not deny that it is often reasonable to value connectedness and continuity. John Perry has noted that the best assurance of a project’s completion may be connectedness between the person-stage that is now concerned with the project and the later stages what will put in the work to complete it [17]. Sometimes continuity and interconnectedness will be part of the value of or even, as Jennifer Whiting argues, partially constitutive of a project or relationship [18]. In other cases, however, the unpleasantness of the psychological connections that will be established may sharpen one’s personal concern in avoiding a project. The personal concern that any sane person has in not volunteering for weekly meetings of the Dean’s Special Subcommittee for the Remediation of Redundant Redundancy will gain urgency from thoughts of the strong but painful psychological connections that would be established by participation. Connectedness and continuity are unreliable guides to what is actually of personal concern.

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By reframing duties to save in terms of personal concern, I consider those duties to be driven not by default assumptions about the value of biological life, or even about the value of connectedness or continuity per se, but by richer duties of respect for the concerns that actually matter to the person. Using a personal concern approach, the success of an attempt to save will vary with the extent to which prior personal concerns are disrupted, and crude measures of lives saved may be found to overstate the success of the latest and greatest in acute care.

Are some personal concerns privileged? A personal concern approach can draw ethically relevant distinctions between continuation and replacement that a purely impersonal stance misses. However, there is reason to wonder whether it draws quite the right distinction or whether it, too, misses something of significance. Recall poor old Brian’s predicament: the only way he could avoid dying of a brain tumor in six months was to bring his personal history to an immediate end with the installation of a shiny new brain. One would generally expect someone to pick six months over nothing, but it is easy to imagine exceptions: Shiny New Brain II: Brian, the second of that name, has six months to live, but his stock options do not vest for a year. There is only one way for him to survive, biologically and legally, for long enough to realize the capital gains that his family will need to stay out of the poor house: he must have an immediate brain transplant. Brian II does not relish having his personal existence cut short but he is more concerned about his family’s future. Brian II requests installation of a shiny new brain. There is a very strong presumption against doctors terminating their patients, even for the greater benefit of others, and even when the benefit to others would best promote what the patient most cares about. Having set aside the self/other distinction in order to avoid indeterminacies of continuation, one might wonder whether a personal concern approach can even articulate this plausible presumption. It can. A personal concern approach can do so by giving ethically defensible priority to special kinds of personal concern, as long as it does so without re-importing considerations of personal continuation. A plausible option is to give priority to what I will call ‘‘first personal concerns.’’ First personal concerns are simply those personal concerns that have a first person perspective. The first person perspective is exemplified in remembering last night’s pizza rather than just knowing that pizza was eaten last night; looking forward to seeing Patagonia instead of hoping my parents have a good time there; planning for my retirement as opposed to planning for my child’s education. Despite the examples that come most readily to mind, having a first personal perspective does not presuppose personal continuation. Derek Parfit notes three requirements for saying that some person, P, remembers an experience: P seems to remember an experience; P had the experience; and P’s seeming to remember is caused, in the right way, by P’s having had the experience [12, p. 207]. If one drops the

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requirement of P’s continuation, one gets Parfit’s notion of quasi-memory: P seems to remember an experience; someone had the experience; and P’s seeming to remember is caused, in the right way, by that experience [12, p. 220]. Memory researchers have found that we can be induced to have the perspective of a first person memory of someone else’s experience [19]. Whether these count as quasimemories will depend on whether having apparent memories induced by researchers can count as the right kind of cause, but they do have the first person presentation of P seeming to remember. Looking forward, one can make a similar move by dropping the presupposition of personal continuation from ordinary intention in order to yield a notion of quasi-intention [12, p. 261]. Similarly, first personal concerns can be viewed as quasi-self-regarding concerns in that they have the perspective of ordinary self-regarding concerns but lack the requirement of continuation. On a standard personal survival approach, the plausible presumption that Brian II’s physician must not agree to his request for early termination amounts to prioritizing his self-regarding interests over his admittedly stronger concerns in securing the wellbeing of his family. This can be reframed under a personal concern approach as giving priority to Brian II’s first personal concerns. Though the two approaches will converge in Brian II’s case, there are differences. For example, since medical teletransportation involves patient termination, a personal survival approach will need special modifications or exceptions to allow it, whereas the mere fact of biological death is, in itself, unproblematic from the perspective of first personal concern. Whether one considers this a feature or a bug will depend on one’s feelings about teletransportation. None of this is intended as an argument that first personal concerns should be given priority, but just that the approach has the resources to do so. Actually, I find it rather hard to believe that we can justify refusal to advance what a patient actually cares most about on the grounds that those concerns are insufficiently selfish or quasi-selfish.

Ordinary cases I have argued that, from a personal survival perspective, there is a presumptive duty for doctors to save a life when that will save the patient, a duty not to save a life when that would result in replacement of the patient, and a clash between these contrasting duties in intermediate cases of indeterminacy. From a personal concern perspective, the presumptive duties are neither to save nor to refrain from terminating a patient, but to promote the patient’s personal concerns. Despite paying no attention to personal survival, a personal concern approach aligns well with strong intuitions about ordinary cases: saving people will generally be endorsed as promoting personal concerns while terminating people will be frowned upon as profoundly inimical to personal concerns. Because it pays no attention to survival, a personal concern approach brings ethically substantive considerations to bear in tough intermediate cases, and with all-or-nothing questions of survival set aside, it

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does so without imposing jarring ethical discontinuities on continua that shift by degrees. Even in ordinary cases, any credible view must recognize the ethical importance of personal concerns: we already recognize that morbidity matters and that a surgeon who discloses only the odds of biological survival, mentioning nothing of the prospects for the patient continuing to participate in cherished projects and relationships, is doing a lousy job of getting informed consent. Thus, our ordinary way of thinking about life saving procedures is, in effect, a personal concern approach with a personal survival criterion tacked on. Another way to arrive at a personal concern approach, then, is to start with our ordinary approach and then to question whether we should really worry about biological or personal survival at all. Does it really do any work? If a full discussion of personal concerns leaves a patient uncertain as to whether a treatment is worthwhile, it is hard to imagine that even the most authoritative pronouncements of the hospital’s metaphysics committee would be of any help. Applying a personal concern approach in clinical contexts requires a reasonable grasp of the impact of disease processes and the interventions intended to treat them. Unfortunately, there are striking areas of ignorance where such knowledge is most needed. It has been noted, for example, that ‘‘Because of the priority of removing the immediate threats to health or life…, side effects of surgical brain injuries were not given much attention until recently’’ [20, p. 204]. In other words, prioritizing biological survival has distracted research attention away from the long term impact that life-saving interventions can have on what patients actually care about, away from what a personal concern approach recognizes as the ethical substance of difficult treatment decisions. If we drop that distraction, we can focus on what does matter: the patient’s personal concerns. Acknowledgments My thanks to Galen Giaccone, Jessica Best, Melissa Koenig, Brittany Boyle, David Fuhrman, and to two anonymous reviewers of this journal for their careful reading and insightful commentary on versions of this paper. For rich discussion of presentations of the ideas in this paper, I am indebted to Philosophy Department students and faculty of the University of South Carolina, to participants in the American Society for Bioethics and Humanities Philosophy Interest Group, and to my colleagues at the University of Delaware Center for Science Ethics and Public Policy’s Research Group. This research was supported by the Center for Science Ethics and Public Policy and the National Science Foundation EPSCoR program, grant EPS-0814251.

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