This is an ambitious, wide-ranging and welcome book. DeGrazia’s aim is
to articulate and defend not one but two conceptions of human identity, and
then to examine their consequences for practical issues in bioethics. Most
bioethicists, explicitly or implicitly, appeal to conception of personal identity when they engage in
arguments over killing and letting die at what Jeff McMahan (whose own recent
book The Ethics of Killing is the
most obvious comparison to the present volume) calls ‘the margins of life’: the
beginnings of life (and therefore abortion) and the endstages (and therefore
advance directives, dementia, and persistent vegetative states). Commonly, they
argue that the foetus is not yet a person, and that therefore killing it is
permissible, or that the patient with very severe dementia, or who is
permanently unconscious, is not the same person as the one who made the advance
directive. DeGrazia seeks to evaluate these claims.

The common view of personal identity is personalist: it holds that human
beings are essentially persons. DeGrazia rejects this view, in favor of a
biological approach: we are essentially human animals, he holds. Thus, we come
into existence when the animal does, and go out of existence only with its
death. Accordingly, the survival of our personality or even of consciousness is
not necessary for the survival of ourselves. In defending this view, DeGrazia
clearly identifies some counterintuitive implications of personalist views. But
it is far from clear that his favored alternative is any less problematic.
First, some of his arguments against personalism are rather too quick. Consider
his claim that the prince and the cobbler, in Locke’s famous example, should
not be treated as a case in which people swap bodies, but as a case in which
two people are systematically deluded. It is easy to see how the personalist
might reply to this: by insisting that the swapping bodies story is the better
one if and only if there is a causal story to be told about the origins of the
beliefs that each person professes after the swap, which traces the origins of
these beliefs back to the other body. Second, and as DeGrazia himself
acknowledges, it is wildly counterintuitive to hold, as his story seems to
commit him to doing, that Siamese twins who share a single body but have two
heads, as in the case of Abigail and Brittany Hensel, are in fact one person.
Third, DeGrazia’s argument that personalists are committed to a
counterintuitive claim, that each of us was not born, is somewhat undermined by
the fact that he is himself committed to the equally counterintuitive claim
that each of us was not conceived (since, as he later argues, he thinks that
identity dates not from conception, but from some later time).

Having defended an account of personality identity, DeGrazia turns to
the notion of narrative identity: the kind of identity with which we are
concerned when we ask ourselves who we are (what do I want?).  His discussion
here is useful, though it seems to me to add little to Marya Schechtman’s
groundbreaking work. This chapter gets sidetracked somewhat, into a discussion
of free will, autonomy, and related issues. Inevitably, given that he can
devote relatively little space to the topic, DeGrazia’s account here seems
inadequate. He claims that a preference is autonomous if it is the product of
influences that the agent does not consider alienating and with which she
identifies. Thus, an agent who is coerced into handing over her money is not
autonomous, because she has the preference only because she is threatened. But
consider Jill’s preference to vote for John Kerry. She preferred to vote for
Howard Dean, and voted for Kerry only because Dean did not receive the
Democratic nomination. It seems that given that Jill has this preference only
as a result of forces beyond her control that she prefers not to have operated,
her preference is not autonomous. But that’s counterintuitive. In general,
DeGrazia seems forced to hold that preferences that are the product of adapting
to the demands of reality are not autonomous.

DeGrazia’s next chapter is devoted to definitions of death, and the
extent to which his accounts of identity can illuminate both these definitions,
and the ethical issues that surround end-of-life questions. Given his
organismic conception of personal identity, DeGrazia believes that the
identification of death with the cessation of brain function is mistaken. Now
part of the reason why physicians have been eager to embrace a whole, or even a
higher, brain conception of death is that it makes harvesting organs for
transplant much easier, and therefore promises to save many whose quality of
life can be expected to be high. DeGrazia acknowledges the validity of this
concern, and urges what he calls a daring proposal as a response: abandon the
rule that the donor of a major organ be dead. If a patient has consented to
organ donation when he or she enters an irreversible coma, for instance,
physicians should be allowed to honor the request, even though the death of the
patient will inevitably result. In effect, patients should be allowed to opt
for the definition of death they prefer. Alternatively, DeGrazia suggests, we
might continue to pretend that whole-brain death is death.

DeGrazia then turns to what he calls the someone else problem, which can
arise when a person makes an advance directive requiring physicians to withhold
treatment from them if they become severely demented. The problem is this: the
person who made the directive no longer exists when it is time to carry it out.
But why should the directive of a person who has vanished from existence carry
any weight when it comes to the treatment of a human being who may be contented
with their existence? Not surprisingly, given his organismic conception of
personal identity, DeGrazia rejects the claim that the demented individual is
not the person who made the advance directive. So there is no someone else
problem after all. DeGrazia argues that we ought to give some weight to an
autonomous individual’s preferences with regard to how she should be treated
once she is no longer autonomous. But her time-relative interests (a notion
DeGrazia takes over from McMahan) may conflict with her autonomous wishes. Generally,
but not invariably, DeGrazia suggests, the latter ought to trump the former.

 DeGrazia’s next chapter is
devoted to technologies of self-transformation, low and high-tech. These
include genetic enhancements, psychopharmacology and cosmetic surgery: all
designed to improve how a person looks, feels, and even her personality. Many
people feel that enhancements are impermissible or inauthentic. DeGrazia argues
that there is no convincing case for a blanket prohibition on enhancement
technologies in general, or on any particular such technology. Instead, he
suggests, their use must be assessed case-by-case. The problem with this
approach, however, is that it ignores collective action problems. Many
individual cases of apparently permissible use of enhancements can gradually
change the social field in which individuals make their rational choices.
Sometimes collective action needs to be taken to control or prohibit a
technology, in order to enhance the autonomy of individuals.

Finally DeGrazia turns to the question of prenatal identity, and the
ethical issues that cluster around our treatment of fetuses. He argues that the
enhancement and treatment of fetuses raises no special problems, even though
(on his account) such interventions can alter the identity of the resulting
person. He also argues that at least the great majority of abortions are
ethically permissible, even though (once again on his account) the fetus
aborted is numerically identical to the person who would have existed but for
the abortion. McMahan’s time-relative interests account is once again called in
to  do the ethical heavy lifting.

There is much to quibble with in this book. It covers a great deal of
ground, and inevitably the arguments are not conclusive. Loose ends are left,
possible replies go unexamined. Nevertheless, DeGrazia’s book is a high-quality
contribution to debates in bioethics and related areas. It does much to connect
the ethical issues considered with the contemporary philosophical debate over
personal identity, and to distinguish different senses of identity all too
often confused. With the appearance of books like this, bioethics can take its
place as a respectable area of enquiry, with standards as high as those that
govern other philosophical subdisciplines.

© 2005 Neil Levy

Neil Levy is
a research fellow at the Centre for Applied Philosophy and Public Ethics,
University of Melbourne, Australia and is author of Being
Up-To-Date: Foucault, Sartre, and Postmodernity (Peter Lang, 2001), Moral
Relativism: A Short Introduction (Oneworld, 2002), Sartre
(Oneworld, 2002), and What
Makes Us Moral?: Crossing the Boundaries of Biology (Oneworld, 2004).

Categories: Philosophical, Ethics