Human Nature and Moral Status in Bioethics

Human Nature and Moral Status in Bioethics Abstract The articles in this issue cover a wide range of topics, including the moral status of human embryos and human-animal chimeras and hybrids, the determination of death, theories of human cognition, and policies on the identity of mitochondrial donors. Despite this variety, there are two underlying questions that tie the articles together: what is a human being? And, what is the basis of moral status? First, I discuss these two questions and why they are important for bioethics. Then I provide summaries of the six articles in this issue and explain how each of them is connected to the questions of human nature and moral status. biological development, circulatory-respiratory criteria, conceptual metaphor theory, dead donor rule, determination of death, embodied cognition, gamete donation, human cognition, human embryos and fetuses, human nature, human-animal chimeras and hybrids, mitochondrial donation, moral status, permanence criterion, psychological identity species-based moral arguments, substance ontology I. HUMAN NATURE AND MORAL STATUS The articles in this issue of Journal of Medicine and Philosophy are eclectic, with topics ranging from the moral status of the embryo to the United Kingdom’s current policies on mitochondrial donation. In spite of this variety, an overarching thread that connects all six articles is their relation to two key questions: (1) what is a human being? and (2) what is the basis of moral status? First, I will discuss each of these questions and explain why they are important for bioethics. Then, I will provide a brief summary of each article and show how they are connected to these two questions. The first question, which I will call the “human nature question,” asks what humans are by nature—what kind of thing a human being is. The term “human being” is ambiguous: it can mean a human person, a human organism, a human substance, a rational agent, a rational animal, an entity with human DNA, or something else. The answer to this question often depends on the type of inquiry at hand. We might be asking what a human being is when viewed from a metaphysical perspective, a moral perspective, a biological perspective, an economic perspective, a political perspective, a religious perspective, and so on. The authors in this issue approach the human nature question primarily from the angles of metaphysics, biology, and ethics. Some of the authors advocate keeping these three perspectives distinct, whereas others think that bioethics requires a synoptic approach that synthesizes all three. The human nature question is central to four of the articles. Mark Brown and Jason Morris debate about when a new human being comes into existence; Dietmar Hübner investigates the nature of human–animal chimeras and hybrids; and Andrew McGee and Dale Gardiner ask when a human being ceases to exist. The second question, which I will call the “moral status question,” asks which individuals and groups are protected by moral norms, and what the grounds are for this moral status. Like “human being,” the term “moral status” is ambiguous. A thing with moral status can be a moral agent with the full array of moral rights and duties (e.g., a normally functioning adult human person), a subject of moral rights but not duties (e.g., a human embryo or fetus), or anything that is an object of moral consideration and part of the moral domain, even if it lacks rights and duties (e.g., animals or the environment). Moral status can be an all-or-nothing property that all status-worthy individuals possess equally or a degreed property that some individuals possess to a greater or lesser extent than others. It can be an intrinsic property or an extrinsic, conferred property. It can be based on a thing’s nature (what it is) or its abilities (what it can do). It can be a function of basic natural capacities (potentialities) or presently exercisable capacities. It can be the ground of negative rights and obligations or of both negative and positive rights and obligations. Moral status has been defined in many ways.1 A standard assumption is that the only individuals with moral status are those capable of being wronged. Another is that X’s having moral status generates moral reasons for me to treat X in certain ways for X’s own sake, rather than for some other reason (e.g., for the sake of the consequences on myself or on people other than X). Some common views of moral status ground it in one or more of the following properties: humanity, personhood, sentience, rationality, consciousness, self-awareness, conation, moral agency, or social relationships. As Tom Beauchamp and James Childress point out, the plausibility of a theory of moral status depends in large part on whether we take possession of the relevant status-conferring property to be a necessary condition or a sufficient condition for moral status. It is much easier to defend criteria for the latter than for the former.2 For example, consider one proposed criterion of moral status: being a rational agent with the capacity for autonomous choice. It is plausible that satisfying this criterion is enough to secure moral status, since a rational agent is the paradigmatic type of being who is capable of being wronged and whose interests are protected by morality. However, making rational agency a requirement for moral status is problematic for at least two related reasons: (1) it counter-intuitively implies that certain groups such as human infants, the severely intellectually disabled, and sentient nonhuman animals lack moral status, and (2) other properties, such as humanity or sentience, also seem to be sufficient conditions for moral status, regardless of whether they are conjoined with rational agency. The four articles that I have already mentioned explore the moral status of certain human or human-like entities or of human beings in a particular state. Brown and Morris debate the moral status of human embryos and fetuses; Hübner asks about the moral status of human–animal chimeras and hybrids; and McGee and Gardiner address the moral status of human individuals who are considered to be dead according to different criteria for determining death. I have noted how four of the articles in this issue are connected to the human nature question and the moral status question. The remaining two articles—Somogy Varga’s article on embodied cognition and John Appleby’s article on mitochondrial donation—may appear to be exceptions because they do not directly address either of these questions. As I will explain below, however, both of these articles are related to the two questions in significant ways. The human nature question and the moral status question are deeply interconnected. Traditionally, an important part of what it means to be human is to be a moral agent with full moral status. Also, moral status is often determined by the kind of entity something is: a human being, an animal, a plant, a rock, and so forth.3 Human beings are the paradigmatic type of being that possesses full moral status. The standard approach in moral philosophy and bioethics is to point to some specific human feature that grounds moral status, such as sentience, autonomy, rationality, or self-awareness. Moreover, it is often the case that whether certain types of entities (e.g., human embryos and anencephalic infants) are thought to be bearers of moral status depends on whether they can be classified as human beings or whether membership in the human species or possession of a human nature is sufficient for moral status. For instance, in his contribution to this issue, Mark Brown argues that the very early embryo has human DNA but is not a full-blown human being because it will undergo a substantial change and cease to exist after the implantation stage (Brown, 2018). Alternatively, many defenders of abortion-choice grant that the unborn entity is a human being but deny it full moral status because it does not satisfy their criteria for personhood (Tooley, 1983). Some pro-life thinkers, by contrast, argue that having a human nature is enough to secure the unborn’s moral status (Beckwith, 2007). In light of the connection between the two questions, one lesson taught by the articles in this issue is that often it is necessary to do metaphysics in order to do ethics. In the context of these articles, we need to answer the metaphysical question of what a human being is if we want to answer some of the moral questions raised by the authors, such as the moral status of the unborn, the moral status of human–animal chimeras and hybrids, and the point at which it is morally permissible to consider a person dead and use her organs for transplantation. A common tendency among contemporary ethicists is to ignore metaphysical questions when doing moral philosophy, which may reflect an underlying assumption that morality does not depend on metaphysics and we can investigate the former without engaging the latter. These articles show why this tendency is problematic and that this assumption is mistaken, at least when it comes to many important issues in bioethics. In a significant number of cases, knowing how we ought to act depends on knowing what we are. II. HUMAN EMBRYOS AND FETUSES The articles by Mark Brown and Jason Morris are their latest contributions to an ongoing debate in this journal over the nature and moral status of unborn human beings. The most recent entries in this exchange are Brown (2007), Morris (2012), and Lee, Tollefsen, and George (2014). This dispute centers on the moral standing of the human embryo and fetus. The three opposing positions of these authors rest on their different answers to the questions: what is a human being? and, what is the basis of moral status? With respect to the first question, there are two broad views on gestational development and the nature of the embryo and fetus. One is the substance theory, which sees individuals as substances with certain essential properties that preserve their metaphysical identity through change. Some discontinuous stages in gestational development are objectively real stages, and some of them involve changes in substance. Brown and Lee, Tollefsen, and George defend the substance theory (see also Smith and Brogard, 2003). The opposing position is the continuity theory, which rejects the ontological category of substance as a real or relevant construct for understanding human development. Instead, it holds that the embryo and fetus undergo a continuous process of gradual change; the so-called stages of development from conception to adulthood are pragmatically useful markers but do not reflect any ontologically real stages or substance changes. Morris defends the continuity theory (see also Morris, 2012). With respect to the second question about moral status, again there are two broad positions held by these authors. One is the intrinsic-property view, which says that the basis of moral status is some intrinsic property that is shared by all members of a certain group (e.g., membership in the human species, personhood, or sentience). This is the position of Lee, Tollefsen, and George, who argue that the moral status of the unborn is intrinsic at all stages of development. The other is the extrinsic-property view, which says that the basis of moral status is social convention: moral status is conferred on individuals in light of a social practice that assigns this status to some group (e.g., being a medical patient or a fellow countryman). Morris defends this position and argues that the moral status of the unborn is conferred at all stages of development. Brown defends a middle-ground position according to which the moral status of the unborn is conferred prior to a certain developmental stage and intrinsic after that stage. In his article “The Moral Status of the Human Embryo,” Mark Brown defends his account of the metaphysical nature and moral status of the unborn against the competing views of Lee, Tollefsen, and George and Morris. After providing a helpful taxonomy of the different theories of gestational development and moral status, he defends the substance theory against two objections raised by Morris in a previous issue of this journal (Morris, 2012). To overcome these objections, Brown defends a version of the substance theory that is different from that of Lee, Tollefsen, and George. For Lee, Tollefsen, and George (2014), there is only one substance change in the life cycle of the unborn, which occurs when gametes cease to exist and the fertilization process brings into existence a new human organism, which remains the same substance with the same essential nature throughout gestational development and into adulthood. Brown rejects this “fertilization only view” and argues that there are two substance changes in the life cycle of the unborn: one that begins at fertilization and involves the substantial change from gametes to blastocyst, resulting in a biological individual that cannot be identified with a human being, and a second that begins at implantation and involves the substantial change from blastocyst to human being.4 Brown’s case for this “two substance theory” is based on an examination of the empirical data of embryonic development as well as a particular metaphysical account of species essentialism, especially the persistence conditions for substantial identity. In short, his argument is that the two developmental phenomena that Morris invokes to criticize the substance view—monozygotic twinning and embryonic chimeric blastomere association—show that the persistence conditions of the early embryo/blastocyst are not the same as the persistence conditions of the human being, hence the two cannot be the same substance. The key point at which the embryo becomes a human being is when it becomes a biological individual that exhibits organic unity through an internal control system. This happens around 8–9 weeks with the emergence of a functional cardiovascular system, which is “a plausible candidate for the internal control system of an organically unified human body” (Brown, 2018, 150). This point marks a substance change and the origin of a human being because “at this point a human body has begun to function as an organism” in virtue of the fact that “a cluster of species specific homeostatic mechanisms function in concert as the central control system that regulates metabolic and developmental processes” (Brown, 2018, 153). Brown also explores how his two-substance theory bears on the question of moral status. He argues that the first substance—the early embryo/blastocyst—has conferred moral status that is comparable to that of transplantable human organs. The second substance, by contrast, is a human being with intrinsic moral status equal to that of other human beings. Brown’s discussion reveals an interesting feature of the taxonomical landscape that is often overlooked. The substance theory is usually coupled with the intrinsic-property view, and the continuity theory is usually combined with the extrinsic-property view. Brown affirms the substance theory and a mixed view of moral status on which the moral status of one substance is conferred, whereas that of the other is intrinsic. So, his discussion reveals that the views need not go together in the usual way. Brown also explores the bioethical implications of his position for issues such as embryonic stem cell research, assisted reproductive technologies, contraception, and abortion. In the final part of the article, he raises an objection to Morris’s position and argues that the continuity theory and extrinsic-property view suffer from explanatory inadequacy and counterintuitive implications regarding moral status. Jason Morris’s article “Misconceptions Inherent in the Substance Ontology Approach to Assigning Moral Status” fits within the same dialectical context as Brown’s. Rather than presenting a positive case for his own continuity theory of human development and extrinsic-property view of moral status, Morris’s goal in this article is to criticize the substance theory of Lee, Tollefsen, and George and respond to their most recent defense of it in an earlier issue of this journal (Lee, Tollefsen, and George, 2014, which is a reply to Morris, 2012). Morris’s first major argument against the substance theory is that even if we accept metaphysical realism about substances, we do not have sufficient rational grounds for identifying when substantial changes have occurred or failed to occur. As he points out, in order for the substance approach to be viable, “we must be able to identify the stage of development after which no further substance changes occur. Only from that stage on would strict ontology lead to the conclusion that the entity in question has the same essence and therefore the same moral status as the adult” (Morris, 2018, 160). Morris contends that Lee, Tollefsen, and George’s claim that there are no substantial changes postfertilization fails to satisfy this condition. He argues that there is not sufficient empirical evidence to support the claim that a substance change occurs or does not occur on the basis of any of the following considerations cited by Lee, Tollefsen, and George: (1) the generation and destruction of organisms; (2) identification of the biological markers in the developmental process; (3) the claim that the anatomy and behavior of the embryo and adult share a teleological directedness toward the same goals; or (4) identification of fundamentally different developmental pathways for different entities. Morris concludes that even if there are real substantial changes, we cannot reliably distinguish them from accidental changes, so the substance approach is untenable. Morris’s second major argument is that the substance theory is an implausible approach to developmental biology. He contends that the term “organism,” which is central to the view of Lee, Tollefsen, and George, does not track objective ontological distinctions or carry any moral implications. Instead, “organism” is an ambiguous term that biologists use in different ways for different purposes, none of which pick out clear ontological boundaries or essences. He also argues that teleological explanations of the kind offered by Lee, Tollefsen, and George are “unnecessary, unproductive, and inconsistent with our understanding of science” (Morris, 2018, 178). In addition, Morris objects that these authors’ claims about the intrinsic, active potential of the embryo are confused because they conflate the potential to develop a property with the possession of that property, and are also biologically inaccurate because they posit a nonexistent teleological drive in the embryo. In the last part of his article, Morris briefly sketches his alternative continuity theory of human development and extrinsic-property view of moral status. He says that the answer to the question of what human beings are is contextual and depends on which human features are most important to our perspective of inquiry, which might be biological, sociological, ethical, religious, and so on. Morris suggests that from the moral point of view, the most promising account is one that sees a human being as a person with psychological capacities such as rationality, conation, and self-awareness. In his view, there is no substantial nature that defines humanity, and moral status is based on social agreement about which human characteristics morally matter in a given context. A common theme running through Morris’s arguments is metaphysical skepticism, which seems to be rooted in epistemological concerns. Morris is skeptical about the status of substances, organisms, and natural teleology as objective ontological realities, and this skepticism plays a significant role in his arguments against the position of Lee, Tollefsen, and George. Although Morris’s goal is not to engage in heavy metaphysical analysis, he admits that he is sympathetic to the Lockean position that “we cannot say anything with certainty regarding substances because, by their nature, these are not accessible to our senses” (Morris, 2018, 182). This kind of epistemological worry is what underlies his argument that we are not in a good epistemic position to distinguish substantial changes from accidental changes, which is one of his main reasons for rejecting the substance theory. Morris’s discussion provides a helpful illustration of why it is difficult to escape these kinds of metaphysical issues in the course of doing bioethics. It also raises a difficult question, which is how our answer to the metaphysical question of what a human being is should affect our answer to the moral question of the grounds of moral status. Lee, Tollefsen, and George and Brown are confident that we have good rational grounds for affirming a particular metaphysical position (the substance theory), and their position on moral status is based on their metaphysical view. Morris is skeptical about metaphysics and does not think we have sufficient epistemic grounds for making metaphysical claims about substances. Moreover, he argues that even if we did, our view on moral status should not depend on a metaphysical account. Thus, the articles by Brown and Morris call into question the relationship between metaphysics and bioethics, which may be integral or peripheral. They also force us to ask how equipped bioethicists need to be when it comes to metaphysics. If it turns out that many bioethical issues are inexorably tied up with metaphysical issues, then the task of the bioethicist might be significantly harder than many people suppose because one will need to be well versed in metaphysical analysis and argumentation to do bioethics well.5 III. CHIMERAS AND HYBRIDS In his article “Human-Animal Chimeras and Hybrids: An Ethical Paradox Behind Moral Confusion?,” Dietmar Hübner addresses the morality of human–animal chimeras and hybrids (HACHs): life forms with biological material from humans and some other species.6 Although such beings might come in a variety of forms, Hübner’s focal example is a “humanzee with a considerably human-like brain, a potential for interbreeding with humans, a halfway-human-like appearance and close-to-human abilities such as rudimentary language use and a basic understanding of abstract concepts” (Hübner, 2018, 189). Although the creation of HACHs is at present a possibility rather than an actual practice, the moral permissibility of creating HACHs and the moral status of such beings is a subject of current bioethical debate and a source of significant moral confusion. Hübner attempts to shed some light on this confusion by diagnosing it as the result of a paradox that stems from the logical relationship between two kinds of species-based moral arguments on opposing sides of the debate. On the one hand, a common moral intuition is that HACHs deserve moral respect and should be accorded some kind of protected moral status in light of their human-like properties. Hübner locates the normative foundations of this intuition in an individual-species argument that focuses on the moral status of individuals. HACHs possess moral status because they are individual members of a biological species group that is characterized by rationality, moral agency, personhood, or some other valuable capacity. On the other hand, another common intuition is that HACHs upset something in the natural and/or social orders, and thus should not be created, and if created should be destroyed. Hübner grounds this intuition in a group-species argument that focuses on the moral integrity of groups. Fixed species boundaries are conceptually and morally significant, and HACHs threaten to undermine species integrity and human identity or dignity because they blur the lines between species groups. Hübner explains that these two species-based arguments, while contradictory in their implications about the morality of HACHs, are interdependent in their conceptual foundations and rational justification. The problem, in a nutshell, is that individual-species arguments admit certain beings to a protective community due to their species membership . . . For that argument to work, however, species boundaries need to be tolerably distinguishable and stable. The protective community into which those individual beings are to be received must constitute a recognizable natural realm with established boundaries—exactly what [group species arguments] try to protect from critical dissolution. (Hübner, 2018, 201) The same reasoning that supports granting HACHs moral status also supports denying them moral status. In light of the fact that these two species-based arguments are mutually interdependent and yet inconsistent in their moral implications, Hübner concludes that there are serious conceptual problems underlying the two opposing views, which generate the dilemmatic paradox that he identifies as the root of the moral confusion surrounding HACHs. Since Hübner’s focus is the moral status of human–animal chimeras and hybrids, it is clear how his article addresses the moral status question. We need to know the grounds for moral status to determine whether or not HACHs have it. The intuition behind the position that HACHs should be morally protected is the thought that such beings either possess some status-conferring property or are members of a species group that possesses such a property. Thus, we must know what the relevant status-conferring property is. Hübner’s article deals with the human nature question as well. For one thing, we need some clear understanding of humanity in order to differentiate between human beings, nonhuman animals, and human–animal chimeras and hybrids. Also, Hübner points out that the morality of creating HACHs often will depend on the type of being in question, and in this article he does not explore how his arguments bear on the different kinds of HACHs that might be created. In addition, Hübner intentionally frames his arguments in terms of the biological category of species, rather than an “abstract” metaphysical category like substance, person, or rational animal (contra the approach of Brown and Lee, Tollefsen, and George). He presents his biological species account as a competitor to the substance theory (Hübner, 2018), but I suspect that the two views are really closer than they may appear, and exploring the relationship between them is a promising topic for further study. IV. THE DETERMINATION OF DEATH The criteria for determining death is a subject of major dispute in contemporary bioethics and was the focus of a recent symposium in this journal (Moschella, 2016). According to the United States’ Uniform Determination of Death Act: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead” (President’s Commission, 1981, 73; see Brown, 2018, 155). These two options represent the most popular positions in the current debate about human death. It is important to recognize that there are two related but distinct issues involved in this debate. One is the definition of death. A second is the criteria that should be used to determine when a person has died. The latter issue is the primary focus of Andrew McGee and Dale Gardiner’s “Donation after the Circulatory Determination of Death.”7 In this article, the authors defend the permanent–circulatory–respiratory criterion of death against some recent criticisms pressed by Franklin Miller, Robert Truog, and Don Marquis (Truog and Miller, 2008, 2010; Marquis, 2010; Miller and Truog, 2012). According to McGee and Gardiner, in all contexts human beings should be declared dead on the basis of the permanent cessation of circulatory–respiratory function. They also defend the Dead Donor Rule, which says that a patient must be determined to be dead before her organs can be procured for transplantation. Their central contention is that a declaration of death should be based on a judgment about the permanent cessation of circulatory–respiratory function, rather than on a judgment about its irreversible cessation. Throughout the article, McGee and Gardiner respond to some prominent objections to their position and make some important points of clarification concerning the standards for determining death. One of these clarifications is a distinction between being dead and being known to be dead, which the authors use to show that the question under dispute is really the reasonableness of a diagnosis of death. They argue that “permanence is not merely a proxy for irreversibility, but a way of knowing whether circulatory and respiratory function will be reversed or not . . . the requirement of determination of irreversibility ‘in accordance with accepted medical standards’ effectively means that we can interpret ‘irreversibility’ to mean permanence” (McGee and Gardiner, 2018, 216). On their view, in order to know that someone has died, we do not have to rule out all counter-possibilities whatsoever. Instead, we must rule out only genuine counter-possibilities that are relevant to the particular situation at hand. In many cases, resuscitation via CPR will be a relevant possibility. In cases where CPR is the only way a patient could be resuscitated and CPR is inappropriate for some reason (e.g., a DNR/DNAR order), then we do not need to rule out resuscitation via CPR and we can justifiably declare that the patient has died. In such a case, we can know that someone has died when we have no reason to believe that auto-resuscitation is a genuine possibility. More generally, McGee and Gardiner’s claim is “not about what might not happen in principle; it is about what will happen in this patient’s case. The category of the patient enables us to know when permanent cessation is reached” (McGee and Gardiner, 2018, 218). Critics like Marquis claim that the irreversibility criterion is superior to the permanence criterion because irreversibility is an intrinsic dispositional property of patients, whereas permanence is a relational property that is based on what is normatively appropriate to the situation and what other individuals are capable of or willing to do. McGee and Gardiner respond that the concept of reversibility is better understood as a relational property analogous to “reparable” or “retrievable” rather than a dispositional property like “soluble” or “breakable.” Against critics like Miller and Truog, McGee and Gardiner argue that using irreversibility as the criterion for determining death leads to serious epistemological and practical problems. For one thing, it is very difficult to identify the point at which irreversibility is achieved and “it would only be possible to know if the condition were reversible by attempting resuscitation and failing, or waiting in a death watch for several hours” (McGee and Gardiner, 2018, 234). For epistemic and pragmatic reasons, then, it is better to rely on the permanence criterion when making declarations of death. McGee and Gardiner also contend that accepting the criterion of irreversibility would have radical and problematic implications for our current practices of declaring death in hospitals. Although McGee and Gardiner do not directly address the human nature question or the moral status question, both questions have an important bearing on the issues they discuss. With respect to the human nature question, whereas Brown and Morris focus on when a human being begins to exist, McGee and Gardiner examine when a human being ceases to exist. In order to know when a human being dies, we need to know what a human being is. Like Morris, these two authors make a distinction between the metaphysics and the epistemology of the issue: the metaphysical question of what death is differs from the epistemological question of how we can reasonably claim to know that death has occurred. McGee and Gardiner, like Morris, primarily target the epistemological question. With respect to moral status, this article highlights important questions about the moral standing of human individuals at the end of life. The issue of organ donation and the Dead Donor Rule is tied up with the moral status of organ donor patients because a controversial question is whether such patients must be declared dead before it is morally permissible to procure their organs. If so, then which criterion for determining death should we use? Different answers to these questions have important moral implications for how we ought to treat such patients. V. HUMAN COGNITION AND MITOCHONDRIAL DONATION Somogy Varga’s article “Embodied Concepts and Mental Health” engages with cognitive science and the philosophy of mind, specifically an emerging field known as embodied cognition.8 This research program is influenced by the phenomenological tradition in philosophy, and it takes human cognition to be “grounded in aspects of its sensorimotor embodiment” and “the result of a dynamic interaction of bodily (non-neural) and neural processes” (Varga, 2018, 241–242). In other words, human thinking is shaped by our embodied experience and is bound up with our sensorimotor capacities. In the first section of the article, Varga explores the connections between several contemporary theories of embodied cognition and the phenomenology of Maurice Merleau-Ponty. He illustrates various ways in which these theories draw on several of Merleau-Ponty’s insights about the relationship between cognition and physical embodiment. Furthermore, he makes a distinction between two different versions of the thesis that human cognition is embodied (“the embodiment hypothesis”): a stronger version that completely rejects computational and representational models of cognition and a weaker version that is compatible with such models. For the remainder of the article, Varga focuses on one of the most prominent accounts of embodied cognition, George Lakoff and Mark Johnson’s Conceptual Metaphor Theory (CMT) (Lakoff and Johnson, 1980, 1999). According to this view, metaphors are an essential part of thought as well as language: “we use ‘metaphors of thought’ or ‘conceptual metaphors,’ construed as systematic ‘mappings’ (correspondences) between a concrete source domain (closely related to bodily experience), and an abstract target domain” (Varga, 2018, 245). Abstract concepts are grounded in particular domains of bodily experience. For example, our concepts of joy and sadness are based partly on spatial relations: we sometimes describe ourselves as “walking on air” or being “down in the dumps.” Varga argues that CMT is well supported by empirical evidence. Recent behavioral and neuroscientific research confirms that much higher-order cognition is grounded in the bodily experience of one’s environment so that bodily and abstract domains are intertwined via conceptual metaphors giving rise to bidirectional effects: sensory experiences have significant bottom-up effects on higher-order judgments and behavior, and the activation of certain concepts has top-down effects on bodily (perceptual) states. (Varga, 2018, 250) For instance, there is a connection between sensations of weight and moral emotions such as guilt (which is said to feel heavy and “weigh us down”); subjects who are told to recall a past moral transgression tend to report higher subjective feelings of body weight. Varga points to various other data to shore up CMT as an empirically grounded account of cognition. Varga also attempts to strengthen CMT by defending it against some common objections and making two of his own modifications to Lakoff and Johnson’s theory, one that relaxes their bodily constitution requirements for concept acquisition and another that circumvents their implausible metaphysical claim that conceptual metaphors are identical to neural circuits in the brain. At the end of the article, Varga discusses the applications of CMT to mental health. He explains that CMT has theoretical resources that may help improve our understanding and treatment of mental disorders. For example, CMT’s focus on the embodied aspects of cognition and the connections between bodily motor patterns and cognitive-affective patterns make it ideally positioned to address a phenomenon like depression, which involves cognitive, emotional, and bodily dimensions. Varga explores various ways that CMT might be deployed in a clinical setting to help treat mental disorders, and he ends by identifying some important avenues for further research. Varga’s article may appear not to be connected to the two overarching questions of human nature and moral status. Shortly, I will explain how it is related to both questions in significant ways. Because the same thing could be said for John Appleby’s article, which I will summarize next, and because Varga’s and Appleby’s topics are connected to the two overarching questions in similar ways, I will postpone my explanation until the end of this section. In his article “Should Mitochondrial Donation Be Anonymous?,” John Appleby examines the United Kingdom’s policies concerning the identity of donors of reproductive biological materials.9 Currently, in the United Kingdom, gamete donation is open-identity—persons conceived with donated gametes have a legal right to obtain certain information about their donors—whereas mitochondrial donation is anonymous—persons conceived with donated mitochondria are not able to access information about their donors. Appleby argues that both gamete donation and mitochondrial donation should be open-identity and that there are no good reasons to treat the two cases differently. He begins with the initial presumption that mitochondrial donation, like gamete donation, should be open-identity unless there is a good argument for making it anonymous. Then, he addresses a series of arguments in favor of anonymous mitochondrial donation and argues that they all fail. The first argument that Appleby considers and rejects is that there is either a quantitative difference between gamete donation and mitochondrial donation because there are fewer genes in the mitochondrial genome than in the nuclear genome, or a qualitative difference between the two cases because mitochondrial genes have properties different from those of nuclear genes. The second unsuccessful argument is based on the claim that gamete donors are “third parents,” whereas mitochondrial donors are not. The third reason that Appleby rejects is that being conceived through mitochondrial donation is less important for an individual’s “sense of self” than being conceived through gamete donation is. The fourth and final argument that he criticizes is one that identifies four negative consequences that allegedly would result from open-identity mitochondrial donation: (1) it would decrease the number of mitochondrial donors; (2) it would cause some prospective parents to travel to another country where mitochondrial donors are anonymous; (3) it would devalue the position of gamete donors; and (4) it would reinforce the social attitude that donors should be an important part of their offspring’s lives, which detracts from the significance of parents. It is worth saying more about the “sense of self” argument. Appleby’s goal in discussing this argument is to show that considerations about how knowledge of one’s donor bears on one’s sense of self do not provide a sufficient reason to make mitochondrial donors anonymous. In line with the rest of his article, his purpose here is a critical, negative one that refutes arguments for treating gamete donation and mitochondrial donation differently. It seems to me that the sense of self argument can also be turned into a positive argument for Appleby’s position that mitochondrial donation should be open-identity. In this context, one’s sense of self appears to be equivalent to one’s psychological identity (as opposed to numerical or metaphysical identity): the personal characteristics, beliefs, desires, pursuits, relationships, history, and narrative understanding that one considers to be central to who one is. Of all the ways that knowing the identity of one’s mitochondrial donor might affect one’s psychological identity, perhaps the most relevant is the sense of personal history and life narrative. The intuitive idea is that one’s origins are an important part of one’s life story. It is plausible that some, perhaps many, offspring want to know the identity of their gamete donor because they want to know where they come from, which all of us take to be an important aspect of our sense of self. As Appleby points out, this view is supported by empirical evidence from social science (Appleby, 2018, 269). Additionally, it seems to me that the same line of reasoning applies to mitochondrial donors too, who are also relevant to the understanding of one’s history and narrative. Developing this argument would strengthen Appleby’s case by providing an additional positive reason why mitochondrial donation should be open-identity because these identity-related reasons in favor of knowing one’s gamete donor are also reasons in favor of knowing one’s mitochondrial donor. Thus, a sense of self argument for open-identity mitochondrial donation is a way that Appleby’s case might be strengthened.10 I noted earlier that Varga’s article and Appleby’s article are linked to the human nature question and the moral status question in similar ways. Despite initial appearances to the contrary, both of these articles have a significant connection to both questions. Two things that often come up in discussions of human nature and moral status are the human cognitive capacities and the human sense of self. Both the cognitive powers and the sense of self have been seen as defining human characteristics and moral-status-conferring properties. With respect to cognition, a tradition that dates back to Aristotle and enjoys a prominent place in Western thought sees human beings as rational animals, where the cognitive capacities are taken to be the most distinctive and important human feature. This same tradition also emphasizes human animality. For Aristotle, things like pleasure, pain, and the emotions are forms of cognition that essentially involve our animality, and we might see these phenomena as embodied in Varga’s sense.11 And some classical and contemporary thinkers, both within the Aristotelian tradition and outside it, have argued that only beings who possess significant cognitive capacities have moral status. These cognitive and animal characteristics are highlighted in Varga’s discussion of the embodied, sensory aspects of human cognition. With respect to the sense of self, another traditional defining human trait is the sense of self or psychological identity. In addition, self-consciousness and self-awareness are popular criteria of moral status. Since the sense of self plays a prominent role in Appleby’s article, his discussion, like Varga’s, makes a helpful contribution to our understanding of human nature and moral status. VI. CONCLUSION Despite the fact that the articles in this issue address different bioethical debates, they are unified by the valuable contribution they make to the conversations about what it means to be human and what it takes to be a member of the moral community. Although there is much to learn from each article, an important lesson that all of them together teach is that the answers to very different bioethical questions sometimes depend on the answers to deeper metaphysical and moral questions, such as the nature of humanity and the grounds of moral status. For this reason, these articles highlight the importance of philosophical reflection on these fundamental questions for bioethics and medical practice. NOTES 1. See Jaworska and Tannenbaum (2018) for a good overview of some of the major distinctions, theoretical options, and arguments involved in the problem of moral status. 2. See Beauchamp and Childress (2009, Chapter 3) for a defense of this point and a critical examination of some of the most popular theories of moral status. 3. As Beauchamp and Childress note, “The mainstream approach has been to ask whether a being is the kind of entity to which moral principles or other moral categories can and should be applied, and, if so, based on which properties of the being” (Beauchamp and Childress, 2009, 66). 4. A concern with Brown’s terminology is that it is potentially confusing when it comes to the human nature question. He claims that the blastocyst is a “biological individual” that is a “form of human life” but not a “human being” (Brown, 2018, 146). The worry is that the meaning of “human being” may be unclear to some readers, especially considering that on Brown’s view both the blastocyst and the fetus are human substances (of two different kinds). If we assume an ordinary understanding of a human being as an individual living thing that is human, then the blastocyst seems to count because it is a living individual human life form. Brown uses “human being” in a different sense, which becomes clear enough throughout the course of his article. But, it might help to clarify the terminology because the term “human being” carries so many different meanings in ethics (e.g., human organism, human person, human substance, etc.). 5 There is another important question in this territory. If we agree with Morris’s skepticism about realist metaphysics, we must ask what this skeptical position implies for the way we answer the moral status question. Morris defends the conferred status model. But if we adopt the opposing intrinsic-property model and we find ourselves in epistemic doubt about the nature of the unborn entity, what position should we take on issues like abortion, embryonic stem cell research, and assisted reproductive technologies that result in discarded embryos, as well as other beginning-of-life issues? On the one hand, we might think that in light of the metaphysical uncertainty about the unborn entity and the resulting uncertainty about the unborn’s moral status, when the possible rights and interests of the unborn conflict with the rights and interests of others whom we know are human persons with full moral status and interests, the rights and interests of the latter group should prevail. Or we might draw the opposite conclusion: since the unborn entity might be a human being with full moral status, rights, and interests, we should favor caution and act as though the unborn are human beings (even if it turns out that they are not), because the moral stakes are so high. This is an important question that calls for further discussion. 6 For a previous discussion of this issue in this journal, see Eberl and Ballard (2009). 7. These authors also offer a definition of death: “the condition of being permanently lifeless in any relevant circumstance. ‘Relevant circumstance’ refers either to cases where CPR is appropriate, or to cases where it is not” (McGee and Gardiner, 2018, 218). 8 Previous articles in this journal that address similar issues are Fielding (1998) and Clark (2007). 9. Previous articles in this journal related to this issue are Andrews (1989) and Cohen (1999). 10. It seems that Appleby is aware of the type of positive argument I am suggesting here. For example, he says: “contrary to the sense of self argument as used to date in the debate regarding mitochondrial donors, it does seem possible that some future [mitochondrial-donor conceived] persons could also find that the genetic connection they share with their mitochondrial donor is of some significance to their sense of self” (Appleby, 2018, 270). 11. I am grateful to an anonymous referee for mentioning this point about Aristotle. ACKNOWLEDGMENTS Thanks to Jeff Bishop for the invitation to write this introduction, Victor Saenz for helpful advice and instruction, and Jeff Bishop and an anonymous referee for valuable feedback on a previous draft. REFERENCES Andrews, L. 1989. Control and compensation: Laws governing extracorporeal generative materials. Journal of Medicine and Philosophy  14(5): 541– 60. Google Scholar CrossRef Search ADS   Appleby, J. 2018. Should mitochondrial donation be anonymous? Journal of Medicine and Philosophy  43(2): 261– 80. Beauchamp, T. and J. Childress. 2009. Principles of Biomedical Ethics . 6th ed. Oxford, United Kingdom: Oxford University Press. Beckwith, F. 2007. Defending Life: A Moral and Legal Case Against Abortion Choice . New York: Cambridge University Press. Google Scholar CrossRef Search ADS   Brown, M. 2007. The potential of the human embryo. Journal of Medicine and Philosophy  32(6): 585– 618. Google Scholar CrossRef Search ADS   ————. 2018. The moral status of the human embryo. Journal of Medicine and Philosophy  43(2): 132– 58. Clark, A. 2007. Re-inventing ourselves: The plasticity of embodiment, sensing, and mind. Journal of Medicine and Philosophy  32(3): 263– 82. Google Scholar CrossRef Search ADS   Cohen, C. 1999. Selling bits and pieces of humans to make babies: The gift of the Magi revisited. Journal of Medicine and Philosophy  24(3): 288– 306. Google Scholar CrossRef Search ADS   Eberl, J. and R. Ballard. 2009. Metaphysical and ethical perspectives on creating animal-human chimeras. Journal of Medicine and Philosophy  34(5): 470– 86. Google Scholar CrossRef Search ADS   Fielding, H. 1998. Body measures: Phenomenological considerations of corporeal ethics. Journal of Medicine and Philosophy  23(5): 535– 45. Hübner, D. 2018. Human–animal chimeras and hybrids: An ethical paradox behind moral confusion? Journal of Medicine and Philosophy  43(2): 187– 210. Jaworska, A. and J. Tannenbaum. 2018. The grounds of moral status. In The Stanford Encyclopedia of Philosophy , ed. E. Zalta, Spring 2018 ed. [On-line]. Available: https://plato.stanford.edu/archives/spr2018/entries/grounds-moral-status (accessed January 29, 2018). Lakoff, G. and M. Johnson. 1980. Metaphors We Live By . Chicago: University of Chicago Press. ————. 1999. Philosophy in the Flesh: The Embodied Mind and Its Challenge to Western Thought . New York: Basic Books. Lee, P., C. Tollefsen and R. P. George. 2014. The ontological status of embryos: A reply to Jason Morris. Journal of Medicine and Philosophy  39(5): 483– 504. Google Scholar CrossRef Search ADS   Marquis, D. 2010. Are DCD donors really dead? Hastings Center Report  40(3): 24– 31. Google Scholar CrossRef Search ADS   McGee, A. and D. Gardiner. 2018. Donation after the circulatory determination of death: Some responses to recent criticisms. Journal of Medicine and Philosophy  43(2): 211– 40. Miller, F. and R. Truog. 2012. Death, Dying and Organ Transplantation . New York: Oxford University Press. Morris, J. 2012. Substance ontology cannot establish the moral status of embryos. Journal of Medicine and Philosophy  37(4): 331– 50. Google Scholar CrossRef Search ADS   ————. 2018. Misconceptions inherent in the substance ontology approach to assigning moral status: A reply to Patrick Lee, Christopher Tollefsen, and Robert George. Journal of Medicine and Philosophy  43(2): 159– 86. Moschella, M., ed. 2016. Brain death and human organismal integration: A symposium on the definition of death. Journal of Medicine and Philosophy  41(3): 229– 36. Google Scholar CrossRef Search ADS   President’s Commission for the Study of Ethical Problems in Medicine. 1981. Defining Death: A Report on the Medical, Legal and Ethical Issues in the Determination of Death . Washington, DC: US Government Printing Office. Smith, B. and B. Brogard. 2003. Sixteen days. Journal of Medicine and Philosophy  28(1): 45– 78. Google Scholar CrossRef Search ADS   Tooley, M. 1983. Abortion and Infanticide . Oxford, United Kingdom: Clarendon Press. Truog, R. and F. Miller. 2008. The dead donor rule and organ transplantation. New England Journal of Medicine  359(7): 674– 5. Google Scholar CrossRef Search ADS   ————. 2010. Counterpoint: Are donors after circulatory death really dead, and does it matter? No and not really. Chest  138(1): 16– 8. Varga, S. 2018. Embodied concepts and mental health. Journal of Medicine and Philosophy  43(2): 241– 60. © The Author(s) 2018. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Journal of Medicine and Philosophy Oxford University Press

Human Nature and Moral Status in Bioethics

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Abstract

Abstract The articles in this issue cover a wide range of topics, including the moral status of human embryos and human-animal chimeras and hybrids, the determination of death, theories of human cognition, and policies on the identity of mitochondrial donors. Despite this variety, there are two underlying questions that tie the articles together: what is a human being? And, what is the basis of moral status? First, I discuss these two questions and why they are important for bioethics. Then I provide summaries of the six articles in this issue and explain how each of them is connected to the questions of human nature and moral status. biological development, circulatory-respiratory criteria, conceptual metaphor theory, dead donor rule, determination of death, embodied cognition, gamete donation, human cognition, human embryos and fetuses, human nature, human-animal chimeras and hybrids, mitochondrial donation, moral status, permanence criterion, psychological identity species-based moral arguments, substance ontology I. HUMAN NATURE AND MORAL STATUS The articles in this issue of Journal of Medicine and Philosophy are eclectic, with topics ranging from the moral status of the embryo to the United Kingdom’s current policies on mitochondrial donation. In spite of this variety, an overarching thread that connects all six articles is their relation to two key questions: (1) what is a human being? and (2) what is the basis of moral status? First, I will discuss each of these questions and explain why they are important for bioethics. Then, I will provide a brief summary of each article and show how they are connected to these two questions. The first question, which I will call the “human nature question,” asks what humans are by nature—what kind of thing a human being is. The term “human being” is ambiguous: it can mean a human person, a human organism, a human substance, a rational agent, a rational animal, an entity with human DNA, or something else. The answer to this question often depends on the type of inquiry at hand. We might be asking what a human being is when viewed from a metaphysical perspective, a moral perspective, a biological perspective, an economic perspective, a political perspective, a religious perspective, and so on. The authors in this issue approach the human nature question primarily from the angles of metaphysics, biology, and ethics. Some of the authors advocate keeping these three perspectives distinct, whereas others think that bioethics requires a synoptic approach that synthesizes all three. The human nature question is central to four of the articles. Mark Brown and Jason Morris debate about when a new human being comes into existence; Dietmar Hübner investigates the nature of human–animal chimeras and hybrids; and Andrew McGee and Dale Gardiner ask when a human being ceases to exist. The second question, which I will call the “moral status question,” asks which individuals and groups are protected by moral norms, and what the grounds are for this moral status. Like “human being,” the term “moral status” is ambiguous. A thing with moral status can be a moral agent with the full array of moral rights and duties (e.g., a normally functioning adult human person), a subject of moral rights but not duties (e.g., a human embryo or fetus), or anything that is an object of moral consideration and part of the moral domain, even if it lacks rights and duties (e.g., animals or the environment). Moral status can be an all-or-nothing property that all status-worthy individuals possess equally or a degreed property that some individuals possess to a greater or lesser extent than others. It can be an intrinsic property or an extrinsic, conferred property. It can be based on a thing’s nature (what it is) or its abilities (what it can do). It can be a function of basic natural capacities (potentialities) or presently exercisable capacities. It can be the ground of negative rights and obligations or of both negative and positive rights and obligations. Moral status has been defined in many ways.1 A standard assumption is that the only individuals with moral status are those capable of being wronged. Another is that X’s having moral status generates moral reasons for me to treat X in certain ways for X’s own sake, rather than for some other reason (e.g., for the sake of the consequences on myself or on people other than X). Some common views of moral status ground it in one or more of the following properties: humanity, personhood, sentience, rationality, consciousness, self-awareness, conation, moral agency, or social relationships. As Tom Beauchamp and James Childress point out, the plausibility of a theory of moral status depends in large part on whether we take possession of the relevant status-conferring property to be a necessary condition or a sufficient condition for moral status. It is much easier to defend criteria for the latter than for the former.2 For example, consider one proposed criterion of moral status: being a rational agent with the capacity for autonomous choice. It is plausible that satisfying this criterion is enough to secure moral status, since a rational agent is the paradigmatic type of being who is capable of being wronged and whose interests are protected by morality. However, making rational agency a requirement for moral status is problematic for at least two related reasons: (1) it counter-intuitively implies that certain groups such as human infants, the severely intellectually disabled, and sentient nonhuman animals lack moral status, and (2) other properties, such as humanity or sentience, also seem to be sufficient conditions for moral status, regardless of whether they are conjoined with rational agency. The four articles that I have already mentioned explore the moral status of certain human or human-like entities or of human beings in a particular state. Brown and Morris debate the moral status of human embryos and fetuses; Hübner asks about the moral status of human–animal chimeras and hybrids; and McGee and Gardiner address the moral status of human individuals who are considered to be dead according to different criteria for determining death. I have noted how four of the articles in this issue are connected to the human nature question and the moral status question. The remaining two articles—Somogy Varga’s article on embodied cognition and John Appleby’s article on mitochondrial donation—may appear to be exceptions because they do not directly address either of these questions. As I will explain below, however, both of these articles are related to the two questions in significant ways. The human nature question and the moral status question are deeply interconnected. Traditionally, an important part of what it means to be human is to be a moral agent with full moral status. Also, moral status is often determined by the kind of entity something is: a human being, an animal, a plant, a rock, and so forth.3 Human beings are the paradigmatic type of being that possesses full moral status. The standard approach in moral philosophy and bioethics is to point to some specific human feature that grounds moral status, such as sentience, autonomy, rationality, or self-awareness. Moreover, it is often the case that whether certain types of entities (e.g., human embryos and anencephalic infants) are thought to be bearers of moral status depends on whether they can be classified as human beings or whether membership in the human species or possession of a human nature is sufficient for moral status. For instance, in his contribution to this issue, Mark Brown argues that the very early embryo has human DNA but is not a full-blown human being because it will undergo a substantial change and cease to exist after the implantation stage (Brown, 2018). Alternatively, many defenders of abortion-choice grant that the unborn entity is a human being but deny it full moral status because it does not satisfy their criteria for personhood (Tooley, 1983). Some pro-life thinkers, by contrast, argue that having a human nature is enough to secure the unborn’s moral status (Beckwith, 2007). In light of the connection between the two questions, one lesson taught by the articles in this issue is that often it is necessary to do metaphysics in order to do ethics. In the context of these articles, we need to answer the metaphysical question of what a human being is if we want to answer some of the moral questions raised by the authors, such as the moral status of the unborn, the moral status of human–animal chimeras and hybrids, and the point at which it is morally permissible to consider a person dead and use her organs for transplantation. A common tendency among contemporary ethicists is to ignore metaphysical questions when doing moral philosophy, which may reflect an underlying assumption that morality does not depend on metaphysics and we can investigate the former without engaging the latter. These articles show why this tendency is problematic and that this assumption is mistaken, at least when it comes to many important issues in bioethics. In a significant number of cases, knowing how we ought to act depends on knowing what we are. II. HUMAN EMBRYOS AND FETUSES The articles by Mark Brown and Jason Morris are their latest contributions to an ongoing debate in this journal over the nature and moral status of unborn human beings. The most recent entries in this exchange are Brown (2007), Morris (2012), and Lee, Tollefsen, and George (2014). This dispute centers on the moral standing of the human embryo and fetus. The three opposing positions of these authors rest on their different answers to the questions: what is a human being? and, what is the basis of moral status? With respect to the first question, there are two broad views on gestational development and the nature of the embryo and fetus. One is the substance theory, which sees individuals as substances with certain essential properties that preserve their metaphysical identity through change. Some discontinuous stages in gestational development are objectively real stages, and some of them involve changes in substance. Brown and Lee, Tollefsen, and George defend the substance theory (see also Smith and Brogard, 2003). The opposing position is the continuity theory, which rejects the ontological category of substance as a real or relevant construct for understanding human development. Instead, it holds that the embryo and fetus undergo a continuous process of gradual change; the so-called stages of development from conception to adulthood are pragmatically useful markers but do not reflect any ontologically real stages or substance changes. Morris defends the continuity theory (see also Morris, 2012). With respect to the second question about moral status, again there are two broad positions held by these authors. One is the intrinsic-property view, which says that the basis of moral status is some intrinsic property that is shared by all members of a certain group (e.g., membership in the human species, personhood, or sentience). This is the position of Lee, Tollefsen, and George, who argue that the moral status of the unborn is intrinsic at all stages of development. The other is the extrinsic-property view, which says that the basis of moral status is social convention: moral status is conferred on individuals in light of a social practice that assigns this status to some group (e.g., being a medical patient or a fellow countryman). Morris defends this position and argues that the moral status of the unborn is conferred at all stages of development. Brown defends a middle-ground position according to which the moral status of the unborn is conferred prior to a certain developmental stage and intrinsic after that stage. In his article “The Moral Status of the Human Embryo,” Mark Brown defends his account of the metaphysical nature and moral status of the unborn against the competing views of Lee, Tollefsen, and George and Morris. After providing a helpful taxonomy of the different theories of gestational development and moral status, he defends the substance theory against two objections raised by Morris in a previous issue of this journal (Morris, 2012). To overcome these objections, Brown defends a version of the substance theory that is different from that of Lee, Tollefsen, and George. For Lee, Tollefsen, and George (2014), there is only one substance change in the life cycle of the unborn, which occurs when gametes cease to exist and the fertilization process brings into existence a new human organism, which remains the same substance with the same essential nature throughout gestational development and into adulthood. Brown rejects this “fertilization only view” and argues that there are two substance changes in the life cycle of the unborn: one that begins at fertilization and involves the substantial change from gametes to blastocyst, resulting in a biological individual that cannot be identified with a human being, and a second that begins at implantation and involves the substantial change from blastocyst to human being.4 Brown’s case for this “two substance theory” is based on an examination of the empirical data of embryonic development as well as a particular metaphysical account of species essentialism, especially the persistence conditions for substantial identity. In short, his argument is that the two developmental phenomena that Morris invokes to criticize the substance view—monozygotic twinning and embryonic chimeric blastomere association—show that the persistence conditions of the early embryo/blastocyst are not the same as the persistence conditions of the human being, hence the two cannot be the same substance. The key point at which the embryo becomes a human being is when it becomes a biological individual that exhibits organic unity through an internal control system. This happens around 8–9 weeks with the emergence of a functional cardiovascular system, which is “a plausible candidate for the internal control system of an organically unified human body” (Brown, 2018, 150). This point marks a substance change and the origin of a human being because “at this point a human body has begun to function as an organism” in virtue of the fact that “a cluster of species specific homeostatic mechanisms function in concert as the central control system that regulates metabolic and developmental processes” (Brown, 2018, 153). Brown also explores how his two-substance theory bears on the question of moral status. He argues that the first substance—the early embryo/blastocyst—has conferred moral status that is comparable to that of transplantable human organs. The second substance, by contrast, is a human being with intrinsic moral status equal to that of other human beings. Brown’s discussion reveals an interesting feature of the taxonomical landscape that is often overlooked. The substance theory is usually coupled with the intrinsic-property view, and the continuity theory is usually combined with the extrinsic-property view. Brown affirms the substance theory and a mixed view of moral status on which the moral status of one substance is conferred, whereas that of the other is intrinsic. So, his discussion reveals that the views need not go together in the usual way. Brown also explores the bioethical implications of his position for issues such as embryonic stem cell research, assisted reproductive technologies, contraception, and abortion. In the final part of the article, he raises an objection to Morris’s position and argues that the continuity theory and extrinsic-property view suffer from explanatory inadequacy and counterintuitive implications regarding moral status. Jason Morris’s article “Misconceptions Inherent in the Substance Ontology Approach to Assigning Moral Status” fits within the same dialectical context as Brown’s. Rather than presenting a positive case for his own continuity theory of human development and extrinsic-property view of moral status, Morris’s goal in this article is to criticize the substance theory of Lee, Tollefsen, and George and respond to their most recent defense of it in an earlier issue of this journal (Lee, Tollefsen, and George, 2014, which is a reply to Morris, 2012). Morris’s first major argument against the substance theory is that even if we accept metaphysical realism about substances, we do not have sufficient rational grounds for identifying when substantial changes have occurred or failed to occur. As he points out, in order for the substance approach to be viable, “we must be able to identify the stage of development after which no further substance changes occur. Only from that stage on would strict ontology lead to the conclusion that the entity in question has the same essence and therefore the same moral status as the adult” (Morris, 2018, 160). Morris contends that Lee, Tollefsen, and George’s claim that there are no substantial changes postfertilization fails to satisfy this condition. He argues that there is not sufficient empirical evidence to support the claim that a substance change occurs or does not occur on the basis of any of the following considerations cited by Lee, Tollefsen, and George: (1) the generation and destruction of organisms; (2) identification of the biological markers in the developmental process; (3) the claim that the anatomy and behavior of the embryo and adult share a teleological directedness toward the same goals; or (4) identification of fundamentally different developmental pathways for different entities. Morris concludes that even if there are real substantial changes, we cannot reliably distinguish them from accidental changes, so the substance approach is untenable. Morris’s second major argument is that the substance theory is an implausible approach to developmental biology. He contends that the term “organism,” which is central to the view of Lee, Tollefsen, and George, does not track objective ontological distinctions or carry any moral implications. Instead, “organism” is an ambiguous term that biologists use in different ways for different purposes, none of which pick out clear ontological boundaries or essences. He also argues that teleological explanations of the kind offered by Lee, Tollefsen, and George are “unnecessary, unproductive, and inconsistent with our understanding of science” (Morris, 2018, 178). In addition, Morris objects that these authors’ claims about the intrinsic, active potential of the embryo are confused because they conflate the potential to develop a property with the possession of that property, and are also biologically inaccurate because they posit a nonexistent teleological drive in the embryo. In the last part of his article, Morris briefly sketches his alternative continuity theory of human development and extrinsic-property view of moral status. He says that the answer to the question of what human beings are is contextual and depends on which human features are most important to our perspective of inquiry, which might be biological, sociological, ethical, religious, and so on. Morris suggests that from the moral point of view, the most promising account is one that sees a human being as a person with psychological capacities such as rationality, conation, and self-awareness. In his view, there is no substantial nature that defines humanity, and moral status is based on social agreement about which human characteristics morally matter in a given context. A common theme running through Morris’s arguments is metaphysical skepticism, which seems to be rooted in epistemological concerns. Morris is skeptical about the status of substances, organisms, and natural teleology as objective ontological realities, and this skepticism plays a significant role in his arguments against the position of Lee, Tollefsen, and George. Although Morris’s goal is not to engage in heavy metaphysical analysis, he admits that he is sympathetic to the Lockean position that “we cannot say anything with certainty regarding substances because, by their nature, these are not accessible to our senses” (Morris, 2018, 182). This kind of epistemological worry is what underlies his argument that we are not in a good epistemic position to distinguish substantial changes from accidental changes, which is one of his main reasons for rejecting the substance theory. Morris’s discussion provides a helpful illustration of why it is difficult to escape these kinds of metaphysical issues in the course of doing bioethics. It also raises a difficult question, which is how our answer to the metaphysical question of what a human being is should affect our answer to the moral question of the grounds of moral status. Lee, Tollefsen, and George and Brown are confident that we have good rational grounds for affirming a particular metaphysical position (the substance theory), and their position on moral status is based on their metaphysical view. Morris is skeptical about metaphysics and does not think we have sufficient epistemic grounds for making metaphysical claims about substances. Moreover, he argues that even if we did, our view on moral status should not depend on a metaphysical account. Thus, the articles by Brown and Morris call into question the relationship between metaphysics and bioethics, which may be integral or peripheral. They also force us to ask how equipped bioethicists need to be when it comes to metaphysics. If it turns out that many bioethical issues are inexorably tied up with metaphysical issues, then the task of the bioethicist might be significantly harder than many people suppose because one will need to be well versed in metaphysical analysis and argumentation to do bioethics well.5 III. CHIMERAS AND HYBRIDS In his article “Human-Animal Chimeras and Hybrids: An Ethical Paradox Behind Moral Confusion?,” Dietmar Hübner addresses the morality of human–animal chimeras and hybrids (HACHs): life forms with biological material from humans and some other species.6 Although such beings might come in a variety of forms, Hübner’s focal example is a “humanzee with a considerably human-like brain, a potential for interbreeding with humans, a halfway-human-like appearance and close-to-human abilities such as rudimentary language use and a basic understanding of abstract concepts” (Hübner, 2018, 189). Although the creation of HACHs is at present a possibility rather than an actual practice, the moral permissibility of creating HACHs and the moral status of such beings is a subject of current bioethical debate and a source of significant moral confusion. Hübner attempts to shed some light on this confusion by diagnosing it as the result of a paradox that stems from the logical relationship between two kinds of species-based moral arguments on opposing sides of the debate. On the one hand, a common moral intuition is that HACHs deserve moral respect and should be accorded some kind of protected moral status in light of their human-like properties. Hübner locates the normative foundations of this intuition in an individual-species argument that focuses on the moral status of individuals. HACHs possess moral status because they are individual members of a biological species group that is characterized by rationality, moral agency, personhood, or some other valuable capacity. On the other hand, another common intuition is that HACHs upset something in the natural and/or social orders, and thus should not be created, and if created should be destroyed. Hübner grounds this intuition in a group-species argument that focuses on the moral integrity of groups. Fixed species boundaries are conceptually and morally significant, and HACHs threaten to undermine species integrity and human identity or dignity because they blur the lines between species groups. Hübner explains that these two species-based arguments, while contradictory in their implications about the morality of HACHs, are interdependent in their conceptual foundations and rational justification. The problem, in a nutshell, is that individual-species arguments admit certain beings to a protective community due to their species membership . . . For that argument to work, however, species boundaries need to be tolerably distinguishable and stable. The protective community into which those individual beings are to be received must constitute a recognizable natural realm with established boundaries—exactly what [group species arguments] try to protect from critical dissolution. (Hübner, 2018, 201) The same reasoning that supports granting HACHs moral status also supports denying them moral status. In light of the fact that these two species-based arguments are mutually interdependent and yet inconsistent in their moral implications, Hübner concludes that there are serious conceptual problems underlying the two opposing views, which generate the dilemmatic paradox that he identifies as the root of the moral confusion surrounding HACHs. Since Hübner’s focus is the moral status of human–animal chimeras and hybrids, it is clear how his article addresses the moral status question. We need to know the grounds for moral status to determine whether or not HACHs have it. The intuition behind the position that HACHs should be morally protected is the thought that such beings either possess some status-conferring property or are members of a species group that possesses such a property. Thus, we must know what the relevant status-conferring property is. Hübner’s article deals with the human nature question as well. For one thing, we need some clear understanding of humanity in order to differentiate between human beings, nonhuman animals, and human–animal chimeras and hybrids. Also, Hübner points out that the morality of creating HACHs often will depend on the type of being in question, and in this article he does not explore how his arguments bear on the different kinds of HACHs that might be created. In addition, Hübner intentionally frames his arguments in terms of the biological category of species, rather than an “abstract” metaphysical category like substance, person, or rational animal (contra the approach of Brown and Lee, Tollefsen, and George). He presents his biological species account as a competitor to the substance theory (Hübner, 2018), but I suspect that the two views are really closer than they may appear, and exploring the relationship between them is a promising topic for further study. IV. THE DETERMINATION OF DEATH The criteria for determining death is a subject of major dispute in contemporary bioethics and was the focus of a recent symposium in this journal (Moschella, 2016). According to the United States’ Uniform Determination of Death Act: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead” (President’s Commission, 1981, 73; see Brown, 2018, 155). These two options represent the most popular positions in the current debate about human death. It is important to recognize that there are two related but distinct issues involved in this debate. One is the definition of death. A second is the criteria that should be used to determine when a person has died. The latter issue is the primary focus of Andrew McGee and Dale Gardiner’s “Donation after the Circulatory Determination of Death.”7 In this article, the authors defend the permanent–circulatory–respiratory criterion of death against some recent criticisms pressed by Franklin Miller, Robert Truog, and Don Marquis (Truog and Miller, 2008, 2010; Marquis, 2010; Miller and Truog, 2012). According to McGee and Gardiner, in all contexts human beings should be declared dead on the basis of the permanent cessation of circulatory–respiratory function. They also defend the Dead Donor Rule, which says that a patient must be determined to be dead before her organs can be procured for transplantation. Their central contention is that a declaration of death should be based on a judgment about the permanent cessation of circulatory–respiratory function, rather than on a judgment about its irreversible cessation. Throughout the article, McGee and Gardiner respond to some prominent objections to their position and make some important points of clarification concerning the standards for determining death. One of these clarifications is a distinction between being dead and being known to be dead, which the authors use to show that the question under dispute is really the reasonableness of a diagnosis of death. They argue that “permanence is not merely a proxy for irreversibility, but a way of knowing whether circulatory and respiratory function will be reversed or not . . . the requirement of determination of irreversibility ‘in accordance with accepted medical standards’ effectively means that we can interpret ‘irreversibility’ to mean permanence” (McGee and Gardiner, 2018, 216). On their view, in order to know that someone has died, we do not have to rule out all counter-possibilities whatsoever. Instead, we must rule out only genuine counter-possibilities that are relevant to the particular situation at hand. In many cases, resuscitation via CPR will be a relevant possibility. In cases where CPR is the only way a patient could be resuscitated and CPR is inappropriate for some reason (e.g., a DNR/DNAR order), then we do not need to rule out resuscitation via CPR and we can justifiably declare that the patient has died. In such a case, we can know that someone has died when we have no reason to believe that auto-resuscitation is a genuine possibility. More generally, McGee and Gardiner’s claim is “not about what might not happen in principle; it is about what will happen in this patient’s case. The category of the patient enables us to know when permanent cessation is reached” (McGee and Gardiner, 2018, 218). Critics like Marquis claim that the irreversibility criterion is superior to the permanence criterion because irreversibility is an intrinsic dispositional property of patients, whereas permanence is a relational property that is based on what is normatively appropriate to the situation and what other individuals are capable of or willing to do. McGee and Gardiner respond that the concept of reversibility is better understood as a relational property analogous to “reparable” or “retrievable” rather than a dispositional property like “soluble” or “breakable.” Against critics like Miller and Truog, McGee and Gardiner argue that using irreversibility as the criterion for determining death leads to serious epistemological and practical problems. For one thing, it is very difficult to identify the point at which irreversibility is achieved and “it would only be possible to know if the condition were reversible by attempting resuscitation and failing, or waiting in a death watch for several hours” (McGee and Gardiner, 2018, 234). For epistemic and pragmatic reasons, then, it is better to rely on the permanence criterion when making declarations of death. McGee and Gardiner also contend that accepting the criterion of irreversibility would have radical and problematic implications for our current practices of declaring death in hospitals. Although McGee and Gardiner do not directly address the human nature question or the moral status question, both questions have an important bearing on the issues they discuss. With respect to the human nature question, whereas Brown and Morris focus on when a human being begins to exist, McGee and Gardiner examine when a human being ceases to exist. In order to know when a human being dies, we need to know what a human being is. Like Morris, these two authors make a distinction between the metaphysics and the epistemology of the issue: the metaphysical question of what death is differs from the epistemological question of how we can reasonably claim to know that death has occurred. McGee and Gardiner, like Morris, primarily target the epistemological question. With respect to moral status, this article highlights important questions about the moral standing of human individuals at the end of life. The issue of organ donation and the Dead Donor Rule is tied up with the moral status of organ donor patients because a controversial question is whether such patients must be declared dead before it is morally permissible to procure their organs. If so, then which criterion for determining death should we use? Different answers to these questions have important moral implications for how we ought to treat such patients. V. HUMAN COGNITION AND MITOCHONDRIAL DONATION Somogy Varga’s article “Embodied Concepts and Mental Health” engages with cognitive science and the philosophy of mind, specifically an emerging field known as embodied cognition.8 This research program is influenced by the phenomenological tradition in philosophy, and it takes human cognition to be “grounded in aspects of its sensorimotor embodiment” and “the result of a dynamic interaction of bodily (non-neural) and neural processes” (Varga, 2018, 241–242). In other words, human thinking is shaped by our embodied experience and is bound up with our sensorimotor capacities. In the first section of the article, Varga explores the connections between several contemporary theories of embodied cognition and the phenomenology of Maurice Merleau-Ponty. He illustrates various ways in which these theories draw on several of Merleau-Ponty’s insights about the relationship between cognition and physical embodiment. Furthermore, he makes a distinction between two different versions of the thesis that human cognition is embodied (“the embodiment hypothesis”): a stronger version that completely rejects computational and representational models of cognition and a weaker version that is compatible with such models. For the remainder of the article, Varga focuses on one of the most prominent accounts of embodied cognition, George Lakoff and Mark Johnson’s Conceptual Metaphor Theory (CMT) (Lakoff and Johnson, 1980, 1999). According to this view, metaphors are an essential part of thought as well as language: “we use ‘metaphors of thought’ or ‘conceptual metaphors,’ construed as systematic ‘mappings’ (correspondences) between a concrete source domain (closely related to bodily experience), and an abstract target domain” (Varga, 2018, 245). Abstract concepts are grounded in particular domains of bodily experience. For example, our concepts of joy and sadness are based partly on spatial relations: we sometimes describe ourselves as “walking on air” or being “down in the dumps.” Varga argues that CMT is well supported by empirical evidence. Recent behavioral and neuroscientific research confirms that much higher-order cognition is grounded in the bodily experience of one’s environment so that bodily and abstract domains are intertwined via conceptual metaphors giving rise to bidirectional effects: sensory experiences have significant bottom-up effects on higher-order judgments and behavior, and the activation of certain concepts has top-down effects on bodily (perceptual) states. (Varga, 2018, 250) For instance, there is a connection between sensations of weight and moral emotions such as guilt (which is said to feel heavy and “weigh us down”); subjects who are told to recall a past moral transgression tend to report higher subjective feelings of body weight. Varga points to various other data to shore up CMT as an empirically grounded account of cognition. Varga also attempts to strengthen CMT by defending it against some common objections and making two of his own modifications to Lakoff and Johnson’s theory, one that relaxes their bodily constitution requirements for concept acquisition and another that circumvents their implausible metaphysical claim that conceptual metaphors are identical to neural circuits in the brain. At the end of the article, Varga discusses the applications of CMT to mental health. He explains that CMT has theoretical resources that may help improve our understanding and treatment of mental disorders. For example, CMT’s focus on the embodied aspects of cognition and the connections between bodily motor patterns and cognitive-affective patterns make it ideally positioned to address a phenomenon like depression, which involves cognitive, emotional, and bodily dimensions. Varga explores various ways that CMT might be deployed in a clinical setting to help treat mental disorders, and he ends by identifying some important avenues for further research. Varga’s article may appear not to be connected to the two overarching questions of human nature and moral status. Shortly, I will explain how it is related to both questions in significant ways. Because the same thing could be said for John Appleby’s article, which I will summarize next, and because Varga’s and Appleby’s topics are connected to the two overarching questions in similar ways, I will postpone my explanation until the end of this section. In his article “Should Mitochondrial Donation Be Anonymous?,” John Appleby examines the United Kingdom’s policies concerning the identity of donors of reproductive biological materials.9 Currently, in the United Kingdom, gamete donation is open-identity—persons conceived with donated gametes have a legal right to obtain certain information about their donors—whereas mitochondrial donation is anonymous—persons conceived with donated mitochondria are not able to access information about their donors. Appleby argues that both gamete donation and mitochondrial donation should be open-identity and that there are no good reasons to treat the two cases differently. He begins with the initial presumption that mitochondrial donation, like gamete donation, should be open-identity unless there is a good argument for making it anonymous. Then, he addresses a series of arguments in favor of anonymous mitochondrial donation and argues that they all fail. The first argument that Appleby considers and rejects is that there is either a quantitative difference between gamete donation and mitochondrial donation because there are fewer genes in the mitochondrial genome than in the nuclear genome, or a qualitative difference between the two cases because mitochondrial genes have properties different from those of nuclear genes. The second unsuccessful argument is based on the claim that gamete donors are “third parents,” whereas mitochondrial donors are not. The third reason that Appleby rejects is that being conceived through mitochondrial donation is less important for an individual’s “sense of self” than being conceived through gamete donation is. The fourth and final argument that he criticizes is one that identifies four negative consequences that allegedly would result from open-identity mitochondrial donation: (1) it would decrease the number of mitochondrial donors; (2) it would cause some prospective parents to travel to another country where mitochondrial donors are anonymous; (3) it would devalue the position of gamete donors; and (4) it would reinforce the social attitude that donors should be an important part of their offspring’s lives, which detracts from the significance of parents. It is worth saying more about the “sense of self” argument. Appleby’s goal in discussing this argument is to show that considerations about how knowledge of one’s donor bears on one’s sense of self do not provide a sufficient reason to make mitochondrial donors anonymous. In line with the rest of his article, his purpose here is a critical, negative one that refutes arguments for treating gamete donation and mitochondrial donation differently. It seems to me that the sense of self argument can also be turned into a positive argument for Appleby’s position that mitochondrial donation should be open-identity. In this context, one’s sense of self appears to be equivalent to one’s psychological identity (as opposed to numerical or metaphysical identity): the personal characteristics, beliefs, desires, pursuits, relationships, history, and narrative understanding that one considers to be central to who one is. Of all the ways that knowing the identity of one’s mitochondrial donor might affect one’s psychological identity, perhaps the most relevant is the sense of personal history and life narrative. The intuitive idea is that one’s origins are an important part of one’s life story. It is plausible that some, perhaps many, offspring want to know the identity of their gamete donor because they want to know where they come from, which all of us take to be an important aspect of our sense of self. As Appleby points out, this view is supported by empirical evidence from social science (Appleby, 2018, 269). Additionally, it seems to me that the same line of reasoning applies to mitochondrial donors too, who are also relevant to the understanding of one’s history and narrative. Developing this argument would strengthen Appleby’s case by providing an additional positive reason why mitochondrial donation should be open-identity because these identity-related reasons in favor of knowing one’s gamete donor are also reasons in favor of knowing one’s mitochondrial donor. Thus, a sense of self argument for open-identity mitochondrial donation is a way that Appleby’s case might be strengthened.10 I noted earlier that Varga’s article and Appleby’s article are linked to the human nature question and the moral status question in similar ways. Despite initial appearances to the contrary, both of these articles have a significant connection to both questions. Two things that often come up in discussions of human nature and moral status are the human cognitive capacities and the human sense of self. Both the cognitive powers and the sense of self have been seen as defining human characteristics and moral-status-conferring properties. With respect to cognition, a tradition that dates back to Aristotle and enjoys a prominent place in Western thought sees human beings as rational animals, where the cognitive capacities are taken to be the most distinctive and important human feature. This same tradition also emphasizes human animality. For Aristotle, things like pleasure, pain, and the emotions are forms of cognition that essentially involve our animality, and we might see these phenomena as embodied in Varga’s sense.11 And some classical and contemporary thinkers, both within the Aristotelian tradition and outside it, have argued that only beings who possess significant cognitive capacities have moral status. These cognitive and animal characteristics are highlighted in Varga’s discussion of the embodied, sensory aspects of human cognition. With respect to the sense of self, another traditional defining human trait is the sense of self or psychological identity. In addition, self-consciousness and self-awareness are popular criteria of moral status. Since the sense of self plays a prominent role in Appleby’s article, his discussion, like Varga’s, makes a helpful contribution to our understanding of human nature and moral status. VI. CONCLUSION Despite the fact that the articles in this issue address different bioethical debates, they are unified by the valuable contribution they make to the conversations about what it means to be human and what it takes to be a member of the moral community. Although there is much to learn from each article, an important lesson that all of them together teach is that the answers to very different bioethical questions sometimes depend on the answers to deeper metaphysical and moral questions, such as the nature of humanity and the grounds of moral status. For this reason, these articles highlight the importance of philosophical reflection on these fundamental questions for bioethics and medical practice. NOTES 1. See Jaworska and Tannenbaum (2018) for a good overview of some of the major distinctions, theoretical options, and arguments involved in the problem of moral status. 2. See Beauchamp and Childress (2009, Chapter 3) for a defense of this point and a critical examination of some of the most popular theories of moral status. 3. As Beauchamp and Childress note, “The mainstream approach has been to ask whether a being is the kind of entity to which moral principles or other moral categories can and should be applied, and, if so, based on which properties of the being” (Beauchamp and Childress, 2009, 66). 4. A concern with Brown’s terminology is that it is potentially confusing when it comes to the human nature question. He claims that the blastocyst is a “biological individual” that is a “form of human life” but not a “human being” (Brown, 2018, 146). The worry is that the meaning of “human being” may be unclear to some readers, especially considering that on Brown’s view both the blastocyst and the fetus are human substances (of two different kinds). If we assume an ordinary understanding of a human being as an individual living thing that is human, then the blastocyst seems to count because it is a living individual human life form. Brown uses “human being” in a different sense, which becomes clear enough throughout the course of his article. But, it might help to clarify the terminology because the term “human being” carries so many different meanings in ethics (e.g., human organism, human person, human substance, etc.). 5 There is another important question in this territory. If we agree with Morris’s skepticism about realist metaphysics, we must ask what this skeptical position implies for the way we answer the moral status question. Morris defends the conferred status model. But if we adopt the opposing intrinsic-property model and we find ourselves in epistemic doubt about the nature of the unborn entity, what position should we take on issues like abortion, embryonic stem cell research, and assisted reproductive technologies that result in discarded embryos, as well as other beginning-of-life issues? On the one hand, we might think that in light of the metaphysical uncertainty about the unborn entity and the resulting uncertainty about the unborn’s moral status, when the possible rights and interests of the unborn conflict with the rights and interests of others whom we know are human persons with full moral status and interests, the rights and interests of the latter group should prevail. Or we might draw the opposite conclusion: since the unborn entity might be a human being with full moral status, rights, and interests, we should favor caution and act as though the unborn are human beings (even if it turns out that they are not), because the moral stakes are so high. This is an important question that calls for further discussion. 6 For a previous discussion of this issue in this journal, see Eberl and Ballard (2009). 7. These authors also offer a definition of death: “the condition of being permanently lifeless in any relevant circumstance. ‘Relevant circumstance’ refers either to cases where CPR is appropriate, or to cases where it is not” (McGee and Gardiner, 2018, 218). 8 Previous articles in this journal that address similar issues are Fielding (1998) and Clark (2007). 9. Previous articles in this journal related to this issue are Andrews (1989) and Cohen (1999). 10. It seems that Appleby is aware of the type of positive argument I am suggesting here. For example, he says: “contrary to the sense of self argument as used to date in the debate regarding mitochondrial donors, it does seem possible that some future [mitochondrial-donor conceived] persons could also find that the genetic connection they share with their mitochondrial donor is of some significance to their sense of self” (Appleby, 2018, 270). 11. I am grateful to an anonymous referee for mentioning this point about Aristotle. ACKNOWLEDGMENTS Thanks to Jeff Bishop for the invitation to write this introduction, Victor Saenz for helpful advice and instruction, and Jeff Bishop and an anonymous referee for valuable feedback on a previous draft. REFERENCES Andrews, L. 1989. Control and compensation: Laws governing extracorporeal generative materials. Journal of Medicine and Philosophy  14(5): 541– 60. Google Scholar CrossRef Search ADS   Appleby, J. 2018. Should mitochondrial donation be anonymous? Journal of Medicine and Philosophy  43(2): 261– 80. Beauchamp, T. and J. Childress. 2009. Principles of Biomedical Ethics . 6th ed. Oxford, United Kingdom: Oxford University Press. Beckwith, F. 2007. Defending Life: A Moral and Legal Case Against Abortion Choice . New York: Cambridge University Press. Google Scholar CrossRef Search ADS   Brown, M. 2007. The potential of the human embryo. Journal of Medicine and Philosophy  32(6): 585– 618. Google Scholar CrossRef Search ADS   ————. 2018. The moral status of the human embryo. Journal of Medicine and Philosophy  43(2): 132– 58. Clark, A. 2007. Re-inventing ourselves: The plasticity of embodiment, sensing, and mind. Journal of Medicine and Philosophy  32(3): 263– 82. Google Scholar CrossRef Search ADS   Cohen, C. 1999. Selling bits and pieces of humans to make babies: The gift of the Magi revisited. Journal of Medicine and Philosophy  24(3): 288– 306. Google Scholar CrossRef Search ADS   Eberl, J. and R. Ballard. 2009. Metaphysical and ethical perspectives on creating animal-human chimeras. Journal of Medicine and Philosophy  34(5): 470– 86. Google Scholar CrossRef Search ADS   Fielding, H. 1998. Body measures: Phenomenological considerations of corporeal ethics. Journal of Medicine and Philosophy  23(5): 535– 45. Hübner, D. 2018. Human–animal chimeras and hybrids: An ethical paradox behind moral confusion? Journal of Medicine and Philosophy  43(2): 187– 210. Jaworska, A. and J. Tannenbaum. 2018. The grounds of moral status. In The Stanford Encyclopedia of Philosophy , ed. E. Zalta, Spring 2018 ed. [On-line]. Available: https://plato.stanford.edu/archives/spr2018/entries/grounds-moral-status (accessed January 29, 2018). Lakoff, G. and M. Johnson. 1980. Metaphors We Live By . Chicago: University of Chicago Press. ————. 1999. Philosophy in the Flesh: The Embodied Mind and Its Challenge to Western Thought . New York: Basic Books. Lee, P., C. Tollefsen and R. P. George. 2014. The ontological status of embryos: A reply to Jason Morris. Journal of Medicine and Philosophy  39(5): 483– 504. Google Scholar CrossRef Search ADS   Marquis, D. 2010. Are DCD donors really dead? Hastings Center Report  40(3): 24– 31. Google Scholar CrossRef Search ADS   McGee, A. and D. Gardiner. 2018. Donation after the circulatory determination of death: Some responses to recent criticisms. Journal of Medicine and Philosophy  43(2): 211– 40. Miller, F. and R. Truog. 2012. Death, Dying and Organ Transplantation . New York: Oxford University Press. Morris, J. 2012. Substance ontology cannot establish the moral status of embryos. Journal of Medicine and Philosophy  37(4): 331– 50. Google Scholar CrossRef Search ADS   ————. 2018. Misconceptions inherent in the substance ontology approach to assigning moral status: A reply to Patrick Lee, Christopher Tollefsen, and Robert George. Journal of Medicine and Philosophy  43(2): 159– 86. Moschella, M., ed. 2016. Brain death and human organismal integration: A symposium on the definition of death. 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Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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