AUTHENTICITY (Penultimate draft. Please cite the final version, available in: Bioethics, 4th Edition. Edited by Bruce Jennings. Farmington Hills, MI: Macmillan Reference USA, 2014.) Authenticity is an important ethical concept. It is also a potentially confusing one, due to the variety of ways in which it has been used throughout its history. Artifacts such as paintings or dollar bills can be described as authentic or inauthentic. In such cases, the attribution of authenticity suggests, as indicated by the Oxford English Dictionary, that something is "what it professes in origin or authorship...genuine." But more importantly for a discussion of the concept within bioethics, people and their choices, actions, and lives are also assessed in terms of their authenticity. The term is then susceptible of a wider range of possible meanings (even though it can still be used in a similar sense to that relevant to inanimate objects), which this entry will attempt to spell out. Despite this plurality of meanings, however, authenticity is typically assumed to be a desirable thing. In the healthcare context, for instance, it is deemed of crucial importance that a patient's decision, say to refuse treatment, should be authentic; if there are grounds for thinking that it is not, this may be taken to mean that it is permissible to override it. Authenticity is also usually viewed as a significant consideration in the private conduct of one's life. As Charles Taylor, among others, has pointed out, many people in Western society – especially since the 1960s – are committed to the moral ideal of living an authentic life, a life that is uniquely their own. This use of the concept has for example become salient in the debate on the ethics of human enhancement. A brief history of the concept As traditionally conceived, authenticity fundamentally involves the idea of being true to oneself. This idea, however, can itself be understood in different ways. One major sense, connected to the OED's definition of "authentic" given above, has to do with sincerity: being true to oneself, on this construal, means accurately representing who one is, including one's beliefs and feelings, to others. This is the sense already found in the famous lines spoken by Polonius in Shakespeare's Hamlet, in which the character advises his son Laertes: This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man. (Act 1, scene III) In his classic work Sincerity and Authenticity, Lionel Trilling precisely argues that sincerity really came to prominence as a value in Western society at about the time Hamlet was written, the late sixteenth century. While this value retains its importance through the following centuries, it is only once being true to oneself starts mattering beyond the fundamentally public virtue of sincerity that the moral ideal of authenticity is truly born. Taylor traces this development of the ideal in The Ethics of Authenticity, through Rousseau and, in particular, Herder and the Romantic movement. For the Romantics, we should be true to ourselves not simply for the sake of presenting our true colors to others, but also, more importantly, because of the intrinsic value of expressing and realizing our fundamental, inner nature. For one thing, this means realizing our best capacities, resulting for instance in the creation of great works of art. But an even more pressing reason for living authentically is, on this view, that this true self or inner nature is the ultimate source of knowledge for us about how we ought to live, about what a good life means for each of us as the individual (s)he is. As Taylor puts it, "there is a certain way of being human that is my way. I am called upon to live my life in this way, and not in imitation of anyone else's" (p.29; emphasis in original). In the twentieth century, however, the Romantic tenet of a true self in accordance with which one ought to shape one's life came under attack from existentialist philosophers, with whose thought the term "authenticity" is perhaps most closely associated. This criticism is most evident in the work of Jean-Paul Sartre. Sartre adamantly rejected the idea that we have anything like a true self, a rejection most radically expressed in his early work Existentialism and Humanism, where he famously maintained that "[m]an is nothing but that which he makes of himself" (p.28). To believe as the Romantics did that features one hasn't chosen can even partly define who one is represents, for Sartre, just an instance of bad faith, the very opposite of authenticity. Authenticity for Sartre means avoiding bad faith by facing up to the fact that we are fundamentally free to write the story of our life, and thus fundamentally responsible for the kind of person we become; there is no pre-given self laying down in advance the path we ought to follow. Two contrasting approaches to authenticity in analytical philosophy The contrast between the Romantic view of authenticity and the Sartrean one is reflected in the more general contrast drawn by some authors (such as Erik Parens and Neil Levy) between accounts of authenticity that emphasize self-discovery, and those that focus on self-creation. The main analyses of authenticity stressing self-creation that have been proposed after Sartre tend to acknowledge more explicitly the limits that constrain our ability to shape ourselves as we wish. They do, however, still reject the idea of a pre-given self providing guidance as to how to live authentically – unless such a self is identified with our highest-priority values and commitments. Authenticity, according to the self-creation approach, involves living our life in accordance with these. No further constraints are placed on the authenticity of our choices and actions: for instance, someone could in principle make an authentic decision to radically change her physical appearance and psychological make-up, provided that she did so in keeping with her core values and commitments. This approach thus treats authenticity as closely related to – if not identical with – the notion of autonomy, understood broadly as self-governance in the light of one's highest-priority values. In The Importance of What We Care About, Harry Frankfurt can be read as providing an analysis of authenticity as autonomy: on this account, acting authentically means acting on the basis of desires that one wholeheartedly endorses. The notion of wholeheartedness implies the absence of ambivalence in one's second-order endorsement of those first-order desires, as well as the absence of any inconsistency between one's second-order attitudes. David DeGrazia's account of authenticity in his book Human Identity and Bioethics is in many ways similar to Frankfurt's, though DeGrazia views autonomy as a necessary but not sufficient condition of authenticity. Honesty, in the sense of accurate presentation (both to others and oneself) of who one is, is required as well (pp.108-12). Detailed, systematic expositions of the self-discovery approach to authenticity are more difficult to come by in analytical philosophy. Nevertheless, supporters of that approach can be said to share the following two ideas. First, each of us does have something like a true self, a set of traits (not limited to our values and commitments) which, taken together, define who we fundamentally are, and do so whether or not we happen to endorse them. Secondly, authenticity entails living in accordance with such a true self, that is to say, expressing it, when appropriate, in our behavior (rather than hiding or repressing it), or preserving it even when we might be tempted to change it, for instance because it would promote some of our interests. Some passages in Taylor's Ethics of Authenticity can be taken to provide one of the most comprehensive outlines of the self-discovery model, though it is not fully clear to what extent Taylor is willing to accept the idea of a true self that includes things beyond a person's values and commitments. Bernard Williams also expressed an affinity with that model. As he summed up to journalist Stuart Jeffries: "If there's one theme in all my work it's about authenticity and self-expression... It's the idea that some things are in some real sense really you, or express what you [are] and others aren't." Among bioethicists, Carl Elliott and the President's Council on Bioethics have also endorsed a true self approach to authenticity. They differ, however, in the exact way they understand the notion of a true or authentic self. While the President's Council appears to identify it with an essence of some kind, Elliott does not. In light of those descriptions, the distinction between the self-discovery and selfcreation approaches shouldn't be interpreted too rigidly. Versions of the self-creation model less radical than Sartre's, such as DeGrazia's view, do make some space for the possibility of self-discovery. They do not rule out, for instance, that we might discover what our fundamental values and commitments are. Conversely, not all variants of the self-discovery approach posit an essential, unchangeable self. Some – perhaps the more plausible ones – do allow that we can to some degree deliberately shape who we authentically are, by working on ourselves to develop new traits and skills. Still, there remains an important difference between even the more moderate versions of each approach: DeGrazia, for instance, is keen to stress that only those of our features that we identify with, and have made part of our own self-conception, can define who we are fundamentally, that is, our identity as individuals. It should finally be mentioned that the various accounts considered so far are primarily aimed at offering a criterion for the authenticity of our choices and actions, rather than our psychological features, such as our emotions, desires, or moods. Authenticity in relation to such features has usually been discussed in a separate literature. Some authors, however, do use criteria that echo those described above. Kevin Mulligan, for example, has argued that authentic emotions must escape rational and willful control, stressing, in the spirit of the self-discovery model, the need for spontaneity; other authors differ, stating instead that an authentic emotion must simply cohere with our autonomously formed values and beliefs (see Kraemer for a summary of that debate). Given that discussions about authenticity in bioethics are often concerned with the alteration of our psychological make-up (including our emotions or moods) for purposes of treatment or enhancement, such discussions might benefit from taking into account both of these bodies of literature on the concept of authenticity. The following sections will consider the relevance of that concept to three areas of debate in bioethics: end-of-life decision-making, the technological enhancement of human beings, and the treatment of mental disorder. Authenticity and end-of-life decision-making The issue of authenticity arises in the medical context when a person must decide whether or not to undergo some treatment to save her life. It also arises when someone seeks help with actively ending her life, in countries – like the Netherlands – where practices like euthanasia and physician-assisted suicide are legal. The question then is whether the person's expressed wish (say, to end her life) is authentic or not. This wish may be directly expressed by the person at the present time, or it may have been formally expressed in the past through an advance directive, the latter being relevant when the person is now regarded as lacking decision-making capacity, for instance as a result of a neurodegenerative disease. In either case, however, the concern about the authenticity of the person's request has to do with whether it accurately reflects her preferences and values. The relevant sense of authenticity at stake here is thus analogous to autonomy as conceived by Frankfurt or DeGrazia. It is considered important to ensure that someone's decision to end her life should be truly her own, and that it should not have been distorted by false or incomplete information, or by social pressures. If a person's choice is indeed judged authentic in this sense, the conclusion will usually be that it ought to be respected. In such cases, considerations of authenticity are viewed as taking precedence even over the patient's best interests. Consider an adult person who, on religious grounds, refuses a blood transfusion that would almost certainly save her life. Many would regard her decision as going against her own interests. Nevertheless, the consensus among doctors is that this decision should not be overridden if it is a genuine expression of the person's core values. Best interests can carry more weight in cases where a patient has lost capacity, and no formal expression of her wishes regarding treatment is available. Even then, however, they need not be the decisive consideration. If the person deciding on behalf of the patient (the "surrogate") possesses sufficient knowledge of the latter's beliefs and values, she is supposed to try and determine what the patient would have chosen if she still had capacity. In other words, the decision she reaches should ideally be an authentic reflection of the patient's values and beliefs. Again, such a decision might not necessarily coincide with what most would regard as the patient's best interests. The self-creation approach to authenticity seems of greater relevance than the selfdiscovery one to the question whether a person's decision to refuse life-saving treatment (or her request to be helped to die) should be respected. Even if such a person possessed, for instance, great artistic gifts, few would argue that this would justify paternalistically overriding her refusal of treatment on the grounds that she should keep on living in order to give full expression to her authentic self. That said, such considerations might legitimately be appealed to in an attempt to convince the person to change her mind. They might also appropriately figure in her own decisionmaking process: "Art still needs my contribution, I must go on." This suggests that while the self-creation model is more relevant to issues of public regulation, the selfdiscovery one might be more important for the more personal question of how one ought to live. Authenticity and the enhancement debate The late twentieth and early twenty-first centuries have seen a growing interest in questions of authenticity within the debate on the technological enhancement of human beings – particularly so-called "neuroenhancement", the process of intervening into a healthy person's brain, using procedures like psychoactive drugs or brain stimulation, to modify her mood, personality, or other psychological features in desired ways. A key impulse behind that debate was the publication in 1993 of psychiatrist Peter Kramer's book Listening to Prozac. In it, Kramer describes some patients who no longer meet the strict criteria for depressive (or any other) disorder, yet are reportedly transformed by the use of the drug, in ways many would judge desirable. Vulnerable, shy, and unconfident people become resilient, assertive, and socially savvy, with such benefits for their social and professional lives that some of them asked Kramer to remain on Prozac even once they were no longer considered at risk of relapsing into depression. Kramer's account raises a general worry, shared by authors like Elliott and the President's Council. While this kind of neuroenhancement might seem to carry great benefits, doesn't it threaten the authenticity of the subject being enhanced? This worry needs to be spelt out further. It is sometimes suggested that the enhanced individual will not be the same person as the initial one, and that this is inherently problematic. However, as DeGrazia as shown (pp.231-2), this suggestion seems based on a failure to sufficiently distinguish between different senses of the phrase "being the same person", or of the idea of individual "identity". It seems implausible to think that the technological alteration of our personality or mood must produce a numerically distinct individual, with the implication that the original one has simply been destroyed. An alternative line of argument states instead that the qualitative changes to the person's identity produced by neuroenhancers are problematic from the perspective of authenticity. Yet why should they be regarded as such? One of the strongest arguments offered for that conclusion is Elliott's suggestion that mood brighteners like Prozac might disconnect certain people from the appropriate sense of alienation they are experiencing in the face of a world that is amiss. His worry is that the drug might make the person feel better at the cost of silencing the voice of her authentic self, a voice that might not be pleasant yet is nevertheless a source of important insights about her life circumstances. (See Elliott's piece "The Tyranny of Happiness".) Authors like DeGrazia have responded to Elliott by arguing for a different understanding of the notions of authenticity and identity. Suppose that someone experiencing the feelings of alienation described by Elliott wants to get rid of them with the help of Prozac. To the extent that this person doesn't identify with her sense of alienation, this feature is not part of her identity on DeGrazia's view. Therefore, removing it through pharmacological means does not threaten her authenticity. It will not betray anything like a true self. On the contrary, the person's decision to shape her psychology in this way can be fully authentic, provided that it is in line with her values and preferences, and does not involve deception of any kind. This brings us back to the fundamental disagreement between the self-discovery and the selfcreation approaches to authenticity. Neil Levy has proposed a way of resolving the conflict between these two approaches, using an analogy with people who choose to undergo sex reassignment surgery on the basis of their feeling that they are, for instance, really a woman trapped in a man's body. Such cases, Levy argues, illustrate the fact that enhancement technologies can actually help people become who they really are, allowing their authentic self (as the self-discovery model understands it) to shine through. He thinks that claim should be extended to the use of pharmaceuticals like Prozac for enhancement purposes, and concludes that regardless of which approach to authenticity one subscribes to, the use of neuroenhancers can be seen as promoting our authenticity. The statements made by some of Kramer's patients, who claimed that they were "no longer themselves" without Prozac, do seem to lend support to that conclusion. Yet while Levy seems right that the self-discovery model does not warrant a systematic condemnation of enhancement use as inauthentic, it has nevertheless been argued that this model is in fact more conducive to worries about authenticity than the self-creation one (see Erler). If so, the debate between the two camps is not at an end yet. Authenticity and mental disorder A third context within bioethics in which the concept of authenticity has received much attention is the treatment of mental disorder. The issues here largely overlap with those raised in relation to the enhancement debate – unsurprisingly, since both discussions focus on interventions into the brain involving similar procedures (antidepressants like Prozac, stimulants like Ritalin), only for different purposes (treatment vs. enhancement). Indeed, these interventions were originally designed with the aim of treating psychological disorders like depression or Attention Deficit Hyperactivity Disorder (ADHD), and their enhancement potential was only discovered accidentally. The issue of authenticity has been discussed in relation to various groups of people with mental disorder. Ilina Singh has studied children with ADHD; Ineke Bolt and Maartje Schermer have interviewed adults with the same condition. Tony Hope and colleagues have interviewed female patients with anorexia nervosa, while David Karp has related the experiences of people with depressive disorder. In all of these contexts, a key question that arises particularly for patients and their relatives is whether medication that treats the disorder undermines the person's authenticity. The worry that it might do so is arguably less widely shared than the corresponding worry in relation to neuroenhancement, yet some patients (and, in the case of children with ADHD, their parents) do give voice to it. Others, by contrast, take the view that medication actually helps restore the authentic self that had been masked by pathology – a view with which many clinical practitioners would agree. Alternatives are to regard both the disordered and the "well" self as equally authentic, or to simply reject the notion of an authentic self altogether. Patients who feel that medication takes away part of their identity by removing the disorder sometimes suggest that they are thereby being deprived of intrinsically valuable features, such as spontaneity or creativity in the case of ADHD. But the worry about losing part of oneself does not seem to systematically depend on the assumption that the relevant aspect of one's identity is valuable independently of its being part of oneself. What do the philosophical perspectives on authenticity considered above imply in this sort of cases? For advocates of the self-creation model, concerns about authenticity are only appropriate when a patient does not clearly endorse her motives for seeking treatment, or the changes that the medication produces in her. If she does endorse them wholeheartedly or autonomously, her use of medication must count as fully authentic. It is unclear whether supporters of a true self analysis of authenticity will want to disagree here. This will depend on whether or not they are prepared to accept that mental disorder can be part of a person's authentic self. While several of the authors mentioned earlier in this section agree that the self-discovery approach can help illuminate discussions of mental disorder and authenticity, they understandably tend to avoid taking a firm stand on the nature of the relation between the two. In favor of the view that mental disorder necessarily overshadows a person's authentic self, one might stress the common intuition that treating clinical depression through medication does not fundamentally change who the patient is, but simply restores her. However, as mentioned previously, this intuition is not universally accepted with respect to all forms of mental disorder. To this should be added that the way the concept of mental disorder is applied by the medical profession at any point in time does not stand beyond criticism. Some characteristics, like homosexuality, were once viewed as disorders but are no longer so, and some that are still so classified in the 2000 version of the DSM manual, edited by the American Psychiatric Association, have been said not to deserve that label. Allan Horwitz and Jerome Wakefield have made such an argument in relation to certain forms of depression that they regard as normal responses to distressing life circumstances – something strongly reminiscent of Elliott's idea of "good" alienation, alienation bound up with authenticity. Finally, it has been suggested that some people with mental disorder find the concept of a true or authentic self useful when coping with their condition. For instance, Hope and colleagues have reported that some patients with anorexia nervosa find it helpful to conceptualize their authentic self as the healthy, non-anorexic one, viewing by contrast their anorexia as an inauthentic part of themselves, against which they are struggling (p.23). Such observations raise the question whether the concept of a true self can be of use to clinical practitioners trying to help their patients get better. Another question is whether, even when the concept does appear to help a patient in her process of recovery, her use of that concept might still in principle conflict with the actual truth about who she "really" is – assuming of course there is such a truth. Conclusion While it is commonly accepted that authenticity is a significant moral value, there are different ways of thinking about the concept, leading to conflicting positions on certain issues in bioethics. The self-creation approach, with its emphasis on autonomy, seems most relevant to questions about regulation and respect for people's decisions, whether to refuse treatment or to use some neuroenhancer. It is commonly agreed that if these decisions are authentic, they should be respected, provided they do not harm others. The self-discovery model of authenticity, on the other hand, might be more relevant to how we should live our lives, and how we should encourage people to live theirs, either directly or by influencing the general social ethos. It also suggests some important concerns about technological interventions into the brain, whether for treatment or enhancement purposes, that the self-creation approach tends to neglect. That said, supporters of the self-discovery model have typically not spelt out their views as fully as those on the other side of the debate. There clearly remains room for further discussion on the question whether the idea of an authentic self can be construed in a plausible manner, as opposed to being merely studied from a sociological perspective; and if it can be so construed, what its exact nature is, and how – if at all – the technological interventions previously discussed might threaten a person's proper relation to that self. BIBLIOGRAPHY American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text rev. Washington, DC: Author. Bolt, Ineke & Schermer, Maartje. 2009. "Psychopharmaceutical Enhancers: Enhancing Identity?" Neuroethics 2:103-11. DeGrazia, David. 2005. Human Identity and Bioethics. Cambridge: Cambridge University Press. Elliott, Carl. 1998. "The Tyranny of Happiness: Ethics and Cosmetic Psychopharmacology." In: Enhancing Human Traits: Ethical and Social Implications, pp.177-86, ed. Erik Parens. Washington DC: Georgetown University Press, Elliott, Carl. 2003. Better Than Well: American Medicine Meets the American Dream. New York; London: W.W. Norton. Erler, Alexandre. 2012. "One Man's Authenticity Is Another Man's Betrayal: a Reply to Levy." Journal of Applied Philosophy 29(3): 257-65. Hope, Tony, Jacinta Tan, Anne Stewart et al. 2011. "Anorexia nervosa and the language of authenticity." Hastings Center Report 41 (6): 19-29. Horwitz, Allan V. & Jerome C. Wakefield. 2007. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into a Disorder. Oxford: Oxford University Press. Karp, David A. 2006. Is It Me or My Meds? Cambridge, Mass.: Harvard University Press. Kraemer, Felicitas. 2009. "Picturing the Authenticity of Emotions." In Emotions, Ethics, and Authenticity, pp.71-90, eds. Mikko Salmela and Verena Mayer. Amsterdam; Philadelphia: John Benjamins Publishing Company. Kramer, Peter. 1993. Listening to Prozac. New York: Viking Press. Levy, Neil. 2011. "Enhancing Authenticity". Journal of Applied Philosophy 28 (3): 308-18. Parens, Erik. 2004. "Kramer's Anxiety". In Prozac As a Way of Life, pp. 21-32, eds. Carl Elliott and Tod Chambers. Chapel Hill: University of North Carolina Press. Sartre, Jean-Paul, 1980 [1946]. Existentialism and Humanism, translated by Philip Mairet. London: Methuen. Singh, Iilina. 2005. "Will the 'Real Boy' Please Behave? Dosing Dilemmas for Parents of Boys with ADHD." American Journal of Bioethics 5 (3): 34-47. Taylor, Charles. 1991. The Ethics of Authenticity. Cambridge, Mass.: Harvard University Press. The President's Council on Bioethics. 2003. Beyond Therapy: Biotechnology and the Pursuit of Happiness. New York: Dana Press. Trilling, Lionel. 1972. Sincerity and Authenticity. Cambridge, Mass.: Harvard University Press. OTHER RESOURCES: authenticity, n. Oxford English Dictionary, 2nd edition, 1989; online version March 2012. URL = <http://www.oed.com/view/Entry/13325>. Jeffries, Stuart. "The Quest for Truth". The Guardian, 30 November 2002. Available online, URL = <http://www.guardian.co.uk/books/2002/nov/30/academicexperts.highereducation>. Alexandre Erler Research Associate Oxford Uehiro Centre for Practical Ethics University of Oxford, United Kingdom