Deep brain stimulation, authenticity and value: further reflections Citation for published version (APA): Nyholm, S. R., & O'Neill, E. R. H. (2017). Deep brain stimulation, authenticity and value: further reflections. Cambridge Quarterly of Healthcare Ethics, 26(4), 658-670. https://doi.org/10.1017/S0963180117000159 DOI: 10.1017/S0963180117000159 Document status and date: Published: 22/09/2017 Document Version: Accepted manuscript including changes made at the peer-review stage Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the "Taverne" license above, please follow below link for the End User Agreement: www.tue.nl/taverne Take down policy If you believe that this document breaches copyright please contact us at: openaccess@tue.nl providing details and we will investigate your claim. Download date: 02. Feb. 2020 Cambridge Quarterly of Healthcare Ethics (2017), 0 , 1 – 13 . © Cambridge University Press 2017. doi:10.1017/S0963180117000159 1 Continuing the Conversation Deep Brain Stimulation, Authenticity and Value Further Refl ections SVEN NYHOLM and ELIZABETH O'NEILL Abstract: In this article, we engage in dialogue with Jonathan Pugh, Hannah Maslen, and Julian Savulescu about how to best interpret the potential impacts of deep brain stimulation on the self. We consider whether ordinary peoples' convictions about the true self should be interpreted in essentialist or existentialist ways. Like Pugh, Maslen, and Savulescu, we argue that it is useful to understand the notion of the true self as having both essentialist and existentialist components. We also consider two ideas from existentialist philosophy- Jean-Paul Sartre and Simone de Beauvoir's ideas about "bad faith" and "ambiguity"-to argue that there can be value to patients in regarding themselves as having a certain amount of freedom to choose what aspects of themselves should be considered representative of their true selves. Lastly, we consider the case of an anorexia nervosa patient who shifts between confl icting mind-sets. We argue that mind-sets in which it is easier for the patient and his or her family to share values can plausibly be considered to be more representative of the patient's true self, if this promotes a well-functioning relationship between the patient and the family. However, we also argue that families are well advised to give patients room to determine what such shared values mean to them, as it can be alienating for patients if they feel that others try to impose values from the outside. Keywords: deep brain stimulation ; authenticity ; the true self ; essentialism ; existentialism ; values ; anorexia nervosa When patients and their families express concerns about the impact that deep brain stimulation (DBS) can have on the self, are these concerns always primarily about psychological continuity over time, or are they sometimes concerns about something else? Moreover, should we take it for granted that DBS either has a bad effect on the self or else is neutral, having no effect on the self? In our previous article on this topic in the Cambridge Quarterly of Healthcare Ethics , we argued that neuroethical discussions of DBS should be concerned not only with continuity over time, but also with the impact of DBS on what patients and their families think of as the patient's "true self." We also argued that sometimes, the effect of an intervention such as DBS is neither bad nor neutral with respect to the self; rather, it can also be positive, by helping to rehabilitate or make manifest the patient's true self. In such cases, the patient can be understood as achieving greater "authenticity" with the help of DBS. 1 In their article in this issue, Jonathan Pugh, Hannah Maslen, and Julian Savulescu move the conversation on DBS and authenticity forward, partly by highlighting and discussing a number of issues that we did not comment on in our previous article. 2 We are delighted to have this opportunity to engage in a dialogue with them about how best to interpret and analyze the idea of authenticity and the true self in relation to its importance for DBS patients and their families. Pugh, Maslen, and Savulescu, address a number of theoretical points before returning to the sorts of practical cases that motivate the debate about DBS and authenticity. They emphasize a general distinction between "essentialist" and "existentialist" understandings of authenticity and the practical implications QA AQ1 Sven Nyholm and Elizabeth O'Neill 2 of this distinction. They also discuss the question of what it is to value something. They do so because, like us, they think that people's values are closely related to what they and others will perceive as representative of their true selves. Here, we will follow their lead. We will fi rst discuss the essentialism/existentialism distinction as a way of deepening the analysis of peoples' intuitions and beliefs about the authentic or true self. We will consider a certain type of unavoidable ambiguity at the heart of the human condition that this distinction suggests. Like them, we will also discuss the relation between peoples' values and what they regard as their true selves. Most importantly, however, we will return to a practical case that Pugh, Maslen, and Savulescu also discuss: namely, the type of case in which DBS patients (or other patients) are shifting between different mind-sets, and the question therefore arises if any of these mind-sets is more representative of the patient's true self. In particular, Pugh, Maslen, and Savulescu focus on patients with anorexia nervosa (AN), because such patients are sometimes unstable in their mind-sets. 3 Suppose that in one mind-set an AN patient believes that his or her condition is a health problem that should be treated. But the patient then sometimes shifts back to a mind-set in which he or she places a higher value on being extremely thin than on being "healthy" by common medical standards. Such cases raise two distinct and diffi cult types of questions. First, are there any general reasons for the patient or a third party to regard one mind-set as more representative of the person's authentic or true self? Second, under what conditions, if any, would a third party be warranted in intervening to encourage the mind-set that that third party thinks is more authentic? When we discussed this type of case of shifting, confl icting mind-sets in our earlier article, we made a suggestion about how family members- and also the patients themselves-might go about deciding which mind-set is more representative of the patient's true self. Our suggestion was that a mind-set in which the patient is inclined toward values that are widely endorsed and viewed as sensible or legitimate, even by those who do not share them, is, ceteris paribus, a better candidate for being representative of the patient's true self than an alternative mindset in which the patient is inclined toward values without that feature. Pugh, Maslen, and Savulescu reasonably request further explanation for why such mind-sets should be considered more representative of the person's true self. We will address this question here. The reason we offer has to do with what will be a main theme of the second half of these further refl ections having to do with the social roles that values play in our lives. However, we want to be very clear about the restricted nature of our claim on this topic. Our point that the shared status of some values can shed light on authenticity applies primarily to circumstances in which a patient experiences shifting mind-sets that prevent appeals to stable values to resolve authenticity questions. Furthermore, even in those cases, using information about more easily shared values to identify the more authentic mind-set does not necessarily provide either the patient or a third party with an overriding reason to think that this mind-set should be pursued. Manifesting a characteristic that one interprets as representative of one's true self is a value, but there are other important values- for example, the value of respecting a person's personal autonomy-that also matter greatly. This point will be further developed later. Deep Brain Stimulation, Authenticity and Value 3 Essentialism and Existentialism, Part 1: Internal Coherence and Synchronic versus Diachronic Self-Concepts In our earlier article, we made the following six observations about the notion of the true self: (1) The concept permeates human thinking, and, therefore, will affect how stakeholders interpret the results of DBS. (2) The true self is a synchronic notion that permits us to describe effects of DBS on the self, which the diachronic concept of personal identity does not. (3) The extent to which the true self is expressed can be a matter of degree. (4) The degree to which persons feel that their true self is expressed can be infl uenced by their modes of functioning, which can be affected by DBS. (5) In some cases, radical transformation can make the true self more fully expressed. (6) Which features are considered characteristic of a person's true self depends, in an important sense, on which features that person values. 4 As Pugh, Maslen, and Savulescu note, in focusing on these six points, there was an issue that we did not comment on in our discussion; namely, whether we had in mind an "essentialist" or "existentialist" conception of the true self. To address this question here, we should fi rst be clear about our aim. Our previous article addressed the true self as a concept that tends to concern ordinary people, including patients, and which, therefore, is worth considering in DBS decisions. We did not directly engage with the question as to whether there is a true self that exists independent of peoples' concept of it. 5 Consequently, our present interest in questions about essentialist and existentialist conceptions of the true self is primarily in whether people tend to conceptualize the true self in existentialist or essentialist ways, and whether there might be any practical benefi ts associated with either, or both of these ways, of conceptualizing the self. Pugh, Maslen, and Savulescu argue that our points (2) and (6) suggest an existentialist understanding of the notion of the true self. What does that mean? According to an existentialist view of the true self, which characteristics are part of one's true self is a matter of the choices people make and the agency they exercise. Thus understood, being one's true self is a matter of "self-creation." By contrast, an essentialist interpretation of the true self sees it as a static set of characteristics to be discovered. 6 We did not set out to present an existentialist interpretation of how people think about the true self in our previous article. However, we do think that there are some ideas within existentialist philosophy that are useful in this overall discussion. In the next section, we briefl y discuss some such ideas; but here, our focus is on the discussion by Pugh, Maslen, and Savulescu. As they note, there is some reason to think that the folk concept of the true self is essentialist to a signifi cant extent, in the sense that people typically think of the characteristics that constitute the true self as "deeply inherent within the person." 7 This is consistent with a more general phenomenon of folk essentialism. 8 However, it is worth considering whether there are also existentialist aspects to ordinary peoples' conception of the true self, in the sense that people view the true self as partially determined by the free choices and the agency of the human person. Very likely, most people have intuitions and beliefs about the true self that point in confl icting directions. Pugh, Maslen, and Savulescu prefer a combined view, "the dual-basis framework," that understands being one's true self in an authentic way to involve both discovery and choice about who one wants to be. 9 We are in broad agreement with those AQ2 Sven Nyholm and Elizabeth O'Neill 4 authors here. Rather than viewing essentialism and existentialism as opposing interpretations of the true self, we fi nd it useful to view the true self as partially discovered, but also potentially something over which people have some control. Whether people manage to manifest what they take to be their true self surely depends on multiple factors, both in and outside of their control. We believe that it is possible to take this sort of view without abandoning the six points we made in our earlier article. With regard to point (2) from our previous article in particular, Pugh, Maslen and Savulescu argue that there may be a tension between our claim that the true self is a synchronic notion and the task of determining which features of a person are aspects of their true self, which often entails considering enduring aspects of the self. Moreover, as they and also Alexandre Erler and Tony Hope point out, one reason patients are frequently concerned with the true self is that they are in pursuit of practical guidance. 10 Pugh, Maslen, and Savulexu suggest that our view may face a problem that Erler and Hope take existentialists to face: namely, failing to provide choice-independent guidance about which characteristics are more representative of the true self. We recognize this as an important concern, and will discuss it presently. First, we briefl y elaborate on our characterization of the true self as a synchronic notion. Our discussion of synchronicity was motivated by the idea that patients' concerns about authenticity need not be solely rooted in a desire to maintain past characteristics. As an example, we mentioned that although it might be more in keeping with the past for a patient with severe OCD to continue having obsessions and compulsions, it might seem to that patient that his or her true self might be better realized if upon DBS treatment, the patient manages to fi nally get his or her obsessions and compulsions under control. 11 Part of our point about synchronicity was that at any given moment of assessment, regardless of personal history or future, persons can always be thought of as exhibiting their true selves to some more or less fully realized degree. Moreover, judgments about authenticity and the true self are also made at particular moments in time; and, such judgments about the characteristics that constitute an individual's true self may change. Lastly, whether the mere persistence of a given characteristic over time makes it more likely to be counted as part of the true self ultimately depends on the particular conceptualization of the true self endorsed by whoever is making a judgment, and whether it is manifest. 12 Pugh, Maslen, and Savulescu propose an alternative interpretation of the true self. They say that on this account, one can appeal to a person's values over time to resolve questions about which characteristics are authentic. However, we are skeptical that this proposal offers benefi ts that a synchronic interpretation of the concept of the true self could not. So what is their account? They write, "the true self is best construed as being constituted by the cohering elements of the individual's nexus of values and their rational beliefs." 13 In effect, these authors offer a procedural account of authenticity, according to which people can change their manifest characteristics authentically if this change is intelligible and justifi able in accordance their existing set of values and rational beliefs. 14 Such a coherence-based account implies, as the authors themselves note, that it is possible for a person to undergo radical transformational changes authentically, provided that it is coherence that supplies rational guidance for each change that the agent makes. This does place constraints on the possible ways that a person Deep Brain Stimulation, Authenticity and Value 5 can change at any given moment, since this depends on the person's existing suite of values and beliefs, but it also means that in principle there are no essential, unchangeable aspects of one's values, beliefs, and characteristics. As a consequence, in principle there are also no essential, unchangeable aspects of the true self. This certainly strikes us as an interesting proposal. We agree that coherence can be important for understanding which values, beliefs, and characteristics are best counted as part of someone's true self. Furthermore, we see that a coherence view of the true self can provide guidance also in cases in which a person counts a longstanding, disvalued characteristic, such as OCD, as not being part of his or her true self. However, we think that the supposed diachronic nature of this account is unnecessary for obtaining this practical guidance. The action guidance here is supplied solely by the procedural aim of obtaining coherence among one's own values, beliefs, and characteristics, given a starting set of the same. Whether such features have endured or are quite new does not really matter for helping someone ascertain which of two possible features is more authentic in the sense of cohering with the person's earlier positions. The person needs only to refer to his or her existing features, ascertain how coherence can be promoted, and then choose one of the actions that would promote coherence; for example, jettisoning an existing characteristic or adopting a new value. What matters for action guidance here is not continuity over time as such, but rather the more "logical" feature of coherence among the different states of mind that people can transition between. Therefore, we conclude that having a diachronic view of authenticity is not strictly required for action guidance. A purely synchronic version of Pugh, Maslen, and Savulescu's coherence account illustrates this. That being said, we suspect that in most cases in which people feel that their conceptions of their true self have provided them with practical guidance, it is probably something more substantial and content related than coherence among their mental states that gave them this sense. Most likely, people who feel that they achieve guidance by a conception of their true self will typically fi nd that they are able to pinpoint some aspect of themselves with which they strongly associate or are moved by some value that they truly wish to live by. Many people do want to be "true to themselves," and this can mean trying to be consistent; however, oftentimes it is likely to mean something more substantial related to what they think they are like or what they aspire to be. Essentialism and Existentialism, Part 2: The Neuroethics of Ambiguity Taking a wider and more general perspective, and setting aside for the moment Pugh, Maslen, and Savulescu's discussion, might it be helpful for patients to think of their true selves in a partly existentialist way? It is true that there are many real constraints on which characteristics people can actually manifest. On the other hand, people also have substantial control over which characteristics they exhibit. As far as making choices based on authenticity, agents may not obtain much practical guidance about how to be authentic if they think that the features that defi ne their true self are completely up to them. However, we believe that it may promote both autonomy and wellbeing if people believe that they have some choice and control over which of the characteristics that they do, or could, manifest are authentically their own. This bring us to some basic ideas from the work of existentialist philosophers Jean-Paul Sartre and Simone de Beauvoir that we propose as being relevant. Sven Nyholm and Elizabeth O'Neill 6 Beginning with Sartre, the concept of "bad faith," which he discusses in the second chapter of his Being and Nothingness , is important in this context. 15 Briefl y stated, this is the idea that if we believe that we have a very strongly fi xed essence and that all the norms and rules we think of ourselves as subject to are all absolute and non-fungible, then we are subject to a sort of self-deception: "bad faith." We then fail to recognize a freedom that we possess as human beings to shape ourselves and our situation. We deceive ourselves-according to this idea of bad faith-if we think that human society and culture have to be exactly as they are and that we have an essence about which we can do nothing. Also important from existentialist philosophy is what Simone de Beauvoir calls the "ethics of ambiguity:" 16 the idea that our human condition is deeply ambiguous in nature. On the one hand, we are constrained by biology and shaped by society and culture, but on the other, we also possess freedom to shape ourselves and to transcend constraints and boundaries imposed on us from both the inside and the outside. According to de Beauvoir, we need, as human beings, to accept this unavoidable ambiguity as being part of the human condition. To be "honest" with ourselves, to live in an "authentic" way, any sensible person, according to her analysis, needs to accept and embrace this ambiguity. These ideas from Sartre and de Beauvoir underscore the point that there may be value in conceptualizing authenticity and true self as partly under one's own control. DBS raises questions about authenticity in part because it can seemingly confer on the patient and the medical team an ability to alter what the patient can be and do. In effect, it also has the potential to change how the patient views his or her true self, and what values, beliefs, and characteristics that patient views as authentic. This is suggested by Pugh, Maslen, and Savulescu's earlier discussions of DBS as a treatment for AN. In our opinion, technology-including advanced medical technologies like DBS-has the potential to widen and deepen the freedom people have to shape ourselves and to take control of who and what we are as human beings and as individuals. 17 Technology can affect which features we are capable of exhibiting, the centrality and role of particular characteristics in relation to other characteristics, and how we view those characteristics. When such freedom-enhancing technologies are under human control, there is further reason for including existentialist elements in our philosophical interpretations of what it is for a person-a DBS patient or any other person-to realize what that person regards as his or her true self. Notably, some bioconservatives worry about precisely this aspect of technologies that can be used for self-shaping. Bioconservatives are theorists who oppose the use of modern technology to manipulate or "enhance" human beings. Michael Sandel, for example, worries that if human beings go too far in shaping themselves using biomedical and other kinds of technologies, we will be left in a situation where we have control over almost all aspects of our own nature. In such a situation, there is "nothing to affi rm or behold outside our own will." 18 It is better, Sandel thinks, to leave certain aspects of our own nature untouched. We should accept these aspects of ourselves as simply "given," and not created by human agency. Whether or not Sandel intends his discussion in that way, his argument suggests that he too endorses-if only implicitly-something similar to what de Beauvoir calls the "ethics of ambiguity": that human life is a mix of things that we have to accept as given as well as things that we can infl uence or control. Sandel may fi nd Deep Brain Stimulation, Authenticity and Value 7 it alarming that neurotechnologies such as DBS have the potential to shift the balance among the different aspects of our ambiguous human existence; however, to the extent that such shifts can help to promote patients' autonomy and well-being, we think that the technological developments that produce them should potentially be welcomed. To summarize the main points of this section: the way we are, including how we perceive our "true selves," depends on multiple factors, which encompass everything from biology to society/culture to the choices we make and the agency we exercise. It would be a form of "bad faith" to deny our freedom to infl uence and shape ourselves and our human situation; however, human existence is "ambiguous" at its core: we have to accept some aspects of ourselves, whereas other aspects are under our control. As a result, we suspect that there is practical value in conceptualizing the true self as having both existentialist and essentialist components. However, the relationship between what is simply "given" and what we can infl uence is not static. New and developing technologies-including medical technologies such as DBS-shift the boundaries and constraints of the human condition. This adds an additional level of complexity to the question of authenticity. Authenticity and the Case of the AN Patient with Confl icting, Shifting Mind-Sets As mentioned, in our earlier article we discussed a topic that Pugh, Maslen, and Savulescu had also discussed in their previous work on DBS and authenticity; namely, the possibility of using DBS to treat AN. One important issue in their discussion, which we also picked up in ours, was that AN patients may shift between different mind-sets, where the values they endorse in one mind-set appear different from the values they endorse in another mind-set. Tony Hope et al. report that they sometimes fi nd this situation in their clinical work with AN patients. 19 The question here was whether there is a particular mind-set in which an AN patient can be said to better be able to manifest her true self. Patients may sometimes enter into a mind-set in which they view AN as a problem for which they need help. But the same patient may then shift to an alternative mind-set in which her values seem to change, and in which she values extremely thinness more than anything else. Drawing on Jacinta Tan and colleagues' discussion of what they call "pathological values," we made a suggestion about how patients and their families might think about this circumstance. 20 Tan et al. suggest that the sorts of values a patient exhibits in the latter sort of mind-set are so closely tied in with the patient's illness that they can be regarded as "pathological," and, for that reason, less authentic than values not associated with the patient's AN. Our suggestion was somewhat different. If the patient and the patient's family want to assess which mind-set best represents the patient's true self, we proposed that one consideration that could guide such assessments is whether the values of one mind-set (and not the other) are viewed as sensible or legitimate even by those who do not hold them. In other words, these are values about which people think there can be reasonable discussions and disagreements. In such a case, we suggested that the patient and the family might have reason to think that the mind-set featuring values with that particular feature is more authentic than the mind-set featuring values without it. 21 We can label the values that are viewed as sensible or legitimate even by those who do not hold them "tolerable values." Sven Nyholm and Elizabeth O'Neill 8 Patients with AN who experience shifting mind-sets sometimes have values in one mind-set that fall squarely outside of the range of what their family and others with whom they interact consider tolerable. For example, Tan et al. note that AN patients sometimes start valuing achieving extreme thinness as the highest value in life, including their own safety. According to our suggestion, if an AN patient shifts between such a mind-set and one where he or she places a more typical degree of value on thinness, that patient and the patient's family would have reason to regard the mind-set in which thinness is valued over health-even at the cost of death-as being less representative of the patient's true self. As noted by Pugh, Maslen, and Savulescu, this idea has some appeal inasmuch as it supplies guidance about authenticity; however, in our earlier work we did not elaborate on the reasons substantiating this suggestion. In the next section we offer more in defense of our proposal by turning to another topic discussed at some length by Pugh, Maslen, and Savulescu; namely, the question of what it is to value something. First we will very briefl y return to their suggestion that self-discovery is achieved through the creation of coherence among one's different mental states and attitudes. The just-described AN-patient could become more coherent overall by remaining in the mind-set that Tan et al. call "pathological": the mind-set in which they have the sort of unhealthy values and attitudes some AN patients are drawn to. But the patient could also become more coherent by trying to remain in the mind-set in which their values are more "tolerable" for others and "healthy." Therefore, the idea that we achieve authenticity by being more coherent seems to offer no clear reason why it might make sense to view a more tolerable and healthy mind-set as more authentic than a mind-set that strikes many people as pathological. This is another important reason why we think, as mentioned, that it makes sense to look for more substantial and value-based reasons for making judgments about when a patient manages to best manifest his or her true self. Valuing and the Social Role of Values According to Pugh, Maslen, and Savulescu, to better understand the way in which people's values relate to what it is for them to manifest their true selves, we need to refl ect on what is involved in valuing something. As these authors point out, we had little to say about the nature of valuing in our previous article. Here, we want to emphasize the importance of the role that values play in social interactions. In our view, the social role of values has practical implications for authenticity. In particular, we believe that it has implications for the sort of case described previously, in which patients have shifting mind-sets, and the values they incline toward in some mind-sets are more "tolerable" than those that they incline towards in others. Importantly, it is the case that people often seek to associate with others who share their values. Shared values help to organize and structure peoples' interpersonal interactions, which in turn infl uence their future actions, beliefs, values, and manifested characteristics. In short, human beings characteristically associate, unite, or commune with others on the basis of shared values. Notably, this phenomenon plays an important role in infl uential accounts of how human morality originated historically. Several theories of the evolution of morality posit that it was a need to cooperate that provided the conditions in Deep Brain Stimulation, Authenticity and Value 9 which humans acquired capacities for morality. 22 Interactions with others are made possible by shared values governing how such interactions should proceed. For example, cooperation generally requires agreement on shared goals and shared expectations about how individuals are to behave in important situations. 23 One explanation for how humans came to evolve a capacity for values, particularly moral values, rather than merely desires, is that such values and other components of moral psychology played an integral role in supplying both the motivation to comply with norms and the ability to signal reliability as a potential partner. 24 Setting aside the more distant origins of human valuing, the importance of shared values in amicable social interactions is an apparent aspect of everyday life. Friends and romantic partners tend to share basic values, and often these shared values can be thought of as part of the basis of their relationships. In contrast, disagreement about values, especially values that an agent considers moral, can incline people to distance themselves from those with whom they disagree. 25 This is not a new observation – Cicero, for example, argued that what draws potential friends together is the perception of good qualities in each other. A lasting friendship, Cicero argues, is based on "mutual goodwill and affection" along with "agreement in all things, both human and divine;" that is, the sharing of values. 26 Moreover, less personal relationships can also be based on shared values and interests in a similar way. Notably, this can be so even when the values in question may strike some as rather self-centered, such as those related to "self-tracking" technologies. Social scientists studying the so-called "quantifi ed self" movement have noticed that people who track and monitor themselves and their own health using self-tracking technologies are often motivated to seek out others with similar interests, both online and offl ine, such as at conferences and other social meetups. 27 Therefore, whether in close personal relationships, or in ones that are less close, shared values help to bring people together and sustain their relationships. With that observation in place, we return now to the issue of patients with shifting mindsets. Recall that our proposal is that if patients (e.g., AN patients) are unstable in their mind-sets in a particular way, they and their families have reason to regard the mind-sets in which they share values as being more representative of their true selves. We propose that the just-described social role that values play supplies a reason for patients and their families to regard such a mind-set in that way; specifi cally, that this mind-set is more likely to enable well-functioning relationships. If a medical technology such as DBS can help a patient to remain in a mind-set in which that person shares important values with the other people in his or her life, then DBS will also help support the patient's mutual relationships. 28 To make this more concrete, consider an unstable AN patient who sometimes enters into a mind-set in which she values extreme thinness more than her own safety, and in which anyone whom she perceives as "fat" will be viewed as unworthy. When the patient enters into such a mind-set, her family is likely to feel alienated, just as the patient is likely to also feel alienated from the family, given their very different mind-sets. In contrast, when the patient shifts toward a mind-set in which she distances herself from these ideas about extreme thinness, it is likely to be much easier for the patient and the family to come together on the basis of shared values. Hence for the sake of their relationship, there is reason for the AN patient and the patient's family to see the latter mind-set as being more representative of the patient's true self. AQ3 Sven Nyholm and Elizabeth O'Neill 10 Valuing Wholeheartedly, and Individuality However, as mentioned, the problem of shifting mind-sets raises not just one, but at least two diffi cult questions. First, there is the question just discussed about determining which mind-set is to be considered more authentic. But there is also a second, more practical question, determining under what conditions a third party would be warranted in actively encouraging a patient to pursue the mind-set that the third party believes is more authentic. This issue is briefl y considered next. Even if one takes the idea of a person's "true self" to be very important-indeed, important enough for us to refl ect on what principles ought to guide judgments about people's true selves-the value of manifesting what is considered a person's true self is certainly not the only value that matters in healthcare or other contexts. Values such as whether something is a medical benefi t or if it respects personal autonomy, also need to be taken into account. 29 Whether a person is able to manifest what we, or that person, consider to be that person's true self is not the be-all and end-all of treatment decisions when considering whether or not to use a technology such as DBS to treat a certain condition. Even in circumstances in which we think that it can make sense to ask which of shifting mind-sets best represents a person's true self, and even if there can be good reasons for making judgments about this issue in certain ways, we do not believe that this value should take priority over other values in treatment decisions. Although this is an issue of concern to many people, it is also important to underscore that this is not the only value that matters in these contexts, and a determination of which mind-set is more authentic need not determine the conclusion about which mind-set should be chosen. In addition, when a third party advocates for one mind-set over another, there is a risk of threatening the patient's perception of his or her own authenticity. Although we have emphasized the importance of shared values for relationships, and proposed that they can be a contributor to one's sense of authenticity, people often react poorly if they feel that values are being imposed on them by others. If people are to feel that they are being their own true selves authentically, as they live in accordance with certain values, they need to be given room to form their own ideas and conceptions of what it is for them to live by these values in a way with which they are comfortable. Therefore, even if families and patients are able to agree that a mind-set in which the patient's values are closer to the family's is more representative of the patient's true self, families nevertheless need to avoid imposing upon the patient overly restrictive ideas about what these values imply about how the patient should live his or her life. Just as not being able to share values can be alienating, so too can having to live by somebody else's conception of those values. Pugh, Maslen, and Savulescu note that John Stuart Mill was surely right in maintaining that many people value developing their own individuality. What makes it possible for people who are different in certain ways to share values is that, in practice, many values come both in a more general form, allowing different people to share them, and in more fully specifi ed forms, which are the ways people interpret them within the context of their lives. In order to take on some common human value and make it our own, we typically need to form our own conception of what it means to live by that value within the specifi c context Deep Brain Stimulation, Authenticity and Value 11 of our individual life. This is how values can be put into more concrete practice within a person's life: general ideals need to be interpreted, specifi ed, and applied to specifi c conditions before individuals can live by them. How does this relate to authenticity, and to what persons will associate with their true self? An important implication is that for people to feel that they are authentically being their "true selves" when acting in accordance with some value shared by others, they will most likely need to have a conception of what this value means to them and how it fi ts with their personal situation. When we interpret the degree to which other people are being "their true self," we are likely to do so using our own ideas about how to live by certain values. 30 But for these others to feel that they are being their true selves in acting in accordance with some value, it needs to be one that they endorse and with which they agree. Only then are they likely to feel that their adherence to the value is truly "authentic." Concluding Summary To summarize these further refl ections, we have noted that our earlier article did not take a position on whether we should accept an essentialist or an existentialist understanding of the true self. At that time, we were more focused on ordinary people's tendency to postulate a true self than on whether or not there really is such a thing as a true self. However, we agree with Pugh, Maslen, and Savulescu that it makes good sense to discuss this distinction between essentialism and existentialism as a way of deepening the analysis of "authenticity" and the "true self" as concepts that concern people in relation to interventions such as DBS. Also, as we argued, we also believe that there are interesting ideas in the existentialist literature and other related sources that are relevant in this neuroethical context. Just as Simone de Beauvoir argues that the human condition is marked by a deep "ambiguity," neuroethical discussions of DBS's impact on the self should be attentive to the fact that multiple and potentially contradictory factors typically conspire to infl uence what patients and their families perceive as most representative of the patient's true self. And as technologies such as DBS and similar medical technologies become more advanced, it would also be what existentialists call "bad faith" to think that human beings have a fi xed essence that cannot be altered, even if we should also recognize that there still are many factors in a person's life that are outside of their control. We also agree with Pugh, Maslen, and Savulescu that the analysis of DBS and authenticity can be deepened by paying close attention to what is typically involved in having values that we try to live by. Whereas these authors mainly focus on how values can be integrated into an overall coherent psychology, our focus here was on two slightly different components: fi rst, the social role of values within human life; and, second, the crucial need for people to develop their own understandings of what it means for them to live by the values that they endorse within their particular personal situation. By refl ecting on these aspects, we will have a better understanding of what sorts of arguments might be brought to bear on cases in which patients shift between different mind-sets. Some of these mind-sets endorse values that can be easily shared with other people; whereas other mind-sets endorse harder to share values. The social role of values supports viewing more "tolerable" mind-sets as the mindsets that patients and their families have reason to see as best expressing the patient's Sven Nyholm and Elizabeth O'Neill 12 true self. However, like other people, patients need to be given space to formulate their own view on how these values relate to their lives. Only then, can patients truly make these values their own, and only in living in accordance with these values are they most likely to feel that their true self is authentically manifested. Notes 1. Nyholm S , O'Neill E . Deep brain stimulation, continuity over time, and the true self . Cambridge Quarterly of Healthcare Ethics 2016 ; 25 ( 4 ): 647 –58. 2. Pugh J, Maslen H, Savulescu J. Deep brain stimulation, authenticity and value. Cambridge Quarterly of Healthcare Ethics . 3. Hope T , Tan J , Stewart A , McMillan J . Agency, ambivalence and authenticity: The many ways in which anorexia nervosa can affect autonomy . The International Journal of Law in Context 2013 ; 9 ( 1 ): 20 – 36 . 4. See note 1, Nyholm, O'Neill 2016 , at 651–4. 5. Hence contrary to Sabine Müller et al.'s interpretation of our discussion in a recent article of theirs, we were not practicing "metaphysics" when we discussed the true self. Rather, we were interested in people's values and self-conceptions. Müller S, Bittlinger M, Walter H. Threats to neurosurgical patients posed by the personal identity debate. Neuroethics (in press) online fi rst at: DOI 10.1007/ s12152-017-9304-0 6. Levy N . Enhancing authenticity . Journal of Applied Philosophy 2011 ; 28 ( 3 ): 308 –18. 7. Haslam N , Bastian B , Bissett M . Essentialist beliefs about personality and their implications . Personality & Social Psychology Bulletin 2004 ; 30 ( 12 ): 1661 –73. 8. See note 7, Haslam et al. 2004 ; Gelman, S. The Essential Child: Origins Of Essentialism In Everyday Life . New York: Oxford University Press; 2003; Linquist, S, Machery, E, Griffi ths, PE, Stotz, K. Exploring the folkbiological conception of human nature. Philosophical Transactions of the Royal Society of London B: Biological Sciences 2011;366(1563):444–53. 9. See note 6, Levy 2011 . 10. Erler A , Hope T . Mental disorder and the concept of authenticity , Philosophy, Psychiatry, & Psychology 2015 ; 21 ( 3 ): 219 –32. 11. See note 1, Nyholm, O'Neill 2016 , at 650. 12. The ways that people make judgments about the true self also seem to make room for the possibility that features counted as part of a person's true self have never been exhibited at all. That is why people think that practices such as meditation can "unlock" the true self, as if it had been dormant throughout a person's life. See note 1, Nyholm, O'Neill 2016 , at 651. 13. See note 2, Pugh et al.; Ekstrom, LW. A coherence theory of autonomy. Philosophy and Phenomenological Research 1993;53(3):599–616. 14. See note 2, Pugh et al. 15. Sartre JP . Being and Nothingness . New York : Washington Square Press ; 1993 . 16. De Beauvoir S . The Ethics of Ambiguity . London : Kensington Books ; 1976 . 17. Technology can also narrow people's minds, and in effect make them less free-or at least less fl exible-in their personal agency. The polarizing effect of social media is an example of where a technology can seem to make people less free, and more strongly infl uenced by factors outside of their own agency. 18. Sandel M. The case against perfection. The Atlantic, April 2004; available at: https://www.theatlantic. com/magazine/archive/2004/04/the-case-against-perfection/302927/ (last accessed 28 Feb 2017). 19. See note 3, Hope et al. 2013 . 20. Tan J , Hope T , Stewart A , Fitzpatrick R . Competence to make treatment decisions in anorexia nervosa: thinking processes and values . Philosophy, Psychiatry, & Psychology 2006 ; 13 ( 4 ): 267 –82. 21. See note 1, Nyholm, O'Neill 2016 , at 656. Notice that this proposal does not provide guidance about authenticity either in a case in which both of the patient's confl icting mind-sets involve only tolerable values, or in a case in which both of the mind-sets feature intolerable values. It also does not have anything to say about the authenticity of values outside the tolerable range when they belong to an agent who does not have shifting mind-sets. 22. Tomasello M . A Natural History of Human Morality . Cambridge, MA : Harvard University Press ; 2016 ; Sterelny K. Cooperation, culture, and confl ict . The British Journal for the Philosophy of Science 2016 ; 67 ( 1 ): 31 – 58 ; Boyd R , Richerson PJ . The Origin and Evolution of Cultures . Oxford : Oxford University Press ; 2005 . 23. See note 22, Tomasello 2016 . Deep Brain Stimulation, Authenticity and Value 13 24. See note 22, Tomasello 2016 ; Stanford K The difference between ice cream and Nazis: The evolutionary function of moral projection." Lecture, 2011; available at http://ir.lib.uwo.ca/rotmanseries/5/ (last accessed 28 Feb 2017), Greene J. Moral Tribes . New York: Penguin Press; 2013. 25. Skitka LJ , Washburn AN , Carsel TS . The psychological foundations and consequences of moral conviction . Current Opinion in Psychology 2015 ; 6 : 41 – 4 . 26. Cicero. On Old Age. On Friendship. On Divination . Cambridge, MA: Harvard University Press; 1923. 27. Sharon T, Zandbergen D. From data fetishism to quantifying selves: Self-tracking practices and the other values of data. New Media & Society (in press) online fi rst at: DOI: 10.1177/1461444816636090 28. One of the negative psychosocial effects of DBS that has been observed is that it can have a negative impact on people's personal relationships. We hypothesize that this is more likely to happen if the side effect of the DBS treatment is that it changes patients' values and interests in a way that makes them clash with those of family members; for example, their spouses. See Agid Y, Schüpbach M, Gargiulo M, Mallet L, Houeto JL, Behar C. Neurosurgery in Parkinson's disease: The doctor is happy, the patient less so? Journal of Neural Transmission, Supplement 2006;70:409–14. 29. Hübner D , White L . Neurosurgery for psychopaths? An ethical analysis . American Journal of Bioethics 2016 ; 7 ( 3 ): 140 –9. 30. Newman G , Bloom B , Knobe J . Value judgments and the true self . Psychology Bulletin 2013 ; 40 ( 2 ): 1 – 14 . AUTHOR QUERIES QA The distinction between surnames can be ambiguous, therefore to ensure accurate tagging for indexing purposes online (eg for PubMed entries), please check that the highlighted surnames have been correctly identifi ed, that all names are in the correct order and spelt correctly. AQ1 Pages to be determined after issue is paginated. AQ2 Please update Neuroethics citation, especially publication year. AQ3 Please update, particularly publication date.