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Abstract

Authenticity is conceptually and historically related to the concept of autonomy, which has had a central place in bioethical theory and clinical ethics, for example, in the concepts of informed consent and patient rights. Unlike autonomy, however, the concept of authenticity has not played a central or independent role in either bioethical theory or in practice. To see why this is the case, this entry brieﬂy reviews the conceptual and historical background of the concept of authenticity and discusses the important relationship of the concept of authenticity and autonomy. It will conclude with a discussion of the increasing role that authenticity is playing in bioethical treatments of a range of issues associated with the diverse topics of enhancement, advance care planning, and long-term care.

Introduction

Conceptual And Historical Background

It is widely recognized that during the seventeenth and eighteenth centuries, a new awareness of the importance of individuals became the center of attention (Varga and Guignon 2014). The individual as such and not his or her status in society emerged as the focus of interest. As a result, individuals came to be understood as standing separate not only from society and the predeﬁned places which they inhabited but from each other. This tended to diminish the signiﬁcance of family as well as social status. Instead, the particular life stories of individuals acquired a new importance that led to what has been called the emergence of “inwardness” (Taylor 1989, 1991). With these developments, concepts and virtues that traditionally pointed to a set of expectations that derived from one’s place in society or social role such as sincerity or honor came to be replaced by new concepts that eventually gave rise to a set of values or virtues associated with what is now called authenticity. This change occurred gradually and involved multiple complex changes that cannot be documented here, but eventually what emerged was the modern concept of authenticity and its associated normative or ethical framework.

Like autonomy, its counterpart concept, authenticity has a wide range of meanings and functions in various ways in theoretical accounts. At its core, the concept refers to being true to oneself, which is the touchstone for determining the meaningfulness of one’s life. One’s social role or the social circumstances in which one developed or ﬁnds oneself, including family, thus recede in importance. Choice or decision-making, unfettered by convention, entered into philosophical discourse with the emphasis on individual freedom. In political philosophy, the concept of a social contract, namely, a contract among individuals in which they voluntarily cede to the state their control and authority over themselves in deﬁned ways, came to the fore and had a tremendous impact in Western thought, most notably in the American and French revolutions and the subsequent political changes that these wrought. In literature, narratives of the lives of individuals began to emerge that included and then focused on the inward thoughts and feelings of the protagonists as they made their way in the world and interacted with others, often in conﬂict with their perceived social roles. Through these various paths, the concepts of autonomy and authenticity emerged. Even when the emphasis was on personal autonomy, the implicit concept underlying the meaning of autonomy is that of an authentic or an interior self or person. In philosophical thought, attention focused on choice or decision-making that is guided by rational reﬂection, for example, a consideration of the costs, beneﬁts, and alternatives of the particular options in light of an understanding of one’s own preferences : or desires. Such a view of autonomy as free choice predicated on a rational assessment of one’s particular preferences : gradually came to the fore. It is well known in bioethical theory, but it coexists with views of autonomy that center more on authenticity in the sense that the autonomous person and their decision-making are founded on a self that has a core identity as well as a peripheral structure. Being true to oneself in decision-making, which is what genuine expression of autonomy involves, thus means to base decisions on one’s core values and commitments and not on those that are secondary or peripheral to oneself.

Rousseau’s The New Heloise (1997) is the locus classicus of this view. Actions that emanate from peripheral aspects of the self and reﬂect values that are peripheral to the self, in effect, deny the essential nature of one’s self and amount to a kind of self-betrayal or an annihilation of the self. The dialectic of authenticity or self-identity and inauthenticity or alienation became a central theme in existential thought. Such a view of the self or person as having a core or essential inwardness with its corollary unique worthiness and worth also accorded with the long religious tradition of and reﬂection on confession and on caring for the integrity of one’s personal soul. The Christian tradition that dominated Western thought long recognized the inner worth of the self or soul that is capable of salvation no matter how much loss of integrity that the self-suffered through sin.

In the nineteenth and twentieth centuries, the philosophical work of so-called existentialist thinkers like Søren Kierkegaard (1970), Martin Heidegger (2010), and Jean-Paul Sartre (1992) developed the concept of authenticity more fully, and, in an important way, their work promoted the popularity of the concept of authenticity in the late twentieth thought, a period of time in which the ﬁeld of bioethics emerged. Although it cannot be discussed further here, it is an interesting and important historical question about how autonomy and freedom of choice expressed and patient rights, for example, came to dominate bioethical thinking to such an extent that it tended to obscure considerations of authenticity.

Central in the existentialist line of thought is the view that human beings live their lives in such a way that they care about who and what they are. Humans thus exist for the sake of ourselves and engage in actions and occupy social roles as ways to achieve particular images of what it is to be human in our own particular case. This line of so-called existentialist thought focuses on the unique identity of the self that unfolds as a unique being in the world, to use a Heideggerian formulation, through various actions of self-formation. While Heidegger recognized that the project of self-formation occurs over and against a social pre-given world, Sartre insisted that all values are generated in particular human engagements in the world. As a result, there can be no pre-given construct of value inherent in things outside the agency of the individual.

Individual persons are not just selves, that is, beings with a psychological sense of interiority, but are a unique kind of being, namely, a for-itself (pour soi) that is fundamentally different from all other things, which exist only in-itself (en soi). Human persons, through reﬂection and self-awareness, can distance themselves from the entities that only exist in itself. Thus, humans have the quality of transcendence; we are always open to a range of possibilities for deﬁning ourselves. In this sense, transcendence is tied to the concept of freedom. We are free as a fact of our nature. We exist without constraints and are able to constitute ourselves through our own choices and actions. Even though the circumstances in which we ﬁnd ourselves provide limitations to our self-deﬁnition, we are always free to choose and, in so doing, to deﬁne the meaning of those circumstances and limitations.

These existentialist accounts of authenticity are, to be sure, much more complex than I have outlined, but limitations of space prevent a more thorough discussion. Sufﬁce it to say that although authenticity is conceptually linked with autonomy, there is at least the following difference. Whereas the idea of autonomy emphasizes the individual’s ability to govern oneself as well as the relative independence of one’s deliberation from manipulation or inﬂuence by others, authenticity stresses a self-reﬂective capacity that when exercised properly leads to the forging or asserting of one’s own reasons and motives for actions and choices, which give meaning to things and the world. Authenticity thus introduces the idea that commitments, desires, and values exist for the self, and they should outweigh the restrictions of a purely rational reﬂection and deliberation. In other words, the self, though able to exercise rational deliberation and choice, does so authentically when the deliberation and choice is guided by the identity that the self has forged over time. The commitments, desires, and values that constitute the identity of the particular self are the afﬁrmative product of constitution by the self without any constraints including purely rational ones. When the accounts of autonomy are thoroughly infused with authenticity, they recognize that genuine moral choices are those which resonate with one’s self-identity and not some idealized version of rational choice such as a utilitarian calculation. Thus, an authentic person is one who acts in accordance with the particular beliefs, commitments, desires, motives, or values that have come to constitute their unique personhood as a self. In this sense, the elements that make up the identity of the self-express who that person really is. So, to say that a person is “authentic” is to say that that person acts in ways that accord with their identity established through their free choices in the past. As Varga and Guignon (2014) conclude, “… authenticity introduces the idea that there are motives, desires and commitments that sometimes should outweigh the restrictions of rational reﬂection.”

Authenticity And Autonomy In Bioethics

Given these points, it must be acknowledged that certain common views of autonomy not only in political theory but in bioethics tend to stress the freedom of individuals in ways that seem to make choices and decisions about healthcare and their well-being understood as a purely calculative rational exercise without further regard for considerations such as deep-seated values, emotions, or commitments. In light of the above discussion, however, it can be concluded that although these interpretations of autonomy are commonly touted, they do not withstand serious or critical scrutiny. The glib emphasis on freedom of choice that is implicit in many uncritical versions of patient autonomy and patient rights tends to obscure the complex considerations of authenticity and identity that provide the most compelling reasons for the practice of respecting patient autonomy and patient rights in the ﬁrst place. Such misguided libertarian interpretations of autonomy are predicated on a view of autonomy that is obsessed with freedom of choice. Fortunately, they are counterbalanced in bioethics by other views. Two important and highly inﬂuential views are the hierarchical and historical concepts of autonomy which clearly accept that a defensible theory or concept must be deeply connected with authenticity to be fully meaningful.

A widely recognized account in bioethics derives from the work of Harry Frankfurt (1971) and Gerald Dworkin (1988) on the nature of autonomy and autonomous choice. Their hierarchical theory takes the view that an agent’s attitudes that are positive toward something, the so-called pro-attitude, are autonomous when they cohere with the wider set of pro-attitudes of the individual. These pro-attitudes of an individual are hierarchically structured so that a person can be regarded as autonomous with respect to a ﬁrst-order pro-desire with regard to something if that individual also had a second-order desire to have the ﬁrst-order desire in question and also if that individual wanted that desire to motivate action based on the desire. This harmony between the higher and lower order desires is what constitutes genuine expressions of autonomy on hierarchical theories, and it is what Gerald Dworkin calls authenticity (1988, p. 25). This means that an action is autonomous if an agent fully or wholeheartedly identiﬁes with it in such a way that it accords with who that person truly is. Although I have used the term desire in this context, what is at stake is a much broader concept of pro-attitudes that also include moods or character traits. When identiﬁcation fails to occur, alienation or inauthenticity is the result.

Besides hierarchical theories of autonomy/ authenticity, there are also historical or narrative theories. If, for example, the alteration of the person’s pro-attitudes were caused through some manipulation by another person and the alteration that occurred were so complete that the person would afterwards identify with the pro-attitudes introduced by another, then the paradoxical result is that the person would identify with pro-attitudes that are not historically their own and so the pro-attitudes in question, despite the resultant identiﬁcation, would be inauthentic just because they were the result of manipulation. That is, since the pro-attitudes are not historically grounded in the identity of the person, since that person did not develop them over time through their own actions. Instead, the pro-attitudes were caused by a manipulation attributable to the agency of another person. The fact that the person who was altered now happens to identify with the resultant pro-attitudes is irrelevant, because of the external manipulation by another person. Thus, historical or narrative views of authenticity/autonomy thus provide a normative foundation that gives traction in dealing with complex bioethical problems.

One challenge that occurs in cases like the one discussed above is that it is very hard to sort out which changes are the direct result of inauthentic manipulations from those that are the result of authentic autonomous choices of the person. If a person who feels sad or simply down agrees to join a friend for regular exercise and thereby increases the types of neurochemicals that enhance mood and thereby that person acquires a set of new pro-attitudes, the speciﬁc changes do not seem to be directly caused by cognitive or intentional actions to achieve those speciﬁc results since all the person wanted was “to feel better” in a rather undifferentiated way. The fact that the exercise regimen was undertaken at the invitation or even urging of the friend does not seem highly relevant. The speciﬁc changes in mood and pro-attitude that occur are admittedly the result of the exercise regimen, but it is hard to see that they are in any signiﬁcant sense the speciﬁc result of autonomous actions or intentions. So, are these changes inauthentic? Many people would say no, but that common sense response to a rather simple example does not seem certain. One is left with uncertainty about how to analyze this situation. So it should not be surprising that uncertainties, if not quandaries, are common in the discussions of the more subtle changes that might occur as the result of the wide range of enhancement technologies that are now being discussed in bioethics. These include the proposed alteration of human DNA through various genetic interventions, alteration of human emotions and capacities, for example, for improved performance in intellectual and athletic activities, through the use of drugs that alter brain chemistry or medical devices like deep brain stimulation (DBS), or through other means such as neuroimplants or brain-machine interfaces. Many thinkers appeal to the concept of authenticity in discussions of these enhancements, often as a way to check or limit the use of such technologies. Given the complexities associated with the concept of authenticity, as has been seen, it is not surprising that authenticity is applied in the discussion and debate over enhancement technologies with such a wide range of meanings that there is no straightforward or standard view of authenticity that runs throughout.

Authenticity In The Enhancement Debate

Since the goal of enhancement technologies is to alter fundamental human capacities in some way, it is understandable that the concept of authenticity has relevance. One position develops a line of argument that stresses that there is little reason to worry or be concerned about enhancement procedures since they do not fundamentally alter a person’s numerical or diachronic identity (DeGrazia 2005). This sort of identity is simply identity over time, which has been argued as not compromised by enhancement. However, enhancement that alters the personality of an individual to such a degree that they might be so different that they are not true to themselves is problematic, because it seems to other commentators to be inauthentic. Thus, both defenders and critics of certain forms of enhancement utilize concept of authenticity and identity. It should be pointed out that DeGrazia’s defense of enhancement involves a sense of identity that seems less relevant to what many thinkers ﬁnd problematic about enhancement technologies. It is not numeric identity or biological continuity that concerns most thinkers who are concerned about enhancement technologies (Bolt 2007). Rather they are concerned about a different and, they might claim, a more ethically relevant sense of authenticity that is adversely impacted by enhancement technologies. What exactly is the sense of authenticity and which speciﬁc alterations in terms of the degree and content that they produce are most problematic varies from thinker to thinker. Bublitz and Merkel (2009) point out that the main disagreement seems to divide among those who hold what they call “essentialist views, in which authenticity is threatened by everything that makes people depart from who they truly are and existentialist views, in which we create ourselves according to our own ideals, and an authentic personality consists of self-deﬁned and self-established characteristics” (2009, p. 360–61). The threat to authenticity occurs not because the neuro-enhancements directly cause the actions that are non-autonomous; if they did, they would, in an important sense, not be actions all. Rather, the enhancements transform personality traits in such a way that the resultant traits are inauthentic. This might occur by modifying a person’s motivational structure or dispositional tendency to undertake particular actions. Of course, the problematic effects of enhancement occur only when the degree of enhancement affects a person’s motivational structure to a sufﬁcient degree.

Some of the disagreement among critics of neuro-enhancements, for example, is tied to their underlying concepts of autonomy. These critics give greatest emphasis to notions of autonomy as liberty, that is, freedom of choice without external constraint or restriction, rather than on considerations of authenticity, but most critics at least implicitly recognized that there are minimal capacities that autonomy presumes which are anchored in a concept of authenticity. Enhancements that signiﬁcantly alter such a minimal set of capacities that provide the foundation for authentic expressions of autonomy are therefore seen as problematic. The target of such criticism of enhancement based on considerations of authenticity is, as pointed out earlier, wide indeed. Considerations of identity and authenticity seem to be central in the debate over a wide range of enhancement technologies.

In the context of psychopharmacology, Carl Elliott (2003) has argued that moral questions arise because of issues or conﬂicts between clinical therapy and enhancement, risks and safety, or coercion and justice. The problem of so-called cosmetic psychopharmacology involves the way it raises questions about the role of happiness in a good life or our very humanity. Concerns have been raised about the threat to the meaning and value of identity and authenticity. Speciﬁcally, Elliott argues that cosmetic psychopharmacology can compromise one’s conception of life as a project. The idea of life as a project is that life has meaning only when it is self-determined and is controlled by us. Only with this measure of control can we have full responsibility for the various undertakings that make up our lives. Since there is no universally accepted answer to the question “how should one live?” authenticity requires that everyone should determine their own original way of life. Only in doing so is the life we live our own rather than being the life of someone else.

Psychopharmacology used for cosmetic purposes of enhancement of one’s feelings or emotions threatened to eliminate that sense of control. Even though the use of a drug like Prozac might give you a better personality, the personality that results is not your own on this view. The claim is that a drug like Prozac can compromise the sense of self-fulﬁllment, a concept that is essential to the ethic of authenticity. Without a sense of self-fulﬁllment, one’s life cannot be fully meaningful. Even were one to achieve a happy and meaningful life, the meaning of this life will ring hollow since it would not be produced by the uniqueness that is an individual authentic life. Other thinkers, however, have defended the view that not only in the case of psychopharmacology as an enhancement technology but also in the case of cosmetic surgery and genetic enhancement there is no fundamental identity-related threat. In the case of DeGrazia, however, the operative sense of identity with which he works and defends is that of numeric identity, a quite truncated sense of identity that is marginal to a full sense of authenticity and self-fulﬁllment.

Authenticity In Advance Care Planning And Long-Term Care

The relevance of authenticity also extends beyond the topic of enhancement to advance care planning and long-term care. In the case of advance care planning, the question arises whether advance medical directives of various sorts such as living wills or powers of attorney for healthcare that are now widely in use internationally or so-called Ulysses contracts should be enforced and honored in situations in which the person, albeit changed, still exhibits personality traits. Various medical conditions or circumstances can compromise or simply alter the core capacities of the individual. Some of these conditions alter the capacity to express or exercise one’s autonomy or, in the case of coma or severe dementia, obliterate it. Other conditions, however, alter the capacity of individuals to function in ways that are typical for them. In adapting to these changed medical circumstances, individuals inevitably develop different identities. Some have argued that the resultant identities are so different that they constitute the development of a new person, but more realistically in many instances the changes are consistent with a person’s life narrative, even though the values and preferences : that come to be expressed as a result of adaptation to serious medical problems can differ signiﬁcantly from how the person previously functioned. To put it in philosophical terms, their pro-attitudes have changed. Although it is understandable that these changes might occur, the question that arises is whether these changes simply occur at the lowest level or whether they are accompanied by higher-level endorsement. Different theories of authenticity point commentators in different directions in discussion of these issues.

The rationale behind advance directives is that they allow presently competent individuals to make decisions about their wishes for care in the future circumstances in which they are unable to express or even know their own wishes. Unfortunately, many advance directives are quite vague about the kind of circumstances that are envisioned, but beyond that problem there is a more central issue involving authenticity. The problem is that advance directives express preferences in a prospective fashion and are meant to be observed at some future point. The question is whether so-called precedent autonomy, which is authentic expressions of self-determination, should be honored for a person who is now, for example, still functional to some extent but dependent on signiﬁcant amounts of daily care. Should, for example, an advance directive written by a young person who refuses surgery or hospitalization if he were decision ally incapable and dependent on long-term care prohibit surgery or hospitalization if it were for an acute, highly reversible condition and the person was thriving in the long-term care environment?

Some have questioned whether this is legitimate, because it cannot be known if the preferences expressed in the advance directive are the same as the preferences of the person who has changed and adapted to the circumstances of long-term care. When the person is fully conscious but demented or otherwise decisionally incapacitated, the question arises as to what extent should the person’s present preferences , the low-level pro-attitudes, override the competently articulated wishes of precedent autonomy. Accounts of authenticity that view a person’s life as a narrative that the person constructs through their actions and intentions tend to have difﬁculties with reliance on past preferences to guide present decisions. Because a person’s identity emerges over time in a narrative fashion, an authentic life is one which is constantly unfolding. It expresses beliefs, commitments, and values that deﬁne who the person is, and these are reﬂected in the actions and decisions that person undertakes.

Adaptation to one’s social world and personal circumstances is fundamental to the development of authenticity and identity (Agich 2003). If so, then precedent autonomy loses its prima facie authority. Hence, respecting an advance directive to refuse life-sustaining medical interventions is not just a matter of honoring a person’s precedent autonomy in some abstract fashion but rather should be based upon an understanding of how the refusal of life support ﬁts into the authentic life story of that individual as it is expressed in the present. Less clear but no less difﬁcult cases involve not dramatic life and death decision-making but decisions about everyday care for individuals who lack the capacity to care for themselves.

Residents of long-term care facilities or individuals with incapacities that are compromised enough to require in-home care services frequently manifest ambivalence about current care. They may express preferences , but not all of them are grounded in a realistic assessment of their current situation. Some preferences regarding personal and medical care are so unrealistic that even if they are authentic, they might not have any normative relevance. Other preferences , however, which are simply not part of caregivers’ standard way of doing things, seem to provide a normative force against what are merely “standard” practices of institutions, which reﬂect the preferences of caregivers themselves or their managers. The question is to what extent are caregivers ethically obliged to honor a dependent person’s preferences , which are expressions of that person’s unique or authentic identity. In long-term care situations, it is quite common that conﬂict and negotiation occur around what constitutes authentic preferences and the degree to which they might reasonably be accommodated in the course of providing care.

Conclusion

In all of the areas of enhancement, advance care planning, and long-term care, a central theme concerns the authenticity of individual preferences and how medical and other interventions accord with or compromise the unique identity of individuals. What is clear from the vast

literature on authenticity is that, like the concept of autonomy, there is no single theory or meaning that captures all that people care about. Nonetheless, treatment of issues arising with respect to enhancement, advance care planning, and long-term care cannot avoid a consideration of authenticity. Even when the ethical concerns are expressed primarily in terms of autonomy, as in notions of precedent autonomy, what is at stake are the meanings captured by the underlying concept of authenticity. Without the support of the concept of identity or authenticity, precedent autonomy would be reduced to temporal priority and, so, would not be authoritative. The term authenticity and its cognates are used, especially in bioethics, to indicate that what is most important in an ethical, existential, or ontological sense involves considerations central to being a person, namely, individual uniqueness and self-worth.

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