Pugh 2017
Pugh 2017
Pugh 2017
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Abstract: Deep brain stimulation has been of considerable interest to bioethicists, in large
part because of the effects that the intervention can occasionally have on central features of
the recipient’s personality. These effects raise questions regarding the philosophical concept
of authenticity. In this article, we expand on our earlier work on the concept of authenticity
in the context of deep brain stimulation by developing a diachronic, value-based account
of authenticity. Our account draws on both existentialist and essentialist approaches to
authenticity, and Laura Waddell Ekstrom’s coherentist approach to personal autonomy. In
developing our account, we respond to Sven Nyholm and Elizabeth O’Neill’s synchronic
approach to authenticity, and explain how the diachronic approach we defend can have
practical utility, contrary to Alexandre Erler and Tony Hope’s criticism of autonomy-based
approaches to authenticity. Having drawn a distinction between the authenticity of an indi-
vidual’s traits and the authenticity of that person’s values, we consider how our conception
of authenticity applies to the context of anorexia nervosa in comparison to other prominent
accounts of authenticity. We conclude with some reflections on the prudential value of
authenticity, and by highlighting how the language of authenticity can be invoked to justify
covert forms of paternalism that run contrary to the value of individuality that seems to be
at the heart of authenticity.
aspects of the self that are regarded as symptoms of the mental disorder as inau-
thentic; however, other patients may hold precisely the opposite view.10 Moreover,
the very aim of DBS in this context may be to try to evoke changes to some of
the values, beliefs, or affective responses that might be deemed pathological, or to
undergird the patient’s disorder. In earlier work, we have tried to address some of
the issues pertaining to authenticity in the context of using DBS as an experimental
treatment for anorexia nervosa.11 In this work, we defended a diachronic conception
of authenticity, and a corresponding approach to its assessment, according to which
patients are encouraged to reflect on changes to their moods and behavior both
when “on” and “off” stimulation, to better determine whether the patient embraces
them as authentic over time.
This initial discussion has been fruitfully taken up and further advanced in an
article by Sven Nyholm and Elizabeth O’Neill in this journal.12 Here, we hope to
further advance this discussion by exploring the differences between our interpre-
tations of authenticity in the context of using DBS in the treatment of psychiatric
disorders. We will begin by briefly introducing the concept of authenticity, before
summarizing some areas of seeming theoretical disagreement between our dia-
chronic conception of authenticity, the synchronic approach endorsed by Nyholm
and O’Neill, and the broadly essentialist “true self” view advocated by Erler and
Hope. We will then consider the practical implications of these disagreements for
understanding of the issues pertaining to authenticity in context of using DBS to
treat anorexia nervosa.
Introducing Authenticity
As an initial starting point, we can say that to be authentic is to live in accordance
with one’s “true self.” If such language of a “true self” is to be of any practical
significance, then it seems that one must also accept that there can be elements of
a person’s self more generally that are not part of the “true” self, but instead merely
peripheral. To live inauthentically is to fail to live in accordance with the true ele-
ments, even if one can be understood as living in accordance with these peripheral
elements. The key question for a theory of authenticity is how we should identify
those features of the self that are “true,” and those that are peripheral.13,14
As Nyholm and O’Neill also recognize, social psychology can give us a number
of clues about how we do in fact seem to go about identifying these features. In a
recent review, George Newman et al. point out that when an individual makes an
assessment either about his or her own “true self” or another’s, that person tends
to emphasize features that have positive valence, particularly if those features are
moral features.15 Further, and interestingly for our purposes, research in this area
also suggests that these sorts of positive features of the self tend to be understood
in an essentialist fashion; that is, they are understood to constitute a “discrete,
biologically based, immutable, informative, consistent” characteristic that is “deeply
inherent within the person.”16
We will refer to this as the essentialist conception of authenticity. According to
this sort of view, to live authentically is to live in accordance with this deep essence;
the path to authenticity on this account is one of self-discovery of this (usually
positive) essence.
However, the mere fact that social psychologists have shown that people tend to
make judgements about authenticity in accordance with this model clearly does
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not entail that this is the correct approach to the question of authenticity. First, it
seems plausible that the true self could have negative valence, even if people do
not assess their own true self (or the self of another) in this way. More significantly,
however, some critics of this approach to authenticity have claimed that the idea
that we have a hidden essential self that is waiting to be discovered is deeply prob-
lematic, and most likely a fiction.17 Drawing on themes from existentialist philosophy,
advocates of authenticity who dispute the notion of an essential self have claimed
that authenticity should be construed as a form of self-creation. To live authentically,
in strong versions of this view, is to choose the person that one wishes to become,
unburdened by the dictates of a fixed essence. Through this approach, we can
identify authentic elements of the individual’s self by identifying those elements
that the individual reflectively endorses.18
The essentialist and existentialist conceptions have sometimes been understood
as representing two poles on a continuum of theories of authenticity,19 and even as
rival conceptions. For example, in their discussion, Erler and Hope argue that
(1) existentialist conceptions of authenticity lack practical utility for those who
wish to draw on the notion of authenticity to help guide their choices and commit-
ments, and (2) that those with mental disorders often draw on an essentialist con-
ception.20 For Hope and Erler, the purported lack of practical utility associated
with the existentialist conception derives from the conceptual difficulty of how
individuals may plausibly be said to authentically choose their own characteris-
tics in the way that the existentialist approach seems to demand. We will elaborate
on this criticism of the existentialist conception subsequently.
However, as we mentioned, critics similarly raise concerns about the essentialist
conception of authenticity, in particular its seeming reliance on a hidden essential
self. In view of the fact that each conception of authenticity has both apparent
flaws and strengths, we may well feel attracted to both understandings.21 Rather
than seeking to explain why one sort of conception is more convincing, a more
plausible strategy may be to try and seek some common ground between the two.
This strategy becomes more plausible once we concede that one need not be
committed to strong forms of essentialism or existentialism of the sort that we
have caricatured here. Neil Levy captures this point as follows:
We believe that Levy captures an important insight with this framework, which we
will henceforth refer to as the dual-basis framework. We return to this framework
of authenticity later.
At this point, however, it should be noted that Nyholm and O’Neill do not
invoke the terminology of either self-creation or self-discovery in their discussion
of authenticity in the context of DBS. Instead, they identify what they take to be six
core features of the true self:
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1) The true self permeates human thinking and so 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 that 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 their true self is expressed can be influenced
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 he or she values.23
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Erler and Hope think that this sort of conception is problematic because it lacks
practical value for those who wish to draw on the notion of authenticity to help
guide their choices and commitments. They write: “When a person is struggling
with the question of what are her authentic desires (or other relevant psychological
aspects of the self) it is not particularly helpful to be told that whatever she decides,
as long as she commits herself wholeheartedly or has reflected carefully, will be
authentic. The question of authenticity, from this perspective, precedes and informs
which desires the person wishes to endorse or which decisions she makes.”28
We take it that the point Erler and Hope are making here is that existentialist
conceptions of authenticity such as Frankfurt and DeGrazia’s arguably put the
cart before the horse. Such theories claim that to ascertain whether some element
of the self is authentic, we broadly need to consider whether the agent would
identify with it after reflection; however, if such reflection is to be a guide to
authenticity, we surely need to know that the sort of reflection being conducted is
itself authentic.
We will not be concerned here with the exegetical question of whether this is a
fair criticism of DeGrazia’s conception of authenticity. We believe that it is possible
to develop a dual-basis view of diachronic authenticity that builds on the idea of
reflective endorsement but that avoids Erler and Hope’s criticism. At this point
however, we may note that Erler and Hope’s criticism seems problematic for exis-
tentialist authenticity conceived as a purely synchronic notion in the way that
Nyholm and O’Neill outline. The reason for this is that if authenticity is a purely
synchronic notion, then it is not clear what basis there could be for grounding the
authenticity of elements of the agent’s self, including that agent’s present values,
other than the values that the agent exhibits here and now; however, this is the very
element of the self whose authenticity is under question.
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their desire to x or to realize their desire to y, given their other coherent values and
rational beliefs. If they deem it more valuable for them to realize x than y, then
their preference to realize this desire may be incorporated as a cohering element of
their true self.30
In developing this account, Ekstrom claims that cohering rationally endorsed
elements of the self are good candidates for constituting the true self for three rea-
sons. First, they are particularly long-lasting because they are well-supported with
reasons. This is important because, as Ekstrom recognizes in her discussion: “a
variety of beliefs and desires . . . come and go in us in a rather fleeting manner. But
we expect our character to be more continuous than this – if not constant, then
at least not in a state of perpetual fluctuation.”31 Second, cohering elements
will be fully defensible against external challenge by virtue of their support from
the coherent nexus in which they reside. Third, they will also be elements that the
agent feels comfortable owning, by virtue of that same fact.32
Consider first the implications of this coherence approach to the relationship
between narrative identity and authenticity. First, on the rationalist understand-
ing that we have sketched, persons can clearly disvalue significant elements of
their personal history. Accordingly, with respect to Nyholm and O’Neill’s OCD
example, the mere fact that the person’s history has included experiencing the
symptoms of OCD, does not tell us anything about the implications that treatment
may have for authenticity. In order to ascertain this, we would need to know how
the patient values his or her experience of these symptoms. For example, some
successful academics might plausibly value their obsessiveness over details of
their work; conversely, compulsive hand-washers may want desperately to be rid
of their anxiety and compulsive behavior.
To this point, it might be claimed that the coherence approach seems to be an
account of authenticity that contrasts the concept with the notion of narrative
identity, in so far as we claim that one can disvalue significant elements of one’s
personal history. However, this understanding of authenticity departs from
Nyholm and O’Neill’s synchronic understanding, in so far as an agent’s values are
most plausibly understood in a diachronic sense. We believe that this also helps
to explain how a coherence approach to authenticity can avoid Erler and Hope’s
criticism regarding practical utility, as we will now explain.
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sufficient for establishing authenticity; we can still ask whether the rational evalu-
ation itself is incorporated into the agent’s true self. This is the point that Erler and
Hope’s critique of Frankfurt and DeGrazia’s account raises. However, the coherence
approach can offer an answer to this question by investigating whether the rational
evaluation is incorporated into a coherent character system, whose lineage can be
traced back over a diachronic process of intelligible rational change.
The crux of Erler and Hope’s criticism of existentialist accounts seems to be that
if the language of authenticity is to be of practical value, there needs to be some
sort of foundational essential self whose characteristics can plausibly undergird
our judgements of authenticity. This has parallels with the approach that epis-
temic foundationalists adopt in understanding the justification of knowledge;
epistemic foundationalists claim that certain beliefs are basic, and that our other
beliefs are epistemically dependent on these basic beliefs. Whereas epistemic
foundationalists face difficulties in accounting for the items of basic knowledge,
adopting a foundationalist approach to the self faces the analogous problem of
stipulating the existence of a foundational, or basic, essential self. The coherence
approach that we advocate also has a parallel in epistemology.35 Epistemic coher-
entists do not claim that the justification of knowledge requires basic items of
knowledge, but rather that our beliefs constitute knowledge in so far as they
belong to a coherent system of mutual justification. Just as epistemic coherentists
do not need to stipulate basic items of knowledge, those who adopt a coherence
approach to authenticity do not need to stipulate the existence of an essential self.
That said, although the coherence approach is existentialist in spirit, it also
incorporates significant elements of the essentialist approach. We have already
seen that Ekstrom stresses the long-lasting nature of elements of the cohering self,
and the importance of this feature. A second point that Ekstrom does not acknowl-
edge but that is apposite here is that we do not develop our values in a vacuum;
our beliefs about what we have reasons to pursue are likely to be informed by
fixed elements of our lived experience, including our awareness of our past expe-
riences, and the set of traits and dispositions that we have, in part in virtue of our
biology. The extent of our self-creation is thus limited: authentic change on this
account is difficult and always only partial in the manner that Levy raises in his
discussion of what we call the dual-basis framework. Our values and essential
elements of our characters may thus be understood in a symbiotic fashion; it is
through the lens of our evaluations, themselves developed in the light of our per-
sonal history and our stable, long-lasting characteristics and traits, that we are able
to understand which of our features we want to be incorporated into our under-
standing of who we really are.
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physique may come to value athletic activity and excellence more than an agent
who substantially lacks athletic prowess. In relation to authenticity, we noted in
the previous section that we do not develop our values in a vacuum, and that our
values and essential elements of our characters may be understood in a symbiotic
fashion.
However, the relationship between our traits and our values is clearly not a
determinate relationship. We can disvalue aspects of our character and behavior,
and our values can generate and sustain rationally endorsed desires that motivate
behavior that resists the influences of more basic drives and urges. Therefore,
despite the inevitable interaction between traits and values, we will argue in this
section that there is still an important distinction to draw between the authenticity
of our more essential traits on the one hand, and the authenticity of our values
on the other, with significant implications for how troubled we should be by the
effects of a DBS intervention (or the effects of a psychiatric condition). The dual-
basis framework, which acknowledges the essential nature of many of our traits,
yet allows for authentic rejection or modification of these traits, supports this
distinction.
We will argue that we should be most concerned about DBS interventions that
affect the authenticity of an agent’s values, especially where these values inform
treatment decisions. Interventions that affect the authenticity of an agent’s traits,
on the other hand, are only problematic in so far as the agent, all things consid-
ered, (authentically) disvalues this influence. We now illustrate this distinction
and its implications with two examples.
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that impacts on the patient’s values in this way is more problematic than a treat-
ment that renders only (a number of) the patient’s traits inauthentic. In case one,
the patient’s inauthentic hypersexual urges were clearly undesirable, not least for
the patient himself. However, in this case, the patient was in a position to decide
whether the benefits of the intervention (reduced PD symptoms) outweighed the
cost of the inauthentic urges and associated behaviors. Therefore, even if the DBS
treatment has an effect on the patient’s authenticity (as it pertains to that patient’s
traits), this aspect of inauthenticity would only rule out continuing with the DBS
treatment if, from the patient’s assessment of his or her best interests, the harms of the
treatment outweighed the benefits. As we will explore, this example may be an
instance in which authenticity (at least of traits) is less relevant than the question of
what, overall, leads to the better life for the patient. However, although the incidence
of inauthentic traits does not necessarily provide a decisive reason against continu-
ing a DBS treatment, we do not suggest that inauthentic traits are irrelevant to treat-
ment decisions. Further, inauthentic values have acute relevance, as we now argue.
In case two, inauthentic values (or lack of authentic values) flowing from a sig-
nificant increase in apathy would, we argue, provide a much stronger reason
against continuing with the treatment, especially where the inauthentic values
inform the treatment preferences of the patient. For example, if, as a result of
increased apathy, the patient expressed a preference to continue with the treat-
ment, because that patient did not care about the broader effects (including the
increased apathy), then this treatment preference should be treated as much less
instructive. This will especially be the case if the treatment preference is in tension
with preferences expressed “off” stimulation. Consider also a case in which a
patient develops hypersexuality under stimulation but does not regard this behavior
as abnormal, and perhaps even endorses this change. In these cases, the normative
significance of the inauthenticity of the patient’s values differs from the signifi-
cance of the unpleasantness of exhibiting inauthentic traits. The patient, with the
patient’s physician and family members, can evaluate the inauthentic traits resulting
from DBS, whereas inauthentic values resulting from DBS affect the very grounds
of the patient’s treatment decisions.
In the next section, we will turn to examining how the diachronic approach to
assessing authenticity bears on the case of anorexia nervosa.
1) The authentic self is the well self and aspects of the self that are part of the
mental disorder are inauthentic.
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However, we will argue that the prevalence of inner conflict in persons with mental
disorders such as anorexia nervosa, and these different ways in which such indi-
viduals draw on the concept of authenticity, do not speak decisively against adopt-
ing a coherence approach to authenticity in this context. Indeed, as we suggested
in our discussion, we are all conflicted to some degree.
The first thing to note is that, as a procedural account of authenticity, the coherence
approach is compatible with either (1) or (3) being true of a particular individual.
Some essentialist views of authenticity only advocate something like (1) as being
true for all individuals with anorexia nervosa; for example, Jacinta Tan et al. have
argued that the anorexic patient’s extreme positive evaluation of low weight is not
authentic because it is a “pathological value.”’38 With this sort of approach, the
authenticity of certain elements of the self can be determined by their substantive
content; a strong desire to maintain an extremely low weight is necessarily inau-
thentic because that desire is itself part of the pathology of anorexia nervosa. One
benefit of this approach is that it provides an approach to authenticity that offers
clear practical guidance to those with mental disorder. However, the problem with
this approach is, as Erler and Hope observe, that many persons with mental disor-
der claim something like (3); they believe that their “pathological values” are part
of their authentic self.
The substantive approach resolves this conflict in favor of a view of authenticity
that reflects (1), stipulating that pathological values cannot be held authentically.
This strategy gives authority to the healthcare provider over the patient herself
with regard to the question of the authenticity of the patient’s internal states. We
have argued elsewhere that this strategy is problematic;39 however, it is important
to be clear that the coherence approach does not similarly resolve the conflict in
favor of a view of authenticity that instead reflects (3) simply by fiat. To simply
say that what the patient herself “feels” or “believes” at a nonreflective level has
unquestionable authority with regard to the authenticity of elements of her self
would be problematic, given the high degree of inner conflict and vacillation that
such patients experience with regard to this very issue. Rather, in cases in which
these “pathological” values may plausibly be understood to have been incorpo-
rated into the agent’s authentic self-understanding, this must be grounded by the
coherence of those values with other long-standing cohering elements of the
agent’s character system, elements that are rationally intelligible to that agent.
Establishing that this is the case requires going deeper than simply asking what
the patient herself believes or feels at a given moment. It may require investigating
the reasons why she holds the desires she does, and how the values that undergird
those desires relate to other values and beliefs that she holds. This strategy may
help to elucidate whether these desires are grounded by the patient’s own rational
endorsements, and whether they have any basis in reality. Moreover, it may serve
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to tease out potential inconsistency and conflict. However, with this approach,
particularly if such conflict does not exist, it is quite possible for an agent to
authentically hold the values that are characteristic of anorexia nervosa as part
of her self-conception, particularly in the case of chronic sufferers who may have
shaped and developed a coherent character system over many years to accommo-
date this “pathological” desire.
Position (4) perhaps raises a deeper problem for the coherence approach;
namely, that two cohering selves with radically different evaluative perspectives
might plausibly reside in the same agent. Such an agent may thus lack stable values.
Here, with the coherence approach, authenticity must partly be a matter of self-
discovery, in so far as the agent must identify the distinct aspects of her coherent
selves; however, it must also be a matter of self-creation, in so far as the agent must
decide which of those selves to prioritize as her most authentic self. This is where
the crux of the problem lies for the coherence approach in such cases: on what
basis can the individual make this decision? The very values that she might appeal
to in order to justify her decision are bound up in the very character systems that
she may be choosing between.
The coherence approach cannot offer an easy answer in such cases of inner con-
flict; however, this is perhaps a fitting response to such hard cases. At least the
coherence approach may allow third parties to offer some practical guidance
about how the individual might go about making this decision, perhaps by draw-
ing her attention to the strength of certain reasons, and the goods at stake in her
decision. Furthermore, it is notable that such cases also raise significant issues for
the essentialist perspective. Although the essentialist might claim that there is a
right and wrong answer to the question “which of the two selves is the authentic
one?” the essentialist still faces the epistemological question of how we should
arrive at the correct answer to this question.
Nyholm and O’Neill suggest that in this sort of case, we should assume that the
value set that is widely endorsed by others is the authentic one. We will raise our
doubts about this response at the end of this section. Prior to doing so, we will first
briefly consider the other positions identified by Erler and Hope.
The coherence approach also provides a basis for position (2). Although authen-
ticity is compatible with radical change with this approach, for such change to
be authentic it must be rationally intelligible to the agent, as we explored in the
previous section. Interventions that serve to directly induce psychological changes,
such as psychoactive drugs or DBS, may in some cases result in feelings of alien-
ation because they cause the patient to undergo changes that are unintelligible to
that patient, in the light of the patient’s other values and beliefs. Depressed patients
who takes Prozac may feel alienated from their elevated mood if the drug serves
only to increase their positive affect without engaging with other elements of their
character system that may play a role in their condition (such as apathy and feel-
ings of worthlessness). This stands in contrast to indirect interventions that aim to
evince changes in the patient’s mood by rationally engaging with the patient, for
example, in talk therapy.40 Changes brought about via such interventions will
more likely be intelligible to patients, in so far as they are brought about by changes
that the patients themselves decided to make to their modes of thinking.
Nonetheless, other patients on psychotherapeutics such as Prozac claim that it
enables them to find their true self, presumably by creating intelligible changes,
possibly rooted in primitive existing aspects of their own psychology. Therefore,
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this is not to say that all directly induced psychological changes must be experi-
enced as alienating with this approach. In cases in which the patient has consented
to a direct intervention, the psychological change induced may be understood as
intelligible to the patient in the light of the values that moved them to consent to
treatment. For example, suppose a patient consents to undergo DBS for anorexia
nervosa. If stimulation is successful in reducing her desire to maintain a low
weight, the patient may understand this change in her evaluative stance as intel-
ligible to her in light of her prior desire to change, even if the precise (direct) mech-
anism by which the change occurred is not intelligible to her.41
The final position acknowledged by Erler and Hope, according to which “there
is no issue of authenticity” is a position that is best understood as one regarding
the value of authenticity and the role it should play in treatment decisions, rather
than a position about the nature of authenticity per se. As such, the position is
compatible with the coherence approach that we have outlined here, although it is
perhaps in tension with the first feature of Nyholm and O’Neill’s claim that
authenticity is treated as a normative ideal. To conclude we will offer some further
reflections on the role that authenticity plays in well-being, and the reasons
that those with mental disorder or their care team give for holding the view that
authenticity is irrelevant to treatment decisions, or at least less relevant than
the patient’s welfare.
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outlined here. Throughout the chapter, Mill defends the importance of developing
one’s own character and living in accordance with it, stating that living in accor-
dance with one’s own character is to be understood as living in accordance with
the desires and impulses that express one’s “own nature as it has been developed
and modified by his own culture.”44
Evidence from modern-day social psychology suggests that people tend to echo
this Millian view in their understanding of the value of authenticity.45 This litera-
ture suggests that people value authenticity because it plays a central role in “giving
meaning to their lives.” Such an understanding of the value of authenticity fits
neatly with Mill’s observation that: “If a person possesses any tolerable amount of
common sense and experience, his own mode of laying out his existence is the best
not because it is the best, but because it is his own mode.”46
With this in mind, consider now the justification that individuals offer in favor
of position (5): Jams Hughes, one of the advocates of this position in the context of
using medication for attention-deficit/hyperactivity disorder (ADHD) discussed
by Erler and Hope, denies the importance of authenticity and claims instead that
“The real question for me is whether the drug makes the taker happier and more
able to accomplish life goals.”47 Hughes implicitly seems to endorse a theory of
well-being that incorporates hedonistic elements (in so far as feeling happy is cen-
tral to what matters to him) as well as elements of a desire-fulfilment approach to
well-being (in so far as it is important that they are able to accomplish their life
goals). In light of the previous discussion of the value of authenticity, this approach
to well-being might seem impoverished if it is understood to eschew all reference
to authenticity; for example, we might wonder to what extent accomplishing a
goal increases well-being if it is not an expression of one’s own character. However,
as distinguished, one can express one’s character by choosing between modes of
living and experiences that are open to oneself (including those made open by
biomedical intervention), even where some of these are less aligned to one’s more
biologically immediate dispositions.
Those who endorse position (5) might plausibly raise the complaint that even
supporters of authenticity should concede that it is not the only prudential value. In
cases of mental disorder, it may also be a prudential value that is incompatible with
other plausible constituents of well-being, including, for example, the experience of
positively valenced mental states. Considering the precise role of authenticity in
well-being would take us far beyond the scope of this article. However, we believe
that this brief reflection on this matter raises a concern about Nyholm and O’Neill’s
preferred strategy when we face epistemic uncertainty regarding the authenticity
of an individual with unstable values. In cases of such uncertainty in which we
cannot rely on the patient’s own values, Nyholm and O’Neill suggest that
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We recognize the appeal of this strategy in that it provides us with a clear action-
guiding principle in cases of epistemic uncertainty. However, the previous reflec-
tions suggest that more work needs to be done on explicating why the fact that a
mind-set incorporating values that fall inside the range of widely endorsed values
should be understood as the mind-set that is more expressive of the person’s
true self. This sort of view seems inimical to Mill’s championing of individuality
against the forces of custom, and his derisory claim that “he who lets the world, or
his own portion of it, choose his plan of life for him, has no need of any other fac-
ulty than the ape-like one of imitation.”49 We do not deny that a case can be made
in favor of Nyholm and O’Neill’s claim; our point here is that it seems prima facie
problematic to ascertain authenticity, a concept whose value is tied to individual
meaning, by reference to the values of others. This is not merely a pedantic theoreti-
cal foible. In light of the close relationship between authenticity and autonomy
according to many approaches (including our own), the identification of authentic
desires as those that are congruous with widely shared values raises the prospect
that this strategy might in practice amount to dressing up considerations of benef-
icence in the language of autonomy; this in turn, is a good recipe for paternalism,
albeit via the back door.
Conclusion
We have defended a coherentist approach to authenticity that draws on both exis-
tentialist and essentialist themes. It grounds claims of authenticity by an appeal to
the agent’s diachronic values, recognizing that such values, although not immu-
table, are likely to be long-lasting and difficult to change. We believe that this
diachronic approach is better placed to respond to Erler and Hope’s critique of
existentialist approaches to authenticity than the synchronic approach outlined by
Nyholm and O’Neill. Although the approach that we have defended denies the
presence of a hidden essential coherent self that requires discovery, the coherentist
approach can offer practical guidance to those who wish to invoke the language of
authenticity in their practical deliberations. When considering whether some ele-
ment of the self is authentic, we must consider not just whether the individual
rationally endorses it, but also whether that evaluation is incorporated into a
coherent character system, whose lineage can be traced back over a diachronic
process of intelligible rational change. We have also drawn attention to the
conflicting nature of character traits, and how authenticity may involve greater
emphasis on some, and downplaying others.
This account will not provide us with a “one- size-fits-all” answer to ques-
tions of authenticity in mental disorder, or to questions regarding the implica-
tions of DBS for authenticity; much will depend on how individual agents
view their own condition in their self-conception and their other evaluations,
and whether DBS is most aptly construed as effecting their traits or their
values themselves. However, we take this flexibility to be a strength of our
approach, in that it is able to adapt to the individual experiences of psychiatric
disorders and treatment. If we are serious about protecting the value of indi-
viduality that seems to be at the heart of authenticity, then we believe that
there is good reason to be wary of less flexible approaches, in so far as they
threaten to impose an objective conception of the good onto others in the name
of their authenticity.
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Notes
The funding information was not included in the print or original online version of this article.
It has now been added as an acknowledgment footnote on page 640. A corrigendum has been
published.
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