Ethics Discussions at PEA Soup: Jennifer Hawkins’ “Well-Being, Time, and Dementia,” with Critical Précis by Valerie Tiberius

We are very pleased to now begin our announced Ethics discussion of Jennifer Hawkins' piece, “Well-Being, Time, and Dementia." Here is Valerie Tiberius' critical précis to kick off the discussion, posted below the fold. Thanks in advance to everyone who participates, and we're looking forward to it being a great discussion! 

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Comments on Jennifer Hawkins’ “Well-Being, Time, and Dementia” for PeaSoup/Ethics Collaboration

Valerie Tiberius

tiberius@umn.edu

April 29, 2014

    This is a terrific paper, and I am completely convinced of Hawkins’ main conclusion that it is not good for Rupina to die.  Rupina is Hawkins’ opening character (see p. 508 for the full description).  Earlier in her life Rupina wrote an advance directive stipulating that she should not receive treatment for any potential fatal condition should she contract Alzheimer’s dementia.  When we are introduced to her she is in the middle stage of Alzheimer’s, but (unlike some Alzheimer’s patients) she is happy most of the time and seems to be enjoying her life.  Hawkins argues, against Ronald Dworkin and Jeff McMahan, that if Rupina were to develop pneumonia, it would be best (prudentially) for her to receive life-saving antibiotics.  Hawkins is careful to distinguish her conclusion about Rupina’s prudential good – her well-being – from many other conclusions one might wish to draw about the case (such as what we ought to do, all things considered); Hawkins’ goal is to illuminate the nature of well-being through this example.

    The argument for the main conclusion about Rupina consists in three separate arguments against three reasons for taking past desires (such as were expressed in Rupina’s advance directive) to be relevant to a person’s well-being.  The last section of the paper (VII, starting on p. 540) provides a helpful summary.  Here I’ll focus on the third of the three reasons, “the life-object approach”, since this is the one that most interests Hawkins.   The idea here (articulated in different ways by Dworkin and McMahan) is that there are holistic properties of lives that add value to a life that cannot be reduced to the value of individual parts of the life.  Examples of such properties include thematic unity and narrative structure.  For Dworkin, according to Hawkins, temporally local goods "are almost never as important for us as is fashioning our lives into good lives, viewed holistically. As self-creators, Dworkin thinks that we strive to give our lives meaning and structure, and this can, in certain cases, lead us to try and impose a particular shape or form on our lives.  Rupina’s attempt (while competent) to ensure that her final phase of life is not a demented phase can be views as such a move—as an attempt to ensure that her life as a whole will not be marred by the presence, at the end, of an element so thematically at odds with the rest” (520).

    Hawkins articulates a similar argument inspired by McMahan, but I won’t elaborate that more complex argument here. 

    Hawkins' argument against the life-object approach depends on two premises:  (1) that all prudential value is value at a time and (2) the nonalienness principle (NA), which says that for something to count as good for a person it must be the case that if that thing enters her experience, it does so in a positive way (the precise formulation is on p. 527).  Hawkins defends NA by appeal to intuitions and by arguing that almost all theories of well-being accept it.  So, the argument goes, because Rupina will not register the decision to withhold life-saving antibiotics in any positive way, and because there is no competing timeless prudential value of a life with a certain shape or ending that is independent of what she now values (i.e., a value that does not obtain at any specific time), withholding the medicine is bad for Rupina.  On Hawkins way of think about well-being “our good must change as we change because it must, in some sense, fit with our current capacities for positive response” (539).  I think this is exactly right.  Since that makes for a boring commentary, however, I’ll raise some questions about the non-alienness principle in what follows.

    Hawkins rightly points out that some people will be suspicious of her nonalienness principle because of intuitions about cases in which something is good for you now despite the fact that you will not respond positively to it, because you will develop in such a way that you will eventually respond positively enough to it that your life would be worse without it.   She gives the example of a person who thinks dancing is dumb, but who would love dancing were she to develop a taste for it.  Here is Hawkins’ verdict about the case:  “while dancing is a good choice for me now, it is not good for me right now.  It will only be good for me once I start to respond positively to it in the appropriate way…” (528).  Similarly, the benefit of broccoli for children who hate broccoli:  broccoli is a good choice for children, but it is not (intrinsically) good for them until they start to like it. There are two important distinctions here:  the familiar distinction between intrinsic and instrumental goods, and the less familiar distinction between a good choice and a ‘good for’.   A good choice may be a good choice because of its relationship to intrinsic value, or because it is the choice of something that will be instrumental to an intrinsic value.  The nonalienness principle is a claim about intrinsic goods only (527). 

    We can see from the examples, that NA has some implications for what to say about the way in which improvement, development or growth are good for people.  Something that will make you into a person who enjoys a better whole life (call these self-developing actions, or SDAs), but to which you do not respond positively now is instrumentally good for you, not intrinsically good for you.  Note that in talking about a better “whole life” here, I do not mean to be disagreeing with Hawkins’ first premise.  There is an unproblematic sense of a good whole life, according to which a better whole life is one with more prudentially good segments or moments.  (Hawkins discusses the unproblematic sense of a “whole life” as a collection of events that occur over time on p. 519; I am just adding that a better whole life is one in which there are more events that are good for the person.  This is the sense of a good or better whole life that I intend in the rest of my comments). 

    At first reading, I thought this seemed like not quite the right thing to say about development, particularly when it comes to children.  To my ear, it is strange to say that activities such as reading, sharing toys and trying different foods are merely instrumentally good for children who do not respond positively to these activities at first, that these are good choices, but not intrinsically good for them.  But then I thought about the case of children whose prospects are tragically cut short, cases in which it is not true that these developing activities are instrumental to creating intrinsically valuable positive engagement with these activities later in life (because there will be no later).  In such cases it does seem like the disliked (not positively responded to) self-developing activities are not good for these children.  It does seem plausible to say that for a child who will not live past the age of 8, learning to play the violin is not good for her if she does not respond positively to it. 

    So, perhaps it is right to say that disliked developmental activities are only instrumentally good for children.  After all, as Hawkins points out, instrumental goods can be very good indeed.  The trouble with this, however, is that for SDAs to be instrumentally good for children, it has to be the case that developing into a person who will be able to have a better whole life (a life with more segments that contain higher well-being) is intrinsically good for them and, according to NA, this means that the children have to be such that they would respond positively to being such a person or having such a life.  But it’s not clear that young children can comprehend the idea of a whole life well enough to respond to it in any way at all (certainly infants cannot).  This does seem to be a problem since NA is formulated so that it is how the person would respond at the current moment that counts.  That is, it’s not the case that a life with the greatest number of well-being segments is good for a person at T1 if she would respond positively to that life at the end of it or when she’s older; rather, this good whole life is only good for her at T1 if she would respond positively to it at T1.

    Of course, the case of children presents special problems for theories of well-being with subjectivist leanings, so let’s think about how it is with adults.  As Hawkins very wisely emphasizes, adults are also developing – or at least changing – and this is plausibly relevant to our good just as it is relevant to the well-being of children.  Adults buy self-help books, go to therapy, meditate, and so on to try to change themselves into people who will respond positively to things to which we do not now respond positively.  I might engage in rigorous retraining to overcome my heroin addiction, or obsessive love of power, because without these desires I will have more good moments of time over the whole course of my life.  What can Hawkins say about the value of these activities compatibly with NA?

    There are some SDAs that NA can countenance as intrinsically good for a person.  The easiest case is one in which I actually enjoy (say) meditating now and it is also true that it will make me into a kind of person who has more prudentially valuable moments overall.  Further, we can respond positively to actions under different descriptions, and there might be cases in which an activity is viewed positively under the description of a self-developing activity (e.g., “the thing I’m doing to be less anxious in the long term”).  That is, there are cases in which we do not respond positively to some features of the activity we do to make ourselves prudentially better off in the future, but we respond positively to other features, or to the activity under certain descriptions.  It seems to me that NA can countenance such activities as intrinsically good for us even though there’s a sense in which we do not respond positively to them now.  Finally, as in the case of children, the instrumental value of SDAs is pretty darn important.  

    Is this enough?  I’m not sure, for reasons similar to those I raised in the case of children.  Unlike very young children, most adults are capable of understanding and responding positively to the idea of a better whole life; the problem is that they might not do so.  I’m worried about cases in which a person does not respond positively to a better whole life (that is, a life with more good segments than she would have if she didn’t change) because she is severely depressed, suicidal, self-loathing, cynical, pessimistic or otherwise disordered.  In such cases the fact that X is a means to a life that contains more moments that are good for her will not make X instrumentally good for the person since the end to which X is a means is not something she responds positively to.  Hawkins briefly considers cases in which a person is temporarily unable to appreciate things that are intuitively good (529-30) and she bites the bullet (admitting that the intuitive goods are not good for the person until she regains her ability to respond positively to them).  I don’t find this terribly plausible in the particularly case of the good of a life that contains many good-for segments.  It does seem to me that the facts about a person’s whole life (just seen as the sum total of good moments) can make it the case that some things are good for her despite a lack of positive response now to a whole life with more good moments, or to a changed version of herself who is able to live such a life.

    Concerns about the value of SDAs have led to what I think is an odd implication of NA:  that the intrinsic value of a life with more good-for segments depends on a person’s responding positively to a whole life like this.  If anything is intrinsically valuable for a person, a life with the most good-for segments seems like an excellent candidate.  Maybe the right thing to say is that NA applies only to segments of a life and that a whole life with more good moments in it is good for a person independently of her positive response to it.  Of course, according to NA, we must respond positively to the individual moments that make up the good life, but this doesn’t mean we’ll response positively to actions that will lead us to a life with more such moments in total.  In other words, one might say that a life in which we get the most “good-for stuff” (whatever that is) is good for us, however we feel about it.  (This may amount to saying that there is one timeless good:  the good of a life in which you have the most good-for moments).   Abandoning NA for whole lives does provide a solution to the problem of self-development and the related problem of disordered agents, because it will ensure that actions that create a person who will get more well-being overall will be instrumentally good for that person.  Notice that this admission of a limitation on NA would not change the verdict about Rupina, because given Rupina’s current positive responses, she is now accumulating more good-for moments by staying alive.  It’s not true about Rupina that a life with a higher total of good-for moments would be one in which she dies of pneumonia now.

21 Replies to “Ethics Discussions at PEA Soup: Jennifer Hawkins’ “Well-Being, Time, and Dementia,” with Critical Précis by Valerie Tiberius

  1. Hey Jennie,
    Nice paper! I have some questions about the nonalienness principle (NA). To get at them I wanted to ask if you would similarly want to endorse a similar principle (NA-Bad) for prudential bads i.e.
    (NA-Bad)
    it is a necessary condition of X’s being intrinsically bad for A at T1 that either (1) A respond negatively to X at T1 if she is aware of X at T1 or (2) A be such that she would respond negatively to X at T1 if she were aware of X at T1.
    Here is a worry I have about this principle. Suppose that there is some medical condition, one more general than anhedonia, which prevents people from having any negative affective responses whatsoever. I take it to be plausible that having no affective life whatsoever would be (very) non-instrumentally bad for someone. But as I read NA-Bad, it says that having no affective life wouldn’t be bad for someone. After all, someone in this position won’t react satisfy either (1) or (2) as they won’t react negatively to their being in such a condition. This makes me worry about NA-Bad (and, in turn, NA).
    Would you want to resist adopting NA-Bad? Or am I mistaken in thinking NA-Bad has the consequence I suggest (or mistaken that it’s problematic)?

  2. This is an extremely rich and stimulating article, and Valerie raises some important questions as well. I hope the rush of thoughts doesn’t leave what follows a jumble! I want to focus on some issues relating to the non-alienness (NA) principle. To start, I agree that it is better for Rupina to live, and that the most plausible explanation for this highlights the distinctive importance of hedonic goods for well-being, especially ill-being. (I doubt that a desire account can plausibly explain such cases: besides points about the relevance of past desires already noted by Jennie, it seems that whether life is worth continuing depends largely/wholly on matters of pleasure and suffering. For another, someone with dementia might not even have well-formed desires; at a certain point thinking may become too disorganized for us to really be able say what the person wants.)
    But: is dementia bad for Rupina? If, on balance, she’s happy and getting what she wants, it seems the answer must be no, given the way NA is formulated (ie, grounded in your immediate propensities for positive response). In fact it could be good for her, and for people generally, to slide into happy dementia, freed from many frustrations of ordinary life.
    This is a version of a familiar worry for many subjective accounts of welfare. Perhaps you would be better off with a lobotomy, or a series of brain procedures to ensure that your wants/likes conform to however the world happens to be. Or you could secure a chemical version of such a life, becoming a lotus eater or using soma, say. Perhaps this is a mirror image of Valerie’s self-development activities (self-devolvement activities?). But these scenarios are easier to dismiss because they’re typically so exotic. Dementia hits closer to home, and I think the bullet is harder to bite here.
    In my view, such worries point to the importance of the self (and of authenticity) for well-being, and that this might best be accommodated by interpreting NA a little differently. Perhaps non-alienness merely requires that WB be grounded in the individual’s makeup (a view I’ve called internalism elsewhere), or more narrowly in the “self” (myself, I favor a “self-fulfillment” view of WB). Part of what’s sad about dementia is the disintegration of the self: “she’s not herself anymore”; “all that’s left is a shell.”
    This sort of move doesn’t settle exactly how to handle Rupina’s case. One possibility is that the old self is gone, and that the misfortune is essentially the death of that self, leaving only an individual capable of pleasure and suffering, but no longer self-fulfillment. (This may be why it seems a little odd, to me anyway, to think of Rupina’s happiness as “inauthentic,” the way we might regard the lotus eater’s happiness.)
    Alternatively, perhaps the lasting commitments that defined the self prior to dementia continue to have some authority (and may be relevant to dealing with “shape of a life” issues). Consider cases of intermittent lucidity, where the person is normally out of it, but every so often the lights come on and the “old Rupina” comes back. If Rupina had one of those moments, and during it affirmed her wish to die, would it still be best for her to live? My sense is yes, but perhaps only because, absent great suffering, it seems best for her to live regardless of what she wants. But the fact that she no longer lives with the sort of dignity she always cherished nonetheless seems to me important—even if she does not cherish it now. It seems sad that her life has come to this.

  3. Yes, an excellent paper, Jennifer, one with which I agree quite a bit. And thanks to Val for the excellent commentary.
    Like Val and Guy, I too would like to press on NA a bit. On perhaps a caricature of the views, successful stoics or Buddhists have eliminated their positive (and negative) responses to the vicissitudes of life, without there no longer being things that are good (or bad) for them.
    Relatedly, to follow up on a case Val mentioned, would you want to say that there’s nothing good for those in the grips of clinical depression? The case you mentioned that’s closest to this neighborhood (529-30) is one of temporary inability to appreciate things that are intuitively good. As Val points out, you bite the bullet here, saying the relevant events are “goods in the making,” but this seems one bullet too far, especially for someone who perhaps isn’t just temporarily in the grips.
    Further, one wonders to what extent *Rupina* is capable of “appreciating” the relevant goods in her own case, such that her own response even matters. Indeed, what does the requisite sort of capacity for “appreciation” amount to, precisely?
    I have another question about the person-units at issue, but I’ll explore that in a different comment.

  4. My second question, Jennifer, is actually a pair of related questions. First, as Connie Rosati has very recently pointed out in an unpublished paper (“On Reasons of Personal Good”), there are certain past desires that have a kind of hold on us, namely, as certain sorts of commitments, and their grip obtains even when we might have changed significantly in the meantime. Connie’s examples is of committing herself to give blood once she reached the minimum weight requirement. Even when the values that were relevant to providing reasons for the formation of the commitment have faded, the fact that I committed still provides me with a reason to do the thing or accrue the “good” in question. One can imagine that its satisfaction prompts no positive response on my part, however; it was just on the checklist of things I had to do. (I’m not sticking Connie’s own point, I should add.)
    The second question: we have the capacity to take up various perspectives on our lives. So I can (and usually do) take up the right-now perspective on me and mine, and from there, X might be good. But I may also be able to take up the perspective of me-qua-larger unit. And from that latter perspective, X may not involve any positive response (perhaps I see it’s insignificance in the larger scheme). Which is the correct perspective? Both are “from now,” as it were, but each takes into account different stretches of time. A straightforward example: one might undergo a series of small pleasures, to each of which one has positive responses from the now-perspective, but when one steps back to take a larger view of one’s pain-filled life, those little pleasures are laughably insignificant; one might almost pity oneself for them.

  5. Wow, it is only day 1 and already some great feedback is up! I will try to respond comment by comment. And I’ll start with the very helpful opening remarks from Valerie Tiberius. She focuses on my principle, NA. So I will start with her questions about NA and the goodness of a whole life. Like Valerie, the sense of ‘whole life’ I am using here is just the sense in which a whole life is better if it has more good segments in it, and I have deliberately left it open for the time being what it is that makes segments good. As Valerie explains, a lot in my discussion turns on distinguishing between intrinsic and instrumental value and also on the additional distinction I introduce between things that are good-for a person at a time, and good choices (which are good in virtue of the way they relate us to things that are good-for). My answer to Valerie focuses on good choice.
    Valerie is concerned about how to handle cases where we have the intuition that a certain life would be better for someone. A child or a young person might fail to appreciate now a true fact of this sort, and her concern is that my NA principle will then suggest that this can’t be a fact—that a life I fail to appreciate the value of is not a life that is good for me. It is certainly true that a person might, early on in life, have several quite different paths open to her, several possible lives that might be hers. Moreover, not all the possible futures will be equally good. To greatly simplify let us imagine a person with three possible paths open to her: A, B, and C. If she continues along in the manner of living she is currently following, she will follow path C. But let us suppose it would really be good for her to follow life A. Right now she fails to appreciate or respond positively in any sense to life A. Does this mean it is not good for her? I don’t think I have to say this. Instead I would want to say that pursuing life A is a good choice for her.
    I deliberately allowed that choices can be good despite our inability in many cases to recognize them as such or appreciate them in any way. Choices, as I think of them, are moves that agents can make that alter their relations to possible goods. Choices are good when they improve our position relative to prudential value. But they are not to be confused with intrinsic prudential goods themselves, which must (according to NA) enter our experience (if they do) in some sort of positive way. Now I take it that we are speaking somewhat loosely when we talk about a life having value for a person, because what we really mean is that many of the things in that life have value. Different theorists will point to different aspects of lives as valuable, but whatever you think the good stuff is (whether it is psychological or not, whether your view is monistic or pluralistic) a life is good in virtue of having a great deal of that stuff in it. Given this, I think my principle NA really only applies to the constituent items of a life, and so Valerie need not worry about the child or young person who currently fails to appreciate the idea of living life A. For the child is not currently living life A, and none of its constituent goods have yet been realized for her. NA simply tells us that if life A is to count as good for her, it must be true that if she pursues life A it can’t turn out that she continually finds herself unmoved by all of the supposedly good aspects of life A. If these aspects (whatever they are) cannot be appreciated by her in the living of the life, then that life is not really good for her after all. However, if we suppose that NA is satisfied with respect to these items—i.e that she would respond positively to them in the living of the life—then my view allows us to say right now that pursuing such a life is a good choice for her regardless of her current lack of interest, appreciation, etc.
    More in the morning–responses to Guy, David, Dan, etc.

  6. Hi, Jennifer.
    Thanks for such a stimulating paper. I had a few thoughts, but let me start with a clarificatory question: What exactly is the question about which you are in disagreement with Dworkin?
    My sense for most of the paper was that the question is not whether Rupina’s death would be intrinsically good for her. Rather, I took you to be arguing for the following claim:
    (1) Rupina’s total welfare – all of the welfare that accrues to her at any time, plus all of the welfare that accrues to her atemporally (if there is any) – will be higher if she does not die now than it will be if she dies now.
    But when I got to the end of the paper, I started to have doubts. You write: “Together these [NA and the rejection of timeless goods] lead to the conclusion I favor, that it is not good to let Rupina die. After all, she will not now respond to such a decision in any sort of positive way. Whatever type of theory of well-being one adopts, and however one construes positive registration, she will not register such a decision positively. It will not bring her pleasure, it will not make her happy, it will not lead her to judge her life in a positive way, and so on.” (p. 538) This passage seems to suggest that the question is whether Rupina’s death has the kind of goodness for her that NA is supposed to be a necessary condition on – namely, intrinsic prudential value. So it suggests that you’re arguing for this claim:
    (2) Rupina’s death would not be intrinsically good for her.
    I now think that perhaps you’re arguing for (1) by arguing for (2). If (2) were false, and if Rupina’s death would be sufficiently intrinsically good for her, then its goodness for her could outweigh the prudential value that she would accrue in the future if she continued living. Perhaps this is the only plausible way that (1) could turn out to be false. By ruling out (2), you are ruling out the possibility that Rupina’s death would have enough intrinsic prudential value to outweigh the intrinsic prudential value that she’d accrue in the future if she didn’t die. So in ruling out (2), you are ruling out the only plausible reason to doubt (1). Have I understood you correctly?
    Thanks again.

  7. Hi Jennifer,
    Very interesting paper. Similarly to David, I wonder what the relevant conditions for what counts as a “positive response” are. Are they determined by the theory of well-being? You state that a positive response can be either a emotional or rational response (or some combination). My worry is that, depending on how a positive response is cashed out, Rupina may not be capable of responding positively. If, say, we hold that a positive response requires that Rupina judge that X is consistent with her values, beliefs, principles, etc., she may be unable to respond positively to most things (given her diminished state).
    I also share Dan’s intuition that the “original” Rupina is “dead” in the sense that she is no longer a person with a robust self conception which governs how she goes about her life. The problem being that, on a practical level, claiming that Rupina is essentially dead seems to ignore the importance of specifying an advance directive.

  8. Reply to Guy Fletcher’s post May 5, 1:57pm
    You ask about a negative version of NA, and in particular about what I would say about someone with no affective responses. You write: “Here is a worry I have about this principle. Suppose that there is some medical condition, one more general than anhedonia, which prevents people from having any negative affective responses whatsoever. I take it to be plausible that having no affective life whatsoever would be (very) non-instrumentally bad for someone. But as I read NA-Bad, it says that having no affective life wouldn’t be bad for someone. After all, someone in this position won’t really satisfy either (1) or (2) as they won’t react negatively to their being in such a condition. This makes me worry about NA-Bad (and, in turn, NA).”
    First, let me say that I tried to formulate NA in a way that was neutral about the precise kind of positive psychological state in question. And that meant also that it didn’t have to be an affective response. For some theorists the positive response in question might be an evaluative judgment. That being said, some theorists might worry about the capacities for evaluative judgment of someone who completely lacks affective capacity. Even if the two are independent, they might influence each other in important ways such that the lack of one makes the other impossible or skews it horribly.
    Part of the delicate problem of defending NA is that different theorists of well-being will have very different ways of filling out the kind of psychological responses that matter. And depending on the case, their particular way of filling it out may be counter-intuitive or at least seem counter-intuitive to theorists of a different persuasion. This is to notice a flaw of the particular theory in question, and we all know that each of these theories has various flaws. My goal wasn’t to try to defend any one of these views here, but just to point to something they all seem to be trying to preserve, but it is hard not to fall into that trap. In that sense, I am walking a tight rope.
    To come back to your example of the person who lacks affective capacity. I take it that a classical hedonist, who defines welfare value in terms of pleasure and pain understood as affective responses, will encounter precisely the problem you point to. The hedonist will have to say that since the person is not feeling pain, this disease that destroys affect is not bad for her, at least not intrinsically bad for her in the moment. Now, of course, if she got over the disease she would be able to experience pleasure, and this is good. So if there is something she could do now, to help her recover from the disease, then the hedonist could say that it would be a good choice for her now to do that thing (whatever it is). But the hedonist does seem committed for the time being to saying that she is stuck in a welfare neutral zone.
    However, this points to an issue about terminology that may be partly what you are getting at. I said just now that the hedonist could say that it would be a good choice for her now to do whatever will help her recover from the disease. But I didn’t say it is intrinsically good for her to get over the disease. And perhaps part of your issue has to do with my terminology. In the Ethics paper I distinguished between intrinsic welfare value and instrumental welfare value, and I intended to limit these to items (in an extremely broad sense of item) that bring value or disvalue to us in the living of our lives. I then also distinguished between value claims at this level and what I called good (or bad) choices. A good choice, I said, is one that alters your position in relation to obtainable goods in a good way. But I resisted calling good choices intrinsically good. So, for example, IF I were a hedonist (which I am not) and I used these distinctions in relation to your example of the person who has the disease that undermines affective capacity, I would say that right now, because she has the disease, nothing is intrinsically good or bad for her. But if there were something she could do to cure herself of the disease, I would say that it is currently a good choice for her to do that thing. Why? Because it would move her towards being open to intrinsic value again. And this in turn seems to depend on the intuitive plausibility of something like the idea “it is good to be able to realize intrinsic good.” Is that itself a claim about intrinsic value? I think of it as a meta-level claim. At any rate, I am not sure much turns on my choice of terminology, as long as the distinctions I have drawn remain (re-label them if you like) and as long as NA is understood to be a principle involving the lower-level goods that we encounter in the living of our lives.
    Let me stop there, and see if that addresses your worry.

  9. Okay, now to try to answer/respond to the thought-provoking comments form Dan Haybron, May 5th, 2:30
    Dan asks whether dementia itself is good for Rupina. He is pointing to a general problem as he recognizes, for many subjective theories of well-being, a problem about how to explain the goodness or badness of whole ways of living or being. If I understand him correctly, he is pointing to some real and interesting problems, but I do not think they are problems for me in this particular essay.
    It is helpful to distinguish a couple of questions here. We might want to ask, given that a person has already become demented and could not have avoided this, what counts as good for her now, given that she is demented. Call this question one. We might also want to ask whether it was good for her to become demented (the intuitive answer here is that it is was not). Call that question two. I take NA to place a constraint on answers to question one. It says that a necessary (though perhaps not sufficient) constraint on local, in-life goods is that, if they enter our experience, they must do so in a positive way. Of course, I take it that a full theory of well-being will want to tell us many other things besides just what NA tells us. It will want, for example, to give us a way of ranking possible lives, i.e. a way of understanding what makes some lives better or worse than others. And I haven’t tried to get into that here. But I certainly think it is a consistent view to think both that it was unfortunate for Rupina to become demented (because a life without dementia is a better life for her because of the welfare goods it contains that a life with dementia lacks), and yet, now that she is demented, that her good is highly dependent on what she is like now.
    So I am intrigued by Dan’s question whether dementia is good for Rupina, but I don’t think it really poses a problem for my claims in the paper. I don’t think NA, as I describe it, forces anyone to say that dementia is good for Rupina. And it certainly doesn’t entail that the life with dementia in a better overall life for her.
    Nonetheless, the second question above is an interesting question, and many theories of well-being have a hard time handling it in an intuitively compelling way. There are real and interesting problems that arise for theorists of well-being when it comes to meta-level claims about what kind of life or even what kind of creature living a life it is better (or worse) to be.
    In his comments, Dan points to two distinct approaches to question number two. Classical hedonistic accounts of welfare—that define welfare in terms of pleasure and pain understood as affective phenomena—explain which lives are better in terms of which lives have more pleasure overall. Famously, this led to the seemingly absurd conclusion that it might be better to live a life that looks quite unlike a human life if it were a life that included great amounts of pleasure, more than would ordinarily be found in a human life. Would we better off living the lives of pigs (the conclusion Mill struggled with) or living the lives of Huxley’s soma eaters? Most of us think not, but this is just another way of reporting that most of us aren’t classical hedonists. And by bringing up question two, Haybron points to a problem classical hedonists might have when confronting dementia. I describe Rupina as enjoying her life overall. Her pleasures are simple, but they are definitely pleasures. Most dementia patients are not like her, but given that she is like this, a really simple form of classical hedonism might even support the idea that she is better off now that she is demented, and it would have been good for her if she could have become demented sooner! That strikes me as absurd, but it is a conclusion that some hedonists might have to embrace.
    Dan points instead to the idea that what makes a particular continuation of a life better than another is that it is the continuation of the life which best preserves and fulfills the self. This would explain the badness of a shift into dementia in terms of loss of that self. However, while I am sympathetic to the idea that it is bad to become demented, I am not hopeful that we can explain this by appealing to the importance of preserving a certain core self. Much would, of course, depend on what the self really is, and how its boundaries are defined, but there are, it seems to me, many instances in which it is true that an individual would be better off if only she could change in some fundamental way, if she could alter herself in some deep way that would entail altering the core or authentic self (however it is defined). Since I doubt that it is always bad to alter the self, and indeed sometimes think it is very good to do so, I am not very hopeful about that way of answering question two.

  10. Hey Jennie,
    Thanks for the reply!
    My bad, I shouldn’t have said ‘affective’ for the reason you mention (namely wanting to be neutral on the relevant psychological states in NA).
    What I’m mainly interested in is whether, given your acceptance of NA, you’d endorse NA-Bad. Background to the question: I’m sceptical about NA because I think that there’s sufficient reason to reject NA-Bad and I can’t think of a good argument for accepting an asymmetry here. My doubts about NA-Bad stem partly from cases of subjects who lacks the ability to have the kinds of responses that NA appeals to. It seems to me that lacking these responses (and the capacities to have them) is, itself, a prudential negative, aside from any effects it might have.
    So, reformulating the example, suppose that someone has a condition wherein they lack all of the non-alienation-relevant responses (whatever these are, so not just affective ones). Other things equal, wouldn’t that be bad for them by itself? That seems right to me but NA-Bad seems unable to deliver that. For NA-Bad says:
    (NA-Bad)
it is a necessary condition of X’s being intrinsically bad for A at T1 that either (1) A respond negatively to X at T1 if she is aware of X at T1 or (2) A be such that she would respond negatively to X at T1 if she were aware of X at T1.
    and A’s psychology, as described above, prevents each of (1) and (2) being satisfied in this case.
    (Finally, I like the distinction in the paper between (i) what’s good for someone and (ii) a good choice for them. But I didn’t mean to be getting at that. I’m not thinking about choices at all.)

  11. Hi Jennifer,
    Great paper, as many have mentioned. I just wanted to add something to Dave and Ryan’s concerns regarding what counts as a positive response, and whether Rupina is capable of it. You’ve argued, convincingly I think, that death can’t be good for Rupina, because NA isn’t satisfied in that case.
    But at the conclusion of the paper, your C5, you add that it is in Rupina’s best interest to live. I take you to mean here that it would be good for her to live, and that others have reason to give her the antibiotic as a result.
    But that latter claim seems to depend crucially on whether Rupina can respond positively to receiving antibiotics and continuing to live, that is, whether NA can be met in that situation either. If Rupina can’t respond positively to anything, in virtue of her condition, then although death isn’t good for her, living isn’t either, because she can’t positively respond in either case. I’m wondering whether, on at least some accounts of “positive response,” nothing is good for Rupina, because she lacks the requisite capacities for certain kinds of positive response.
    Again, great paper, and do let me know if I’m just missing something here.

  12. Criminy—in my haste I used a boneheaded misreading of the NA principle, or rather skipped over some crucial reasoning that led to my worry. Sorry about that. So I agree, NA does not entail that happy dementia isn’t a bad thing: it could, for instance, deprive you of engagement with important values, the higher pleasures, etc. *But*, I’m not sure NA, formulated in a way that allows for such cases, is really a stable position: doesn’t it still allow one’s good to be substantially alien?
    Take hybrid views like the Adams/Darwall/Kagan approaches that focus broadly on enjoyment of the good. Such views are able to throw subjectivists a bone by tossing in a goodie, pleasure, that softens the sting of grounding well-being (WB) externally, in independently valuable goods (we might thus call such views “externalist”). This only limits how alien your good can be to you; it doesn’t remove the worry. This is perhaps easiest to see in thinking about how such views rank different lives.
    Suppose, for instance, Alma, a violinist, has a passion for Cajun music, but only a faint interest in Classical—which, let us suppose, is a more valuable form of music. She likes it, but mostly it doesn’t do much for her. It is open to the hybrid theorist to say Alma would be better off playing Classical than Cajun, even if she would be much less happy and satisfy fewer of her desires. NA ensures that she at least gets something in the bargain—it rules out an “eat your vegetables” account of WB. But it still allows much, perhaps most, of the story to be grounded independently of what the individual is like. Which is to say, I think, that it leaves ample room for WB to be alien to the individual—just not completely alien. (I’ve run a version of this argument contra Darwall in a recent paper.)
    So it seems to me that the alienation concerns motivating NA create pressure to strengthen the principle, so that the metric of benefit is grounded not just partly, but entirely, in the particularities of the individual—yielding at least some form of internalism. Ie, WB should be entirely dependent on what the individual is like. But if we do that, then we risk an extreme subjectivism that allows dementia to be a stroke of great fortune for someone like Rupina—my original worry. So I’d want to put less weight on the person’s immediate propensities for positive response, eg by focusing on deeper features like her values, the self, etc, and perhaps giving some weight to certain past commitments…
    I hope this more clearly addresses your view! (BTW, I agree that it can be good to change the self in fundamental ways, but that their are authenticity-preserving—eg, meditation—and authenticity-undermining—eg, lobotomy—ways of doing so; only the former contribute to self-fulfillment.)

  13. Thanks for replying to my comments, Jennie! You say in your reply: “Now I take it that we are speaking somewhat loosely when we talk about a life having value for a person, because what we really mean is that many of the things in that life have value.” I guess I was operating on the assumption that whole lives can be more or less good for people. It seems fairly natural to me to say that it would be good for me (intrinsically) if it were true that I was on a path to live a life that has a lot of good moments in it. (And better for me if it’s true that I’ll live a life with more good moments in it than some other life I might have lived).
    I’m not entirely sure what’s at stake here. But one thing might be that if you say that a whole life can be good for someone, then you have an answer to the counter-examples involving long-term depression.

  14. Hi Jennie,
    I really enjoyed your paper! I wanted to raise a worry and ask a classificatory question.
    (1) The worry arises from your treatment of the timing of diachronic prudential goods, like thematic unity and narrative structure in a life (pp. 537-38). Your discussion at p. 537 implies that, on your view, a complex (diachronic) state of affairs can be good for you at T1 even if that state of affairs does not (fully) obtain at T1. If that’s right, I would think that you should also accept that a state of affairs can be good/bad for you at a time even if it obtains at some completely different time. If you accept that, then (given your endorsement of NA) it seems plausible that it would be bad for earlier-Rupina (in light of her attitudes, reflected in her advance directive) that later-Rupina is saved from a fatal condition. After all, she has negative attitudes toward that future state of affairs and it later comes to pass. And if we’re not just talking about what is good/bad for later-Rupina but instead interested in what is, as you say, ‘best overall for someone like Rupina’, then I would think that any remotely plausible assessment of what is good/bad for Rupina overall (drawing upon what is good/bad for Rupina at different times) would yield the result that it’s overall better for her to be allowed to die. So, that’s the worry. Perhaps I’ve just overlooked something obvious or misread you. I’m interested to hear what you think.
    (2) I’m just curious: What sort of claim do you take NA to be? Do you take it to be a conceptual truth, or a substantive normative claim about the good life, or perhaps some other type of claim? Does a person’s denial of NA indicate that she is conceptually confused or perhaps just talking about something other than prudential value as you understand it? Or do you look upon objective list theorists much as you probably look upon skinheads–as people who just have very different ideas about the good life than you do but whose ideas are perfectly coherent? (There’s no objection in the offing. I’m just eager to know how you and others understand NA!)

  15. Reply to Dave Shoemaker
    Dave wrote:
    “Like Val and Guy, I too would like to press on NA a bit. On perhaps a caricature of the views, successful stoics or Buddhists have eliminated their positive (and negative) responses to the vicissitudes of life, without there no longer being things that are good (or bad) for them.”
    Jen replies:
    Do they (Stoics, Buddhists) eliminate all responses, or simply emotional, and appetitive responses? I thought it was mainly those. Even there, presumably they can’t really eliminate all responses, rather they try to minimize and regulate the responses they have. In formulating NA I tried to be as neutral as I could be between theories that frame responses in affective terms and those that frame them in judgmental terms. Stoics and Buddhists (like you, I am relying on caricatures of these views) seem to me to be those who specifically distrust affective response, and who if they formulated a theory of specifically prudential value, would focus on judgment. But if that’s right, then NA would still allow that things can be good or bad for them.
    Interestingly, some thinkers who distrust affective responses seem to concede (at least partly) that those responses are potentially valuable. They seem to view our capacity for affective response as a kind of sensitivity that leaves us vulnerable to pain (emotional and physical), and this, in turn, is viewed as an intrinsic bad. On their view, our affective capacities might in principle produce, or put us in touch with, either prudential goods or prudential bads. But given the way the world actually is, with all its sorrows, they will more often be the source of, or put us in touch with, prudential bads. On this kind of view, elimination of affective capacity is, in a sense, a way of embracing prudential flatness or neutrality, a way of ensuring that nothing is good or bad for you, but this choice is driven by the thought that this is the only way to avoid a life of prudential bad.
    Dave continued:
    “Relatedly, to follow up on a case Val mentioned, would you want to say that there’s nothing good for those in the grips of clinical depression? The case you mentioned that’s closest to this neighborhood (529-30) is one of temporary inability to appreciate things that are intuitively good. As Val points out, you bite the bullet here, saying the relevant events are “goods in the making,” but this seems one bullet too far, especially for someone who perhaps isn’t just temporarily in the grips.”
    Jen replies:
    I suspect I am a fairly happy bullet-biter, at least up to a certain point! In the case of clinical depression I assume you are imagining the person who is unable to respond positively to anything at all. I have been trying to distinguish some important types or categories of goodness claims, which I hope can then do the work needed for cases like this.
    So, I am trying to distinguish between the claim that things are good for a depressed person in some kind of immediate sense right now and a meta-level claim to the effect that she would be better off if she were not depressed. I take it that you and I agree that she would be better off not depressed. We could probably also agree that there are certain claims, claims we often frame as simple goodness claims, that are true of her, for example the claim, “It would be good for her to seek treatment” or “Taking time off would be good for her.” But what I think we mean when we say things like that is that these moves are advisable because they would help her to overcome the depression. So the truth of such claims, if they are true, derives (on my view) from the truth of the claim that she would be better off if she were not depressed. They are claims about what I call good choices. While she is in the depression, however, nothing is immediately good for her. She can’t get value from anything. Indeed, it is the fact that she is stranded in a valueless zone that underwrites the importance of getting her out of that state: all that makes life valuable is unavailable to her. So even in the grips of depression, we can say of her that it would be better for her to be in a different state, and we can identify choices that it would be good for her to make if they would lead to her coming out of her depression.
    Dave writes:
    “Further, one wonders to what extent *Rupina* is capable of “appreciating” the relevant goods in her own case, such that her own response even matters. Indeed, what does the requisite sort of capacity for “appreciation” amount to, precisely?”
    Jen replies:
    Well, first, what matters in the way I tell the story, are the facts about what she cannot appreciate or will not like. She is afraid of dying and afraid of sickness, and in a childlike way begs to be healed when she is ill. So although she no longer understands many of the details, when she gets ill, she wants treatment, and will not respond well to the idea of receiving none. I was going for the idea that since positive response is necessary for something to be good, and Rupina doesn’t have any positive response to the thought of death, allowing her to die is not good for her.
    You ask what the capacity to appreciate really amounts to. I tried to frame it even more neutrally by calling it the capacity for “positive response” or referring to the way that things “register positively” in our lives. And again, I was trying to remain neutral on the specifics, even though I was aware that different theorists of well-being would want to fill those in differently.
    Some theorists of well-being probably do want, at least in many cases, to demand something like appreciation, in the sense that they want to require some kind of fairly sophisticated cognitive appraisal, as opposed to just good feelings. So they might wish to claim that a necessary requirement of X’s being good is that you appreciate it in this richer sense. However, such views do then face a problem when it comes to someone like Rupina, for she may no longer possess the capacity to appreciate in that sense. However, this is just to note that many theories of well-being do not handle well the case of children or the case of those with cognitive disabilities of various types and degrees. They cannot, with the resources they currently possess, explain what is good for her. Having been framed initially with only competent adults in mind, the theory requires some kind of modification for these cases, or else it will simply imply that nothing is good for someone like Rupina. And I doubt many people want to say that. Filling out the theory to make it accommodate these cases will be harder for some theories of well-being than for others, and I didn’t try to solve that problem for them in this paper. My goal was just to appeal to a rough intuition that I hoped many people would share, (and which I struggled to formulate it in a way that would be amenable to a variety of theorists) to the effect that something that strikes someone so negatively, couldn’t possibly be intrinsically good for her. (Of course, many things that we highly dislike are instrumentally good for us, and so worth enduring anyway. But that doesn’t seem to be what is going on here). I tried to show that many theorists of well-being seem, at least in a number of contexts, to be committed to a principle, NA, that captures this intuition. I assumed that if the intuition was strong enough, then those theorists who face the difficult task of expanding their theories to account for cases like Rupina’s, will, whatever else they do, want to expand it in a way that preserves this basic idea. They may have to appeal to less sophisticated mental responses when giving an account of the good for someone like Rupina. But if it made sense to accept NA for the main theory, then it will make sense to formulate the extension in a way that is also consistent with NA.
    Dave then asked:
    “My second question, Jennifer, is actually a pair of related questions. First, as Connie Rosati has very recently pointed out in an unpublished paper (“On Reasons of Personal Good”), there are certain past desires that have a kind of hold on us, namely, as certain sorts of commitments, and their grip obtains even when we might have changed significantly in the meantime. Connie’s examples is of committing herself to give blood once she reached the minimum weight requirement. Even when the values that were relevant to providing reasons for the formation of the commitment have faded, the fact that I committed still provides me with a reason to do the thing or accrue the “good” in question. One can imagine that its satisfaction prompts no positive response on my part, however; it was just on the checklist of things I had to do. (I’m not sticking Connie’s own point, I should add.)”
    Jen replies:
    Well, this is interesting and complex. But my first response is that it doesn’t sound to me like a case where fulfilling the earlier intention now is prudentially good for the person. (I am curious what precise point Connie intended the example to do, and whether she had any other examples that were more obviously linked to prudential value?) It might be that one has a reason of some other kind for fulfilling it. For example, maybe a person forms the intention to give blood regularly once they satisfy the weight requirement, because they believe that this is a good thing to do (for others). They think they have moral reasons to give blood, and they also recognize how easy it is for such commitments to fade, and so they want to remain resolute in their intent. Sure enough, as time goes by, other things come to occupy more of their attention, and when the individual actually satisfies the weight requirement, she doesn’t have much motivation to go give blood. But she might still think that her earlier self’s seriousness about it gives her reason to reconsider. Perhaps it helps to put her back in touch with reasons that she has but which aren’t very motivationally potent right now.
    But I take it that you want to ask about a case in which a person’s past desires continue to exert some kind of influence on her now, and where the kind of value at stake is prudential or goodness-for. First, with all due respect, I must confess that I just don’t see how the bare fact that you committed to something in the past can give you a prudential reason now to do it, unless you still have some of the commitments now, or unless it is still true of you now that it would be a good choice for you (i.e. something that will lead you to prudential value if you pursue it). Sometimes past desires (especially in cases where an individual has not changed in fundamental ways) are good evidence for how someone will respond now. So they can be suggestive of facts about current prudential value. But it seems to me that what grounds the current value facts are facts about the current person. For example, a person might at one time in her life gain some insight about the kinds of things that are good for her, and because of this come to desire those things for herself. Over time she may then forget these insights, and simply remember that she once desired X or Y for herself. In such a case, if the insights still hold, the desire is a kind of marker in her life of a time when she knew something she no longer does. But here satisfying the past desire is good only because of facts about the current individual’s current dispositions.
    Dave writes:
    “The second question: we have the capacity to take up various perspectives on our lives. So I can (and usually do) take up the right-now perspective on me and mine, and from there, X might be good. But I may also be able to take up the perspective of me-qua-larger unit. And from that latter perspective, X may not involve any positive response (perhaps I see it’s insignificance in the larger scheme). Which is the correct perspective? Both are “from now,” as it were, but each takes into account different stretches of time. A straightforward example: one might undergo a series of small pleasures, to each of which one has positive responses from the now-perspective, but when one steps back to take a larger view of one’s pain-filled life, those little pleasures are laughably insignificant; one might almost pity oneself for them.”
    Jen replies:
    Hmm. Seems several things are going on in this question. And I have to say that after trying to answer it several times, I am still not quite sure I have correctly grasped what the question is. So much depends on the details of one’s theory of well-being.
    Take your example of the pleasures. If I understand you correctly, the issue is that you might (depending on the perspective you adopt) have different responses to the same things. So if when you experience the small pleasure, you are focused on the here and now, it may strike you as quite good. But another time you may experience a very similar small pleasure at a moment when you are focused on the larger picture of life where, as it seems, the pleasure is one small pleasure in a sea of pains. Because you have that perspective at the time the pleasure occurs, you do not respond positively to the pleasure at that time. So, it seems that in case 1, the pleasure is experienced at T1 and has value at T1 (because there is a positive response at T1), and in case 2, even though there is an identical pleasure at T2, it is not good at T2 because there is no positive response at T2. (Actually to be precise NA makes a positive response necessary but not sufficient for value, so both pleasures might fail to have value for all that has been said. But I assume you used the example of a pleasure because it is usually a good thing. And the issue was just that in some cases if you responded differently it would suddenly not be a good thing).
    First, this way of setting up the question already presupposes something about the kind of response that matters, but of course I deliberately left it open how one might interpret that. My principle NA says only that a positive response of the right sort at time T (where the right sort is settled by one’s theory of well-being) is a necessary requirement for something’s being prudentially valuable at time T.
    This means, second, that different theorists may disagree about the description of the case. For example, a hedonist might not accept the description as I spelled it out in the previous paragraph, because the hedonist might well focus on the kind of affective, immediate response to pleasure that is distinct from our more reflective judgments about a pleasure’s worth. Regardless of the fact that you may judge the worth of a pleasure differently depending on your perspective at the time, the more immediate, felt response may be the same. And so the hedonist may count both pleasures as valuable. On the other hand, some non-hedonistic theorists might interpret NA in terms of reflective attitudes of the sort you describe. Such a theorist would then have to concede that the two pleasures were not both valuable, since one pleasure failed the necessary test for value. Depending on what perspective you adopt at the time you experience a pleasure, the pleasure may lack prudential value because you may not assess it positively. Neither view strikes me as unintelligible. They are just very different.
    However, something about the way you framed the question, made me think you were inclined to view the second position (that allows the pleasure to be valuable when you adopt one perspective and not valuable when you adopt a longer-term one) as odd. But if what determines value in life is not pleasure directly but something like our evaluative attitudes towards the things in our lives, then it seems that much of the moment by moment value in our lives will depend precisely on the kind of perspective we adopt at the time. Indeed, such a view leaves room for the idea that things that might otherwise have brought much value into our lives, sometimes fail to do so, precisely because of the perspective we adopt at the time, which undermines our ability to find value in these things. I am reminded here of people caught up in existential funks, who can’t appreciate the small things in life. And it does seem like a lot of value is lost to them. Actually, the more I think about it, this seems sadly all too familiar.

  16. Hey Jennie,
    Just realized that what I wrote in (1) is quite sloppy. Let me replace the worry with some questions.
    Is it possible, on your view, that a state of affairs that obtains at certain times can be good or bad for a person at other times (when the state of affairs does not obtain)? If it’s not possible, can this be squared with your discussion at p. 537? If it’s possible, do you think this creates trouble for your claim that it is overall best for Rupina to be allowed to live? (My earlier paragraph gestures toward the potential trouble.)

  17. Wow, thanks a lot for the thoughtful and generous reply, Jennifer! Let me mull this over, and if I have any follow-ups, I will let you know.

  18. Reply to Eden Lin:
    Eden asked:
    “What exactly is the question about which you are in disagreement with Dworkin? My sense for most of the paper was that the question is not whether Rupina’s death would be intrinsically good for her. Rather, I took you to be arguing for the following claim:
    (1) Rupina’s total welfare – all of the welfare that accrues to her at any time, plus all of the welfare that accrues to her atemporally (if there is any) – will be higher if she does not die now than it will be if she dies now.
    But when I got to the end of the paper, I started to have doubts. You write: “Together these [NA and the rejection of timeless goods] lead to the conclusion I favor, that it is not good to let Rupina die. After all, she will not now respond to such a decision in any sort of positive way. Whatever type of theory of well-being one adopts, and however one construes positive registration, she will not register such a decision positively. It will not bring her pleasure, it will not make her happy, it will not lead her to judge her life in a positive way, and so on.” (p. 538) This passage seems to suggest that the question is whether Rupina’s death has the kind of goodness for her that NA is supposed to be a necessary condition on – namely, intrinsic prudential value. So it suggests that you’re arguing for this claim:
    (2) Rupina’s death would not be intrinsically good for her.
    I now think that perhaps you’re arguing for (1) by arguing for (2). If (2) were false, and if Rupina’s death would be sufficiently intrinsically good for her, then its goodness for her could outweigh the prudential value that she would accrue in the future if she continued living. Perhaps this is the only plausible way that (1) could turn out to be false. By ruling out (2), you are ruling out the possibility that Rupina’s death would have enough intrinsic prudential value to outweigh the intrinsic prudential value that she’d accrue in the future if she didn’t die. So in ruling out (2), you are ruling out the only plausible reason to doubt (1). Have I understood you correctly?”
    Jennifer replies:
    Thanks for the interesting comment Eden and my apologies for being so slow to respond! I hope this clarifies a bit.
    NA helps to do two things. If you find it plausible, then (a) you are committed to the idea that prudential value is value-at-a-time, and (b) it is not intrinsically good now for Rupina to die.
    The first part (a) is key to answering your question about total welfare (related to your thesis (1)), for I take it to be a question about how her good right now is related to her good over time, i.e. her future. In other words, if we are committed to the idea that value is value-at-a-time, this shapes our answer to the question about total welfare. Since we have rejected the life-object view and we aren’t comparing total life objects, we simply consider how to balance concern for present good with concern for future good, with the aim being to maximize goodness over time. We are all familiar with cases in which we select something that is not good now, but we do so for the sake of greater future good. That seems unproblematic. But then, the mere fact that death isn’t good for Rupina now, is instructive but not sufficient by itself to rule it out as the appropriate choice for her. After all, it might still be a good overall choice, if, for example, her continued life would be one of unbearable suffering.
    However, in this case her future is unlikely to be one of suffering. Her future, at least for some time to come, will no doubt continue to be a happy and pleasant one, and then, she will likely fade into a final phase of dementia where it is arguably true that she is neither happy nor unhappy, and life is neither pleasant nor unpleasant. In the final phases of dementia it appears as though the individual no longer experiences life in a way that makes it either good or bad to continue on. But that is only the final phases, and she is presumably still a long way from that. So, when we look beyond the immediate goods/bads, and consider how to weigh the current choice in light of her likely future, it seems clear that she will be better off living.
    I guess the simplest way to put this as an answer to your original question, is that I have argued for NA as a way of securing both your (1) and your (2).
    I hope that makes sense and helps. Cheers, Jennifer

  19. Reply to Ryan Fischbeck and Eli Weber
    Ryan wrote:
    “Similarly to David, I wonder what the relevant conditions for what counts as a “positive response” are. Are they determined by the theory of well-being?”
    Jennifer replies:
    Yes, really, they depend on one’s theory of well-being, and all I am suggesting here is that most theorists of well-being accept NA and have some notion of positive response in terms of which they interpret it.
    Ryan continues:
    “You state that a positive response can be either a emotional or rational response (or some combination). My worry is that, depending on how a positive response is cashed out, Rupina may not be capable of responding positively. If, say, we hold that a positive response requires that Rupina judge that X is consistent with her values, beliefs, principles, etc., she may be unable to respond positively to most things (given her diminished state).”
    And in a similar vein, Eli writes:
    “I just wanted to add something to Dave and Ryan’s concerns regarding what counts as a positive response, and whether Rupina is capable of it. You’ve argued, convincingly I think, that death can’t be good for Rupina, because NA isn’t satisfied in that case. But at the conclusion of the paper, your C5, you add that it is in Rupina’s best interest to live. I take you to mean here that it would be good for her to live, and that others have reason to give her the antibiotic as a result.
    But that latter claim seems to depend crucially on whether Rupina can respond positively to receiving antibiotics and continuing to live, that is, whether NA can be met in that situation either. If Rupina can’t respond positively to anything, in virtue of her condition, then although death isn’t good for her, living isn’t either, because she can’t positively respond in either case. I’m wondering whether, on at least some accounts of “positive response,” nothing is good for Rupina, because she lacks the requisite capacities for certain kinds of positive response.”
    Jennifer’s reply to Ryan and Eli:
    First, let me emphasize that Rupina is in the middle stages of dementia, so I imagine that she can respond positively in several ways. She is by no means a vegetable. Not even close. She can experience pleasure, but even more than that, she has attitudes towards the things that happen to her. She is happy and expresses as much when people visit her, even if she can’t always remember who the people are. She can get quite involved in various aspects of her daily life, even though it is true that many of the things that concern her now would not have concerned her years ago when she was more cognitively intact.
    But that isn’t really key to what you are asking. The important issue for you is whether some theories of well-being might have a notion of positive response that excludes Rupina. That is certainly possible. However, as I see it, that is a problem for a particular theory of well-being and not so much for me.
    In an earlier version of this paper I took up this issue and discussed it a little. Hedonists have no problem with someone like Rupina, but it is not clear what other theorists would say. Some theorists of well-being are explicit about having a hybrid theory. For example, L.W. Sumner defends a view according to which well-being is constituted by authentic happiness, where ‘authentic’ refers to several external counter-factual conditions that must obtain. These aren’t important for us. The happiness part is what matters here. He understands happiness as a positive attitude towards one’s life accompanied by positive affect. It thus requires capacities for reflection and judgment. Now, although Rupina can have positive affect, it isn’t clear whether she can form a global judgment about her life. She doesn’t have much in the way of a capacity for reflective judgment. Does that mean she can’t be well off, if she can’t be authentically happy? Although Sumner doesn’t discuss cases like Rupina, he is clear that he intends to adopt a different account of welfare for those individuals with lesser cognitive capacities. Authentic happiness is an account of welfare for ordinary competent adults, but he nonetheless thinks that animals have welfare and can do well or poorly, and for them it is a matter simply of positive affect and the absence of suffering. Presumably he would say something similar for Rupina.
    But not every theorist has indicated how he or she would describe welfare for individuals at the margins. In essence, my argument is this: NA is intuitively plausible and many theorists seem to be committed to it. If they are committed to it in the case of competent adults, it seems likely that when it comes to working out the part of their theory that deals with the welfare of individuals who lack the cognitive capacities central to their main account, they would want to expand the theory in some way that preserves NA. In other words, it is not clear why one would go to great lengths to accommodate NA for competent adults, and then reject it for other cases (other than simply the desire to get a different answer for Rupina, but I am referring here to some more principled reason). So, since most theorists of well-being seem committed to NA, and NA tells us it is not good for Rupina to die, then most theorists of well-being should accept that it is not good for Rupina to die.
    Ryan also said:
    “I also share Dan’s intuition that the “original” Rupina is “dead” in the sense that she is no longer a person with a robust self conception which governs how she goes about her life. The problem being that, on a practical level, claiming that Rupina is essentially dead seems to ignore the importance of specifying an advance directive.”
    I can only say so much about this. Many, many people have that intuition. So you are not alone. And indeed, some people have tried to argue, using the tools of personal identity theory, that Rupina is not the same person. (Or since she may not now count as a person at all, depending on how ‘person’ is defined, we could say Rupina is not the same individual as before.) I personally find such moves unconvincing, but a lot depends on which theory of personal identity you adopt. In his book “Human Identity and Bioethics” David DeGrazia has a nice discussion of these matters and explains very clearly why if you accept either an embodied mind account of identity (like Jeff McMahan) or a human animal account (like Olson and DeGrazia himself) then identity holds and Rupina is numerically the same individual.
    Aside from the fact that I tend to think that identity (in the important, numerical sense) holds between Rupina at these two times, I have also been persuaded to give up thinking of the case in identity terms for practical reasons. As I noted, much turns on which theory of personal identity one adopts. But then, if we want to argue for some kind of general conclusions here, ones that will have wide-spread acceptance, and we take that route, then we will need to get widespread general agreement on a theory of personal identity. And that strikes me as unlikely. Moreover, as you recognize, if we take that route, it becomes unclear what the point of advance directives is. Many people are convinced that advance directives, even for cases like Rupina’s, are extremely important. So that also suggests that they would not ultimately accept the identity argument if doing so would undermine the importance of directives. Dan Brock and Allen Buchanan have tried to argue that advance directives remain in force even if identity fails to hold, but I confess I am not persuaded by their account. (If you are interested, though, you can find the reference in the notes in the Ethics article.) So I have just tried to focus on the question of best interests (that question about which philosophers agree so much!!! *grin*), apart from the question of identity.
    Hope all of this is helpful. Again, apologies for being so slow to respond. Cheers all,
    Jennifer

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