The American Journal of Bioethics

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/uajb20

Defining and Defending Personhood: Lessons from

the Disease Debate

Peter H. Schwartz

To cite this article: Peter H. Schwartz (2024) Defining and Defending Personhood:
Lessons from the Disease Debate, The American Journal of Bioethics, 24:1, 41-43, DOI:
10.1080/15265161.2023.2278581

To link to this article: https://doi.org/10.1080/15265161.2023.2278581

Published online: 18 Jan 2024.

Submit your article to this journal

Article views: 103

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=uajb20

THE AMERICAN JOURNAL OF BIOETHICS
2024, VOL. 24, NO. 1, 41–43
https://doi.org/10.1080/15265161.2023.2278581
OPEN PEER COMMENTARIES
Defining and Defending Personhood: Lessons from the Disease Debate
Peter H. Schwartza,b,c
a
Indiana University Center for Bioethics; bIndiana University School of Medicine; cIndiana University–Purdue University at Indianapolis
Blumenthal-Barby (2024) presents strong arguments
that bioethicists should stop using the concept
“personhood.” She points out that “person,” meaning
an entity with full moral rights, is defined in vague
and problematic ways. Definitions have counterintui-
tive and at times offensive implications and sound
unacceptable to non-philosophers. In addition, she
says, determining whether an entity is a person does
not settle how to treat it.
Philosophers have presented similar arguments
against “disease:” the concept is vague and poorly
defined, and determining whether a condition is
pathological does not settle whether healthcare pro-
viders should treat it (Boorse 2016; Hesslow 1993). In
response, I and others have offered more precise defi-
nitions of disease and have argued for continuing to
use the concept for specific purposes (Daniels 2008;
Schwartz 2014, 2016).
My response relies on framing the philosophical
project not as a search for the meaning of the term
(the traditional project of “conceptual analysis”) but
instead as a pragmatic attempt to define a concept
that can do certain sorts of work while avoiding
important problems. This approach, recommended by
Quine (1960) and others, can frame the discussion of
personhood as well. Using this framework, I respond
to some of Blumenthal-Barby’s concerns and describe
appropriate uses of the concept. As Bill Clinton said
in a different context: “Mend it, don’t end it.” (He
was talking about affirmative action, a topic for a dif-
ferent time.)
DEFINING AND USING A CONCEPT OF DISEASE
The concept of disease is central to the philosophy of
medicine, and analytic philosophers have debated the
CONTACT Peter H. Schwartz phschwar@iu.edu
ß 2024 Taylor & Francis Group, LLC
THE AMERICAN JOURNAL OF BIOETHICS 41
proper definition for decades (Boorse 2011). In this
discussion, “disease” is generally taken as synonymous
with “pathology,” or any deviation from health, so a
broken bone counts as “disease.” The concept is hard
to define: Diseases are not just bodily conditions that
people don’t like: I may not like my ugly nose or my
short stature, but those are not diseases. Societal opin-
ion or medical practice does not settle the issue, since
attitudes about desirability and acceptability infect
judgments about which conditions are diseases.
Philosophers have presented many sets of necessary
and sufficient conditions for “disease,” utilizing facts
about harm, biological function, and other factors, but
each definition faces at least some serious counterex-
amples (Boorse 2011). Participants emphasize the
problems with their opponents’ views and downplay
the problems with their own, and the battle goes on.
This stalemate reflects the fact that the philosophers
are offering strict criteria for a concept that, as used
by scientists and the lay public currently, fits the
Wittgensteinian picture of family resemblance, or the
cognitive science model of prototype and similarity
(Ramsey 1992): there are “central cases” (think of
pneumonia or advanced cancer) and then various
dimensions of similarity (abnormality, suffering,
potential mortality). This disconnect means that any
set of necessary and sufficient conditions will fail to
perfectly match the extension of the previously poorly
defined term. This problem faces conceptual analyses
throughout analytic philosophy, for concepts ranging
from “knowledge” to “fairness.”
Quine (1960) recommends that philosophers
should drop the claim that their proposed definition
captures the meaning of the term being analyzed.
When philosophers offer a definition, he recommends,
they should see themselves as proposing a new
Indiana University Center for Bioethics, Indianapolis, IN, USA.
42 OPEN PEER COMMENTARIES
concept to replace the old one. The project begins, he
says, when a concept that plays some important role
is “somehow troublesome”: “ … it is vague in ways
that bother us,” he writes, “or it puts kinks in a theory
or encourages one or another confusion” (Quine
1960, 260). In response, theorists propose a new def-
inition for the term that allows it to play a key role
while avoiding the problems.
Looking at the disease debate in this way, as a
“philosophical explication” as I’ll call it, begins by iden-
tifying the key role, which in this case is to identify con-
ditions that should receive priority in public health and
healthcare. Hesslow (1993) questions whether “disease”
should play this role. The reason why heart attacks are
a focus of public health and healthcare, he argues, has
nothing to do with their disease status: What matters is
that this condition kills and hurts people, and preven-
tion and treatment can greatly improve people’s lives.
No one knows whether and when they will have a heart
attack, so pooling risk through health insurance makes
sense. Describing the history of pain control during
birth and of contraception, Boorse (2016) argues that
medicine has never limited itself to treating diseases.
Thus, according to Hesslow and Boorse, directing
medicine based on which conditions are “diseases” is
misguided: other factors are more important. The simi-
larity to Blumenthal-Barby’s concerns about the use of
personhood in bioethics should be clear.
In the disease debate, I and others have responded
that although it is ethically acceptable for doctors to
treat many healthy conditions, for all sorts of good
reasons, the core activities of medicine and public
health are still oriented around disease—preventing,
treating, and ameliorating its effects—meaning that
the concept of “disease” is essential (Schwartz 2014,
2016). Daniels (2008) has provided a broader justice-
based account of why public health and medicine
should focus on disease, rather than other undesirable
conditions.
DEFINING AND USING A CONCEPT OF
PERSONHOOD
Using the framework of philosophical explication
helps clarify and address some of Blumenthal-Barby’s
concerns. The key role of “personhood” is presumably
answering questions about ethical and unethical
behavior, including which human beings can be ethic-
ally killed by removing their organs for transplant (i.e.
those who satisfy whole-brain-death criteria) or be
allowed to die by withholding standard health care
(e.g. anencephalic infants). Singer has argued that
such actions can be ethically taken on permanently
comatose humans even though they are considered
living persons (Singer 1995), but that approach raises
its own problems.
Proposed definitions for “personhood,” then, should
be evaluated by whether they can play this role and
avoid problems. The definitions that Blumenthal-Barby
describes—e.g. Warren’s, Fletcher’s, and Tooley’s—
each have significant vagueness and misclassify cases.
Seeing the definitions as proposed philosophical expli-
cations helps explain the problem: any well-defined
concept that could replace inchoate notions of
“personhood” will have some counter-intuitive conse-
quences. Vagueness may be inevitable, given the reli-
ance on concepts such as communication or self-
awareness, and still be useful: a definition may focus
attention on specific characteristics of entities without
offering a simple calculus for determining personhood.
Blumenthal-Barby highlights problems posed by
entities such as “human-brain organoids, artificial
intelligence, uploaded minds, [and] human animal
chimeras … ” (7). For instance, a definition may coun-
terintuitively classify such entities as persons, but
these implications may not disqualify a definition.
Even if it is difficult to accept at first, perhaps
uploaded minds or some form of AI in the future
should be recognized as persons. Considering whether
to reject a proposed definition due to a counterintui-
tive implication, vs. changing our views, can be part
of a healthy discussion, a pursuit of a sort of Rawlsian
reflective equilibrium.
An important concern about the proposed defini-
tions is that they fail to classify cognitively impaired
human beings as persons. A requirement of a high
level of cognitive ability is unacceptable due to its
implication that many individuals with reduced cogni-
tion are not persons. But even definitions requiring
lower levels of cognitive ability may rule some
humans non-persons, and this is deeply problematic.
A possible response: Cognitively impaired humans
may be classified as persons by alternative criteria,
based on factors such as familial relationship and spe-
cies membership. That may still be problematic since
their personhood rests on a different basis than
others, but it may be an unavoidable and potentially
acceptable consequence of clarifying the concept.
Blumenthal-Barby argues that drawing a line
between persons and non-persons can blind us to the
many dimensions and infinite degrees of mental life
and moral status that non-persons may have, includ-
ing characteristics that have been described recently
by DeGrazia, Shepherd, and others (Blumenthal-Barby

2023). But, of course, we can do both: identify persons
and recognize and explore the properties and moral
implications of sentience (having experiences that are
better or worse for an entity), special interests (having
projects extended over time), and phenomenal rich-
ness (having different experiences that are unified and
included in a narrative flow over time). Just because
an entity is not a person does not mean that recogniz-
ing and respecting its moral standing is unnecessary.
Far from it.
That leads to the key question: Is it still useful,
after all this, to classify entities as persons or not? I
would turn this around to ask: after we end person-
hood, would we still identify some entities as having
full moral rights? If we would, then we have not truly
eliminated the concept of personhood, even if we
have dropped the word. If we stop doing this, then
Blumenthal-Barby needs to explain more clearly what
the world looks like where there is no class of entities
that have full moral rights. If there is no “inner circle”
of beings with full rights, then nobody is safe.
Deciding how to treat various types of entities ethic-
ally inherently involves drawing lines, ideally using
well-defined concepts.
DISCLOSURE STATEMENT
No potential conflict of interest was reported by the
author(s).
THE AMERICAN JOURNAL OF BIOETHICS
2024, VOL. 24, NO. 1, 43–45
https://doi.org/10.1080/15265161.2023.2278558
OPEN PEER COMMENTARIES
The Concept and Conceptions of Personhood: The Fallacy of Jennifer
Blumenthal-Barby’s Argument
Hon-Lam Li
Southeast University
Ethics is frequently concerned with how to resolve
clashes between competing claims from claimants of
different kinds. The idea of moral status is crucial to
CONTACT Hon-Lam Li honlamli@hotmail.com Department of Medical Humanities, School of Humanities, Southeast University, Jiangning District,
Nanjing, Jiangsu, 211189, China.
ß 2023 Taylor & Francis Group, LLC
THE AMERICAN JOURNAL OF BIOETHICS 43
FUNDING
The author(s) reported there is no funding associated with
the work featured in this article.
REFERENCES
Blumenthal-Barby, J. 2024. The end of personhood. The
American Journal of Bioethics 24 (1):3–12. doi:10.1080/
15265161.2022.2160515.
Boorse, C. 2011. Concepts of health and disease. In
Handbook of the philosophy of science, vol. 16: Philosophy
of medicine, ed. Fred Gifford, 13–64. Oxford: Elsevier.
Boorse, C. 2016. Goals of medicine. In Naturalism in phil-
osophy of health: Issues and implications, ed. Elodie
Giroux, 145–178. Cham: Springer.
Daniels, N. 2008. Just health: Meeting health needs fairly.
Cambridge: Cambridge University Press.
Hesslow, G. 1993. Do we need a concept of disease?
Theoretical Medicine 14 (1):1–14. doi:10.1007/
BF00993984.
Quine, W. V. O. 1960. Word and object. Cambridge, MA:
MIT Press.
Ramsey, W. 1992. Prototypes and conceptual analysis. Topoi
11 (1):59–70. doi:10.1007/BF00768299.
Schwartz, P. H. 2014. Reframing the disease debate and
defending the biostatistical theory. The Journal of
Medicine and Philosophy 39 (6):572–89. doi:10.1093/jmp/
jhu039.
Schwartz, P. H. 2016. Broadening and balancing the goals
of medicine: Battling disease and treating the healthy. In
Naturalism in philosophy of health: Issues and implica-
tions, ed. Elodie Giroux, 199–208. Cham: Springer.
Singer, P. 1995. Is the sanctity of life ethic terminally ill?
Bioethics 9 (3–4):327–42. doi:10.1111/j.1467-8519.1995.
tb00368.x.
understanding how (1) competing claims between a
woman and her fetus, and (2) competing claims
between human beings and nonhuman animals, can