Inherent/transcendental Personhood

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Personhood

The way that people understand and relate to each other contributes towards
the acknowledgement or development and maintenance of personhood.
Nevertheless, being an actual person in the first place is important and
determining what or who is a person involves setting boundaries (Baldwin and
Capstick, 2007). Where someone falls in relation to those boundaries will
determine whether s/he is considered a person or a “non-person”. For some
theorists, particularly ethicists, this means possessing certain capacities.
Others would argue that personhood more or less equates with simply being a
human being, whereas the role of interaction with others has also been
highlighted, as has the importance of the physical body. The following
approaches to personhood will be considered in this section, and a few
examples provided of research into perceptions of personhood:

1. inherent/transcendental personhood
2. capacity-based approach to personhood
3. interpersonal theories of personhood
4. the body
5. empirical research into perceptions of personhood
1. Inherent/transcendental personhood
Being human has been equated with being a person in the sense that being-in-
itself is the only criteria. Kitwood (1997) claimed that personhood was sacred
and unique and that every person had an ethical status and should be treated
with deep respect. (He also later emphasised the relational aspect of
personhood but this is not necessarily contradictory.) In some religions and
according to certain spiritual beliefs, people have a kind of unique inner
essence which may even be believed to continue beyond human life (e.g.
through reincarnation or an after-life). The belief in a kind “non-material soul
that still exists intact underneath all the neurological losses of dementia”
(Post, 2006, p.231) may provide solace to carers and help ensure that
interaction with the person is maintained. However, a belief in the inherent
personhood of people (including those with dementia) does not necessarily
guarantee that they are treated humanely and with respect. Moreover, some
people believe that a person’s essence or soul may be lost or no longer possible
to reach, as reflected in statements made by carers in a recent small-scale
qualitative study:
“But you have to remember, that body is not who the person is. The person is
gone”

“There’s no sense is asking her…. She’s not there…” (Dunham and Cannon,
2008, p. 49)

Not everyone has religious or spiritual beliefs and even those who do, within
the same religion or philosophy of life, may differ greatly with regard to what
they believe and the strength of that belief. However, the main issue is not to
determine which religion has “got it right” or whether people really have an
innate, unique essence or soul but rather to understand how some people
define personhood and to recognise that this may be influenced by their
spiritual or religious beliefs. It could even contribute towards fear of dementia
in that their worst mental image of what dementia might resemble is applied
to a human being. Some people might find it more reassuring to believe that
the person is” no longer there”.

2. Capacity-based approach to personhood


For Kant (and others since, e.g. Cooley, 2007; Dan Brock, 1993), to qualify as a
person, it was necessary to possess rationality (the ability to think and reason
logically) and to be able to communicate this to other people. It is clear from
this definition that many people with dementia who have difficulty with logical
thought and reasoning and/or difficulty communicating this to others would
not meet the selection criteria for personhood. Another example of a capacity-
based approach is that of Warren (1973) who defined six criteria for
personhood, namely consciousness, reasoning, self-motivating activity,
capacity to communicate, presence of self-concept and self-awareness.
For yet others, the capacity to perceive oneself as existing over time is
considered important (Buchanan, 1988; Kuhse, 1999; Parfit, 1984). Dan Brock
(1993), for example, argues that people with severe dementia, whilst members
of the human species are worse off than animals in some respects in that they
have no capacity for integrated and goal-directed behaviour and that due
to memory loss cannot forge links across time that establish a sense of
personal identity across time. He concludes that they lack personhood
(Baldwin and Capstick, 2007).
Some people have a feeling that a person with severe dementia is no longer a
person or at least not the person they once were, even though they are still
alive (Matthews, 2006). Parfit (1984) claimed that people can have current
and former selves which are linked by varying degrees of psychological
continuity, and that there may come a time when the psychological continuity
between the two is so great that one should consider the person as no longer
being the same person. Some go even further suggesting that there may come
a time when a person no longer has any kind of continuity with people in
general and that such people are in effect “non-persons” (Buchanan, 1988).
Tooley (1983) further argues that the ability to see oneself as extending over
time is a necessary condition for being a person and for having a right to life.
Clearly, there is sometimes a tendency to erroneously associate the loss
of cognitive abilities with the loss of the quality of being human (Blanchard,
2006).
However, even if other people need to be able to recognise personhood in an
individual, this does not necessarily imply that the latter has to have the ability
to communicate it (Grobstein, 1981). The hypercognitive definition of
personhood – as Post (2006) calls it - fails to take into account the emotional
and relational needs and capacities of people with dementia (Kitwood and
Bredin, 1992; Post; 2006; Rudman, 1997 – in Post, 2006). It neglects the
more social, expressive, imaginative and even unconscious dimensions of
being human (Crisp, 1999), which nevertheless generally require some degree
of reasoning and memory. Finally, it overlooks the importance of social
interaction in that a person who lacks certain capacities may be considered a
non-person with the result that meaningful interaction with that person may
cease and this will contribute towards further loss of capacity.

3. Interpersonal theories of personhood


Despite certain religious and spiritual beliefs about people having a unique
essence or soul, which might be understood as reflecting a concept of innate
personhood, it is interesting to note that early Christianity differentiated
between the terms “individual” and “person”, whereby the latter was
understood as referring to the individual in relationship to others (Allen and
Coleman, 2006). The following descriptions of personhood also reflect a
relationship-based understanding of personhood:

 “who one is and who one can be are defined in the context of authentic
relationships” (Malloy and Hadjistavropoulos, 2004, p.152)

 “It is a standing or status that is bestowed upon one human being, by


others, in the context of relationship and social being. It implies recognition,
respect and trust” (Kitwood, 1997, p.8)
 “rooted in relationships with others and therefore requires the presence
of another human being” (Penrod et al., 2007, p.64)
 “a dynamic concept, refined and articulated through constructs and
subsequent social intercourse” (Jenkins and Price, 1996, p.88)

 a status accorded to one human being by another (Moody, 2003)


If personhood is constructed and maintained in a social environment, people
with dementia may find themselves in a vulnerable position due to their
progressive difficulty engaging socially and effectively with others. This may
lead to their gradual withdrawal from social contact with the result that other
people may distance themselves from them, thereby resulting in isolation,
social exclusion, increased vulnerability and possibly, further deterioration of
their condition.

Kitwood not only provided a model of dementia which highlights the


interaction between neurological impairment, the psychology of the person
with dementia and the social environment, but also strongly advocated for the
respect of the personhood of the person with dementia. He explained that
people with dementia are not simply biological entities or the bearers of the
condition but people who are at risk of losing their personhood. His concept of
personhood was influenced to some extent by the work of the German
philosopher Martin Buber (1878-1965).

Buber (1970) identified two different ways that people relate to one another,
which may be of relevance to the maintenance of personhood in people with
dementia. These two ways are described through the word pairs “I-It” and “I-
Thou” (later translated to I-You”). The I-It mode of relating is one in which a
person relates to the other in a cool, distanced, non-involved way which fails
to fully acknowledge the individuality of the other as the other is objectified.
The I-Thou mode of relating, in contrast, involves meeting the other person in
a genuine human exchange. With reference to the I-Thou relationship, Barich
(1998) states, “You become a person (as opposed to an alienated and isolated
individual) when you enter into relation with people.” If people with dementia
are objectified through an I-It mode of relating, their link to the outside world
is threatened and perhaps damaged, especially when they themselves have lost
the capacity to install and actively encourage an I-Thou form of relating.
Buber’s concept was linked to religion in that it was intended to describe how
humans can enter into a relationship with God through their relationships
with others but this should not lessen its relevance to the debate about
personhood.

A common feature of all human interaction is turn-taking/turn-making. This


occurs even before infants have acquired language through
“protoconversations” between caregiver and infant whereby the caregiver is
attuned to and responds to the gestures and bodily rhythms of the infant in a
process of mirroring, echoing and resonating (Stacey, 2003, p137). Caregivers
often act as if the infant’s sounds and gestures were purposeful and
meaningful, and take a key role in supporting and maintaining the interaction.
This lays the foundations for purposeful interaction on the part of the infant
and the development of a sense of self. The actions and attitudes of the
caregivers towards the infant reflect a belief in the personhood of the infant. In
this way, the adults relate to the infant not in the I-it form (i.e. as if the infant
were an object) but in the I-Thou form. The caregivers are in a position of
power as they could ignore the infant’s actions and take the stance that s/he is
not capable of interaction. This may happen in some cases, but eventually the
child will develop language and start interacting with the outside world and
his/her personhood will be acknowledged and confirmed through interaction.
In the case of dementia, the same degree of understanding and tolerance is
less common. Unlike the infant who is considered to be in the process of
developing the capacity for meaningful communication with the support of
adults, people with dementia are often considered as having had this capacity
and lost it (which may reflect a capacity-based approach to personhood).
Nevertheless, they also need additional support from others at some point in
time to maintain contact and share meaningful interaction (in the I-Thou
mode of relating) so as to benefit from social inclusion and maintain their
sense of personhood. People with advanced dementia may have difficulty
communicating in ways that other people are willing to accept as meaningful.
If other people do not consider their utterances and behaviour as valid forms
of interaction and are not motivated to take on a more supportive role in the
interaction, then turn-taking breaks down and people with dementia gradually
becomes objects to which personhood is no longer accorded. Grobstein (1981)
claims that the central criterion of personhood is that it can be recognised by
others. If so, people who have difficulty communicating their personhood (e.g.
newborn infants, people in the last stage of dementia and people who are
unconscious) are dependent on others to recognise it.

The concept of personhood has also been linked to the different selves that a
person may have. Sabat (2001) described three different selves: 1. the self of
personal identity (expressed through sentences using “I” such as “I feel, I
think etc,); 2. the self comprised of the attributes a person possesses and 3. the
self consisting of the social self or personae presented to others (e.g. through
social roles). People who have dementia gradually lose the ability to maintain
their social roles without necessarily having the opportunity or capacity to
take on alternative, valued social roles, particularly as doing so depends on
mutual recognition and cooperation, and more fundamentally, recognition of
their personhood. (note: insert something here about studies indicating that
people losing social roles does not necessarily imply loss of all notion of self)

Kitwood argued that there were two aspects to the person (i.e. the adapted self
and the experiential self). The adapted self and the experiential self represent
two different ways of being. The former is described as “highly and tightly
socialised, particularly in relation to the performing of given roles” (Kitwood,
1997, p. 15). The latter arises out of simply being with people within a context
of equality and mutual respect and attention. The experiential self may persist
throughout life until death provided that the right conditions are provided.
According to Kitwood, the I-Thou form of relating described by Buber,
provides the ideal framework for preserving and enhancing this aspect of
personhood.

Perceptions of personhood may differ according to the stage of life. According


to Kitwood and Bredin (1992, p.275), “In an ethical sense, personhood is
attributed even to the newborn infant. In an empirical sense, personhood
emerges in a social context.” Myser (2007) contrasts the terra incognita of the
infant (a kind of developing personhood, imagined and projected by carers),
with terra cognita of the adult (full personhood co-constructed with other
members of society) and finally of “fading personhood” (in constant need of
being re-constructed and restored with the assistance of carers and society).
The following extract highlights the relational aspect of personhood and the
perceived duty for people who come into contact with a person with dementia
to look for the person and not just at the dementia:

“Being a “person” is the fundamental philosophical and sociological position


of a human being, with value, intelligence, a history and a present. The
challenge in dementia is to continue to seek for and not to dismiss that
person.” (Lawrence, 2007, p.555)
4. The body
Descartes described a split between mind and body, whereby the substance of
each was separate and distinct. Whereas the body was considered as having a
material form, the mind was deemed unlocatable. According to the situated-
embodied-agent view (Hughes, 2001 – in Moody, 2003), personhood is
maintained or bestowed on a particular person whose human existence is
linked to a physical body in a particular familial, cultural and historical
context. Based on Heidegger’s notion of Dasein (being-there), Merleau-Ponty
(2002) developed a concept which is now often referred to as the body-subject
implying that every human has a body (being a physical creature) and is
capable of thought, reflection and communication. These two parts are not
separate as in Descartes body/mind dualism but rather a unified form which
experiences the world and expresses itself in a bodily form. When a person
sees, s/he is dependent on the eyes but there is an “I” behind the eye. As
dementia progresses the person can no longer rely on the unified form.
Consciousness is expressed through bodily activity but the body, as a vehicle
for expression, is breaking down. This does not mean that there is no
consciousness.

At a more psychological than philosophical level, Jenkins and Price (1996)


draw attention to the way that people tend to make analogies between their
bodies and elements or aspects of everyday life (e.g. viewing their body as a
home, servant or vehicle). When the body starts to let the person down and
the unified form fails to function, the body might start to be seen as a traitor,
an enemy or a prison. The way that a person perceives the body of someone
with dementia (e.g. an empty shell, prison etc.) might affect the way they
relate to them. Such analogies may conjure up powerful images which may in
turn influence and even serve to justify certain negative modes of relating
which are detrimental to the recognition and maintenance of personhood.

5. Empirical research into perceptions of personhood


Kitwood challenged the capacity-based view of personhood drawing attention
to evidence from case studies provided by Mills and Coleman (1994, p.213 – in
Downs, 1997) which suggests that people with dementia retain a personal
awareness of their individual uniqueness of being until death. He also
highlighted the work of Sabat and Harré (1992) based on interviews and
observation of 3 people. They concluded that it is the social and public self
that is lost in severe dementia but not the private sense of self (Downs, 1997).
These studies were extremely small scale but perhaps suggest that the way
that people define or understand personhood may affect whether or not they
find it. For example, a person might walk through a field of dandelions and
claim that they saw no flowers as they consider dandelions as weeds.

Personhood is an elusive thing which cannot be easily measured. However, it


is possible to investigate people’s beliefs about it. Myser (2007) carried out
ethnographic research with 250 healthcare professionals and carers between
1988 and 1990 in Sweden, India and the United States of America in a variety
of settings. One of her aims was to examine the ethical concept of personhood
as perceived by healthcare professionals and lay people. She identified seven
key themes:

1. Emphasis on abilities and potential more or less unique to human


beings (e.g. logical thought and reasoning) and importance of people
being able to communicate these abilities in such a way that other people
can recognise them.
2. Ability to relate to other people (involving self-awareness and ability to
communicate capacities)
3. Aesthetic aspect of personhood (example given: ....”if a patient looked
like a distorted frog or monster, the patient might not evoke feelings of
sympathy or empathy and therefore might not be recognized as having
moral status or personhood....” p. 56)
4. Possession of additional capacities/human qualities (including
intellectual, emotional, relational and moral capacities). A superior
intellect in the absence of “human qualities” would not be considered as
reflecting personhood. [I wonder if they had in mind the possibility of
aliens]
5. “Speciesism” grounded in the “instinct” to identify with and value
people in our own group (which might include severely handicapped
people if part of “our own particular group”).
6. Status cues and the extent that a person is perceived as being wanted by
others.
7. The concept of a continuum whereby personhood evolves over time
through contact with the person concerned and through the development
of empathy and the creation of relationships.
The above themes represent how personhood is perceived by those who were
interviewed and is not an argument for viewing personhood in that particular
way. However, it reveals the way that personhood is seen as something that
arises out of social interaction. Each of the themes is linked in some way to
interaction between people, or at least to how people understand each other.
This combined philosophical and psychological understanding of personhood
combines both ethical and psychosocial elements.

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