ATTITUDES, SOULS, AND PERSONS: CHILDRENWITH SEVERE NEUROLOGICAL IMPAIRMENT†

Carl Elliott*Center for Bioethics, University of Minnesota, Minneapolis, Minnesota

What I want to do here is not so much to construct anargument as to confess some misgivings. My misgiv-ings concern children of a special kind who are

familiar to anyone who has spent much time around a pediatrichospital. These are children who are profoundly, irreversiblyneurologically damaged. I do not have in mind children who aresimply developmentally delayed. I mean children who willnever be able to speak, to walk, to sit up, or to feed themselves.Sometimes they are blind or deaf. Their intellectual abilities areextremely limited, often so much so that they have never beenable to recognize their own parents. The cause of their condi-tion is often anoxic brain injury or head trauma, or perhaps, lesscommonly, a genetic condition with neurological effects.

What do we make of these children? How are we sup-posed to treat them? There is often no reason to doubt that withthe proper kind of care they could live for many years intoadulthood. They require an extraordinary degree of attention,and not just by health care workers. Their parents often look likewar veterans, exhausted and shell shocked. Inevitably, questionsarise as to how aggressively to treat these childrens’ medicalproblems—whether to treat a pneumonia, or replace an intra-cranial shunt, or start dialysis, mechanical ventilation, or tubefeedings. These are burdensome interventions, most of them,but interventions that can often prolong a life.

Parents and pediatricians invariably want to do what is bestfor the child. But when they ask me what I think would be best,I am at a loss as to how to respond. Best interests? What are theinterests of such a child? Sometimes they seem to take pleasurein being stroked or being in the water; on the other hand, theyoften feel pain—from spastic limbs, perhaps, or more often,from the medical procedures they have to undergo. Are theyloved? Yes, often very deeply. The lives of entire families areoften structured around the care of such children and are markedby a special kind of grace and tragedy. Often the parents andsiblings of such children have made personal sacrifices of heroicproportions, but are still haunted by guilt for what they have notdone, or for the things they have secretly wished for. The ironyis that the object of this guilt and sacrifice and love is totallyunaware of it. How are we supposed to think about a life likethis from a moral point of view? Does it make any sense to thinkabout the “best interests” of such a child?

In his classic article “Toward an Ethic of Ambiguity,”John Arras points out that when a child is devoid of any of thecapacities we think of as distinctly human, asking about his orher “best interests” amounts to little more than asking which

way the balance of pleasure and pain tilts.1 Some severelyimpaired children will be in unremitting pain, and then we cansay with some confidence that the balance tilts toward with-holding or withdrawing treatment. But what about childrenwho are not in pain, but who lack (and will always lack) thecapacity to think, to communicate, to give love, or to beconscious of receiving it? The answer to the question of whethersuch children have an interest in continued life will often be atentative “yes.” But it will be a “yes” tinged with hesitation anduncertainty, because the question seems to skirt the more fun-damental problem, which is whether the language of “interests”really captures what is morally at stake. Can we do no betterthan to think of these children as repositories of pleasure andpain?

Personhood and Thick Ethical ConceptsOne well-traveled avenue that philosophers addressing

these issues have taken is the one that leads to the question,“What is a person?” The idea here, of course, is that in order todetermine the moral status of severely damaged or limitedhuman beings, we must ask ourselves whether or not they arepersons. Why? Because we all know, more or less, what themoral status of a person is—that persons deserve a certain kindof respect, that they have rights, that we owe them duties thatwe do not owe animals or nonsentient life, and so on. If aneurologically damaged child (or for that matter, an anence-phalic, a fetus, or an adult in a persistent vegetative state) is aperson, then we must treat her morally as we treat other persons.But if she is not, then we are justified in treating her in otherways—say, as a being whose interests can be safely overriddenfor the interests of those who are persons.

So how do we tell what a person is? By their capacities:intelligence, speech, self-consciousness, abstract thought, theability to relate to others, and so on.2 So, the argument goes, thereason we might be inclined to say that these severely damaged

†From: Slow Cures and Bad Philosophers: Essays on Wittgenstein, Medicine, and Bioethics,pp. 89–102, 2001. Edited by Carl Elliott. � 2001, Duke University Press. All rightsreserved. Reprinted by permission of Duke University Press.*Correspondence to: Carl Elliott, Associate Professor (Philosophy, Pediatrics), Directorof Graduate Studies, Center for Bioethics, University of Minnesota,Suite N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455. E-mail:ellio023@umn.eduReceived 5 December 2002; Accepted 11 December 2002Published online in Wiley InterScience (www.interscience.wiley.com).DOI: 10.1002/mrdd.10054

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIESRESEARCH REVIEWS 9: 16–20 (2003)

© 2003 Wiley-Liss, Inc.

children are not persons is that their ca-pacities, and their potential to developthese capacities, are so limited. If youcannot and will never think, speak, un-derstand language, or form a relationshipwith others, you are not a person andtherefore do not have the moral status ofa person. Englehardt, for example, argu-ing that adults are persons because of thefact that they are free, rational, and re-sponsible for their actions, concludes thateven normal children are not persons: “Ifbeing a person is to be a responsibleagent, a bearer of rights and duties, chil-dren are not persons in a strict sense.”3

So what is wrong with this ap-proach? Part of the problem is its (unstat-ed) view of the philosopher’s role: as akind of language czar, who devises stan-dards for the use of words and tells thelinguistic community how to use them.“Person” is thus transformed from its or-dinary use to a technical, philosopher-defined use, which, on Englehardt’s con-ception, does not include children. Butthe point of this kind of definitional ex-ercise, while widely accepted (at least im-plicitly) in analytic philosophy, is by nomeans clear, nor is the exercise practicallyuseful in any obvious way. In any case, itis subject to the kinds of criticisms thatWittgenstein levelled against philosophi-cal theory: “It is not our aim to refine orcomplete the system of rules for the useof our words in unheard-of ways”(PI § 133).

A more damaging problem withthis approach, however, is the way itconfuses what Wittgenstein would callthe “grammar” of the word “person.” Itsuggests that “person” is a factual term,one that can be answered by looking at abeing’s capacities or potential for devel-oping those capacities. But then it as-sumes that the answer will give us moralguidance: tell me if this is a person, and Iwill tell you what you ought to do. Thisexpectation is, however, deeply con-fused. “Person” is a moral term, not justa factual one, and the question “Is thisbeing a person?” is itself a moral ques-tion.

“Person” is what philosophers suchas Bernard Williams would call a “thick”ethical concept, one that represents a fu-sion of fact and value.4 Thick ethicalconcepts are unlike the very general eth-ical concepts such as good and ought uponwhich moral theorists have tended toconcentrate, and whose meanings are al-most entirely evaluative. But they are alsounlike purely factual words such as“curly,” “purple,” or “carrot.” Theyhave both factual and evaluative ele-ments; that is, they fuse “is” and “ought.”

Thick ethical concepts like coward, bully,cruel—and, so I would argue, person—map onto things in the world, like purelyfactual concepts, but they also representethical evaluations of those things ontowhich they are mapped. In other words,to call a person a coward or cruel is topick out and describe something abouthim, in the same way as calling him afather or a Canadian, but it is also tocommunicate a particular type of ethicalevaluation. And the ethical evaluation isnot something that follows from the de-scription, nor is it a kind of add-on, orattachment. It is built right into themeaning of the word.5

This is the reason it is misguided tothink we can decide what beings are per-sons by purely factual criteria. To try todevise purely factual criteria for applyingthe word “person” is like trying to devisepurely factual criteria for applying theword “coward.” Criteria for being acoward that made no mention of anykind of ethical evaluation—that did notconvey that cowardice involves a failureof courage, that to call a person a cowardis to insult him, that to behave like acoward is something that one ought notto do, and so on—such criteria wouldnot be able fully to convey the meaningof the word. Indeed, it is hard to see howone could understand how people applya thick ethical concept without sharing (ifnot actually, at least imaginatively) theevaluative component. Without at leastan imaginative understanding of whatsort of evaluation is carried by wordssuch as “coward,” “cruel,” or “person,”these concepts would simply be arbitraryways of dividing up the world.6

Attitudes and SoulsIn the Philosophical Investigations,

Wittgenstein writes, “My attitude to-wards him is an attitude towards a soul. Iam not of the opinion that he has a soul”(PI § 178). I want to suggest that to treata severely neurologically damaged childas a person—or, in Wittgenstein’s moreapt phrase, as a “soul” —involves takingup a certain attitude toward him. By “at-titude,” I mean the kind of stance im-plicit in our dealings with other persons,such as the recognition that a person de-serves a special kind of respect, that he orshe is to be given a proper name (ratherthan, say, a number), that he or she is tobe referred to with the pronouns “he” or“she” and “him” or “her” rather than“it,” and so on. Taking up this attitudetoward a person does not follow neces-sarily from any fact about him; it is not alogical consequence of anything that Ibelieve about him (“I am not of the

opinion that he has a soul”). Rather, theattitude—an attitude toward a soul—isbuilt right into the language that we useto describe him.

Our uncertainty about severelydamaged children, it seems fair to say, isless about whether they are properly de-scribed as “persons” than about what at-titude toward them it is appropriate toadopt and what language best expressesthis attitude. The problematic ethicalquestions that bioethicists tend to askabout such children—can we allow thischild to succumb to an easily treatablepneumonia? are we obligated to ventilatea vegetative patient indefinitely at theparents’ request? can we transplant aheart from an anencephalic child?—areproblematic exactly because they are sit-uated within this broader uncertainty. Ifwe are uncertain how to answer theseethical questions, it is because ourbroader, more general attitudes towardthese children are themselves ambivalentand poorly articulated.

Now, to take up this sort of atti-tude toward a human being—an attitudetoward a soul—is in part to recognizethat she is the proper object of certainmoral attitudes. That is, it is to recognizethat we have duties toward her, that shehas rights, and so on. But an attitudetoward a soul, I want to suggest, is notsolely a moral attitude. It encompasses allthe complex ways that we treat our fel-low human beings. Some of these mayinvolve moral attitudes, such as the ideathat all human lives have dignity, or thatall lives are to be valued equally. Butothers seem closer to matters of custom,manners, or tradition, such as the ideathat a person should be referred to by aname, or that when a person dies sheshould be given a funeral. Our moralattitudes are situated within this muchbroader family of attitudes.

All this is to say that our ambiva-lence about how to behave toward theseseverely damaged children is not solely amoral ambivalence. It is a broader am-bivalence about what attitude is appro-priate to such damaged, limited humanlives. Let me give an example. I wouldfind it very disturbing, though not in anystrictly moral sense, to see parents hold abirthday celebration for an anencephalicchild—to bring him a cake, put a birth-day hat on him, sing to him, and so on.Why? Partly, perhaps, because the childwill never be capable of recognizing thesignificance of the event; partly also be-cause the celebration would remind meof the gap between an anencephalic andordinary children, like my own. But Ithink these are part of a larger reason,

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which is that a birthday celebration im-plies that an anencephalic is a child likeany other. And celebrating the birth of ananencephalic suggests that we take up thesame attitudes towards her that we taketoward other children: that this child willbe a part of the family like any otherchild, that her life will have a narrativelike that of an ordinary human being,from birth through childhood and adult-hood to death. It suggests that this is thekind of being for which a birthday cele-bration is appropriate. And what seemspainfully obvious is that an anencephalicis not such a being; that the reasons whywe celebrate a birthday are absent here;that the passage of another year of life canhave no meaning for a being without acortex.

Now, by saying that taking up suchattitudes would not be morally disturb-ing, I do not mean to trivialize them or toimply that they would have no moralresonance. I only want to make the pointthat these attitudes should not be reducedto their moral components; that the word“moral” does not fully capture what it isto take up such an attitude; and thatwhen we take up the wrong attitude, itdoes not seem quite right simply to callthe attitude immoral. I might say, forexample, that it is immoral for parents torefuse to give their children names, or,even worse, to give them names like, say,Fluffy, or Rover; it is immoral, but it isnot simply immoral. It seems closer to thetruth to call it unsettling, or even justcreepy, because it seems to represent aninappropriate attitude to take up toward achild. It suggests the attitude one takestoward a thing or a pet; it denies the childher humanity. Many of us would find itdeeply disturbing. But the reason is thereverse of the reason the birthday cele-bration for an anencephalic is disturbing,which is that the celebration seems toattribute to that child a humanity that shedoes not have.

This may help to explain some ofthe rancor and division over the issue ofusing anencephalics as organ sources.Opposition has little if anything to dowith cruelty, suffering, or violations ofrights, but rather is often expressed interms like “dignity” and “respect.” Thiskind of language expresses a discomfortwith the attitude toward the anence-phalic that using them as organ sourcesseems to represent. It comes close totreating them as objects or things. Butwhat is wrong with treating them as ob-jects, one might say? They are nevercon-scious beings, more like corpses than hu-man beings. The answer, I suspect, hassomething to do with what Wittgenstein

is gesturing toward when he writes, “Thehuman body is the best picture of thehuman soul” (PI § 178). Anencephalicsare, after all, living infants who oftenlook very much like ordinary infants. Itshould not be all that surprising thatmany people (especially parents) find itdifficult to take up the same attitude to-ward them that we do towards objects oreven corpses.

Yet neither is it easy to take up thesame attitudes toward them as towardordinary human beings, and it should notbe surprising that the attitudes of doctorsare often much different from those ofparents, or even the lay public. When Iwas a thirdyear medical student, my ro-tation in internal medicine took place atthe county hospital in Charleston, SouthCarolina. I can remember following oneof the interns on ward rounds, a partic-ularly sharp and easygoing man who,when the rotation began, took the timeto introduce me to each patient on theward, most of whom were (this being acounty hospital in South Carolina) poorand black. We passed through the roomof one patient, an elderly woman whowas, if not permanently vegetative, veryclose to it. She was getting no treatmentother than tube feedings and hydration.The intern’s instructions to me wereroughly this: “Think of it this way. She’sa plant; you’re the gardener; your job isto make sure she is watered.” And thenwe moved on to the next patient.

To understand why this kind ofremark is in equal parts callous, deeplyembarrassing, and, in a despairing way,weirdly appropriate, you probably willneed to have spent some time in a county(or Veterans Administration) hospital,where exhausted and often bitter resi-dents take care of America’s sick anddisabled poor. This is the vacuum inwhich attitudes toward severely impairedpatients develop, and the intern’s remarkreflects those attitudes: hostility at havingto take care of such a patient, a sense offutility surrounding her future, and a sen-sibility trained to ignore deeper questionssurrounding life and death.

Forms of LifeAnother way of making these

points would be to say that we havedeveloped a certain kind of language thatwe use in describing ordinary persons,their behavior and mental lives, and ourbehavior toward them. It includes notonly moral language, but also the lan-guage of religion, kinship, ritual, politics,and so on. The moral question iswhether, and in what ways, this language

extends to such severely damaged chil-dren.

But putting it this way makesthings sound simpler than they are. Itsounds as if the attitudes we take uptoward other beings are essentially a mat-ter of what we decide. But this is not quiteright. Our attitudes toward other beingsare rooted in, if not exactly instinctivebehavior, still more or less thought-freebehavior—reactions rather than con-scious deliberations. (This is part of whyWittgenstein contrasts attitudes withopinions.) Now, I do not mean to sug-gest that all of our dealings with otherpersons are mechanical and withoutthought—that we do not make consciousdecisions to argue with other people, orto flirt, or to joke with them. What isdoes mean is that in the background of allthis behavior is the attitude that this is thekind of being with which you can argueand flirt and joke. And this attitude is notsomething that we ordinarily decideupon; it is simply what we do. As Witt-genstein says, “The essence of the lan-guage game is a practical method (a wayof acting)—not speculation, not chatter”(PO, p. 399).

Now, does this mean that whatattitude we take toward another being issomething over which we have no con-trol, or that it cannot be influenced bythe will? Of course not. To take a super-ficial example: think, for example, of thedifferent attitudes a doctor takes toward ahuman being, first, when he is percussinghis chest, and next, when he is playingagainst him on the basketball court. Anattitude toward a human being as theobject of a diagnostic examination is dif-ferent from an attitude toward a humanbeing who is about to take you to thehoop. Patients are different from oppo-nents. And which attitude you take up ismore a kind of unconscious reaction, de-pending on the context, than a consciousdecision. It is less like changing yourmind than like falling back into a habit.Another way to put this point is to saythat our attitudes toward other beings arebuilt into the language that we use todescribe them, and the language is em-bedded in a way of behaving towardthem—what Wittgenstein calls a “prac-tical method.” This practical method isnot something that is best described asdeliberative action, but something that isreactive and habitual. As Wittgensteinputs it: “The origin and the primitiveform of the language game is a reaction;only from this can more complicatedforms develop. . . . Language—I want tosay—is a refinement. ‘In the beginningwas the deed’” (PO, p. 395). This point

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is connected to another problem in thedebate over personhood, or the quest tofind some key difference between theseseverely damaged children and a personand to put your money on that differenceas the morally crucial characteristic. Phi-losophers have tried on various occasionsto name, as the morally crucial character-istic, consciousness, the capacity forspeech, and the capacity to feel pain,among many others. The point I wouldlike to make, following Cora Diamond,is that it is not enough just to ask whethera given characteristic is morally impor-tant; we also have to ask what a particulargroup of human beings has made of thatcharacteristic.7 A biological characteristicbecomes something for moral consider-ation when human beings make some-thing of that characteristic: in their reli-gion, art, literature, rituals, institutions—and in their ethics. In some cultures ayoung girl’s menarche is of tremendousmoral significance, while in others it isnot. Some cultures make a lot of thedifferences between men and women,while others do not. Menopause is im-portant for some cultures, for others not.The birth of twins may be, depending onthe culture, a sign from God, a curse, ornothing other than a reason to dress thechildren alike and give them rhymingnames. My point is that saying somethingabout the moral significance of these bi-ological characteristics (or lack thereof) isnot just a matter of saying somethingabout those characteristics themselves,but of the form of life in which thosecapacities do or do not make a difference.

Think, for example, of the waysthat we North Americans distinguish be-tween the concepts of pets, livestock, andvermin. In the case of rabbits, there are nobiological differences that distinguish be-tween the categories. We eat rabbits aslivestock, we keep them as pets, and wepoison them as vermin when they getinto the garden. Our attitudes towardrabbits differ dramatically in all threecases, and so does the way we treat themmorally, but these differences do not de-pend on their biological characteristics.Another example: Westerners, unlikemany Asians, find it horrifying and repul-sive to think about eating a dog. Is thisexplainable in terms of the dog’s charac-teristics? No, or at least not wholly; and ifyou want to understand why a peoplefind this horrifying, you have to under-stand what a culture has made of thesecharacteristics.

This helps explain why, in the caseof neurologically damaged children, con-structions such as “best interests” oftenseem less than helpful. We can say that

severely damaged children have an inter-est in avoiding pain and in things thatgive them pleasure, but we cannot saymuch more. It is even hard to say, stick-ing solely to the language of interests,why severely damaged children like thishave an interest in avoiding things thatmany people have a gut reaction against,like being used as a living organ donor,or being anesthetized and used as teach-ing instruments, or, to use an examplefrom a science fiction short story, havingtheir skin used as handbag leather afterthey die. If we want to say why we findsuch things repellent and horrifying, weusually fall back on concepts such asharms to dignity or the “symbolic value”of a body, which may not explain muchbut at least get us closer to the idea thatthese actions represent objectionable at-titudes toward such children.

CONCLUSIONI have tried to express some of my

misgivings about the notion that we candecide how to behave toward neurolog-ically damaged children based solely ontheir capacities, or even by asking what isin their interests. How we think aboutand behave toward them is tied to theattitude we take toward them, which isin turn tied to a form of life. But whatdoes this tell us?

First, it suggests that there is nosingle morally correct attitude to taketoward such infants, but rather a range ofattitudes, which are in turn embedded inparticular cultures. It would not surpriseme, for example, to hear an anthropolo-gist speak about one culture that reveredsuch damaged children and another cul-ture that simply discarded them, and thateach attitude was tied in complex andsubtle ways to the culture’s religion,structures of kinship, beliefs about healthand illness, and so on. Even in our own(Western) culture(s) we hear a broadrange of opinions on the appropriate be-havior toward such children that touchon everything from infanticide to disabil-ity rights to the sacredness of every hu-man life. The capacities and interests ofsuch damaged children do not give us, orany culture, a determinate answer onhow to behave toward them. And howwe do behave toward them cannot bethought about separately from all of ourother cultural resources.

Second, I do not believe we cancompletely separate how we think aboutdamaged children from the way we thinkabout ordinary children. A culture mightwell think about severely damaged chil-dren in very different ways dependingon, say, whether they think of children as

a kind of family property, or whetherthey think of a damaged child as a kind ofcurse or divine retribution, or whetherthey think of the deaths of a number ofsmall children as natural or unavoidable.8In such contexts one can imagine thedeath even of a less severely impairedchild to be a matter of indifference, oreven something to be desired. But theseare not the ways we in industrializedWestern countries have come to think ofchildren. We have inherited a certainideal of the family and its importance,and while our attitudes toward childrenare complex and often contradictory, it iscertainly true that we devote consider-able resources to thinking about therights of children and our duties towardsthem.9 We treat them as, if not ends inthemselves, at least ends to be, and manypeople think of their children as the mostprecious and important things in theirlives. Whatever attitudes we hold towardseverely neurologically damaged childrenwill have to be reconciled with thesemore general attitudes toward childrenand family life.

Finally, and perhaps most crucially,whatever our attitudes toward severelyimpaired children, they will have to bereconciled with broader cultural under-standings about the purpose and signifi-cance of human life. By this I mean notjust what Wittgenstein calls Lebensformen,or forms of life, but that dimension ofLebensformen relating to questions such aswhat constitutes a meaningful life, orwhen a life has sense, or what kind of lifecounts as a success or a failure. Differentcultures and different eras have asked andanswered such questions in dramaticallydifferent ways, of course, and many in-dividuals may answer them differentlyeven within a single culture, especially inimmigrant countries such as the UnitedStates and Canada. But understandingsabout questions such as these form thebackdrop against which human practicestake place and help shape our concep-tions of the moral dimensions of thosepractices, including our actions regardingseverely impaired children.

What is particularly difficult to rec-oncile here are our attitudes toward suchchildren and certain widely shared West-ern views about the meaning of humanlife. I have in mind the cluster of convic-tions surrounding what Charles Taylorcalls “the affirmation of ordinary life.”10

These convictions locate significance inthings like our families and the people welove, but also in meaningful work—thesatisfaction of artistic or literary creativ-ity, the sense of higher mission involvedin social or political activism, the gratifi-

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cation of doing a job well, the fulfillmentof a moral duty to provide for one’sfamily and loved ones. These kinds ofconvictions locate significance largely inthe individual and how he or she choosesto live a life. Thus, the significance of alife is intimately tied to the choices aperson makes, which may involve, forexample, developing a relationship withGod, fulfilling a calling, carrying outone’s duties, or many other things.

What makes these understandingsabout the significance of life difficult toreconcile with our attitudes toward chil-dren is that such understandings make ameaningful life inaccessible to any childwith severe neurological impairment.(And, for that matter, to many childrenand adults with less serious damage.) If aperson will never be capable of appreci-ating the emotional bonds of family, willnever be able to find meaning throughthe life of work, and will never be able toreturn love to another human being,then she will not be able to live the kindof life to which many Western culturesgive meaning. This is not the only way ofseeing the lives of such children, ofcourse. Things might be otherwise incultures where meaning is bound upwith a being’s place in the natural order,or with the transmigration of souls, orany number of other cosmologies. Butthese are not the cosmologies that formthe selves of most Westerners. Perhapsthis is why the lives of profoundly dam-aged children strike many Westerners asespecially tragic. These children throwinto vivid relief the contrast between thekind of life that allows us to achieve thegoods that make life worth living and the

very different kind of life that lies aheadfor such a child.11

This may help us to understand theinternal contradictions of clinical deci-sions for these children and the reasonswhy they often appear so intractable. Onthe one hand, we are understandablywary of withholding or withdrawingbeneficial treatment for such children.We are the inheritors of a strong traditionof rights and equality that makes us re-luctant to withhold treatment from a per-son on the grounds of her intelligence ordisabilities. We also see that the lives ofthese children may have deep signifi-cance for their families. Yet on the otherhand, we recognize that these lives fail tomeet the criteria by which we count ourown lives as meaningful. We try to con-vince ourselves that we should protectvulnerable lives, but we cannot imaginethis as a life we would want to continueliving. We say all lives deserve respect,but our measure of the good life forourselves does not include a life like this.We say that all lives are equal in the eyesof God, but we wonder why God hasallowed such a life to come into being.

NOTES1. John Arras, “Toward an Ethic of Ambiguity,”

Hastings Center Report 14 (Apr. 1984):2533.

2. For a sampling of such writings on personhood,see H. Tristram Englehardt, “Ethical Issues inAiding the Death of Young Children,” inIntervention and Reflection: Basic Issues in Med-ical Ethics, 4th ed., ed. Ronald Munson (Bel-mont, Calif.: Wadsworth, 1992), pp. 119–126; Joseph Fletcher, “The CognitiveCriterion of Personhood,” Hastings Center Re-port 4 (Dec. 1975): 4–7; Mary Anne Warren,“The Moral Significance of Birth,” in Femi-nist Perspectives in Medical Ethics, ed. HelenBequaert Holmes and Laura M. Purdy

(Bloomington: Indiana University Press,1992), pp. 198–215; Michael Tooley, “Abor-tion and Infanticide,” Philosophy and PublicAffairs 2, no. 1 (1975): 29–65; John A. Rob-ertson, “Involuntary Euthanasia of DefectiveNewborns,” Stanford Law Review 27 (1975):246–261; Daniel Dennett, “Conditions ofPersonhood,” in The Identities of Persons, ed.Amelie Oksenberg Rorty (Berkeley: Univer-sity of California Press, 1976); and variousessays collected in What Is a Person? ed. Mi-chael F. Goodman (Clifton, N.J.: HumanaPress, 1988).

3. Englehardt, “Ethical Issues in Aiding the Deathof Young Children,” p.120.

4. Bernard Williams, Ethics and the Limits of Philos-ophy (Cambridge, Mass.: Harvard UniversityPress, 1985), p. 129.

5. Cora Diamond has made this point more force-fully than I have here in her extraordinaryessay “Eating Meat and Eating People,” inThe Realistic Spirit: Wittgenstein, Philosophy,and the Mind (Cambridge, Mass.: MIT Press,1995), pp. 319–334.

6. Williams, Ethics and the Limits of Philosophy, p.141.

7. See Diamond, “Eating Meat and Eating People.”8. For two very different cultural worldviews and

their relationship to children, see, e.g., NancyScheper-Hughes, Death without Weeping: TheViolence of Everyday Life in Brazil (Berkeley:University of California Press, 1992) andAnne Fadiman, The Spirit Catches You and YouFall Down: A Hmong Child, Her American Doc-tors, and the Collision of Two Cultures (NewYork: Farrar, Straus and Giroux, 1997).

9. For a provocative and deeply moving account ofsome of these contradictions, see John D.Lantos, Do We Still Need Doctors? (New York:Routledge, 1997).

10. See Charles Taylor, Sources of the Self The Mak-ing of the Modern Identity (Cambridge, Mass.:Harvard University Press, 1989).

11. One of the few works I know of that takes onthese deeper questions about dying children isthe wonderful essay by Margaret Mohrmann,“Are Children Our Future? Reflections onDestiny and Dying Children,” presented at aconference on Bioethics and Human Destiny:Jewish and Christian Perspectives, LomaLinda Center for Christian Bioethics, LomaLinda, California, February 1997.

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