1This paper discusses whether and how metaphysical theories of the human person can also have moral implications, particularly on attitudes and obligations towards patients with disorders of consciousness, in particular patients in a chronic vegetative state.
2Several philosophical questions about the person are related but different, such as the question of the metaphysical essence of the person (what it is to be a person, as opposed to a nonperson), the problem of personal identity (spatio-temporal permanence – persistence question – and the conditions for reidentification – evidence question), and the problem of the person in a moral sense (what moral implications for an entity that is recognized as a person) (Olson, 2007). In this regard, it is important to recognize the distinction between metaphysics and ethics of the person and avoid deriving a complete set of moral principles solely from metaphysical theories. Doing so risks committing the is-ought fallacy, as descriptive statements cannot logically entail prescriptive claims.
3However, while metaphysical commitments cannot logically entail moral conclusions, certain theoretical approaches may carry prescriptive force by informing, influencing and constraining ethical considerations. Specifically, the connection between metaphysical and moral issues seems particularly strong when considering questions of personal identity and bioethics (or neuroethics). It seems reasonable to think that criteria for the existence and persistence of personhood could shape moral attitudes concerning moral personhood, in particular towards individuals in blurry and complex situations, such as patients with disorders of consciousness. I will analyze some metaphysical theories of the person, discussing potential ethical implications for the care and management of patients in vegetative states, a specific condition under the broader category of disorders of consciousness.
4First, some definitions are necessary to avoid misconceptions:
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- 1 Moral status can be conceptualized as either a graduated spectrum or a binary “all or nothing” stru (...)
Moral status: X has moral status if and only if x is worthy of direct moral consideration. By direct moral consideration I mean the identification of non-derivative and non-mediated obligations or values, as the object of evaluation is the entity itself by virtue of its intrinsic values.1 By indirect moral consideration, on the other hand, I mean the identification of derived and mediated obligations, i.e. those which, although addressed to that entity, derive their motivation from some relationship with other entities.
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Moral personhood: If an entity is regarded as a person, then it has full moral status (i.e., highest degree) and vice versa (Jaworska & Tannenbaum, 2019). In this sense, we can speak of the dignity of the person, which produces an effect of recognition respect (Darwall, 1977) that takes the form of stringent duties of non-interference, non-maleficence, and fair treatment, as well as – not as stringent – demands for assistance and of beneficence.
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- 2 In 2010, the alternative notion of Unresponsive Wakefulness Syndrome (UWS) has been proposed (Laure (...)
Vegetative state: The vegetative state (VS)2 is a condition due to severe brain injury in which the patient is in a state of wakefulness and maintains neurovegetative functions (e.g., autonomous breathing, sleep-wake cycle and spontaneous eye-opening, digestion, metabolism, thermoregulation), but without any clinical symptoms of self-awareness, awareness of the environment, and preserved cognitive functions (the patient may show some non-purposeful reflexive motor behavior and facial expressions) (Schnakers & O’Brien, 2023).
5In light of the frequent possibility of recovery of consciousness even after several months or years, various medical associations and institutions have recently begun to reject terms such as “permanent” and “irreversible” vegetative state, replacing them with “chronic” or “prolonged” (Giacino et al., 2018; Kondziella et al., 2020). Moreover, there is a large body of empirical evidence showing that there is still a significant rate of misdiagnosis of the vegetative state (i.e., cases of covert consciousness and cognitive-motor dissociation) (Young et al., 2021). However, for the sake of this specific theoretical argument analysis of theories of the person, when referring to the vegetative state, I will assume an ideally 100% certain diagnosis, both in terms of the absence of awareness and the absolute impossibility of future recovery.
6Second, to circumscribe the target of the paper, some other premises are necessary to determine the range and limits of the argument:
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I will refer to issues related to human beings, although some of the theories of personhood here analyzed may also refer to nonhuman entities.
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I will refer to real-world non-branching cases, specifically the vegetative state.
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I will only refer to accounts that support that personhood is derived from properties related to human beings as such. I will not consider those theories that understand personhood (ontologically and/or morally) as an extrinsic product of special relations or conventional acts.
7There is a sort of misunderstanding about the concept of person that we use in everyday language, a misunderstanding that has reverberated in the bioethical domain and more recently extended into the field of neuroethics (Blumenthal-Barby, 2024). This issue becomes clear if we take the vegetative state as a case in point. Consider the following two statements:
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“A human being in a chronic vegetative state is not a person anymore and therefore we have no obligations towards them as such.”.
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“A human being in a chronic vegetative state is still a person and should be respected as such”.
8First, these two statements are not opposed with respect to the moral meaning to be given to the person. Both could support the idea that the person has as its intrinsic dignity; also, both sentences make sense to us. Indeed, the VS patient is no longer conscious, i.e., aware neither of himself nor of the world around him, so it may seem plausible to think that the person – somehow – is no longer there; on the other hand, that bodily individual who still breathes autonomously, has sleep-wake cycles, opens his eyes, and produces some reflex movement seems a human person like us, even if he is not conscious anymore. This represents indeed a challenging boundary case regarding the ascription of moral status. The metaphysical question of whether the VS patient is still numerically identical to their previous self, or now a distinct entity, carries significant ethical weight. How different metaphysical theories characterize personal identity and criteria for persistence can influence the moral obligations we have towards VS patients.
9The difference between the two sentences lies in the metaphysics of the person. Indeed, these two statements are based on different criteria of existence and persistence of the person, entailing not only theoretical but also moral consequences for personhood. The first statement is based on the functionalist account of the person, while the second on the substantialist one. The neo-Lockean functional view argues that the person is an intelligent entity possessing a set of mental functions or properties that allows the continuity of the self over time. The substantialist neo-Thomist view argues that the person is an individual entity that exists according to a rational nature, which also includes the vegetative and sensory faculties. From these two conceptual paradigms, a series of contemporary theories of the person emerge, which I will analyze and compare.
10It is possible to categorize some approaches to personhood in the field of bioethics and neuroethics of DOCs. These categories are characterized by the diverse ways in which the concept of person is understood from a metaphysical perspective.
11One way to distinguish these theories is to use the concept of sortal. “Sortal” is a term of Lockean origin but actually refers to the Aristotelian distinction between substance and accidents. Following David Wiggins’ theory, sortal concepts serve to provide the principle of individuation of continuants, that is, entities that continue to exist (Wiggins, 2001). According to Wiggins, in fact, a statement of individuation needs not only a spatiotemporal continuity of the entity, but also a concept capable of pointing to that entity. To understand the identity of an object, it is essential to link it to the sortal under which the object falls; in this sense, identity is dependent on the sortal concept, understood as that concept that answers the Aristotelian substantive question “what is it?” and provides principles of individuation to the object it instantiates. So, to say that a particular entity is the same as another in a particular time is to say that there is a general term or sortal that specifies the criteria of identity, persistence, and existence by providing the relation between different occurrences of that object.
12Wiggins differentiates substance sortals from phase sortals. While substance sortals answer the question “what is x?” or “what sort of substance is it?” (identification and reidentification), which applies to an entity at every moment of its existence (“a dog”, “a tree”, etc.), phasal sortals are a specific type of restriction of the substantive ones and apply to an entity but only when this entity has certain properties (“tall”, “big”, “short”, “brown”, “young”, “old”, “seedling”, “puppy”, etc.); in other words, it answers the question “what is/was/will be x at a certain period t of its entire existence?”.
13Now, through the lens of Wiggins’ sortal theory, we can pose a series of questions: What are the criteria for identifying and tracing the persistence of the entity determined by the concept of personhood? Is personhood itself a sortal concept? If so, is it a substance sortal or a phase sortal? Can the person provide principles for individuating a definite, persistently existing entity, or is it merely a temporary phase of a more general entity? More specifically, the key issue for disorders of consciousness is: what becomes of personhood in such conditions? Is a patient in a vegetative state (VS) still a person? Or have they become some other kind of entity instead? For instance, are they now simply a human being who has ceased being a person? Or do they remain a person in all respects despite their condition?
- 3 Numerical identity is grounded on the principle of the indiscernibility of identicals, which states (...)
14The concepts of numerical identity and qualitative identity might be helpful for understanding the relationship between phase sortals and substance sortals in this context. “Numerical identity” is the relation that every object has only with itself and with no other and concerns the uniqueness and spatio-temporal continuity of an entity: x and y are numerically identical if and only if y=x.3 For example, if one has a favorite mug that chips and discolors over time, it remains numerically identical despite those qualitative changes. Qualitative identity, on the other hand, concerns the similarity or sharing of properties between two objects. Two objects can be qualitatively identical, while being numerically distinct. For instance, two mugs from the same manufacturer may be qualitatively identical in shape, color, and pattern, yet they are still numerically distinct objects.
15In the specific context of this paper, the questions concerning the concept of personhood pertain primarily to numerical identity. i.e., whether and when a person ceases to be numerically identical to themselves over time following huge qualitative, intrinsic changes. The sortal analysis aims to clarify the metaphysical criteria for the numerical identity, persistence and reidentification of personhood. Taken together, one can assume the existence of four sortal relations between person and human being:
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the person as a substance sortal and the human being as a phase sortal;
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the person as a phase sortal and the human being as a substance sortal;
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the person and the human being as phase sortals;
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the person and the human being as substance sortals.
16Following this outline, I will briefly present the following theories: Personism (1), animalism (2), disjunctivism or hybrid view (3), constitution view and ontological personalism (4).
- 4 I adopt the term “personism” from J. Teichman (1996), in order to avoid possible confusion with twe (...)
- 5 One of the early and influential definitions of personhood in bioethics that established the standa (...)
17Personism4 argues that the concept of a person refers to an entity possessing a range of psychological functions or higher-order cognitive processes, e.g., self-awareness, sentience, interests, rationality, capacity for intersubjective relations, agency, and moral autonomy (Levy & Savulescu, 2009; Mcmahan, 2010; Singer, 2011).5 The person is a substance sortal in the sense of a being characterized by some of these capacities (depending on each sub-theory) and the psychological connection over time of the self. In this view, consciousness (and its correlated neural processes) plays a crucial role as the basis and sustaining function of mental processes (psychological – mental – or embodied – neurological – accounts of identity). Therefore, the criterion of consciousness is seen as necessary and sufficient for personhood, while entities that do not yet possess or have permanently lost this characteristic are not considered persons. The human being, on the other hand, is viewed as a phase sortal in relation to the person, because the person could potentially be transferred to another human being or an artificial system. Regarding the vegetative state, since personhood is the substance sortal, numerical identity is based on existing as a person, not merely as a human living being: when personhood ceases, one ceases to exist in an essential way. Thus, the person never actually enters the VS, so that the patient is something numerically different from the preceding person.
- 6 For some animalists, the substantial sortal may not be so much the “human being”, but rather the br (...)
18Animalism argues that we are human animals (members of the species Homo sapiens). Also, most animalists hold that human animals persist over time by virtue of brute-physical continuity (the continuation of biological life) rather than psychological continuity; therefore, psychological continuity is neither necessary nor sufficient for a human animal to persist over time. According to authors such as Eric Olson, what really identifies us is that we are human individuals who go through various stages of development, including that of being persons (Olson, 1997, 2007).6 As human individuals with reference to the substance sortal “human animal” (or animal of some kind), our numerical identity begins as embryos and ends with the cessation of the functions of the brainstem that guarantee the integration of the entire organic system. We can therefore transition through phases like childhood, adolescence, adulthood, and old age (all of which are phase sortals) while remaining the same human animals underneath. Similarly, as human animals, we can acquire the status of persons (defined according to the functionalist approach) and then lose it, like a phase sortal. According to animalism, the VS patient is alive and the same numerical individual, because, despite cortical damage, brain areas such as the brainstem, thalamus, cerebellum, etc. remain preserved, allowing for the normal continuation of various neurovegetative functions (autonomous breathing, sleep-wake cycle, digestion, metabolism, thermoregulation, reflex movements, etc.). Thus, the individual still exists and is the same numerical entity that was previously conscious before entering the vegetative state and losing personhood as a phase sortal.
- 7 In principle, according to the hybrid view, one could also conceive a case where the same individua (...)
19The disjunctivist approach or hybrid view lies somewhere between personism, which holds that we are persons understood as psychologically persistent entities, and animalism, which holds that we are animals that persist through biological continuity (e.g., Langford, 2014; Noonan, 2021). This approach argues that we are – necessarily – purely psychological persistence nor purely biological ones, meaning that we are neither solely animal organisms nor solely psychological persons. Rather, we are bio-psycho-continuers, entities that can maintain numerical identity through either psychological or biological continuity, which are treated as non-mutually exclusive sufficient conditions (both being phase sortals). The substance sortal is therefore the neutral continuer, while the person is a phase sortal connected with the psychological continuer, conceived in this case too through the functionalist psychological approach as an entity possessing a set of mental functions or properties that allows the continuity of the self over time. Therefore, the VS patient is numerically the same neutral continuer as before the brain injury, specifically a continuer who has permanently lost the psychological continuity condition but keeps existing as a continuer by virtue of their ongoing biological persistence.7
20The constitution view is based on the idea that it is possible for two objects of different kinds, with distinct persistence conditions, to exist in the same space and time. As Lynne Rudder Baker (2000) argues, constitution is a unity relation very close to identity, such that if x constitutes y at a given time, then x and y do not exist separately, although they are not the same entity. According to this view, the human body and person belong to two different primary kinds (two substance sortals) and therefore are ontologically distinct, though united by the relation of constitution. Specifically, a person is constituted by a human body but is not identical to that constituent body (Baker, 2000). The relationship of constitution is the same as the relationship between the statue and the piece of clay that constitutes it: just as the statue is not identical to the piece of clay, so the human person is constituted by the human body but not identical to it. Thus, persons are constituted by human bodies but are not identical to them since the former essentially possess the capacity for first-person perspective (while the human body does not). According to the constitution view, since the person is what essentially defines us or what we refer to as a human individual, then in a vegetative state, only the human body exists, as the capacity for first-person perspective is lost (aligning with the functionalist approach insofar as first-person perspective requires consciousness).
- 8 According to the substantialist approach, the term “person” denotes an individual entity existing b (...)
21Ontological personalism argues that the substance sortal that identifies us is the concept of “human persons”, which unifies both “human being” and “person”. In fact, when referring to a “human being”, we are not simply denoting a generic rational animality or mere biological membership in the species Homo sapiens, but rather precisely a (singular) human person.8 The human person is defined as an individual corporeal entity that exists by virtue of a rational nature. The rational faculty, which also encompasses the sensitive and vegetative faculties, provides the vital principle of the living, sentient, and thinking entity. Therefore, the human person, in both animality and personhood, exists essentially as long as the vital faculties persist. In this view, a patient with vegetative state (VS) remains a fully human person, as the rational nature continues to inform the living body through vegetative functions (Eberl, 2020). In other words, the patient is still a person by virtue of their rational nature, even if unable to exhibit or exercise specific functions or properties (e.g., consciousness, cognition, language, autonomy, etc.). This departs from other positions: the patient is neither a human animal who has lost personhood, nor a human being entirely disconnected from the identity of their previously conscious self. Rather, we still identify the patient as the same human person known before the pathological state, while recognizing – precisely because of the persistence of the same person – a radical difference in the manifestation of their rational nature – no longer as an actively exercised capacity, but as an inherent endowment (Kavanaugh, 2001).
22As mentioned in the Introduction, it is not possible to directly derive ethical consequences from the metaphysical level alone. Even if a theory might produce inconsistent outcomes from an ethical perspective, a robust moral theory of the person can still provide adequate duties, motivations, and recommendations for ethical action towards VS patients. Likewise, if a theory were to consider individuals in VS as persons in all respects, this would not automatically entail imposing absolute obligations such as protecting life at all costs or the inability to differentiate resource allocation between vegetative patients and those with other pathologies.
23Nevertheless, certain metaphysical theories of personhood may be better or worse equipped to plausibly account for liminal cases like the vegetative state, avoiding inconsistent arguments, highly counterintuitive results, or objections regarding their explanatory power and comprehensiveness. On a metaphysical level, I argue that ontological personalism seems better able to account for certain issues inherent to the vegetative state compared to other theories, avoiding a number of problems, such as those that follow.
24The intermittent person (personism, constitution view): If the sortal substance “person” depends on the contingent capacities of consciousness and cognition, a person’s life could be highly intermittent, which arguably is, at least, a counterintuitive conclusion and conflicts with the usual meaning of the concept (e.g., a person “emerges” after the initial mental development of the young human being, but then “ceases to exist” following an accident, only to “return” upon awakening from a subsequent coma and a few months in VS, eventually “vanishing” gradually after a period of progressive dementia).
25Personhood as accidental (animalism, disjunctivism): Treating personhood as a mere phase sortal (similar to “being a student”) seems to contradict what we typically intend by the concept of a person, which connotes essential characteristics and the persistency of the entity we consider to be such. This may be accepted if we definitively separate the metaphysical level from the moral level of personhood (but in practice, this is unlikely to occur).
26The indefinite substratum (disjunctivism): Referring to a neutral continuer as the substance sortal, with biological and psychological attributes as phase sortals, does not seem to offer sufficient criteria for individuation and persistence as required (what are we, precisely and fundamentally, not just accidentally?), nor practical factors for reference (we do not typically denote an indefinite, neutral continuer when speaking of a particular individual).
27The dual human-person subject (constitution view): It is difficult to understand how the two primary kinds (person and human being) relate to each other in coexistence; in particular, how and why only the person possesses mental properties, despite sharing the same physical and neurophysiological basis for first-person perspective with the human being. Positing that both have mental properties seems to double the number of corresponding entities and subjects, while arguing that the human being has mental properties only derivatively from the person (Baker, 2000) may commit to a psychologistic position (Olson, 2007).
28The non-rational person (ontological personalism): One could argue that in the vegetative state patient, rationality as general capacity for cognitive activity is lost, since the cortical areas associated with such processes are compromised. Therefore, the patient cannot be considered a person. However, this objection can be addressed by focusing on the concept of rational nature. While functionalist theories are grounded on criteria like consciousness, cognition, sentience etc. as capacities and/or properties in execution, ontological personalism considers these as manifestations of rationality as a natural disposition intrinsic to the human being, regardless of developmental or operating level. In other words, VS patients do not become humans or animals of a non-rational nature, nor do they cease to be persons simply because they are unable to perform rational mental activities in a given time.
29Taken together, ontological personalism seems preferable to other views for conceptual reasons, such as avoiding counterfactual implications about the cessation of existence due to temporary psychological changes, providing more stable criteria for identity and reidentification by anchoring them in a corporeal entity of rational nature, and being better equipped to handle boundary cases without denying personhood status based on mentalistic criteria.
30As for the ethical implications of these theories, we can infer potential normative consequences for patients in vegetative state. Personism, animalism, disjunctivism, and the constitution view are based on or accept the neo-Lockean functional concept of person. However, the way the person is considered for each theory, as substantial sortal or phased sortal, has different ethical implications (leaving aside the possible addition of extrinsic ethical justifications and consequently indirect moral consideration).
- 9 While some might consider these examples as exaggerated, recent developments highlight the practica (...)
31Following personism, patients with VS do not have an inherent right to life or moral status as they are not persons anymore. The metaphysical dualism between “human being” and “person” can have significant ethical consequences. Since the human being is not numerically identical with the person who existed before the vegetative state, not only does patients have no serious right to life, but, in principle, since they have no moral status, there are no direct obligations towards them. Since the holder of rights and moral worth is only the person, there is nothing to prevent the patient in a vegetative state from being killed or kept alive for other purposes, such as organ donation with a beating heart in the absence of previously obtained valid consent, or, one could imagine, for experimentation with new potentially dangerous drugs, or hypothetical organ cultivation for use by other patients (a sort of “factory” for the continuous production of the liver in times of resource scarcity).9 Not all proponents of personism may endorse such strong implications. Extrinsic values can be invoked to motivate indirect moral consideration (see §1) and ascribe partial moral status, such as respect for the patient’s biographical life, for the patient’s relatives, medical duties or other non-intrinsic factors (Gazzaniga, 2005). However, if we take seriously the ontological-ethical separation between human being and person, with the cessation of the person as the substantial sortal that identifies and determines our persistence conditions, there is arguably no person truly entering a vegetative state. On a theoretical and ethical level (not juridical), the previously existing person could lose any moral authority over the biological body and the content of their prior wishes (to sustain life, withdraw treatment, euthanasia, etc.).
32The animalist position is quite different from that of personism regarding the identification of entities through a sortal approach, since the substance sortal is the animal. However, the theoretical framework of the person is the same. On an ethical level, if a defender of animalism grants full moral status to the person, once the person ceases to exist as a phase sortal, there are two possible lines of consequences that can follow: (a) the human animal, as soon as it ceases to be a person, loses grounds for moral consideration, thus opening up possibilities for the use (and potential abuse) of the biological body, as previously outlined (in the absence of other extrinsic motivations to protect it); (b) the human animal, despite the irreversible loss of the sortal “person”, remains the object of indirect moral consideration for other reasons with partial moral status (as in some versions of personism, see above).
33The disjunctivist hybrid approach and the constitution view propose a less rigid view of personism and animalism, thus allowing the theory to be ontologically more “adaptable” in certain complex and ambiguous situations, such as the vegetative state. However, given that both theories rely on a functional conception of person, similar moral potential consequences may apply. As for the hybrid view, since the reference to the concept of person remains functionalist, one could assume the need for direct or greater moral consideration when the psychological phase sortal is present. In such a case, the VS patient does not possess the phase sortal “person”, so the possibilities and ethical consequences highlighted by animalism persist. As for the constitution view, once the substantial sortal “person” is lost, there is no reason to ascribe to the living human being any special moral status, since the sameness of the living human organism is not sufficient for the sameness of the person. In other words, the constitution view maintains the possibilities and ethical consequences highlighted with personism.
34Ontological personalism is the only theory presented here that is based instead on the neo-Thomist substantialist concept of person. This approach seems to reconcile both the intuitions that a VS patient persists as a human person, while simultaneously being different from their prior self (however, without a change in fundamental nature). In this sense, the theory argues that the statement “is no longer a person” refers to the change of qualities and mental properties that certainly characterize the individual (mainly personality and selfhood, but distinct from personhood itself), but these do not determine the criteria for existence, persistence, and reidentification. From an ethical perspective, the VS patient continues to persist as a person, that is, as an individual corporeal entity of rational nature, so there is no loss of direct moral consideration or full moral status in general.
35However, proponents of the functionalist conception of personhood might argue that the persistence of the person entails at least two problematic ethical consequences: the first pertains to issues of justice and fair allocation of resources. If VS patients possess full moral status as persons, it may become problematic to differentiate and prioritize moral obligations between them and patients with more acute conditions involving evident suffering (e.g., acute pain). A strict ontological personalism might have tough time with such morally relevant distinctions. The second is that ontological personalism might entail the risk of slipping into therapeutic adventurism, i.e., an excessive emphasis on cure over care, and into a total non-disposability of life, necessitating the prolongation of the patient’s existence at all costs, regardless of poor prognosis or quality of life considerations.
- 10 A supererogatory act is a morally good, voluntary action that goes beyond duty, is not required, an (...)
36Nonetheless, these two objections would stem from a perhaps superficial interpretation of the ontological personalist view. Regarding the first, it derives from a confusion between possessing full moral status and the resulting moral obligations. Granting a VS patient full moral status as a person does not necessarily entail obligations of beneficence so stringent as to become excessively burdensome (acting in that way would be supererogatory).10 Moreover, considering all patients equally as persons does not equate to placing all clinical conditions on the same level. Where a patient is consciously experiencing acute pain, the resources employed and therapeutic treatment will differ from those for a chronic vegetative case, based on appropriate medical criteria. What ontological personalism demands is a “decent minimum” level of care and assistance as a necessary (though not sufficient) condition for all persons. The second objection conflates the substantialist notion of personhood with the idea of the sanctity of biological life and confuses ontological personalism with a vitalistic approach. In fact, as Eberl (2020) argues, the continuation of a human person’s existence as a bearer of full moral status is a prima facie good. At the same time, avoiding unnecessary suffering and disproportionately burdensome interventions is equally required in order to respect the dignity of the person. In such cases, palliative care procedures are especially appropriate, and it may be morally justified to withhold or withdraw therapeutic interventions that are deemed disproportionate (Eberl, 2003).
37Certain conceptions of the person can influence moral agency, especially when certain metaphysical claims become part of common sense. With respect to theories that tend to underestimate or eliminate the moral status of VS patients, duties of respect for the individual regardless of the state of the patient can prevent or lower attitudes contrary to good clinical practice and acts of non-functional de-humanization (e.g., deindividuation, dissimilarity [Haque & Waytz, 2012]); on the other hand, with respect to theories that tend to consider the VS patient as a person of full moral status, cost-benefit analysis can provide useful information for clinical decisions in situations of scarce medical resources.
38In the preceding section, I have illustrated the various metaphysical and ethical issues that the functionalist approach faces regarding the vegetative state condition. In contrast, although also ontological personalism may raise potential critiques, it appears to be the most plausible and comprehensive theory in addressing the theoretical challenges posed by this liminal case. Now, moving beyond pure theory and recognizing the situation of epistemic and ethical uncertainty such that of VS diagnoses, I believe that an ontology of the person that favors the attribution of moral status to these patients is preferable also on a pragmatic level (beyond its metaphysical consistency). If variables such as geographic and cultural background, as well as religious beliefs can influence moral considerations and clinical decisions regarding patients (Demertzi et al., 2011), then it is reasonable to think that one’s internalized conception of personhood could similarly shape attitudes and approaches in complex clinical situations like the vegetative state.
- 11 I would like to thank Jason T. Eberl and Simone Grigoletto for their helpful comments on an earlier (...)
39Ontological personalism may result useful in improving certain attitudes and approaches to complex clinical and existential situations such as the vegetative state (Clark et al., 2025). Considering this, a clinical education based on a specific ethical perspective on personhood could influence – if not properly orient – some attitudes and habits of healthcare professionals towards patients. A personalist approach may encourage recognizing the patient’s intrinsic moral status, regardless of external obligations, relations, or extrinsic values. This orientation extends beyond single actions, promoting the development of a proactive and lasting ethical-professional habits towards patients with disorders of consciousness. Such a personalist ethics can increase attentiveness to new rehabilitative therapies and avoid numerous epistemic and ethical risks, such as therapeutic nihilism, prognostic pessimism, and self-fulfilling prophecy biases, by acknowledging these patients as vulnerable human persons rather than mere biological entities that need extrinsic values to gain some indirect moral consideration. However, it is important to avoid conflating respect for inherent personal dignity, as advocated by the personalist approach, with excessively empathizing with the patient. The latter, indeed, risks caregiver and healthcare professional burnout from an over-involvement with vulnerable patients’ difficult situations, compounded by the multidimensional burdens they face when caring for patients with disorders of consciousness (Leonardi et al., 2023).11
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