by Nick Payne
The emotional impact, and even the burden, of making significant healthcare decisions for another person can be considerable. The law provides a framework within which to operate, but even when there have been searching discussions about someone’s preferences regarding care, suffering, dignity and death, the gap between agreement in the abstract, and the reality of determining what happens to someone you love can be vast and overwhelming. If the person holding the lasting power of attorney is also the patient’s lover, sibling, child or spouse, he or she is steering a course through their own sense of loss and grief at the damage that illness has wrought.
What then might the ethical response be to someone who has impaired or lost memory? It is, I suggest, to do something that is simultaneously simple and difficult: to accept the person as he or she is now with compassion, empathy and acceptance. No matter how developed medical science becomes or how thoroughly we develop our understanding of disease, to attend to another person as he or she is, not as one would wish them to be, will always be a transformative act of care.
DEBORAH BOWMAN
Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law as well as Dean of Students at St George’s, University of London, and Editor-in-Chief at Medical Humanities Journal
mh.bmj.com @deborahbowman
The Science of Selfhood
The brain is wider than the sky,
For, put them side by side,
The one the other would contain,
With ease, and you besides.
Emily Dickinson,
Complete Poems, 1924
What does it mean to be a self? And what happens to the social fabric of life, to our ethics and morality, when the nature of selfhood is called into question?
In neuroscience and psychology, the experience of ‘being a self’ has long been a central concern. One of the most important lessons, from decades of research, is that there is no single thing that is the self. Rather, the self is better thought of as an integrated network of processes that distinguish self from non-self at many different levels. There is the bodily self – the experience of identifying with and owning a particular body, which at a more fundamental level involves the amorphous experience of being a self-sustaining organism. There is the perspectival self, the experience of perceiving the world from a particular first-person point-of-view. The volitional self involves experiences of intention, of agency, of urges to do this or that (or, perhaps more importantly, to refrain from doing this or that) and of being the cause of things that happen.
At higher levels we encounter narrative and social selves. The narrative self is where the ‘I’ comes in, as the experience of being a continuous and distinctive person over time. This narrative self – the story we tell ourselves about who we are – is built from a rich set of autobiographical memories that are associated with a particular subject. Finally, the social self is that aspect of my self-experience and personal identity that depends on my social milieu, on how others perceive and behave towards me, and on how I perceive myself through their eyes and minds.
In daily life, it can be hard to differentiate these dimensions of selfhood. We move through the world as seemingly unified wholes, our experience of bodily self seamlessly integrated with our memories from the past, and with our experiences of volition and agency. But introspection can be a poor guide. Many experiments and neuropsychological case studies tell a rather different story, one in which the brain actively and continuously generates and coordinates these diverse aspects of self-experience.
The many ways of being a self can come apart in surprising and revealing situations. For example, it is remarkably easy to alter the experience of bodily selfhood. In the so-called ‘rubber-hand illusion’, I ask you to focus your attention on a fake hand while your real hand is kept out of sight. If I then simultaneously stroke your real hand and the fake hand with a soft paintbrush, you may develop the uncanny feeling that the fake hand is now, somehow, part of your body. A more dramatic disturbance of the experience of body ownership happens in somatoparaphrenia, a condition in which people experience that part of their body as no longer theirs, that it belongs to someone else – perhaps their doctor or family member. Both these examples involve changes in brain activity, in particular within the ‘temporo-parietal junction’, showing how even very basic aspects of personal identity are actively constructed by the brain.
Moving through levels of selfhood, autoscopic hallucinations involve seeing oneself from a different perspective, much like in ‘out of body’ experiences. In akinetic mutism, people seem to lack any experiences of volition or intention (and do very little), while in schizophrenia or anarchic hand syndrome, people can experience their intentions or voluntary actions as having external causes. At the other end of the spectrum, disturbances of social self emerge in autism, where difficulties in perceiving others’ states of mind seems to be a core problem, though the exact nature of the autistic condition is still much debated.
When it comes to the ‘I’, memory is the key. Specifically, autobiographical memory: the recollection of personal experiences of people, objects, places and other episodes from an individual’s life. While there are as many types of memory as there are varieties of self (for example, we have separate memory processes for facts, for the short term and the long term, and for skills that we learn), autobiographical memories are those most closely associated with our sense of personal identity. This is well illustrated by some classic medical cases in which, as a result of surgery or disease, the ability to lay down new memories is lost. In 1953 Henry Mol son (also known as the patient HM) had large parts of his medial temporal lobes removed in order to relieve severe epilepsy. From 1957 until his death in 2008, HM was studied closely by the neuropsychologist Brenda Milner, yet he was never able to remember meeting her. In 1985 the accomplished musician Clive Wearing suffered a severe viral brain disease that affected similar parts of his brain. Now seventy-seven, he frequently believes he has just awoken from a coma, spending each day in a constant state of re-awakening.
Surprisingly, both HM and Wearing remained able to learn new skills, forming new ‘procedural’ memories, despite never recalling the learning process itself. Wearing could still play the piano, and conduct his choir, though he would immediately forget having done so. The music appears to carry him along from moment to moment, restoring his sense of self in a way his memory no longer can. And his love for his wife Deborah seems undiminished, so that he expresses an enormous sense of joy on seeing her, even though he cannot tell whether their last meeting was years, or seconds, in the past. Love, it seems, persists when much else is gone.
For people like HM and Clive Wearing, memory loss has been unintended and unwanted. But as scientific understanding develops, could we be moving towards a world where specific memories and elements of our identity can be isolated or removed through medical intervention? And could the ability to lay down new memories ever be surgically restored? Some recent breakthroughs suggest these developments may not be all that far-fetched.
In 2013, Jason Chan and Jessica LaPaglia, from Iowa State University, showed that specific human memories could indeed be deleted. They took advantage of the fact that when memories are explicitly recalled they become more vulnerable. By changing details about a memory, while it was being remembered, they induced a selective amnesia which lasted for at least twenty-four hours. Although an important advance, this experiment was limited by relying on ‘non-invasive’ methods – not using drugs or directly interfering with the brain.
More recent animal experiments have shown even more striking effects. In a ground-breaking 2014 study at the University of California, using genetically engineered mice, Sadegh Nabavi and colleagues managed to block and then reactivate a specific memory. They used a powerful (invasive) technique called optogenetics to activate (or inactivate) the biochemical processes determining how neurons change their connectivity. And elsewhere in California, Ted Berger is working on the first pro
totypes of so-called ‘hippocampal prostheses’ which replace a part of the brain essential for memory with a computer chip. Although these advances are still a long way from implementation in humans, they show an extraordinary potential for future medical interventions.
The German philosopher Thomas Metzinger believes that ‘no such things as selves exist in the world’. Modern neuroscience may be on his side, with memory being only one thread in the rich tapestry of processes shaping our sense of selfhood. At the same time, the world outside the laboratory is still full of people who experience themselves – and each other – as distinct, integrated wholes. How the new science of selfhood will change this everyday lived experience, and society with it, is a story that is yet to be told.
ANIL K. SETH
Anil K. Smith is Professor of Cognitive and Computational Neuroscience, and Co-Director of the Sackler Centre for Consciousness Science, University of Sussex
www.anilseth.com @anilkseth
FURTHER READING
A. K. Seth, ed., Thirty Second Brain (Ivy Press, 2014)
T. Metzinger, The Ego Tunnel (Basic Books, 2009)
D. Wearing, Forever Today: A Memoir of Love and Amnesia (Corgi, 2005)
About Nick Payne
Nick Payne’s If There Is I Haven’t Found It Yet was staged at the Bush Theatre in 2009 and went on to receive that year’s George Devine Award. He is a graduate of the Young Writers’ Programme at the Royal Court, where his next play, Wanderlust, opened in 2010 and was shortlisted for the Evening Standard’s Most Promising Playwright Award. One Day When We Were Young, in a Paines Plough and Sheffield Theatres production, was staged at the Crucible Studio Theatre, Sheffield, in 2011, and later transferred to Shoreditch Town Hall as part of the Roundabout Season. Constellations, which opened at the Royal Court in 2012 and transferred to the Duke of York’s Theatre, won the Evening Standard Theatre Award for Best Play. The Same Deep Water As Me was staged at the Donmar Warehouse in 2013 and was nominated for an Olivier Award for Best New Comedy. Blurred Lines (co-created with director Carrie Cracknell) was staged at The Shed, National Theatre, in 2014. Incognito, a co-commission between Nabokov and Live Theatre, Newcastle, toured the UK in 2014.
Also by Nick Payne
also by Nick Payne from Faber
IF THERE IS I HAVEN’T FOUND IT YET
WANDERLUST
ONE DAY WHEN WE WERE YOUNG
CONSTELLATIONS
THE SAME DEEP WATER AS ME
INCOGNITO
Acknowledgements
Professor Deborah Bowman, John Buzzetti, Alastair Coomer, Barbara Flynn, Ben Hall, Steve King, Kate Pakenham, Mum, Josie Rourke, Professor Anil Seth, Tom Scutt, Professor Murray Shanahan, Nina Sosanya, Zoë Wanamaker, Charlie Weedon, Lily Williams, Dr Rowan Williams, Dinah Wood and all the staff at the Donmar Warehouse.
I would like to acknowledge the following books and their authors: The Brain is Wider Than the Sky by Bryan Appleyard, Levels of Life by Julian Barnes, On Romantic Love by Berit Brogaard, Moonwalking with Einstein: The Art and Science of Remembering Everything by Joshua Foer, Keeper by Andrea Gillies, The Soul of the Marionette by John Gray, Leaving Alexandria: A Memoir of Faith and Doubt by Richard Holloway, The Future of the Mind by Michio Kaku, Inventing the Universe: Why We Can’t Stop Talking about Science, Faith and God by Alister McGrath, Stammered Songbook by Erwin Mortier, Thirty-Second Brain edited by Anil Seth, The Technological Singularity by Murray Shanahan and In Defence of Wonder by Raymond Tallis.
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First published in 2016
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Extract taken from Douglas Dunn’s ‘Anniversaries’ from Elegies © Douglas Dunn, 1985, reprinted by permission of Faber & Faber Ltd.
For the USA, extract from Alice Oswald’s ‘Wedding’ from Spacecraft Voyage 1: New and Selected Poems © Alice Oswald, 1996, reprinted with the permission of The Permissions Company, Inc. on behalf of Graywolf Press, Minneapolis, Minnesota, (www.graywolfpress.org); for rest of the world, reprinted with the permission of Faber & Faber Ltd, from The Thing in the Gap-Stone Style, © Alice Oswald, 2007.
Extract from Christopher Reid’s ‘A Scattering’ from A Scattering, © Christopher Reid, 2009. Reprinted with permission from the author and AretéBooks.
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