In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there is a (...) growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients’ knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption. (shrink)

This paper challenges the two aims of Michael Cholbi’s Rational Will View (RWV) which are to (1) offer an account of why paternalism is presumptively or pro tanto wrong and (2) relate the relative wrongness of paternalistic interventions to the rational powers that such interventions target (Sections 1 and 2). Some of a paternalizee’s choices harm their future selves in ways that would be wrong if they were done to others. I claim this challenges Cholbi’s second aim (2) because the (...) cases his account deems particularly wrong turn out to be not to be as wrongful as expected (Section 3). When this second aim is challenged, it has knock-on effects on the capacity of the RWV to discern which cases of paternalism are generally more wrongful than others, which undermines Cholbi’s first aim (1). I consider responses on behalf of Cholbi’s view but conclude that the account is insufficient on its own to vindicate its two aims (Section 4). Finally, I draw on recent work that adopts ideas from the practical reasoning literature to help determine paternalism’s wrongness (Section 5). I argue this helps Cholbi’s view withstand my objections, but we must remain skeptical of why interceding with rational powers is particularly wrong. (shrink)

Mill’s proscription that ‘the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others’ has become almost axiomatic in bioethics. 1 Bolstered by the rise of patient autonomy during the mid-20th century, Millian conceptions of freedom have become so embedded in bioethical theory, that attempts to justify paternalism have typically involved making one of two claims. Either, they have involved refuting the significance of autonomy as (...) an ethical principle, and questioning whether it should always be taken to outweigh other ethical principles. Or, they have sought to cast doubt on the autonomous quality of specific decisions, challenging them as non-autonomous in some important way. Both approaches are readily apparent in discussions about the moral authority of advance directives, where people have questioned both whether precedent autonomy should always outweigh the person’s current best... (shrink)

In a recent article, Wilkinson puts forward the notion of identity-relative paternalism. According to Wilkinson’s final formulation of this principle, ‘[i]ndividuals should be prevented from doing to future selves (where there are weakened prudential unity relations between the current and future self) what it would be justified to prevent them from doing to others’.1 In medical ethics, it is usually assumed that hard paternalism, that is, acting against a competent person’s wishes for their own benefit, is not justified. According to (...) Mill’s harm principle, we may only limit people’s freedom if they cause harm to others.2 Harm to self is not a sufficient reason for overriding competent persons’ decisions. Wilkinson, however, draws on Parfit’s reductionist view of personal identity to argue that sometimes, patients’ future selves are sufficiently disconnected from their present selves to treat future selves like different persons. If a competent person’s medical decision negatively affects a future self, this should be treated like a case of harm to others. Thus, overriding competent persons’ decisions in such cases—and treating them against their will—could be justified. In this commentary, I point out two problems with this approach. First, I demonstrate that the cases Wilkinson’s argument is based on are not examples of harm to others but rather cases of surrogate decision making gone wrong, …. (shrink)

Dominic Wilkinson’s defence of identity-relative paternalism raises many important issues that are well worth considering. In this short paper, I will argue that there could be two important differences between the first-party and third-party cases that Wilkinson discusses, namely, a difference in associative duties and how the decision relates to the decision maker’s own autonomous life. This could mean that identity-relative paternalism is impermissible in a greater number of cases than he suggests.

In The Harm Principle, Personal Identity and Identity-Relative Paternalism,1 Wilkinson offers a thoughtful argument about medical decision-making and Derek Parfit’s reductionist account of personal identity. I agree that Parfit’s account can contribute to the ethical analysis of patients’ choices. My own work in this area emphasises challenges the reductionist account presents to conventional understanding of advance treatment directives, particularly in cases involving people with dementia.2 I have also urged people making directives to consider the harm their directives could impose on (...) future selves with dementia.3 But as Wilkinson points out, Parfit’s account has implications in other medical contexts as well. Wilkinson presents examples of people making medical decisions that could impose serious harm on their future selves. These examples consider decisions made before a health crisis. Another kind of case involves people in the midst of illness who face a series of ongoing care choices. As people in this situation adjust to their …. (shrink)

Interference is paternalistic when it restricts an individual’s freedom for their own good. Anti-paternalists, such as John Stuart Mill, object to this for various reasons, including that the individual is usually a better judge of her own interests than the would-be paternalist. However, Wilkinson argues that a Parfitian reductivist approach to personal identity opens the door to what he calls ‘identity-relative paternalism’ where someone’s present action is restricted for the sake of a different future self.1 This is an interesting argument, (...) but it is not clear whether it involves permissible paternalism. At the risk of stating the obvious, permissible paternalism must be both permissible and paternalistic. Wilkinson’s identity-relative paternalism could be either, but not obviously both. If the present and future selves are different individuals, then interference is potentially permissible but no longer paternalistic. Alternatively, they are identical, in which case the interference is genuine paternalism, but cannot be justified by appeal to their distinctness. Wilkinson may escape this dilemma by invoking Parfit, who challenges the common notion that identity is all or nothing.2 According to Parfit’s revisionary view, the present and future self may share some connections but not others. However, once we have identified these similarities and differences, there is no further question whether or not they …. (shrink)

I am grateful to the commentators for their thoughtful engagement with my paper.1 I am unable in this short response to reply to all of the important questions raised. Instead, I will focus on the practical application of identity-relative paternalism. Some commentators felt that this novel concept would yield implausible implications,2 others that it would have no impact because of uncertainty,3 or because existing ethical principles would yield the same conclusion.4 In the paper, I proposed the following principle: > Identity-relative (...) paternalistic intervention: Individuals should be prevented from doing to future selves (where there are weakened prudential unity relations between the current and future self) what it would be justified to prevent them from doing to others. What sorts of intervention might fit under this principle? Garstman et al give the example of living kidney donation.2 They imagined ‘Beth’, who altruistically decides to donate a kidney to a third party. Beth’s decision would mean that a future BethT2 would be deprived of a kidney, be at risk of immediate perioperative complications and would be at (somewhat) higher risk of long-term health complications including renal failure. But they argue that we would be justified in preventing someone from inflicting such harms on a third party (eg, we should stop someone from stealing a kidney). Hence, they claim that identity relative paternalism would rule …. (shrink)

Paternalism has attracted new defenders in recent years. Such defenders typically either downplay the normative significance of autonomy or deny that we are sufficiently rational for paternalistic interventions to be objectionable.1 Both of these argumentative strategies constitute challenges to John Stuart Mill’s influential anti-paternalistic ‘harm principle’, which states that coercive interference with the liberty of competent adults is justifiable only if such interference prevents harm to non-consenting third parties (Mill, p. 23).2 In this journal, Wilkinson has provided a novel, provocative (...) defence of paternalism in the medical context—one that (provisionally) accepts rather than challenges Mill’s harm principle.3 Wilkinson’s argument is complex. But he begins with Parfit’s influential account of personal identity.4 According to Parfit, Alice at T1 can be the same person as Alice at T2, but the extent to which Alice at T1 and Alice at T2 are similar depends on the extent to which there are ‘chains’ of strong psychological connections between Alice at T1 and Alice at T2. Strong psychological connections, in turn, are mental states such as intentions or beliefs, or psychological traits. For example, if Alice at T2 remembers very little about herself the day before, and the day before that, all the way to Alice at T1, Alice at T2 has completely different psychological traits than Alice at T1—for example, Alice at T1 was courageous, whereas Alice at T2 is cowardly—then Alice at T1 and Alice at T2 are distinct persons. If the harm principle is correct and Alice is autonomous, it is permissible to interfere with Alice’s liberty only if it prevents harm to some non-consenting third party. But if we accept Parfit’s view on personal identity, then a novel defence of paternalistic intervention emerges: Alice at T2 may well be a distinct person from Alice at T1. So, …. (shrink)

Currently, in the United States, there is no legal obligation for medical professionals or civil courts to uphold patients’ Advance Directives (ADs) regarding end-of-life care. The applicability and standing of ADs prepared by Alzheimer’s patients is a persistent issue in bioethics. Those who argue against giving ADs full status take two main approaches: (1) appealing to beneficence on behalf of the Alzheimer’s patient and (2) claiming that there is no longer any personal equivalence between the AD’s creator and the subject (...) of the AD. In this paper, I present profound arguments against both approaches. Firstly, I argue that the principle of beneficence cannot apply in the case of Alzheimer’s patients, and, secondly, that the moral and legal authority of the AD need not depend on strict equivalence of personal identity. I conclude by arguing that valid ADs protect the dignity and autonomy of Alzheimer’s patients and that, therefore, there are moral obligations to uphold ADs which should be reflected in public policy and legislation. (shrink)