• Ethics

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, …