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On Wilkinson: unpacking Parfit, paternalism and the primacy of autonomy in contemporary bioethics
  1. Linda Sheahan1,2,
  2. Louise Campbell3,4
  1. 1 SESLHD, Kogarah, New South Wales, Australia
  2. 2 Health Ethics, University of Sydney, Sydney, New South Wales, Australia
  3. 3 NUI Galway, Toronto, Ontario, Canada
  4. 4 Joint Centre for Bioethics, Toronto, Ontario, Canada
  1. Correspondence to Dr Linda Sheahan, SESLHD, Kogarah, NSW 2229, Australia; lindas.sheahan{at}

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In his essay on paternalism and personal identity, Wilkinson draws on Derek Parfit’s Reasons and Persons (1984) to call for a reappraisal of the role of paternalism in healthcare decision-making in situations in which patients with capacity make decisions which are likely to have harmful consequences for themselves.1 The imperative to respect autonomy, coupled with JS Mill’s insistence that the state is justified in interfering with an individual’s liberty only in situations in which she harms or threatens to harm another person, leaves clinicians with little room to constrain decisions in which a patient’s choice may seriously harm her. Parfit reduces personal identity to the continuity of psychological and physical traits across the lifecourse, and suggests that, since these sets of characteristics change significantly over time, it may make more sense to view a person at different time points as different ‘selves’, rather than as the same person. Parfit’s defence of paternalism involves arguing that, given this inevitable lack of continuity, causing harm to one’s future self is analogous to harming another person and that intervening to prevent this may be justifiable in accordance with the Harm Principle.2

The issue of personal identity has received considerable attention in the philosophical literature and it remains a vexed question. Parfit’s argument, along with the thought experiments on …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • Wilkinson himself acknowledges this (p9).

  • Wilkinson provides no alternative solution to the question of how to preserve the agency of a patient confronted with the impending or potential loss of her capacity to make her own healthcare decisions problem.

  • A thorough critique of the practical and ethical issues at play in defining and determining ‘best interests’ is beyond the scope of this commentary.

  • This is illustrated by Wilkinson’s example of decisions based on the rolling of a dice.

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