Eli Schantz

After an intensive 4-year process, the World Medical Association (WMA) has revised its International Code of Medical Ethics (ICoME). In their report outlining this process, Parsa-Parsi et al not only describe how the WMA sought to ‘cultivat[e] international agreement’ on a ‘global medical ethos’, but also outline the philosophical framework of the ICoME: how the WMA, as the ‘global representation of the medical profession’, created and revised the ICoME through the process of international professional self-regulation.1 However, there is a significant tension to be found in this framework—one which contrasts the international scope of the ICoME with the supposed source of its legitimacy. Here, we seek to characterise this tension and the doubt which it casts on the legitimacy of the ICoME.

Identity-Relative Paternalism, as defended by Wilkinson, holds that paternalistic intervention is justified to prevent an individual from doing to their 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 Wilkinson, drawing on the work of Parfit and others, defends the notion of Identity-Relative Paternalism from a series of objections. I argue here, however, that Wilkinson overlooks a significant problem for Identity-Relative Paternalism—namely, that it yields unactionable and self-contradictory results when applied to choices where both options present potential harms to future selves.

In “Harmful Choices, the Case of C, and Decision-Making Competence,” Pickering and colleagues advance an argument in favor of externalism, a view in which the competence of a decision maker is judged relative to factors external to their cognition. In advancing this argument, Pickering and colleagues focus on the external factor of harm: In their view, it is the harmfulness of a considered or chosen action that provides evidence against the competence of the decision maker. However, the proper identification of harmful choices and outcomes remains a demanding task, largely because our understanding of what harm is remains deeply incomplete. Despite 50 years of tempestuous debate, the metaphysics of harm remains an unsettled question. The existence of such a debate does not, in and of itself, provide evidence against the externalist position; rather, it is the theories of harm themselves that pose meaningful challenges for the externalist. Our purpose, here, is to illuminate these challenges.