Harm and medical ethics

Imagine your spouse has been cheating for the past 10 years, but you are completely unaware of their infidelity. The good news is your spouse is a very careful person, and all outsiders agree the infidelity has no negative consequences on your marriage or happiness. You will live the rest of your life in blissful ignorance.

But are you worse off because of your cheating spouse? Have you been harmed?

The question of harm – and its counterpart, benefit – is critical to medical ethics. Ethicists speak of the principle of beneficence, which obliges doctors to act for the benefit of their patients, and the Hippocratic principle of non-maleficence, to “do no harm.” Choosing between treatment options requires careful consideration of potential harms and benefits.

What is harm?

The question of what is harm has many answers. Some philosophers, such as Epicurus, think harm is necessarily experiential. In other words, you must experience something bad to be harmed.  According to this view, money secretly stolen from a bank account or a symptom-free cancer are only harms if the victim is aware of them. If you think the above-mentioned cheating spouse is not a harm, then you likely agree with this philosophy.

Other philosophers disagree with this view. Imagine if your friends were paid actors pretending to be your friends. Despite their behavior, your ‘friends’ actually despise you. If you believe in non-experiential harms, you might say you are harmed by having false friends – even if you never know the truth about their friendship-for-hire. And if this is the case, then you can be harmed by the cancer you never knew you had, or the affair you never discovered.

Harm in the clinical setting

Questions about the nature of harm are more than just entertaining thought experiments; they arise often in clinical contexts.

Take, for example, the case of an unconscious patient admitted for an emergency requiring a blood transfusion. The patient’s wife consents to the blood transfusion despite knowing the patient is a Jehovah’s Witness and would have refused the transfusion on religious grounds.

The medical team is unaware of the patient’s beliefs and, with the spouse’s consent, provide the patient with blood. After the operation, the patient regains consciousness. The transfusion saved the patient’s life, but the patient is unaware that he received it.

Was the patient harmed by the transfusion? Would informing the patient cause harm?

It is important to explore fundamental notions like harm and benefit to make sense of the way we treat patients and the way we utilize medical technologies. A properly constructed theory of harm can help us answer difficult questions, such as whether a permanently comatose patient can benefit from withdrawal of life-support, if genetic testing can benefit a future generation, or if doctors should inform a patient of a medical error that causes no physical harm.

And now, whenever somebody proposes an argument based on benefits and harms, you can ask: Do you mean experiential or non-experiential harms? You will make many non-actor friends. I promise.

-By Peter Koch, Ph.D., clinical ethics fellow in the Center for Medical Ethics and Health Policy at Baylor College of Medicine