Conceptual Questions

An instance of harm may be assessed with reference to kind, degree, and duration. Risk assessment, not considered here, also includes the probability of harm's occurrence. According to the Oxford English Dictionary, harm is "evil (physical or otherwise) as done to or suffered by some person or thing; hurt, injury, damage, mischief." As far as harm is relevant to moral deliberation, however, this broad concept must be restricted.

First, harm should be understood as person- (or animal-) regarding, that is, as consisting of events or states of affairs that are negative for someone—as expressed in Joel Feinberg's definition of harms as "setbacks to interest" (p. 31). As long as the sticky question of what counts as interests remains open, this concept of harm is still neutral to various ethical positions. Problems start with determining who counts as a bearer of interests; for instance, do embryos (as potential persons), the deceased or permanently unconscious (as former persons), or animals bear interests? These issues, although obviously important for evaluating abortion, transplantation, decisions to end treatment, or animal protection, will not be pursued here.

Secondly, ethics in general ethics and bioethics in particular have to restrict their focus on those instances of harm that are in some way or other linked to human action. It would not make sense to morally deliberate about ineluctable evils, deplorable though they may be. Rather, harm is ethically relevant only if it occurs or persists in consequence to human agency, be it by action or omission, from intention or negligence, but not from unavoidable ignorance. Thus, what counts as harm with relevance to bioethics is context-relative: harm is contingent upon professional knowledge and medico-technical progress.

Thirdly, bioethics, reflecting both ordinary moral and non-moral language usage, commonly differentiates between harm on the one hand and mere loss or lack of benefit on the other. Harm is not simply conceptually complementary to benefit (interest satisfaction), but it also represents a significant disservice to its victim. Along the scale of interest satisfaction, there are numerous positions of submaximal satisfaction (disbenefits) that it seems inappropriate to call harms. There is thus an asymmetry between harm and benefit in the sense that harm pertains exclusively to the basics of well-being. It may be wrong to prevent someone from obtaining a luxury good, but nevertheless, its consequence does not qualify as harm. Another argument elucidating this asymmetry emphasizes that harm has or leads to distinct phenomenal qualities of bodily or psychological painfulness and suffering, which is by no means true for all instances of lacking benefit (e.g., Noddings). Moreover, pity for someone's experience of harm is a motivation distinct from other forms of benevolence (e.g., Sidgwick).

Not to inflict, to prevent, or to remove harm usually takes moral precedence over providing those benefits the lack of which does not count as harm. Such asymmetry between harm and benefit has been traditionally acknowledged (e.g., by John Stuart Mill), but a more systematic focus on harm is a rather recent development of applied ethics, with its eye to more concrete moral rules (a notable exception being Jeremy Bentham's 1789 taxonomy of "pains" by sources, kinds, and circumstances). The improvement of people's well-being being a more or less central goal of any moral code, concrete efforts must first focus on the most important obstacles to well-being, that is, on existing or potential harm.

Understanding harm as a significant setback to someone's interests already implies that usually it ought to be avoided. In this sense harm is a weak normative concept, carrying a presumption of evaluative negativity. However, not every infliction or non-prevention of harm to another person is, all things considered, necessarily wrong, and in just this sense harm is not a strong normative concept. For instance, not to treat a particular patient in a tragic triage situation may be a deplorable but ethically-justified decision. Likewise, foregoing life-saving surgery on a competent patient because he autonomously decided against it, by no means "wrongs" him, in the sense of violating legitimate moral claims (Feinberg). Where harming thus does not necessarily mean wronging, the same is, of course, also true the other way round. One ought not conflate people's legitimate claims to justice or self-determination with those of not being harmed. Less clear cut is the distinction between harms and offenses, where the latter cause unpleasant, though not harmful, mental states. In the context of medicine, patients might be frustrated, shocked or irritated by inefficient hospital structures or by physicians who behave rudely. Whether such states of offendedness turn into proper harm seems to be but a matter of degree and duration.

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