How to Handle Pluralist Harm Assessment

Undeniably, different people have very different notions of what medical harm would be for themselves or for others. Autonomy-centered bioethics has seen its task as spelling out procedures to foster a "morality of mutual respect" (Engelhardt) and patients' self-determination. This approach leads to particular concern for informed consent, policies for advance directives, substituted judgment, and so on. A contrasting approach urges that instead of inviting radical individualism in assessing medical harm, we redetermine medicine's substantive goals. Daniel Callahan, for example, argues that such individualism results in net harm to all by consuming too many resources for marginal benefits and setting wrong priorities in our lives. Stressing the importance of expectations and cultural presumptions in determining what individuals view as harm, Callahan hopes to find arguments acceptable to the whole of society—in favor, for instance, of decreasing individual expectations for life-prolonging treatment in old age.

Other authors concur that individualistic harm assessment is the wrong paradigm for medicine: "Moral atomism" is viewed as impoverishing medical practice socially and morally, that is, as giving up grounds on which a sense of community and good decision making should develop (Pellegrino and Thomasma). Others see "moral atomism" as leading to a waste of physicians' power to assist patients in pursuing their goals (Brody, p. 50), or as leading to paralysis in crucial policy questions, such as how to determine the best treatment interests of incompetent patients (Emanuel). Ezekiel Emanuel opts for communitarian healthcare settings, where groups of patients and physicians shape medicine according to their shared assessment of harms and benefits; others are confident that the consensus on harm in the context of medicine is substantial (Pellegrino and Thomasma; Cassell; Brody). They see the main problem in "the view that the physician respects autonomy by taking a negative, hands-off stance" (Brody, p. 50), which they argue ought to be given up in favor of assisting patients, in a critical and trustworthy manner, to assess harms and benefits.

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