Prominent Controversies on Medical Harm

A prohibition on killing is often taken to be the most important negative duty of nonmaleficence, death being a major harm for most people. Generally, the same is true for the medical context, with the contested exception of assistance in dying. Proponents of active voluntary euthanasia for terminally-ill patients are not only prepared to give priority to patient self-determination in these situations, but would not even consider the resulting death a harm and its intentional provision maleficent—rather to the contrary. Controversies over these issues across many cultures result from different views on the allegedly harmful or benefiting nature of a patient's death from assistance—be it by active killing, by withholding or withdrawing life support, assisted suicide, or indirect euthanasia. Those who insist on normative differences between these various forms of assistance often give normative weight to the involved causal or intentional differences. A prominent instance of such an argumentation is the controversial Roman Catholic doctrine of double effect, according to which, for example, indirect euthanasia can be justified in spite of the death that may result, since the latter is not intended but merely foreseen as a by-product of beneficent painkilling. Other opponents of aid in dying argue with the social harm than could be expected from one or several of these practices once, established as legitimate option for the terminally ill (the slippery slope argument).

Yet another debate centering on the concept of harm-concerns cases of sexually-active patients who carry a sexually-transmittable virus (e.g., HIV) and refuse to inform their partners. Legal prescriptions aside, bioethicists are divided as to whether the treating physician, who cannot convince his patient to the contrary, has a duty to inform those at risk. Obviously the obligation to prevent harm to others conflicts with the professional obligation to confidentiality; violating confidentiality might also lessen the general trust in physicians' patient advocacy.

The heated controversies on prenatal diagnosis, gene therapy, and wrongful birth and wrongful life issues focus on possible harm to future children or their parents, but also on those who are living with genetic handicaps. Once again, bioethicists dissent on what to identify as harm, how to evaluate its negativity, and how to balance related duties against other ethical obligations.

In summary, there is a remarkable tension between harm's undisputed importance in bioethics and the numerous different ways in which it comes to be conceptualized and evaluated, thus mirroring the plurality of existing ethical approaches.

BETTINA SCHOENE-SEIFERT (1 995) REVISED BY AUTHOR

SEE ALSO: Animal Welfare; Bioterrorism; Buddhism, Bioethics in; Circumcision; Competence; Death; Death, Definition and Determination of; Double Effect, Principle or Doctrine of; Environmental Ethics; Ethics; Harmful Substances, Legal

Control of; Holocaust; Homicide; Human Rights; Infanticide; Injury and Injury Control; International Health; Law and Morality; Malpractice; Mistakes, Medical; Moral Status; Pain and Suffering; Paternalism; Psychiatry, Abuses of; Research, Unethical; Smoking; Utilitarianism and Bioethics; Warfare

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