Jane Haddam’s WordPress weblog

First, Do No Harm

with 8 comments

Ahem.  Well.

I’m thinking this morning that I did this once on the subject of the consent standard, and what resulted from that was that everybody got mad at me.  But then, I’m not all that upset when everybody is mad at me, so maybe I should have a whack at it.

Here’s the thing:  the same thing is wrong with a “do no harm” standard as a basis for moral principle as there was wrong with a “consent” standard for the same. 

It’s okay as far as it goes, but it gets you into trouble almost immediately.

First, let me say absolutely that I am not in favor of doing harm to people.  And I think “do no harm” is a great first principle to have.

But I think “not without consent” is a great principle to have, too.

I’m not arguing that either the need for consent or the need to do no harm is not really a morally correct point of view.

I am saying that they’re essentially secondary–not primary–principles.

The first problem is with the word “harm.”  It’s one of those words that seems on the surface to be very simple, and we’re sure we understand what we mean by it–but we only know what we mean by it because we don’t examine our unstated assumptions about it.

Let’s take my favorite bugaboo case:  there’s an old woman sick and in bed.  She’s fully biologially functional–she doesn’t have to be kept alive on machines; her body breathes on its own and digests food on its own and eliminates on its own and all the rest of it–but she’s comatose, and the prognosis is that she will always be comatose until the day she dies.

The woman has left no instructions about what she would like to happen to her when she is in such a state. 

The chances are that she will live on this way for years as long as she is given an IV tube providing her with sustenance–food and water.

What do we do now?  Where’s the “harm?”

A lot of people would say that the “harm” resides in letting this woman go on living–it would be better to take her feeding tube out and allow her to starve to death than to keep her in this state, no matter how comfortable.

I feel exactly the opposite.  If I am that woman in that bed, the harm, as far as I’m concerned, is in taking my life, the only one I can possibly have.

In spite of the speculations that are given with confidence on occasions like this–she can’t perceive anything anyway; she won’t feel any pain because her mind isn’t conscience to feel it–the fact is we have no idea what a person in this state perceives or feels.  Several people who have awoken from decades-long comas have said that they were able to hear and understand lots of what was going on around them, including discussion about how it would be in “their own good” to have the plug pulled.

Change the situation a little, and we don’t get much farther.  What if the person is in pain?   What if he’s in pain and declares that he wants to die?  Do we harm him by killing him, or by keeping him alive? 

What if he declares he does not want to die, no matter how much pain he’s in?  Do we harm him by killing him, or by keeping him alive? 

And beyond the harm done, or not done, to the patient in this case, what about the harm done or not done to the rest of the community by the decision we make?

Most people would say that avoiding “harm” would mean putting the person to death (“assisting” his “sucide”) would do the least harm in the first case, where the patient wants to die, and keeping the person alive would do the least harm in the second case, where the person wants to live.

But the Dutch experience tells us that it’s not that simple. 

Dutch law allows for “doctor assisted suicide”–by which they mean allowing your doctor to actively kill you–if you’re old, sick and in pain and ask for the “service.”

Repeated studies by the Dutch authorities, however, show that many doctors and nurses “assist” people who have not asked for suicide, and especially that they do so with infants born handicapped or otherwise disabled, and in cases of older people in severe pain who have refused any such assistance.

The underlying assumption is that parents are doing “harm” to their children if they allow them to be born into the world with handicaps that may be physically or emotionally painful to live with. 

As for the old people–even though they say they don’t want to die, no rational person would want to “live like that” (in that much pain, that physically damaged).  If they were thinking clearl, they would make the “rational” choice, so it “harms” them if we don’t make the choice for them and put them to death.

All the arguments here–for what is the “harm” and how we should define it–are internally logically consistent.  They’re all valid arguments.

We can’t choose between them on a rational basis until we define what “harm” is, and to do that we have to first look at each argument and see what it ASSUMES “harm” is. 

“Do no harm” is a great principle, but I don’t actually know what you mean by it until you tell me how you’re defining “harm.” 

But even getting the definition down isn’t enough. 

There are times when dong harm may actually be the right thing, if only to avoid an even greater harm.

Part of the Treaty of Versailles was a provision forbidding Germany from putting military defenses in its industrial sector, backed up by the promise of France to invade as soon as any such defenses were begun.

A couple of years before WWII, Germany did in fact begin rearming its industrial area.  France looked at the situation and…did absolutely nothing. 

It decided that war was such an awful thing, it would be too much “harm” to invade.  And, besides, all countries defended their industrial sectors.  That’s part of what a government does.

But here’s the thing–if France had invaded right then, Germany was not in a military position to defend itself.  The “defenses” would have come down, and Germany could not have started a war, because it could not have held onto its armaments factories if such a war started.

Meaning, that if France had risked the “harm” of invasion and everything that went with it, there would have been no WWII, there would have been no Holocaust–millions of people who suffered horribly and died would have done neither. 

But France couldn’t know that then.  None of us can predict the future. 

Frnce was operating on the principle of “do no harm,” and by doing what immediately looked like no harm, it inadvertantly caused a lot more of it.

There are lots of smaller cases of this sort of thing around us every day.  If a kid is doing badly in school, does “harm” reside in failing him or in letting him pass anyway?  What if he’s failing because he’s just not that bright and isn’t capable of doing the work?  What if he’s failing because his home life is a horror story or drugs and abuse?  What if he’s failing because his self-esteem is in the toilet and, since he thinks he can’t succeed, he gives up without trying?

What about affirmative action, in the sense it’s used in academia, where we install different standards of admission for different races?  Is there more “harm” in refusing admission to a kid who has lower qualifiations but very high potential (because the lower qualifications are caused, say, by his having gone to a school that was inadequate to teach him anything), or by admitting him when he’s not ready to compete and thereby both raising the chances that he’ll flunk out in a year and increasing the conviction among his fellow students that people of “that” race aren’t very bright? 

What about the other side of affirmative action–the students of Asian descent who are denied admission because if you didn’t “correct” for their qualifications there would be “too many” of them on campus?  Do we “do no harm” when affirmative action policies deliberately limit the number of such students–shades of those old Jewish quotas–our campuses are willing to take? 

What if having large numbers of those Asian  American students on a campus raising the standards bar so much that everybody else–including the white students–starts to feel uncomfortable and stupid?

Somtimes it’s not possible to “do no harm.”  Sometimes it’s a question of choosing between harms, and it isn’t always the best answer to choose the least of those. 

But at the end of this, we’re back to the same old thing–WHY is “do no harm” a principle we should respect?

Why is it a bad thing to harm other human beings?  Why should we not harm them if, by harming them, we can do good for ourselves, have more money, for instance, or more property, or extend the empire over a wider area?

No ancient culture had any compunction whatsoever about doing harm to its neighbors,  especially if the neighbors were enemies, and the results of such harm were not all bad.  Civilization has always been spread by conquest, and the areas of the world that were not conquered did not peacefully live in tranquility, but often remained stuck in illiterate, stone-aged cultures of constant feast and famine, casual brutality, disease and early death. 

I said at the beginning that I actually think “do no harm” is a good moral principle to have, and I do.

But I’ll repeat, it’s a secondary one.

Before it makes sense–or can even be consistently applied–we have to know what it is about human beings that means we shouldn’t harm them.

And that’s harder than you’d think.

Written by janeh

March 25th, 2010 at 9:15 am

Posted in Uncategorized

8 Responses to 'First, Do No Harm'

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  1. I’m not going to get angry at you. I doubt if I did last time, either. It all makes perfect sense to me and always has. The difficulty in defining ‘harm’. The fact that sometimes ‘harm’ is inevitable or even, in the long run, beneficial to the person being harmed. And I get horribly depressed and anxious when I read articles in the media supporting assisted suicide, because I can see myself becoming that old lady in the bed without any close family to guard me and at the dubious mercy of someone else’s best wishes for me. I remember my disabled brother, during one of his many hospitalizations, crying out that he didn’t want to die, and the many people, including professionals, and including people conversing with family members at his bedside, who said he should be ‘allowed’ to die.

    “Doing no harm” is one of those anodyne phrases that actually doesn’t mean very much once you think about it. Like ‘natural’. So many people seem to think that anything that’s ‘natural’ (and especially if it feels good) is an unalloyed moral good. Pain is natural. Alcohol and a lot of drugs feel good and are natural. Eating – even for the morbidly obese – is natural and feels good.


    25 Mar 10 at 10:02 am

  2. I read an article recently – I don’t recall where – about a clinic in Switzerland which exists for the sole purpose of helping people die. I believe that the people (you can’t really call them patients, can you?) were all making the choice themselves, but it still gives me a queasy sort of feeling.

    I don’t disagree in principle that people should have the right to end their own lives (not those of others, just their own) but I really don’t like to see it happen.


    25 Mar 10 at 10:24 am

  3. Found it:

    It was the same issue with a story on the management secrets of the Grateful Dead. Counterculture just isn’t what it used to be.


    25 Mar 10 at 10:30 am

  4. I’ve read about that mainly on the BBC site.

    What really gives me the willies are the joint cases, where a husband and wife – generally not both at the same stage of illness – decide to ‘go’ together. It’s so damn easy to get so wrapped up in caring for someone you love that you can’t see any life for yourself after they die – or can’t see any life for them after you die! That’s the cause of some murder suicides, undoubtedly. How anyone can claim that people in such situations are making a calm rational decision, I don’t know!

    There’s something almost schizophrenic about a society that looks at two people who want to kill themselves, and decides that one needs psychiatric care, possibly under suicide watch, and the other a ticket to Switzerland or perhaps a discreet visit from the family doctor. They both want to die, and it’s far from clear that there’s any definitive way to decide which of them (if either) is making a rational decision.

    I once really upset someone on the pro-assisted suicide side of the debate simply by saying that any assisted suicide involving me as the ‘patient’ would be murder since I, now in my right mind, am opposed to it, and the only situation under which I could conceive that I might change my mind and consent would be if I were suffering from a severe depression at the time. And, of course, that wouldn’t be a valid assent. I think the very idea that such decisions might in fact be influenced by, say, clinical depression was so upsetting to the other person that it had to be rejected out of hand.

    There was a case in Ireland years ago in which one of those cowboy euthanasia doctors ‘assisted’ someone with a long history of mental illness, including depression and suicidal tendencies. After all, mental suffering is suffering too, isn’t it? I think the Swiss clinic considers it sufficient reason to take on a client.


    25 Mar 10 at 10:57 am

  5. I was not very clear in my comments in the previous blog about believing the right choice morally is not hurting other people and speaking up when womeone else is harming another person or me. I agree that determing what harm actually is in the situations you mentioned above is difficult. They are also situations in which you are damned if you do and damned if you don’t. What I failed to include were some examples that I find less comples: although free speech is granted by the first amendment, shouting racial slurs at people in a public place does harm them even though the individual shouting them is exercising a right; example two, in a grocery store you witness a parent severely whacking her child. Are you interfering with the parent’s right to discipline her children or saving the child from physical harm by speaking up; example three: you see a person with a sign reading “Hungry and homeless please help” on the side of a freeway exit, are you helping him or harming him by giving him money that could be used to buy drugs or alcohol; a final example: an ex-lover who has physically or emotionally abuseed you moves on to another woman, should you tell the other woman what happened with you or let her find out for herself. The harmful situations are clear to me: the first person should save his comments for a private forum; I would speak to the mother whacking her child and if she didn’t stop I would report her either to a store manager or a police officer; for the person with the sign “hungry and homeless” I would direct him to a shelter, I know from experience that many people in that situation are after drug or alcohol money; and in the final situation, I would attempt to find someone the next lover trusts to pass this on to because she would be unlikely to believe me. These are a few circumstances I believe the kind choice and the harmful one are clear. And what is there about human beings that means we shouldn’t harm them? I rely on the biblical: Love others as you love yourself, do unto others as you would have them do unto you and on a section of 4th aspect of the Eightfold path of Buddhism, Right action: “to abstain from harming sentient beings, especially to abstain from taking life (including suicide) and doing harm intentionally or delinquently” Perhaps that doesn’t answer the question but it is what I believe.


    25 Mar 10 at 12:01 pm

  6. Life *IS* harm. All things that live, harm other things in order to live. We eat plants and animals. Our systems kill bacteria and viruses. We encroach on the environment, mining, cutting trees, farming, building lovely seaside homes. We intrude our presence, smells, sounds, needs, on other people. Just being first in line at the ticket window, harms, in some sense, all the others behind you. Much of life is a zero-sum game…what you have, others cannot.

    So “do no harm” impossible on its face. What is possible is “do the least harm, in any situation.” There are Buddhists who take this to an extreme…wearing masks on their faces to prevent breathing in a gnat, and sweeping the ground before their feet lest they step on an ant. Even so, they eat food that is grown on land that would otherwise be a home for wildlife, so, bzzzzzt! thank you for playing. Unintended consequences will get you every time.

    Recognizing that every act brings harm to something, somewhere, both increases the complexity of decision, and simplifies it. First, you have to be truthful with yourself in evaluating what harm will come from any action, and then you have to accept the consequences of the harm that you *will* cause. Considering the possibility of unintended consequences, as in the example of the French and Germans, is part of telling yourself the truth.

    I think we all hope that as we seek to not harm others more than necessary, they will seek the same toward us. The reciprocal principle is the heart of “do no harm.” I think that reciprocation goes out the window when one party presumes that “they know better” in whatever situation. In all the abusive situations that Jane fears, where old people or ill people or young, helpless and defective people are killed without consent, there’s always *someone* who thinks they know better what is the correct course for another.

    It’s arrogance, of course. Or is it, in every case?

    I look at people who care for animals. Almost all of us have ended a pet’s life, when that life became too painful for the pet, the quality of it too diminished. We recognize in that case that compassion is indeed in ending life, even though we may love our pets as much as we love any person. (and no, I do not equate pets with humans. But human motivations may not differ very much between them)

    So we do recognize that sometimes the end of life is better than suffering, even if the sufferer cannot consent.

    I know there are cases when someone loves a suffering person so much they would do anything to keep them alive, yet they consent to help the sufferer die when they ask to do so, from compassion.

    So we do know that compassion can motivate ending life, rather than venal or arrogant motives.

    In the case of assisted suicide, though, once compassionate motives are made permissible and legal, we cannot exclude non-compassionate motives from becoming operable, because motive is thought, and thought cannot be monitored.

    For some reason, all Jane’s horrible examples are Dutch. Having come from Dutch forebears, I’ll tell you they are terribly bossy people. They *do* think they know better. Perhaps other places are less prone to the attitude.

    And perhaps what we need to do is become far more specific in our discussions and arrangements for our own health decision management. When we become adults, perhaps we should all sit down with a checklist of what we’d like to happen in the case of our incapacitation, or severe damage or whatever. “If you’re permanently unconscious, all your limbs have been amputated, and your heart fails, should you be revived?”

    All Jane’s checkmarks would be “try to save me.” Mine or someone else’s might differ. These choices could be reviewed periodically, since people’s choices may differ at different stages of life.

    It can’t hurt to *discuss* these things as they apply to ourselves, make decisions, and make those decisions known, rather than depending on those around us to carry the water when a situation becomes dire.

    So who among us has an advanced directive? Hands?
    (in the US, an advanced directive is a document describing what actions to take in case of illness or incapacity, and sometimes, naming a person to make those decisions for you.)


    25 Mar 10 at 2:27 pm

  7. A human is not an animal. I think agreement/disagreement with that statement is the source of disputes further on the line. I can say ‘I don’t want to be put down like an animal’ meaning I don’t want to be killed on one person’s say-so, like I killed my cat Betsy (and also, incidentally, that I think there’s a difference in category between humans and the other animals). Others say ‘We don’t let animals suffer; why should we let humans suffer?’ considering the two categories as being one and not believing that humans need or deserve any special protection from being killed. No more than a cat or dog, anyway; perhaps more than a cow has.

    And I didn’t have one of those drawn up when I was setting things in place for my (long deferred, I hope) eventual death. I see them basically as a poor blunt instrument for the purpose, and something that could possibly be taken as me assenting to my own euthanasia. I don’t quite know how to word it so that it covers ALL possibilities. No, I might not want to get that extra round of chemo, the one that has a 1% chance of helping me and a 90% chance of taking away what little time I have left. I’m not so sure about being brought back from heart failure, and even less so about the kind of palliative care that doesn’t feed you artificially. No checklist covers all options. So I’m taking my chances there. Most likely, I’ll have long enough after a terminal diagnosis to decide whether I want the chemo, or I’ll die so fast the point is moot. If I lose the bet – well, my sisters and mother, if they survive me, can fight over it. It’s extremely unlikely all three will outlive me.

    I think the reason Jane’s examples are Dutch is because the Dutch were pioneers with this stuff, and did some studies on their progress from ‘Euthanasia is happening in spite of the law’ to ‘Euthanasia is happening within the law’. If you can call it progress.


    25 Mar 10 at 3:02 pm

  8. Apart from defining “harm” there’s also the issue of foreseeable–and unforeseen–consequences. Take your example of the reoccupation of the Rhineland. We know–we THINK we know–that the French decision was wrong. At least, it’s hard to imagine a worse consequence than WWII and the Holocaust.

    But it’s pretty easy to imagine France re-occupying Germany (look up “Saarland” in your history books) and getting bogged down in a guerilla war with all the usual consequent atrocities. This could go on for decades while the French moral advantage–and finances–crumble and the desperate Germans find other ways to hit back. Think Indo-China and Algeria. Or Palestine and Vietnam. Or 9-11 and Iraq. And remember that if the French had taken the other branch of the decision tree, they’d be ignorant of the one that led to our WWII.

    Which does not make the Interwar French politicians right. It means that even if we can define “harm” and even if we decide what it is about people that makes harming them a Bad Thing we will not have come to the end of moral dilemas.


    28 Mar 10 at 3:50 pm

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