Abstract
Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to “do no harm.” Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to “do no harm.” Because the obligation to “do no harm” is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.
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Notes
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This paper is drawn from chapter 4 of Sharpe VA, Faden Al. Medical Harm: Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness. New York: Cambridge Press, forthcoming.
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Ibid.: 105. Because the specification and balancing of obligation involves intersubjective deliberation and also, at times, subordination of important values, much will depend on the character of the agents in deliberating well and in acknowledging what is lost and gained in our moral choices. In this way, health care ethics must also go beyond principles to an assessment of moral character. See Pellegrino ED and Thomasma DC. The Virtues in Medical Practice. New York: Oxford University Press, 1994.
Ibid.: 192.
I have added this form of nonmaleficence (the imposition of unreasonable risk) to Beauchamp and Childress’s schema. Such a specification is appropriate to the medical con- text since, in medical decision making, the physician has an essential role in the calculation of risk. This prohibition would be adjusted and further specified in the process of informed consent.
Similarly, Robert Veatch argues that a society establishing principles of morality by contract would support the idea of role-specific duties for health care providers. Veatch also does not explain why such duties would be regarded as necessary. See Veatch. A Theory of Medical Ethics.
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Ibid., Rodwin has coined the term “fiducie” to refer to the person whose good is held in trust by the fiduciary.
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Ibid.: 97, n. 87.
Ibid.: 183, n. 19.
Ibid.: 139.
Ibid.
For a critique of Engelhardt’s notion of personhood see Sharpe VA. How the Liberal Ideal Fails as a Foundation for Medical Ethics.
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If, indeed, one can speak of interests at all in the absence of any common conception of the good.
Ibid.: p. 8.
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Ibid.: 107.
Ibid.: 105.
Ibid.: 106–107.
Ibid.: 123.
Ibid.: 114.
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Ibid.
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Sharpe, V.A. (1997). Why “Do No Harm”?. In: Thomasma, D.C. (eds) The Influence of Edmund D. Pellegrino’s Philosophy of Medicine. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-3364-9_14
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