Sorry Miles to Go is a bit late this week. The semester is catching up with me. Everyone loves a good story. Here’s one that’s (more or less) a true one.
Maddie, an 88 year old patient, has several co-morbidities (several things wrong with her leading to her death) including kidney failure and congestive heart failure.
Maddie is on dialysis for her failing kidneys which requires a physician order. Dr. Perla is feeling some moral distress about repeatedly writing an order for dialysis for someone who is clearly not going to get better and is not waiting on a kidney transplant because she would not be a good candidate.
With me so far? Maddie has decisional capacity more or less. (see chapter 3 of Practical Bioethics for a discussion of the difference between competence and decisional capacity) In the mornings, she’s pretty lucid and sometimes asks when she will be going to dialysis. However, in the afternoons, her capacity wanes and she sometimes refuses the dialysis as she gets confused. Sometimes when she comes back from dialysis she’s listless and complains of fatigue and pain (normal for dialysis)
Maddie’s family is adamant that they want her to keep getting dialysis. Dr. Perla sees her dialysis as futile treatment. It isn’t beneficent. It won’t improve Maddie’s condition only maintain it.
Dr. Perla requests that the ethics committee make a recommendation. She asks, “Am I hurting this woman by continuing to write this order after all, there’s no real benefit to her condition.”
Dr. Perla’s comment actually mixes up two different reasons. Non-maleficence and beneficence. The moral duty to do no harm and the duty to help respectively.
It’s fairly evident that ordering dialysis in this case isn’t really going to benefit the patient long term. The question underlying Dr. Perla’s ethical distress is “Am I violating the ‘do no harm’ principle?”
Ordering dialysis won’t help but Dr. Perla wants to know if it’s harming.
Of course it would help if we had a good definition of harm. Philosopher Joel Feinberg wrote a four volume set seeking to define just what harm is. He defined harm as intentionally setting back someone’s vital interests. Just what counts as vital interests? Did I mention it’s a four volume set?
The late Joel Feinberg, Moral Concept Whisperer
I actually prefer the late legal scholar, Alan Werthheimer’s conception. It’s contained in his analysis of force or coercion. Wertheimer argues coercion is the threat to make someone worse-off than their baseline. By extension “harm” would be the act of making someone worse off than their baseline. Non-maleficence is the duty not to make someone worse-off than their baseline.
That is very different than a duty to help someone above their baseline or beneficence. The story with Maddie illustrates why it’s so important to distinguish between non-maleficence and beneficence.
Dr. Perla worries that she’s harming Maddie by providing her dialysis, but dialysis isn’t making her worse off than her baseline. It’s not helping but its also not harming.
It is important in medical culture not to mix up beneficence and non-maleficence. Medical culture prioritizes intervention. Surgeons want to cut. Specialists want to test and diagnose. They want to do something to help.
Accepting that they can’t do something that benefits the patient doesn’t come naturally. But it’s really, really important not to consider “not being able to help” as morally equivalent to “doing harm.” As W.D. Ross says in reading 1.1 of Practical Bioethics, the prima facie duty to do no harm is stronger than the duty to do good.