In lieu of an abstract, here is a brief excerpt of the content:

11 Toward an Ethics of Iatrogenesis Renée C. Fox “Iatrogenesis”is a term with Greekrootsthatliterally means “doctor-originated.” It is customarily applied to the negative side effects of the actions that physicians take in their one-on-one care of individual patients. However, the concept is also applicable to the adverse effects that medical or public health interventions can have on groups of individuals—both on persons for whom these measures were destined and those on whom they have a more indirect, ramifying impact. The phenomenon of iatrogenesis is intrinsic to medicine and medical action in all of its forms. Although Hippocrates’ ancient injunction “do no harm” is still a primary moral commandment under which modern physicians practice medicine, they continually violate this proscription in carrying out their mandated professional responsibilities. No matter how competent, scrupulous, prescient , or humane they may be, physicians cannot totally avoid doing harm as well as good through the preventive, diagnostic, therapeutic, and prognostic actions that they undertake on behalf of the persons for whom they care. The fact that the term “iatrogenesis” is part of the nomenclature of medicine indicates that it is formally recognized as a recurrent happening in the practice of medicine .1 Nevertheless, its origins, manifestations, and import have not been extensively or deeply explored. In the medical literature, the attention accorded to iatrogenesis has tended to focus on the potential “routine” and “idiosyncratic,” “predictable” and “unpredictable,” “tolerable” and “dangerous” toxic effects and allergic side reactions of medically prescribed and administered drugs— often collectively termed “adverse drug events.” In bioethical as well as medical publications, iatrogenesis is frequently con®ated with medical errors and mistakes , with which there is much more overt preoccupation. There is also evidence that many patients do not clearly distinguish between medical errors and “nonpreventable adverse events” (Gallagher et al. 2003). Rarely has iatrogenesis been linked with the concerned re®ection on the types and problems of medical uncertainty that pervade medical and medical sociological writings. And there is virtually no discussion of how physicians think and feel about the harm that can accompany or ensue from actions that they intended to be therapeutic or ameliorative, or about how they actually handle, or should try to manage, these infelicitous events. In this article, I would like to take some preliminary steps toward providing a conceptual framework within which more serious consideration can be accorded to the experiential and ethical implications of iatrogenesis for physicians and the practice of medicine, and to the relationship between iatrogenesis, medical uncertainty, and medical error. I approach this task with a number of underlying, more-than-medical assumptions: that unintended consequences are inherent, general properties of human action and interaction; that many actions have multifarious outcomes, some “good,” some “bad,” some anticipatable , some not, some immediate, some delayed, some ephemeral, some lingering or enduring; that not all of the unwanted and undesirable effects of action are avoidable; and that while some mishaps or mistakes are potentially blameworthy , many are not. Seen in a larger philosophical perspective,these attributes of human action and their repercussions bring in their wake troubling, often dilemma-ridden encounters with the ambiguous boundaries and the complex interplay between doing good and doing harm, in a vast array of endeavors— including those as diverse as writing a novel or providing humanitarian aid: When a surgeon operates on a young girl, he isn’t saying, “I’m going to make an incision on this young lady’s stomach that not only is going to scar her but will affect her sex life to some degree for the next thirty years.” He just says, “Scalpel, nurse,” and does it. The surgeon is focused on the act, not its reverberations. As a novelist you are engaged in something analogous. . . . [Novelists] are sensitive and insensitive. Full of heart and heartless. You have to be full of heart to feel what other people are feeling. On the other hand, if you start thinking of all the damage you are going to do, you can’t write the book—not if you’re reasonably decent. . . . The point is that you are facing a real problem. Either you produce a book that doesn’t approach what really interests you or, if you go to the root with all you’ve got, there is no way that you won’t injure family, friends, and innocent bystanders. (Mailer 2002, 76) * * * Unfortunately, in the parts of the world where we work, there are no harm-free choices. In...

Share