Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness (review)

Virginia A. Sharpe and Alan I. Faden. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Cambridge: Cambridge University Press, 1998. xi + 280 pp. $28.95 (paperbound, 0-521-63490-3).

The recent report issued by the Institute of Medicine (IOM), To Err Is Human, ¹ propelled into public and political view the unacceptable rates of mortality and morbidity incurred by patients in the course of their health care. Summarizing studies done over the last decade, it stated that medical errors kill between forty-four thousand and ninety-eight thousand people annually, and that the costs of these errors amount to $2 billion. The report indicted the health-care system and recommended a range of reforms that would enhance accountability, tighten surveillance, encourage reporting, and build a culture of safety throughout America's health-care institutions. Medical Harm, published one year earlier, is not cited in its pages. This is understandable, but regrettable. It is understandable because the IOM report aims to repair a system marred by the effects of error, and it moves immediately to structural remedies, glancing only briefly at what Virginia Sharpe and Alan Faden describe as the "Historical, Conceptual and Ethical Dimensions" of medical harm. It is regrettable because the members of the Committee on Quality of Health Care who crafted the report might have seen their subject in a more comprehensive and critical light before they moved to the practical issues of improving the system.

Medical Harm is explicitly dedicated to clarifying the complicated notions that surround the double effect of harming while attempting to heal. The authors therefore trace the idea of medical harm through the history of medicine, noting how various dominant medical theories (such as humoralism) and medical attitudes (such as the therapeutic enthusiasm and therapeutic nihilism of the nineteenth century) conceptualize the problem. Their historical excursions are rapid and rather sketchy at times, but are still illuminating: they reveal how the idea of harm, which we tend to take as almost prima facie obvious, is a highly amorphous notion, shifting its meanings as other elements of medical thought shift through time.

The authors' second major aim is to place thinking about medical harm within the context of contemporary medical ethics. The ancient Hippocratic injunction against harming the sick seems to both arise from and foster the paternalistic beneficence that informs physicians' ethics over the centuries. Sharpe and Faden review the contemporary principles of bioethics--beneficence and nonmaleficence, respect for autonomy, and justice--and attempt to weave the concept of medical harm into this ethical structure. They are particularly concerned to show how respect for the autonomy of the patient, with its concomitant obligation of informed consent and its concern about the quality of the patient's life, might modify the way in which medical harm is conceptualized. They select, from among the various theories of medical ethics, Pellegrino and Thomasma's exposition of the fiduciary nature of the medical relationship as the best formulation of the ethical dimensions of the problem of medical harm.

The attempt to place medical harm (the authors prefer "comiogenic," harm incurred in the course of care, to "iatrogenic," harm caused by the physician) within both a historical and a philosophical context is valuable. However, both attempts are somewhat disappointing. The historical discussion, while very illuminating, is, as I said above, somewhat sketchy. This is less the fault of the authors, who have reviewed the literature well, than the fault of the literature, which has yet to expose the wide range of medical thought on this topic. I am certain that the Hippocratic, Hellenistic, medieval, and Renaissance medical literature have much more to tell us about the problem of medical harm. The more disappointing aspect is the inconclusive nature of the ethical argument. After a promising discussion of the centrality of autonomy in modern medical ethics, Sharpe and Faden fail to...