Thus far in our discussion of the moral basis of the injunction against patient harm, we have left the concept of harm largely unspecified. We have not, in other words, explained what counts as a harm to be avoided in the clinical context or what sort of effects are to be considered harmful. In this chapter we examine the values that inform the concept of harm in patient care. Building on our analysis of the moral basis of medicine in the previous chapter, we argue that a more patient-centered ethos will regard the individual patient's values as central not only to determinations of benefit and risk but also to occurrent harm. On the basis of these observations, we provide a framework for the moral evaluation of medical harm and the imposition of risk. We consider conditions under which iatrogenic harm or the imposition of risk may be justified and conditions under which they may be excused. Our discussion of potential excusing conditions for iatrogenic harm makes reference to recent empirical work on the complex etiology of medical mistakes and quality failures. We argue that a model of collective agency and accountability may provide a more fruitful basis for iatrogenic harm prevention than do traditional models of individual agency and accountability.

The concept of ‘iatrogenic illness’

As we saw in Chapter 3, the term ‘iatrogenic illness’ originated in early twentieth century psychiatric writings and referred to neurotic manifestations induced by a physician's diagnosis.