Prevention of avoidable harm and providing benefit: moral differences

Hospital managers can decide to expend resources in different ways. For example resources can be expended on avoiding harms or on improving capabilities (predominantly health). Healthcare institutions can give priority to the control of the spread of infectious diseases in

CEO frequently has to decide between different investment priorities. She may be aiming to produce the greatest benefit overall, for example investing in a diagnostic facility (such as a new type of scanner) which improve the speed and accuracy of diagnosis of cancer or alternatively in a new drug which is twice as expensive than another drug but much more effective. Alternatively the same resources could be expended on hospital cleaning and in so doing obtain an equivalent benefit. We can construct a scenario in which hospital managers have to make a resource allocation decision between three choices. These choices are (A) a patient safety initiative (for example avoidance of prescribing errors), (B) control of MRSA infection, and (C) a new diagnostic scanner. MRSA is given as an example of a healthcare associated infection – which could be avoided with a feasible alternative configuration of services, so for example by improving the quality of environmental cleaning.

For the purposes of this thought experiment we will assume that in each case (A, B or C) the benefit to costs ratio is identical. In each case we cannot say which specific individuals will be benefited or harmed. Many ‘avoidable’ infections are self-limiting with little long-term

impact, for example patients may develop localised stitch abscesses following surgical procedures. These infections are usually self-limiting and of minor inconvenience. In this thought experiment I am assuming comparability of burdens and benefits across the three scenarios. So we will assume that the overall number of deaths prevented for patients will be identical whatever choice is made between A, B and C. The investment in new diagnostic methods saves as many lives as the number of lives saved from investment in avoidance of avoidable infection. We will also assume that there will be no difference in the distribution of risks and benefits across individuals or groups. Every individual patient has an equal chance of risk or benefit. Taking these provisos in to account can we distinguish any morally salient

differences between A, B and C? Is there anything morally different about failing to control MRSA than from failing to provide state of the art diagnostic facilities? Both require investment to save lives. In one case a threat is not being prioritised and in the other a potential benefit is not being realised.

There are a number of morally salient differences between these three potential resource allocation priorities. These include various relational aspects of the institution with the causal pathways, the degree of patient empowerment in acceptance of the risk and/or benefit, public perceptions of the institution, and social implications. In the case of the scanner (C) adverse outcomes result from the unmitigated effects of undiagnosed disease and are independent of the institution in that adverse events do not require institutional involvement. In the patient safety (A) and MRSA (B) cases adverse effects arise as part of the relationship between the institution and the individual patient, in that the adverse effects required the presence of the patient within the institutional context. The avoidable harms (safety initiative, MRSA) when compared with a failure to benefit (scanner)) have the potential for very serious consequences such as loss of public confidence in the institution (safety and MRSA). Patients do not

(generally) consent to avoidable harm arising from a patient safety failure (safety and MRSA). The transmissible aspect of MRSA infection adds additional dimensions to those involved in the patient safety choice in part because of the potential for an epidemic, but also the social burden to the patient of carrying a transmissible infection both in terms of the reactions of others but also the sense of shame associated with personal and public attitudes to transmissible disease.

discusses this heuristic and the implications for thought experiments designed to test moral intuitions (Kamm 2008). She distinguishes intuitions concerning losses and gains from intuitions concerning failing to benefit (non-aiding) and harm. The non-aiding / harming distinction “as it is employed in moral theory is not subject to the same framing effect as the loss/no-gain distinction as it figures in the psychological experiments”. “The loss/no-gain distinction focuses on what happens to a victim. The harming-non-aiding distinction focuses on what an agent does to a victim” (Kamm 2008, p431). This is an important distinction because if we are to use thought experiments to try to identify morally salient considerations and intuitions then we need to understand the biases imposed by human psychology. It is the particular relationship between a healthcare institution, which is relatively empowered, and a patient who is dependent that distinguishes the priority given to prevention of harm (loss) as opposed to treatment (gain) from a simple loss/no gain distinction.

In summary we are comparing a failure to potentially benefit (C) with reduction in the risk of harm (A & B). The scanner does not add additional risks over and above those attributable to the disease process. The potential harm is attributable to the disease process. For A & B the exposure to the risk can only be controlled (by the patient) if the patient avoids hospitalisation and exposure to the risk takes place in a specific context - when the patient is in a dependent relationship with respect to the healthcare institution. Patients do not generally consent to failures of patient safety measures. Harm from avoidable infection acquired in hospital reflects on the extent to which we have observed duties to keep patients safe (Wolff & De- Shalit 2007, p21). The failure to control MRSA has implications for all who may need to go in to hospital in the future and there is potential for disaster either through a collapse of public confidence or uncontrolled infectious disease. The potential harms of transmissible infection

could be considerable and in addition include social costs both for the individual, for the institution and for others.

For Kamm one way of seeing the relationship between harming and not aiding is through the language of rights (Kamm 2008, p430). The recognition of patient rights gives emphasis to the experience of individuals as rights holders in the context of their relationship with healthcare providers. In the next section I ask if the negative right not to suffer avoidable harm trumps the positive right to the benefits of healthcare?