The Harm Principle and Adults: Lessons from the Pediatric Context

Kimberly Sawyer, MD, MA, HEC-C, FAAP – Assistant Professor, Division of Palliative Care, Texas Children's Hospital

Abstract: The Harm Principle, as developed by Douglas Diekema, has been widely discussed as a guiding principle in pediatric ethics for when state intervention on parental decision-making for children may be appropriate. Generally, it states that state agencies should not be involved in parental decision-making unless the parental decision places the child at substantial risk of serious harm (Diekema 2019). While Diekema argues that the Harm Principle extends to decision-making for incompetent adult patients, there has been minimal use of the Harm Principle in adult clinical ethics contexts.

In this presentation, we explore the potential relevance and utility of the Harm Principle as applied to surrogate decision-making for adult patients lacking decision-making capacity. First, we establish the adult patient population to which the principle may usefully apply, considering factors such as duration and scope of the patient’s incapacity and the degree to which the patient’s preferences are known.

We then discuss the advantages and disadvantages of using the Harm Principle over other standards of analysis in cases where it appears surrogates are making potentially harmful decisions for incapacitated patients, and thus where state intervention may be justified. For instance, could the Harm Principle shed useful insight in considering whether to invoke a state policy regarding withholding/withdrawing non-beneficial interventions? What are morally relevant differences between the pediatric and adult contexts that may impact the Harm Principle’s applicability to adults? By exploring this moral landscape, we will offer concluding remarks for clinical ethics practice regarding using the Harm Principle in adult clinical ethics.

Keywords: Harm Principle, incapacitated patients, state intervention