Bioethics is a field that developed in the middle part of the twentieth century to help guide medical decision making and protect vulnerable populations. Ethics in general looks at what is right and wrong. Bioethics in particular, looks at what is right and wrong in the context of living beings and their health and ability to flourish. It is important to know that it arose in the aftermath of the Nuremberg Doctor’s trials of 1947 which exposed the horrific abuses of human subjects in medical experiments in World War II and it continued to gain relevance during the 1960s and 70s when trust in authorities of all kinds, including medical, was being questioned. In many ways, the original purpose of bioethics was not to do good, but to protect people from both harm and coercion.

One moment in my career that really made me think about this was when I was taking care of a patient with dementia who had a large cancer invading his eye. As a head and neck surgical oncologist, I knew that this could potentially be cured and would definitely relieve some of his suffering if we operated to remove his eye. As a clinical ethicist, I knew that even with a surrogate decision maker’s consent for this patient lacking capacity, an orbital exenteration was extreme and would be considered mutilating by many. I did my best to see things from the patient’s perspective and to show kindness and establish trust. He implored me to remove the cancer and ease his pain, but refused the general anesthesia that was necessary. We balanced his understanding and capacity against the values and goals he was able to express and, with the support of a court appointed guardian and our full care team, we proceeded to sedate him and complete the operation. Here again, you see the importance of the order of events. First, is kindness and empathy. Harm is always relative and harm should never come first.