Problems with the “Do no harm” principle in the presence of uncertainty

In a paper entitled, Counterfactual Harm: A Counter-argument, Amit Sawant and Mats Stensrud write:

A core principle in medicine is non-maleficence, often equated with “do no harm.” A formal definition of harm based on counterfactual reasoning has been proposed and popularized. This notion of harm has been promoted in simple settings with binary treatments and outcomes. Here, we highlight a problem with this definition in settings involving multiple treatment options. Illustrated by an example with three tuberculosis treatments (say, A, B, and C), we demonstrate that the counterfactual definition of harm can produce intransitive results: B is less harmful than A, C is less harmful than B, yet C is more harmful than A when compared pairwise. . . . In contrast, an interventionist definition of harm based on expected utility forgoes counterfactual comparisons and ensures transitive treatment rankings.

I agree, and this is related to what we wrote in our Russian roulette paper. I’ve always been uncomfortable with utility functions that depend on outcomes that have never occurred. I recognize that counterfactual utilities can make sense psychologically (this includes concepts such as uncertainty aversion and regret), but not normatively, not for what I’ve referred to as institutional decision analysis. This new paper by Sawant and Mats Stensrud goes beyond our Russian roulette paper by introducing a new example and continuing continuous outcomes.

Also related is this paper by Stensrud with Aaron Sarvet, “Rejoinder to ‘”Harm” in personalized medicine–an alternative perspective.'”