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Indirectly doing harm

BMJ 2009; 339 doi: (Published 30 September 2009) Cite this as: BMJ 2009;339:b3980
  1. Nicholas A Christakis, professor of medicine and of medical sociology, Harvard Medical School, Boston
  1. christak{at}

    If one group must be harmed for another to benefit, what are the implications for public health?

    The benefits of medical care and public health interventions, delivered to individuals and to groups, are indisputably impressive. While there is much debate about the magnitude and accessibility of these benefits—and about whether health has improved over the past century primarily because of advances in medical care, public health measures, or socioeconomic conditions—it is clear that a significant amount of the progress has come about through the direct and intended consequences of medical and public health action.

    However, medical and public health interventions also have indirect and unintended consequences for the individuals and groups who are the objects of the intervention. These unintended consequences are of substantial practical and moral importance, and they have major implications for doctors and for patients.

    In the past such consequences have been construed as a problem of iatrogenesis, a term that literally means “doctor originated” and that is customarily applied to the negative side effects of doctors’ treatment of individual patients.

    Such unintended harm …

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