Balancing benefit and burden. Merely avoiding harm does not carry out the intent of the Hippocratic Oath

Healthcare providers often seek to benefit their patients through the avoidance of harm. This approach to benefit is rooted in the common understanding of the Hippocratic oath as primum non nocere--first, do no harm. A need exists in medical-ethical decision making to rediscover the principle of benefit per se, independent of the principle of avoiding harm. In healthcare the invasive, painful, costly, or repugnant nature of the treatment reflects the burden. Benefit, on the other hand, is personal. Rev. Gerald Kelly, SJ, moved away from considering objective burdens as the principal factor in determining the ethical status of a treatment and toward the presence or absence of some benefit. He also gave insight into the nature of this benefit: The treatment being considered should have a reasonable chance of offering a "remedial" effect. Recent literature has considered the "extent" of improvement as an important element in determining whether a treatment is of benefit. Not just any improvement justifies the treatment, but an improvement that fulfills the patient's reasonable expectations. The Declaration on Euthanasia states that if a treatment will or does fall short of expectations, it may be withheld or withdrawn on the grounds that the burdens involved are disproportionate. To understand a treatment as having proportionate value, one must also take into account that aspect of benefit which has not resulted.