Benign Neglect

Benign neglect is a concept that comes into play more often than you might think in my office. As I mused about this over lunch today it led me to look at the genesis of the term, which I was surprised to find is attributed to Patrick Moynihan when he was in the Nixon white house. (I was most surprised to hear that this famously liberal democrat was in the Nixon white house, but he was in 4 consecutive administrations from JFK through Gerald Ford)  The term was used to refer to a policy recommendation that the issue of race in the late 1960’s could benefit from a period of “benign neglect.”

I think of benign neglect in my office primarily in dealing with patients who are more likely to benefit from not investigating or treating a condition or complaint than by actively managing the condition.  A good example is a woman in her mid 80’s with mild dementia and multiple chronic medical conditions, maybe longstanding diabetes and who has had a coronary bypass surgery 12 years ago who asks if she should have a mammogram. In this case her life expectancy is relatively short, maybe 2-5 years, and the benefit of an early diagnosis of breast cancer is minimal.  In addition the diagnosis is going to force difficult decisions to be made.  Is no treatment, minor treatment, or moderately aggressive treatment best for her situation?  Is she competent to make the choice herself?  The dilemma expands.  Maybe the best approach is to not test for the condition in the first place. In her case most of the time it is an easy consensus to choose not to do the mammogram.

Benign neglect can also apply to situations where leaving relatively harmless conditions alone is better than aggressive treatment.  Examples I see are molluscum contagiosum, where the lesions usually resolve with no therapy in a year or so vs. painful ablative therapy that is far from uniformly successful on the child with the lesions. Another example is with seborrheic keratoses ( the brownish waxy pasted on lesions so common on our skin as we age)  or small lipomas (benign fatty tumors) of the skin.  These generally don’t go away, and often very slowly grow, but usually never bother the patient except cosmetically.  If the y need to be removed later it is not especially more difficult on larger lesions. If patients are comfortable ignoring these, then benign neglect is a great option. Benign neglect is a key to successful parenting too.  It is more widely called ignoring, and involves not rising to the lure of a child’s minor misbehavior.  Often the misbehavior is an attention gaining behavior, and ignoring the behavior will more likely lead to dissipation of it than confrontation or punishment. Examples in early childhood are temper tantrums, and in teens door slamming or a minor cursing. Bringing attention to the behavior may be just the attention the child consciously or subconsciously desired, and the benign neglect of ignoring can be effective at reducing the behavior.

It’s important to understand what you are doing when you choose benign neglect as the best tactic. It is not appropriate when it simply makes your life easier. In order to be truly benign the choice must in it total consequences have a neutral or better impact.  Most of the time when I choose benign neglect I anticipate the likelihood of negative consequences of active intervention to outweigh the likelihood of negative consequences of choosing no active intervention. Benign neglect is an important part of good primary care, yet needs to be used consciously and carefully.

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