 Gardner’s alternate account of harm, the “effect-relative” account, avoids asking whether an act makes a given individual worse off and instead determines harm on the basis of a comparison between various states that may be said to be “intrinsically better or worse off” for a given individual. (Gardner 2015, 2017). To make use of such an approach in the nonidentity context, the proposed analysis would seem to include, as a part of the test for harm, the assumption that the individual exists (Gardner 2015). Thus we ask whether a state in which a person exists and suffers a limitation is worse for that person than a state in which the person exists but does not suffer the limitation (Gardner 2015, 2017). An obstacle for such an account of harm is that it seems to generate too many instances of harm (in the case, e.g., where the state in which the person exists and does not suffer the limitation is, though possible, physically, or causally, unavailable to the relevant agents). Moreover, the question arises how the account can be generalized to produce acceptable results a broader range of cases. If the assumption of existence is part of the test for harm in the nonidentity context, it might seem that we should say as well that the assumption of existence, that is, survival, is part of the test for harm in the case of the open-heart procedure described earlier in this part 3.3.2. 