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Chapter 3: The Moral Climate of Health Care

Section 5. Five Major Moral Principles in Health Care


In Health Care settings and in the institution itself there are a number of basic principles of morality
which evidence themselves. Even if one did not approach cases or situations holding the
principles of any of the standard ethical traditions there would arise these basic considerations and
concepts.

No matter what the ethical approach taken, with the exceptions of egoism and relativism, there is
agreement that there are certain basic principles related to health care that are consistent with the
notion of the GOOD. They are presented here. There is disagreement about how they might be
ordered or what to do in the event there is a conflict between or amongst them.

Those matters aside for now, there will be many occasions to make reference to these principles in
the analysis and discussion of cases in Biomedical Ethics.

Five Major Moral Principles in Health Care:

 I. NON MALFEASANCE
 II. BENEFICENCE
 III. UTILITY
 IV. DISTRIBUTIVE JUSTICE
 V. AUTONOMY

I. Non- Malfeasance- Do NO Harm!! Cause no needless harm or injury according to reasonable


standards of performance.

Observe DUE CARE . This does not mean that there must be no risk of injury but only that there
be no more than acceptable risks.

II. Beneficence- Promote the welfare of others. This is inherent in the relationship of a health care
provider (HCP) and the recipient of care.

E.g. the doctor-patient relationship. However, what exactly is the duty of the HCP?

This comes into particular focus as problematical when the health care providers are also
researchers. There must exist standards so that the benefits to the subjects and others are real
and with a real possibility to be realized.

III. Utility- Attempt to bring about the greatest amount of benefit to as many people involved as is
possible and consistent with the observance of other basic moral principles. Greatest Benefit and
Least harm

IV. Distributive Justice- All involved should have equal entitlements, equal access to benefits and
burdens. Similar cases should be treated in a similar fashion. People should be treated alike
regardless of need, contributions or effort.

The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the same
treatment. However, in what ways are the cases similar? In what relevant ways? Equal in need?
Equal in contributions to society? to the Health Care institution? Equal in effort?

V. Autonomy- People are rational, self determining beings who are capable of making judgments
and decisions and should be respected as such and permitted to do so and supported with truthful
and accurate information and no coercion.

They should have their decision making and actions: a) free of duress of any type, (b) based upon
options that are clearly explained and that are genuine possibilities and (c) given the information
needed for decision making.

Some believe that there can be justifications for violations of the principle of autonomy.

There are four principles cited to justify restrictions on AUTONOMY:

1. HARM Principle- stop an individual whose autonomy is restricted or violated from causing harm
to others

2. PATERNALISM Principle- There are two forms:

 Weak -to stop a person whose autonomy is restricted or violated from self harm
 Strong -to benefit the person whose autonomy is restricted or violated

3. LEGAL MORALISM Principle- legislated morality

Acts of legislation impose restrictions upon all, presumably for the benefit of all

4. WELFARE Principle- restrictions or violations of the autonomy of an individual for the benefit of
all.

EXAMPLES:

Harm- if a person has a highly contagious and life threatening disease that person could be
confined against that person's will

Paternalism-weak- a person attempting suicide by ingesting poison could have the stomach
cleared of the poison in the ER even though refusing treatment.

Paternalism-strong- a 22 year old person could have a gangrenous leg amputated even against a
refusal of treatment.

Legal Moralism - children can be inoculated against disease despite their refusal and that of their
parents.

Welfare- a person with a rare anti-body to a deadly incurable disease threatening the general
population could be made to give a specimen of their blood or bone marrow or other tissue for the
sake of the benefit of the entire society.

More on What are the major principles of medical ethics?

http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#ques3
Four fundamental ethical principles (a very simple introduction)

 The Principle of Respect for autonomy


Autonomy is Latin for "self-rule" We have an obligation to respect the autonomy
of other persons, which is to respect the decisions made by other people
concerning their own lives. This is also called the principle of human dignity. It
gives us a negative duty not to interfere with the decisions of competent adults,
and a positive duty to empower others for whom we’re responsible.

Corollary principles: honesty in our dealings with others & obligation to keep
promises.

 The Principle of Beneficence

We have an obligation to bring about good in all our actions.

Corollary principle? We must take positive steps to prevent harm. However,


adopting this corollary principle frequently places us in direct conflict with
respecting the autonomy of other persons.
 The Principle of nonmaleficence

(It is not "non-malfeasance," which is a technical legal term, & it is not


"nonmalevolence," which means that one did not intend to harm.)

We have an obligation not to harm others: "First, do no harm."

Corollary principle: Where harm cannot be avoided, we are obligated to minimize


the harm we do.

Corollary principle: Don't increase the risk of harm to others.

Corollary principle: It is wrong to waste resources that could be used for good.

Combining beneficence and nonaleficence: Each action must produce more good
than harm.
 The Principle of justice
We have an obligation to provide others with whatever they are owed or deserve.
In public life, we have an obligation to treat all people equally, fairly, and
impartially.
Corollary principle: Impose no unfair burdens.

Combining beneficence and justice: We are obligated to work for the benefit of
those who are unfairly treated.
Code
of
Ethics
Written by Administrator2

A multiple sclerosis (MS) nurse has a professional moral obligation. The purpose of this
obligation is to guide the MS nurse in the practice of multiple sclerosis nursing. This
moral obligation is defined as performance of a morally good act., rather, what ought to
be done or should be done. The multiple sclerosis nurse provides care to promote the
health and well-being of MS patients and families.

Ethical principles that guide the MS nurse are: autonomy, beneficence, non-malfeasance,
stewardship and justice.

• Autonomy: Respect for self-determination.


• Beneficence: Moral requirement to promote good.
• Non-malfeasance: Do no harm.
• Stewardship: Preserve your own being.
• Justice: Fair and equitable determination distribution of resources and fair treatment
for individuals and society.

ANA Code of Ethics for Nurses

1. The nurse, in all professional relationships, practices with compassion and


respect for the inherent dignity, worth and uniqueness of every patient,
unrestricted by considerations of social or economic status, personal attributes or
the nature of the health problem.
2. The nurse’s primary commitment is to the patient, whether an individual, family,
group or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and
rights of the patient.
4. The nurse is responsible for and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse’s
obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal
and professional growth.
6. The nurse participates in establishing, maintaining, and improving healthcare
environments and conditions of employment conducive to the provision of
quality health care and consistent with the values of the profession through
individual and collective action.
7. The nurse participates in the advancement of the profession through contributions
to practice, education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in
promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is
responsible for articulating nursing values, for maintaining the integrity of the
profession and its practices, and for shaping social policy. (June 30, 2001
American Nurses Association).

Guiding Principles of the MS Nurse

1. MS nurses seek what is good for patients and families.


2. The MS nurse recognizes that quality of life is defined by the person with MS.
3. The MS nurse recognizes and respects the patient’s right to care regardless of
age, race, gender, ethnicity, religion, life-style, sexual orientation, economic
status or level of disability.
4. The MS nurse recognizes the patient’s right to MS specialist care.
5. The MS nurse promotes impartial treatment.
6. The MS nurse recognizes the patient’s right to treatment and therapies, including
experimental treatments.
7. The MS nurse recognizes the patient’s right to access of MS drugs.
8. All patients have the right to be informed and understand advanced health care
directives (living wills and durable power of attorney), concerning the right to
receive resuscitation, refuse appropriate treatment, request do-not-resuscitate
orders, or request the discontinuation of life support measures.
9. The MS nurse is responsible for providing information to the MS patient and
family in order to facilitate informed consent for all treatments and procedures.
10. The MS nurse participates in research. The MS nurse is aware of the principles of
informed consent, criteria for inclusion and exclusion in research protocols, the
right of the individual to withdraw from a protocol at any time.
11. The MS nurses recognize and maintain the patient’s privacy, assuring
confidentiality, except, when there is a clear, serious and immediate danger to the
patient or others.
12. MS nurses have a moral obligation to offer access to care, cost containment, and
quality care.
13. MS patients have a right to be informed, without bias, coercion or deception
about treatment options, potential effect and adverse effects of treatments.
14. MS patients have a right to refuse treatment, continuing to receive alternative
care.
15. The MS patient has a right to his medical record (check out) and the right to have
information explained.
16. Decisions regarding care require participation of the MS patient in an ongoing
partnership to develop an effective plan of care. This process considers diversity,
individual autonomy and responsibility.
17. MS nurses practice competently. They consult and refer when indicated by their
professional judgment.
18. MS nurses take appropriate action to protect patients from harm when
endangered by incompetent or unethical clinical practice.
19. MS nurses promote and support improved practice through professionalism,
education, certification and nursing research.
20. MS nurses promote local and national efforts to improve public education,
legislation to ensure access to quality care and long term care initiatives that
meets the health needs of MS patients and families.
21. Decisions regarding care require patient participation in an ongoing partnership
to develop a safe and effective plan of care that considers cultural diversity,
individual autonomy and responsibilities.

SECTION 5: THE PRINCIPLES OF BENEFICENCE AND NON-MALFEASANCE

‘Primum non nocere; above all . . . do no harm'.

-- A fundamental medical principle (from the Hippocratic Oath; see Appendix B.)

LEARNING OUTCOMES
After reading this section of the course, you should be able to:

 Understand the meanings of the Principles of Beneficence and Non-


malfeasance.
 Evaluate the relative merits of a consequentialist and deontological
justification of the Principles of Beneficence and Non-malfeasance.
 Appreciate some of the difficulties with assessing benefits and harms.

 Appreciate in ethical problems where there might be supposed to be a


conflict between the requirements of the Principle of Autonomy on the one
hand and thePrinciples of Beneficence and Non-malfeasance on the other.

KEY POINTS

 The Principles of Beneficence. The well-being or benefit of the individual ought


to be promoted.
 The Principle of Non-malfeasance. One ought to do no harm.
 Consequentialist justification of the Principles of Beneficence and Non-
malfeasance.
Are they really at either end of a continuum from --

1. promoting benefit, to
2. removing harm, to
3. preventing harm, to
4. not inflicting harm?

 Ought we to spend our whole time remedying evil?


 According to deontological theories, the duty of non-malfeasance is a perfect
duty which allows for no exceptions.
 According to deontological theories, the duty of beneficence is an imperfect duty
where we can consult our inclinations about who we shall benefit.
 What is to count as benefit and harm, and who should make the assessment?

 Does the Principle of Beneficence conflict with the Principle of Autonomy?

5.I WHAT ARE THE PRINCIPLES OF BENEFICENCE AND NON-


MALFEASANCE?

As we have seen in earlier examples, the Principle of Autonomy is not the only principle
appealed to in health care decisions. Appeals are also made to the Principles of
Beneficence and Non-malfeasance (see ET1008: Section 12.1.2, Section 15.3.1, 15.3.2
and 15.3.3). The following example provides an illustration of all these principles at
work.

THE NEW DRUG EXAMPLE

There is a new drug which should give an excellent chance of remission for an individual
who has leukemia. However, this drug has not yet been evaluated over the long term so
that there might be the risk of, as yet unknown, harmful side-effects. The consultant
considers that the new drug should be prescribed. Discussion about the possibility of risks
should be omitted on the grounds that the individual would not have sufficient medical
competence to evaluate the these. The consultant is in the best position to determine
which treatment is best for the individual. The nurse considers that the treatment options
should be fully discussed with the individual and that the individual has the right to
decide on the treatment.

The consultant is appealing to the Principle of Beneficence since the assumption is that
the new drug will be for the benefit or well-being of the individual. The consultant also
appreciates the relevance of the Principle of Non-malfeasance, one ought to do no harm,
since the risk of possible harmful side-effects has been considered. The nurse is giving
priority to the Principle of Autonomy since this is considered to be an area in which the
individual has the right to be self-governing. The individual has the right to be given
sufficient information about the possible available treatments and then to decide which
treatment to have.

5.2 JUSTIFICATIONS OF THE PRINCIPLES OF BENEFICENCE AND NON-


MALFEASANCE

As with the Principle of Autonomy, we need to consider how the Principles of


Beneficence and Non-malfeasance could be justified in consequentialist and
deontological terms (see ET1008:Section 12.3, Section 13.2, and 13.3, Section 15.3 and
15.4, Section 16.2 and Section 17.4).

5.2.1 Consequentialist justification

ONLY ONE PRINCIPLE?

It might be argued that really we have only one principle here and that promoting well-
being and not harming just represent opposite ends of a continuum. This is the position
usually adopted by those who justify these principles in consequentialist terms (see
ET1008: Section 13.2). Also, the Hippocratic Oath lists them together:

‘ I will use treatment to help the sick according to my ability and judgment, but I will
never use it to injure or wrong them. ' (see Appendix B.)

The reason for saying that these two principles might represent two ends of a continuum
becomes apparent if one starts to ask what promoting benefit involves. If one adopts a
hedonistic consequentialist position such as that advocated by Mill, then promoting
benefit will involve seeking to maximize as much happiness as possible. Singer's view is
that promoting benefit involves maximizing interest satisfaction. We ought to perform
positive acts to promote what is taken to be of benefit.

However, in addition to acts such as these which quite obviously fall under the Principle
of Beneficence, we also have acts which could be said to be promoting benefit by
removing unhappiness or states of affairs where interests are not satisfied. Possibly, the
majority of health interventions are of this nature since they are attempting to remove
a cause of unhappiness and in this way conform to the Principle of Beneficence.
Treatments are designed to benefit an individual by curing a condition that was detracting
from the well-being of that individual.

Thirdly, we have those acts, which could also be said to fall under the Principle of
Beneficence, that are designed to promote well-being by preventing harm. Advances in
preventative medicine provide a clear illustration of this, of which an obvious example is
the immunization program.

From preventing harm, it is argued, it is a short step to the Principle of Non-malfeasance


which advocates that we ought not to inflict harm. We are benefiting individuals by not
harming them. Indeed, Mill when he formulates his Principle of Utility (see Section 2:
2.3), describes happiness as pleasure and the absence of pain.

One argument that one might advance to deny that there is a continuum between the
Principle of Beneficence and the Principle of Non-malfeasance is that the range of
application of the two principles is different. The latter principle applies to everyone
unlike the former principle. We do not have a duty to benefit everyone although we have
a duty not to harm anyone.

However, this is precisely the point that consequentialist theories deny. They consider
that we have a duty to produce as much good as possible and therefore that the range of
application of the principles is equally wide. Just as it would be wrong to do harm to
someone by, for example, murdering them, similarly, we have a duty to do much more
good in the world than is currently the case. For example, in not giving more to charity,
we are actually allowing many people to die and this is just as bad as killing someone. We
are, after all, evaluating the rightness or wrongness of our actions by the consequences of
our actions and consequences can be produced by omissions as well as acts.

Jonathan Glover is one who supports this sort of view, but he tempers it by suggesting
that we have to work out priorities in our life. He writes:

‘ The moral approach advocated here does not commit us, absurdly, to remedying all the
evil in the world. It does not even commit us to spending our whole time trying to save
lives. What we should do is work out what things are most important and then try to see
where we ourselves have a contribution to make. ' 1

This sort of position is examined in Section 7, when we look at the acts and omissions
doctrine.
If we assume for the moment that we can make a distinction between positive actions and
omissions, then we could list the acts of doing good, removing harm and preventing harm
as being appropriate to the domain of beneficence leaving only the duty of not inflicting
harm (omission) within the province of the Principle of Non-malfeasance.

5.2.2 Deontological justification

Understood in this way, it is argued by supporters of deontological theories that there is


an important difference between the Principle of Beneficence and the Principle of Non-
malfeasance. Kant, for example, talks of the duty of non-malfeasance as being a perfect
duty and the duty of beneficence as an imperfect duty.

Kant defines a perfect duty as `one which allows no exception in the interest of
inclination'. 2 What he means by this can be illustrated by the suicide example that was
used in Section 4. Since the duty of non-malfeasance, not inflicting harm, is a positive
duty, then even if we have a strong inclination to end our lives, this does not entitle us to
commit suicide and make an exception to the Principle of Non-malfeasance. However, in
the case of imperfect duties, such as the Principle of Beneficence, we can consult our
inclinations in the sense that it is up to us to a certain extent to decide whom to help. If a
doctor or nurse wishes to help care for the orphans in Rumania, he or she is not
condemned on the grounds that, for example, there is more need in Iraq. There is some
latitude to decide whom one will help but the duty not to inflict harm is applicable
universally.

This distinction reflects a fairly widespread common sense intuition that perfect duties
such as the duty of non-malfeasance have greater stringency than imperfect duties. That
is, our duty not to harm is greater than our duty to benefit. Therefore, in cases of conflict
between beneficence and non-malfeasance, non-malfeasance will normally override
beneficence. Let us take a somewhat frivolous example. There is one individual who
could donate two of his organs to two other individuals and thereby save their lives at the
expense of his own. The duty of not inflicting harm on this individual to benefit the other
two will take precedence here. Interestingly, some consequentialist might have to reach a
different decision since the consequences of two lives saved as opposed to one might
appear to make the action of removing the organs the right action.

5.3 DESCRIPTION OF CASES


Although common sense intuition might draw this sort of distinction between the
Principle of Beneficence and the Principle of Non-malfeasance, there is a problem in
some cases to decide which principle is applicable.

For example, consider a case 3 where a man has agreed to undergo tests with a view to
donating bone marrow. The tests reveal the compatibility of the bone marrow. The
individual then changes his mind about going ahead with the donation. How would we
describe this case? What duty does the donor owe to the potential recipient of the bone
marrow? Is it a duty of beneficence since it will remove harm, or is it to be described as
falling under the Principle of Non-malfeasance since deciding not to give bone marrow
after having previously agreed to is to inflict harm? If deontological theories are correct
then this will make a difference. If it is described as a duty of beneficence then this does
not have the stringency of the duty of non-malfeasance. The potential donor would not be
obliged to go ahead with the donation. For consequentialist, the description of the action
would presumably not make a difference to whether or not the action was obligatory. The
consequences would be the same regardless of the description and actions are evaluated
as being right or wrong depending on their consequences.

Another area where the description of the action might determine whether or not the case
is deemed to fall under the Principle of Beneficence or the Principle of Non-malfeasance
is in the field of abortion. If we assume that we have an individual from the moment of
conception whom it is possible to harm (see Section 3.4.2), what duty do we owe to this
individual? Do we say that we owe him or her a duty of non-malfeasance and thus that an
abortion would be wrong since we are harming the fetus by killing it? Or do we say that
the Principle of Beneficence allows us the latitude to decide whom we benefit and we are
not obliged to benefit this particular individual? 4 Although we have a duty to benefit, we
do not have a duty to benefit anyone in particular and when we decide to benefit a
particular individual this is more accurately described as a case of supererogation, beyond
the call of duty.

Of course, in the area of health care it might be argued that by becoming a health care
professional one has taken on a duty to benefit the individuals who consult you. However,
this is still a limitation on the range of application of the Principle of Beneficence since
this duty is not owed to everyone.

5.4 ASSESSMENT OF BENEFITS AND HARMS


A major problem with the application of the Principles of Beneficence and Non-
malfeasance concerns how benefits and harms are to be assessed. What is to count as
well-being, what is to count as harm and whose concept of harm and benefit are we to
consider? The health care team's concept of what counts as a harm or benefit might well
differ from the view held by the individual who is subject to their care.

It is important when considering this range of problems to recognize that wellbeing and
harm are evaluative terms. Harms and benefits are not things that can objectively be
determined to be present. They are not like determining how many people are in a room
or whether a light is switched on or not. Rather, they depend on an individual's evaluation
of the situation. Infliction of death, which might be viewed as the ultimate harm for an
individual, might be viewed by some people in some situations as a benefit. Serious
requests for euthanasia indicate that the individual's evaluation of their own life leads
them to view death as a benefit rather than a harm.

In a less extreme case, a surgical procedure to amputate a hand might be considered,


since the alternative of trying to save it will incur great pain and will also put the rest of
the arm at risk. In terms of probabilities of success indicated by similar cases in the past,
the best course of action will be to amputate the hand. However, what is needed is the
individual's own assessment of what these alternatives mean to his life. A concert pianist
might well think it worth the risk of trying to avoid amputation because of his or her
lifestyle. This case illustrates two points:

1. First, that benefits and harms need to be weighed against each other.

2. Second, that the conclusion reached as a result of this weighing might well differ
from individual to individual depending on how they view what counts as well-being for
them.

5.5 THE PRINCIPLE OF AUTONOMY AND THE PRINCIPLE OF


BENEFICENCE

This last point highlights the problem of what is to be done when there is a conflict
between the health care team's weighing of benefits and harms and the individual's
weighing of benefits and harms (see ET1008: Section 16.2.1 and 16.2.3). In the `new
drug example' we saw that the consultant has weighed the benefits and harms of the
different treatments. This would be described as paternalistic, since it is the health carer's
evaluation of what would benefit the individual. Literally, the health carer is acting like a
father by doing what he or she considers best for the individual and by assuming that it is
appropriate to take some of these decisions for that individual. In this case the individual
was not consulted about the treatment options. However, there are cases where the
individual is consulted and their evaluation of benefits and harms differs from that of the
health carers. Ought the individual's evaluation to be given priority always or is
paternalistic intervention justified in some cases? In other words, what do we say about
cases where the Principle of Beneficence appears to dictate one course of action, but this
prescription would conflict with the requirements of the Principle of Autonomy?

The view that we advocate is that autonomy ought always to override these other
principles, but that the difficult question to decide is whether or not the individual can be
regarded as autonomous in each individual case. As we argued in Section 4, the
characteristics necessary for autonomy will vary depending on the complexity of the
decision required, but this still leaves latitude for differences of opinion about whether or
not the Principle of Autonomy applies in an individual case.

For example, if someone adopts a life plan which we think is not the sort of life plan that
a rational individual would adopt are we justified in denying that that individual has
autonomy? In other respects, the individual might be exhibiting rationality in pursuance
of this life plan. An individual might be choosing appropriate means to achieve the end
that he or she has adopted, and their adherence to this end might be consistent with other
aspects of their life. In other words, they would be exhibiting two characteristics that
indicate rationality, but it is being judged that the life plan they have adopted makes it
appropriate to deny that the Principle of Autonomy applies in this particular case. One
such example is given by Beauchamp and Childress 5where an individual is admitted to a
mental institution on the grounds that the life plan they have adopted involves self-
mutilation. Their belief in God has led them to think that God requires these sacrifices
from them in order to prevent even greater harm to the rest of humanity.

The danger of allowing paternalistic evaluation of life plans is that this would enable one
to deny that the individual is capable of an autonomous decision. This would therefore
allow the possibility of a justified paternalistic intervention. Of course, if the Principle of
Autonomy genuinely does not apply, then a paternalistic intervention justified by the
Principle of Beneficence might well be appropriate. The justification would be that the
individual being treated is unable to judge themselves in the particular case what would
benefit them. So paternalism here is not being advocated in opposition to recognizing
autonomy because it is assumed that the Principle of Autonomy is not applicable. Where
the Principle of Autonomy is applicable, then this should have precedence.

The Principle of Autonomy justifiably overrides the Principle of Beneficence and, indeed,
the Principle of Non-malfeasance for the following reason. If an individual has the
characteristics necessary to exercise autonomy in a particular case then this implies the
ability to judge what is beneficial or harmful for that individual. Given that we have
argued that well-being and harm are evaluative terms, the evaluation of an individual who
is capable of making an assessment of what constitutes well-being or harm for them
ought to be the final court of appeal. This is justified on both deontological and
consequentialist grounds. The latter justification would consist of arguing that the
consequences were the best if this were advocated, since the determination of what
counts as a good outcome has been made by the individual concerned. A deontological
justification consists of pointing to the intrinsic worth of exercising autonomy (see
Section 4.2.2)

This last point highlights that we only have the potential for conflict between the
Principle of Beneficence and the Principle of Autonomy if we combine the Principle of
Beneficence with a paternalistic evaluation of benefits and harms. If the individual's
evaluation of benefits and harms is coupled with the Principle of Beneficence, then this is
in conformity with the Principle of Autonomy. The individual will decide to do what he
or she considers will be of most benefit to him or her.

LEARNING EXERCISES

1. Are the Principles of Beneficence and Non-malfeasance totally distinct or are


they just at different ends of a continuum? Give an example of an ethical dilemma in
health care where the answer to this question would lead to different evaluations.

2. Can the Principle of Beneficence ever conflict with the Principle of Autonomy?

http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_bene_nonmal.htm
Ethics Fast Fact
Beneficence vs. Nonmaleficence

Beneficence:

Definition: Beneficence is action that is done for the benefit of others. Beneficent actions
can be taken to help prevent or remove harms or to simply improve the situation of
others.

Clinical Applications: Physicians are expected to refrain from causing harm, but they also
have an obligation to help their patients. Ethicists often distinguish between obligatory
and ideal beneficence. Ideal beneficence comprises extreme acts of generosity or attempts
to benefit others on all possible occasions. Physicians are not necessarily expected to live
up to this broad definition of beneficence. However, the goal of medicine is to promote
the welfare of patients, and physicians possess skills and knowledge that enable them to
assist others. Due to the nature of the relationship between physicians and patients,
doctors do have an obligation to 1) prevent and remove harms, and 2) weigh and balance
possible benefits against possible risks of an action. Beneficence can also include
protecting and defending the rights of others, rescuing persons who are in danger, and
helping individuals with disabilities.

Examples of beneficent actions: Resuscitating a drowning victim, providing vaccinations


for the general population, encouraging a patient to quit smoking and start an exercise
program, talking to the community about STD prevention.

Non-maleficence:

Definition: Non-maleficence means to “do no harm.” Physicians must refrain from


providing ineffective treatments or acting with malice toward patients. This principle,
however, offers little useful guidance to physicians since many beneficial therapies also
have serious risks. The pertinent ethical issue is whether the benefits outweigh the
burdens.

Clinical Applications: Physicians should not provide ineffective treatments to patients as


these offer risk with no possibility of benefit and thus have a chance of harming patients.
In addition, physicians must not do anything that would purposely harm patients without
the action being balanced by proportional benefit. Because many medications,
procedures, and interventions cause harm in addition to benefit, the principle of non-
maleficence provides little concrete guidance in the care of patients. Where this principle
is most helpful is when it is balanced against beneficence. In this context non-
maleficence posits that the risks of treatment (harm) must be understood in light of the
potential benefits. Ultimately, the patient must decide whether the potential benefits
outweigh the potential harms.

Examples of non-maleficent actions: Stopping a medication that is shown to be harmful,


refusing to provide a treatment that has not been shown to be effective.
Balancing Beneficence and Non-maleficence:

One of the most common ethical dilemmas arises in the balancing of beneficence and
non-maleficence. This balance is the one between the benefits and risks of treatment and
plays a role in nearly every medical decision such as whether to order a particular test,
medication, procedure, operation or treatment. By providing informed consent,
physicians give patients the information necessary to understand the scope and nature of
the potential risks and benefits in order to make a decision. Ultimately it is the patient
who assigns weight to the risks and benefits. Nonetheless, the potential benefits of any
intervention must outweigh the risks in order for the action to be ethical.

Fast Facts written by: Steve Pantilat, MD


Steven Pantilat, MD
Associate Professor of Medicine
UCSF School of Medicine
© 2008 by the Regents, University of California. All rights reserved. No part of this
publication may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means without the prior written permission of the UCSF School of Medicine.

Non-Malfeasance
The ethical category of Non-Malfeasance represents the doctor’s attempt to avoid any
act or treatment plan that would harm the patient or violate the patient’s trust, and has
been popularized in the phrase “first, do no harm.” Non-Malfeasance is supported
through Confidentiality and Prevention. Confidentiality means maintaining the privacy of
patient information, and is the framework in which open, comprehensive doctor-patient
communication can take place. Benjamin Franklin’s proverb “an ounce of prevention is
worth a pound of cure” is a pithy but true commentary on the ethical necessity of
Prevention, which comes in two shapes: (1) helping the patient maintain good health to
avoid deteriorating conditions and (2) ensuring that all less invasive treatment options are
considered before recommending higher-risk measures. It is critically important that the
specialist provider of highly invasive treatments uphold Non-Malfeasance by ascertaining
that all less-invasive options have been considered by the patient in conjunction with the
PCP (for Continuity of Care) before attempting invasive treatment.

Chapter 3: The Moral Climate of Health Care


Section 5. Five Major Moral Principles in Health Care
In Health Care settings and in the institution itself there are a number of basic principles of morality
which evidence themselves. Even if one did not approach cases or situations holding the
principles of any of the standard ethical traditions there would arise these basic considerations and
concepts.

No matter what the ethical approach taken, with the exceptions of egoism and relativism, there is
agreement that there are certain basic principles related to health care that are consistent with the
notion of the GOOD. They are presented here. There is disagreement about how they might be
ordered or what to do in the event there is a conflict between or amongst them.

Those matters aside for now, there will be many occasions to make reference to these principles in
the analysis and discussion of cases in Biomedical Ethics.

Five Major Moral Principles in Health Care:

 I. NON MALFEASANCE
 II. BENEFICENCE
 III. UTILITY
 IV. DISTRIBUTIVE JUSTICE
 V. AUTONOMY

I. Non- Malfeasance- Do NO Harm!! Cause no needless harm or injury according to reasonable


standards of performance.

Observe DUE CARE . This does not mean that there must be no risk of injury but only that there
be no more than acceptable risks.

II. Beneficence- Promote the welfare of others. This is inherent in the relationship of a health care
provider (HCP) and the recipient of care.

E.g. the doctor-patient relationship. However, what exactly is the duty of the HCP?

This comes into particular focus as problematical when the health care providers are also
researchers. There must exist standards so that the benefits to the subjects and others are real
and with a real possibility to be realized.

III. Utility- Attempt to bring about the greatest amount of benefit to as many people involved as is
possible and consistent with the observance of other basic moral principles. Greatest Benefit and
Least harm

IV. Distributive Justice- All involved should have equal entitlements, equal access to benefits and
burdens. Similar cases should be treated in a similar fashion. People should be treated alike
regardless of need, contributions or effort.

The formal principle of Justice as Fairness (Rawls’ Theory) similar cases are to receive the same
treatment. However, in what ways are the cases similar? In what relevant ways? Equal in need?
Equal in contributions to society? to the Health Care institution? Equal in effort?

V. Autonomy- People are rational, self determining beings who are capable of making judgments
and decisions and should be respected as such and permitted to do so and supported with truthful
and accurate information and no coercion.

They should have their decision making and actions: a) free of duress of any type, (b) based upon
options that are clearly explained and that are genuine possibilities and (c) given the information
needed for decision making.

Some believe that there can be justifications for violations of the principle of autonomy.

There are four principles cited to justify restrictions on AUTONOMY:

1. HARM Principle- stop an individual whose autonomy is restricted or violated from causing harm
to others

2. PATERNALISM Principle- There are two forms:

 Weak -to stop a person whose autonomy is restricted or violated from self harm
 Strong -to benefit the person whose autonomy is restricted or violated

3. LEGAL MORALISM Principle- legislated morality

Acts of legislation impose restrictions upon all, presumably for the benefit of all

4. WELFARE Principle- restrictions or violations of the autonomy of an individual for the benefit of
all.

EXAMPLES:

Harm- if a person has a highly contagious and life threatening disease that person could be
confined against that person's will

Paternalism-weak- a person attempting suicide by ingesting poison could have the stomach
cleared of the poison in the ER even though refusing treatment.

Paternalism-strong- a 22 year old person could have a gangrenous leg amputated even against a
refusal of treatment.

Legal Moralism - children can be inoculated against disease despite their refusal and that of their
parents.

Welfare- a person with a rare anti-body to a deadly incurable disease threatening the general
population could be made to give a specimen of their blood or bone marrow or other tissue for the
sake of the benefit of the entire society.

More on What are the major principles of medical ethics?

http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html#ques3
Proceed to the next section of the chapter by clicking here> next section.

© Copyright Philip A. Pecorino 2002. All Rights reserved.

Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify
class discussion. They should be read as such. They are not intended for publication or
general distribution.
Return to: Table of Contents for the Online Textbook

Chapter 3: The Moral Climate of Health Care


Section 6. Readings

Medical Errors

Malpractice

9 of 10 Nursing Homes Lack Adequate Staff, Study Finds

Patient Deaths Tied to Lack of Nurses

Nursing Home Abuse

Inadequate Care-Living_Donor_Transplant

Female MDs Deemed More Patient-Oriented


Proceed to the next section of the chapter by clicking here> next section.

© Copyright Philip A. Pecorino 2002. All Rights reserved.

Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify
class discussion. They should be read as such. They are not intended for publication or
general distribution.
Return to: Table of Contents for the Online Textbook
Medical
Ethics

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Philip A. Pecorino, Ph.D.

Queensborough Community College,

The City University of New York

Table of Contents for this Online Textbook

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