Nonmaleficence Ethical Principle

ABSTRACT

            The Principle of Nonmaleficence in the field of medical practice, states the duty of a medical practitioner to do no harm to their patients. This principle will take into practice the Hippocratic oath that they sworn as they entered the profession that they have chosen the oth states that “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.”

            There are undeniably few cases that concern the malpractices of some medical practitioners who do not follow the ethical principles of their profession. There are liabilities that they face from the disciplinary actions done by their own companies, up to the worst extent of having court cases. There are certain organizations that have their own strict implementation of their code of ethics and do their own disciplinary measures for the members who are liable for malpractice of their code of ethics. And one of this is the American Psychologists Association (APA). This is the largest organization of professional psychologists in the world.

            In the practice of their medical profession, medical practitioners are faced with some conflicting circumstances challenging their medical principles that they follow. In the case of nonmaleficence, there are some issues that are somewhat debatable. These are issues of euthanasia, paternalism, futile and pointless treatment, withholding and withdrawal treatments, Do Not Resuscitate Orders (DNR), and few cases of technological failures. Addressing these issues can be by balancing the benefits and burdens that the patient will undergo upon medication, taking the considerations in the principle of double effect under nonmaleficence and always informing the patient of the pros and cons of the treatment giving him/her the power to decide for himself.

Nonmaleficence Ethical Principle:

A Research Paper

1. Introduction

Life is the greatest possession that a person has. No amount of money can ever pay the worth of ones’ life. Respect for the right of everyone’s right to live is very basic. That is why in every profession doing no harm to other people is the number one policy.

Medical practitioners enjoy a profession of saving the lives of the people. More than anybody else, they must be the very first to practice by heart how to do no harm to their patients. They are the ones who would truly define how important life is.

In medical practices, there are four basic principles that medical practitioners took by heart. These are the principle of respect for autonomy, the principle of beneficence, the principle of nonmalificence and the principle of justice. In this paper, let me focus on the third principle which is the principle of nonmaleficence.

Maleficence, from the root word malefic, means to do harm or mischief. Putting the prefix ‘non’, the word nonmaleficence would mean not to do harm. It came from the ancient maxim primum non nocere, which, translated from the Latin, means “first, do no harm.”

Susan McPhail Wittjen defines the principle of nonmaleficence as an obligation not to inflict harm intentionally. Thomas R. McCormick, however, states that it requires of us that we not intentionally create a needless harm or injury to the patient, either through acts of commission or omission. Colin L. Soskolne and Lee E. Sieswerda express it to be an obligation not to harm others. The American Counseling Association defines it as “the concept of not causing harm to others.

Often explained as “above all do no harm”, this principle is considered by some to be the most critical of all the principles, even though theoretically they are all of equal weight (Kitchener, 1984; Rosenbaum, 1982; Stadler, 1986). This principle reflects both the idea of not inflicting intentional harm, and not engaging in actions that risk harming others (Forester-Miller & Rubenstein, 1992)”. Combining all their definitions, the principle of nonmaleficence deals with the demand for unintentional making of an unnecessary harm or injury to the patient, eit(“The Principle of Nonmaleficence:

Illustrative Cases”, 1998)her through acts of commission or omission. It is one of the four major principle that all medical practitioners keep in mind during important life-saving decisions. When a person swears in a medical profession, they commit to only save lives, care for their patients as much as they can and cure their diseases. However, there are inevitable circumstances where they are caught in the middle of two evil decisions.

The risk they had to take is to choose what could be the lesser evil. Let’s take for example; a medical practitioner might be forced to do painful medication to a patient in order to prolong its life. However, the decision doesn’t really lie on the doctors, but rather it is always the patient who has his own hand on his life. What the doctors’ responsibility is to offer the patient the best choices he has.

Another example is the concern with regards to product safety. It is very important that the drugs that are prescribed by the doctors must always have sufficient knowledge on its side effects. If there would occur unexplainable harmful side effects, the purpose of this principle will be defeated. In this case, the doctor could have prevented the harm and yet was not able to do so.

The principle of double effect can also be associated with this principle. There are four conditions that should be followed under this. They are:

 1) the action itself must not be intrinsically wrong, it must be a good or neutral act;

 2) only the good effect must be intended, not the bad effect, even though it is foreseen;

 3) the bad effect must not be the means of the good effect; and

4) the good effect must outweigh the evil that is permitted.

The principle of beneficence is another principle that is either combined or is complemented with the principle of nonmaleficence. This principle which is also one of the four major principles in medicine, states that one must do good or promote good. When there is an increase in the violation of nonmaleficence principle, there is a decrease in the acts of beneficence.

1. Ethical Implications

Talking about the violations of the nonmaleficence principle, according to Dr. Thomas Kerkhoff, there are five don’t’s that guides the medical practitioners. These are:

1. a) do not kill;
2. b) do not cause pain or suffering;
3. c) do not incapacitate;
4. d) do not cause offense; and
5. e) do not deprive others of the goods of life.

He also stated that in taking important actions, one must always take good care of the patient against the risk of such action. If in case the caregiver fails to do so, he commits negligence.

What are the proceedings that one will undergo when he/she commits liabilitites on the principle of nonmaleficence? Giving a concrete example, the American Psychological Association (APA) is an institution that adopts the nonmaleficence principle in their code of ethics. As stated on their beneficience and nonmaleficence principle, “psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research.

When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.” It has its own rules and procedures that they follow with regards to the violations of their code of ethics. Members are required to collaborate fully and in a timely manner with the ethics process.

Failure to cooperate shall not prevent continuation of any measures and itself constitutes a violation of the Ethics Code that may warrant being expelled from the Association. APA has the right to entail sanctions on its members such as warning, deprecation, termination of APA membership, and may also extend to court’s investigation. In greater extent, the APA bylaws may imprison the violator of a crime; expel him/her from an affiliated state psychological association, and even suspension or loss of licensure.

With regards to the conflicts of the psychologists’ ethical responsibilities with law, regulations, or other governing legal authority, the association follows that the psychologists make known their commitment to the Ethics Code and resolve the conflict in their own means. If the conflict is unresolvable via such means, psychologists may stick on to the requirements of the law, regulations, or other governing legal authority.

APA doesn’t only rely on their own Ethics Code for that would imply bias. They also do consult other Ethics Committees about the issues that the psychologists are facing. On their Ethical Standards regarding resolving of ethical issues (par. 1.06), it was stated there that “Psychologists cooperate in ethics investigations, proceedings, and resulting requirements of the APA or any affiliated state psychological association to which they belong. In doing so, they address any confidentiality issues. Failure to cooperate is itself an ethics violation. However, making a request for deferment of adjudication of an ethics complaint pending the outcome of litigation does not alone constitute noncooperation.”

The process of filing complaints of either a member or a non-member based on their Ethics code would require the following:

• A completed APA Ethics Complaint Form;
• Such releases as are required by the Committee;
• A waiver by the complainant of any right to subpoena from APA or its agents for the purposes of private civil litigation any documents or information concerning the case;
• For purposes of determining time limits, a complaint shall be considered filed with APA as soon as a completed complaint form has been received by the Ethics Office. A deficiency or omission in the preparation of the complaint form may, at the discretion of the Director, be disregarded for purposes of determining compliance with time limits.”

The APA is a fully recognized association that represents psychology in the United States. It is an organization which has the largest membership worlwide.

• Ethical, Social, Legal Issues

As I had mentioned earlier, most common ethical problem encountered in the principle of nonmaleficence is that medical practitioners get caught in the middle of two evil decisions. Most commonly debated issue I can say is the Euthanasia. Euthanasia is a practice done by ending the lives of patients who are suffering from a terminal disease or a painful condition in a painless or minimally painful way either by lethal injection, drug overdose or withdrawal of medical support. This practice is a long-time debated issue because of its immoral and inhumane implications.

The problem in euthanasia has also become a social concern. The morality of this practice has always been questioned because of the belief that nobody has the right to take the life of a person. Moralist has equated euthanasia to the crime of murder. They say that doctors must not have provided this kind of choice to their patients since it is in the principle of nonmaleficence that they must never do any harm to their patients. But taking the other way around, euthanasia is not killing by itself.

Euthanasia came from two Greek words “eu” which means good, and “thanatos which means “death”. Therefore, the word euthaniasia can also be equated to “good death”. If that is the case the doctors are not doing any harm to their patients but they are offering them another good choice which is ending the life of their beloveds in a more easy and painless way. Death in this case is not the harm but the pain the patient will feel in prolonging his life.

Paternalism is another issue on this principle. Paternalism is defined as the intentional overriding of one person’s known preferences or actions by another person where the person who overrides justifies the action by the goal of benefitting or avoiding harm to the person whose will is overriden. These are cases in which the principles of beneficence and nomelficence win a fight against the principle of autonomy. An example is if the patient is mentally incapacitated to think well of himself, then the doctor will take the paternalistic approach of curing the patient. However, if the patient will not be able to like the treatment, there comes a problem of overriding his will.

Autonomy is a major consideration in the principle of nonmaleficence. Actually, as I mentioned a while ago, there is a so-called principle of autonomy. This principle states that any notion of moral decision making assumes that rational agents are involved in making informed and voluntary decisions.

According to Alfred Tuaber, the principle of autonomy holds that a patient has the right to make his or her own decision regarding treatment — including the right to refuse treatment — without being coerced by medical staff or family members. In the case of paternalism, autonomy is being set aside in order to implement what is better for the patient. It has become a serious issue since the person takes medication that is beyond his will. However, if it is strongly justified by the doctor, he may win the case.

Futile or pointless treatment is another issue to tackle. Medical futility is a case in which treatment cannot produce any benefits. This kind of treatment involves both value and scientific judgement. It is a question of “will the patient be able to sustain the treatment? Will he be able to get well or just to prolong life with full of pain and suffering? Will there be no means of recovery even after repeated trials of medication?” If the answer is yes, then there comes the pointless treatment. The patient is advised not to undergo any medical treatment since there are no chances of that person to recover even if he/she takes the medication. But the family of the patient would insist on prolongiong their love ones’s life that leads to mischief between the doctors and the families.

Withholding and withdrawing treatments can also become serious problem. The four common reasons why treatment may be withheld or withdrawn are the patients own choice, an undesirable resulting quality of life, the burdens outweigh the benefits, and the treatment just prolongs dying. These treatments include medically provided hydation or nutrition, dialysis and ventillation.

This is subjected to the will and determination of the patient to undergo these treatments. It requires readiness for severe pain. It becomes o problem if the patient will not be able to surpass the pain and discontinue the started medication. It still siuts the nonmaleficence because the decision to withhold or withdraw treatment permits the disease to progress on its natural course. It is not intended to cause death. An example of this is the study about “Withholding Antibiotic Treatment in Pneumonia Patients with Dementia” made by van der Steen JT, et. al.

Another issue is the DNR. DNR stands for Do Not Resuscitate Orders. A DNR order by a physician states that if there is a cardiopulmonary arrest, resuscitation will not be started and is actually prohibited. This order tells that once the heartbeat stops, the nurses or doctors should not perform cardiopulmonary resuscitation (CPR). This is done because if the patient was terminally ill and was still subjected to CPR, it may cause nothing to the patient, sometimes, it may even lead to brain damage. Some people may think that the doctors were only giving up their loved ones that is why they withhold the CPR. But the truth is, this is only to reduce the greater damage it would entail.

Technological failures are also a problem. Most of the life-support systems in many hospitals are machine-made, therefore, it is vulnerable to machine failures. In this case, the hospitals are the ones liable for these failures. Because of this problem, some patients are frightened to take the risk of using these machines. It becomes a problem for both the patient and the doctors as well.

What could be the actions taken in resolving the legal and moral issues of nonmaleficence? A trial in court is the most efficient method used to resovle the issues. However, in order to avoid getting this far, the core solution I can suggest is the consultation of the doctors’ decision to their patients. The decision must always come from them and that’s very basic. Doctors are advised to explain to their patients the overview of the effects of the actions they are going to take. By this, the families of the patients, or even the patients himself may have time to think of what choice they are going to take.

Moreover, the doctors must also consider the laws regarding the actions they are going to take, as to whether they are lawfully acceptable or not. Balancing the burdens and benefits of the patient in receiving the treatment must always be kept in mind. By doing this, the doctors will have little or no worries in committing negligence. Doctors can also get a living will from the patient that states that they are given the authority by the patient to do such action. Or in the case that the patient is incapable of dointg a living will, they can also have the durable power of attorney given by a lawyer in behalf of the person who will receive the medication.

1. Working Through Nonmaleficence Dilema

The establishment of ethical principles aims to guide the worker through difficult scenarios involving morals, values and beliefs. However, these dilemmas are inevitable in the pratcice of these principles. Like for example, I had mentioned a while ago the dilema between euthanasia and the principle of nonmaleficence. I had also mentioned that euthanasia is indeed a good death. The act of euthanasia in fact is morally accepted because in terminating one’s life, we are actually relieving the pain and suffering of the patient.

Another example of a nonmaleficence dilemma is a pregnant woman recently diagnosed to have cancer of the uterus. There is a decision to make between saving the fetus on the cause of letting the mother die, or curing the mother sacrificing the fetus.

Another dilemma is a patient found to have diabetes. One problem of diabetic patient is the inability to heal wounds. In great extent, these wounds will be severely infected if not treated well that may often cause to the removal of the infected body part. However, if the cause of the removal of the body part will prolong his life but would make him/her a disfunctional person, there would the problem arise.

In order to justify the actions to be made, let me emphasize the considerations that must be followed under the principle of double effect:

1) the action itself must not be intrinsically wrong, it must be a good or neutral act;

 2) only the good effect must be intended, not the bad effect, even though it is foreseen;

 3) the bad effect must not be the means of the good effect; and

4) the good effect must outweigh the evil that is permitted.

I had also said that balancing the benefits and burdens that the patient will undergo must be considered before taking any action. For example, if the patient will undergo pain, will he be able to prolong his life? Or will it be better-off if he restrain from taking medications knowing that the patient will not recover anymore so that he will suffer less? For the withholding or withdrawing treatment we can identify the benefits of a treatment may be longer life, comfort, relationships and the ability to communicate. The burdens of a treatment may be pain, suffering, technological dependence, isolation, immobility and emotional or spiritual distress.

Passing of laws that will put guidelines and standardization of the dilemmas in the practice of the principle of nonmaleficence would also help. In Netherlands, under the legislation passed by the Upper House of Netherlands Parliament, a law states that the termination of life on request and assistance with suicide will not be treated as a criminal offence if carried out by a physician and certain criteria of due care have been fulfilled. (“End-of-Life Ethics: Benefits and Burdens”, 1994-2006)These considerations would address all these dilemmas.

We can also look back in the medical history of the patient with regards to his/her ability of recovering from illness. There are some cases that we cannot deny, miracles do happen. Sometimes those cases are the points that moralist would try to ask us. “What if he still recovers? What if he can still survive for another ten years?” those cases are unavoidable. But if we can handle them the history of their recovery, and we can study the possibilities, it would be easy for us to make intelligent decisions.

We can always, reflect on what are the pros and cons of our actions. Medical practitioners must always keep in mind that life is not just something we play on with. They must not forget the Hippocratic Oath that they took which says: “I will use treatment to help the sick, according to my ability and judgement, but I will never use it to injure or wrong them.”

The principle of nonmaleficence can always be used in all matters of life, not only in medical field but in everything we do. Harming is subjective on the pupose one is considering. However, let us also remember that it is not always the case that the end justifies the means. As the principle of double effect imples, the bad cause will not result to a good effect. It will always follow that a good cause will result to a good effect.

As a conclusion, the principle of nonmaleficence must be put into practice by all medical practitioners. However, careful usage of the said principle must be well studied. One must be articulate enough of the consequences of the decisions he has to take. After all, nobody wants to take ones’ life at risk.

1. References

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