BIOETHICSBENEFICENCE / NON-MALEFICENCE

Prof. Utham Murali.

“ Doctors are men who prescribe medicines of which they

know little, for diseases about which they understand even less,

for people about whom they know nothing ”

- Voltaire

Principles of Medical Ethics

• Autonomy

• Beneficence

• Non-maleficence

• Social Justice

Hippocratic Oath

• “I will prescribe regimen for the good of my patients according to my ability and judgment and never do no harm to anyone”

Hippocratic Oath

• “I will prescribe regimen for the good of my patients according to my ability and judgment and never do no harm to anyone”

• “I will follow that system of regimen, which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel”.

Definition

Beneficence Non - maleficence

• Literally – “Being charitable or doing good”.

• Where a doctor should act in the “best interests” of the patient, the procedure be provided with the intent of doing good to the patient.

Definition

Beneficence Non - maleficence

• Literally- “Doing no harm”

• Make sure that the procedure does not harm the patient.

Description

Beneficience Non-maleficence• Requires physicians to take

positive actions for the benefit of patients.

• Because patients do not possess medical expertise and maybe vulnerable because of their illness, they rely on physicians to provide sound advice and to promote their well being.

Description

Beneficience Non-maleficence

• Refrain from providing ineffective treatments or acting with malice toward patients.

• The pertinent ethical issue is whether the benefits outweigh the burdens.

Beneficence – Clinical applications

• To refrain from causing harm, but they have an obligation to help their patients. { On all possible occasions }

• The goal is to promote the welfare of patients & should possessskills and knowledge that enable them to assist others.

• It also include protecting and defending the rights of others, rescuing persons who are in danger and helping individuals with disabilities.

Beneficence

Promotes patient “Best interest” by:

• - Understanding patient perspective

• - Address misunderstandings and concern

• - Try to persuade patient

• - Negotiate a mutually acceptable plan of care

• - Ultimately let the patient decide

Beneficence

• The physician cannot be required to violate fundamental personal values, standards of scientific or ethical practice, or the law.

• If the physician is unable to carry out the patient’s wishes, the physician must withdraw and transfer care of the patient.

Beneficence – Approach

•What does it mean in practice “to act for the good of patients” ?

• What is medically “good” ?

Beneficence – 1st – Acting in the pt’s interest

• Very straight forward Situations - e.g. patient with chest pain / meningitis.

• Complicated Situations - conflict between - Health interests and other important interests that patient might have. e.g. employment interests, religious interests.

• In secondary and tertiary care, health problems can be urgent and overwhelming that patient interests shrunk to coincide with his health interests.

• Doctors have to appreciate and negotiate these contending interests so that the patient sees the primary of the health interest like others.

Beneficence – 2nd

• Onus on doctor to check which treatment are effective or not.

• Role of EBM (Evidence-Based Medicine) to clarify issues.

Beneficence – Limits1. Pt’s driven constraints

• Normally motivated by health interests.

• Conflicts arise when patient’s aim diverge from doctor.

• Patients reject treatment but they must understand fully, implication of their decisions.

Treatment Refusal – Doctor’s Role

Approach to Patient Physician’s act

• Patient’s competence

• Enough information to be provided

• Voluntary effort

Treatment Refusal

Approach to patient Physicians act

• Listening - Demonstrates a commitment to care & trustworthiness

• Correct misunderstandings and misconceptions

• Refusal is fully informed

Beneficence – Limits2. Practitioner- driven constraint & medical responsibility

• Patients request medical services, which doctor consider unnecessary

• Use of EBM guidelines not in the best interest for patients.

Beneficence – Limits3. External constraints

• Lack of resources - e.g. waiting list for investigations, referral and treatments.

• Access to specialists care takes a long time leading to ethical issues - eg. patients dying while waiting for treatment, paying patients by passing public patients for treatment.

Non – Maleficence

• The principle of “Non-Maleficence” requires an intention to avoid needless harm or injury that can arise through acts of commission or omission.

• In common language, it can be considered “negligence” if you impose a careless or unreasonable risk of harm upon another.

Non - Maleficence – Clinical applications

• Not to provide ineffective trts to pts as these offer risk with no

possibility of benefit & thus have a chance of harming pts.

• Not do anything that would purposely harm pts without the action

being balanced by proportional benefit.

• The risks of treatment (Harm) must be understood in light of the

potential benefits.

Non – Maleficence

Forbids Provides

• From providing ineffective therapies

• From acting maliciously or selfishly

• [If no benefit, at least do not harm or make situation worse]

•

• Limited guidance since many interventions also entail serious risks and side effects.

• Standard care

• [If benefit equals harm, do not intervene]

Examples

Beneficience Non-maleficence

• Resuscitating a drowning victim.

• Providing vaccinations.

• Encouraging a pt to quit smoking.

• Talking to community about STD prevention.

Examples

Beneficience Non-maleficence

• Stopping a medication that is shown to be harmful.

• Refusing to provide a treatment that is not effective.

Case – 1 • 32yr patient tests positive for

autosomal dominant heart condition that has a 4% annual risk of sudden death.

• His brother is a pilot but patient specifically does not want his brother to know as he might lose his job.

• Should the brother be informed ?

Case – 1

YES No• Duty of beneficence and

non-maleficence to brother – effective preventative treatments

• Likelihood and seriousness of harm (cardiac death) justifies disclosure

• Risk to others – duty to act in their best interests

Case – 1

YES No

• Brother may not want to do –doctor should respect his autonomy (right not to know)

• Impacts on employment of brother

• Should respect autonomy of patient

• Conflicts with Hippocratic Oath (duty of confidentiality)

Case – 2 • 2 year old male child is having physical deformities and

mentally retarded. h lived to his fifth birthday but not more.

• Parents have no formal education and are working at a factory with a monthly salary of US$500 - to sustain their life and another 3 children with no health insurance.

• Monthly expense for medication and special diet for the child is US$450.

• The parents have requested for the physician to let the child die as the child could never live a normal life, the physician consented the request.

• So he has stopped giving the child his medication and diet

• The child died after 2 days

• Havethe physician breached the

obligation of Non-maleficence ?

The physician can argue that he follows theparents request due to the fact that :

• The ability of the family to support the child is really low as they also need to feed the other 3 child, need to go to school and they are prone to be suffering from malnutrition, its morally wrong for the other child to suffer as well.

But …

Physicians

inflicted harm, even if on compassionate

grounds, hence, the moral dilemma remains.

It is said…

It seems the moral

dilemma remains: whichever way the

pendulum swings, the physician must at all

times be conscious of the dictum: aegroti salus

suprema lex (that is, the good of the patient is

the highest law)

Conclusion – Balancing – Both

• Ethical dilemma arises in the balancing of beneficence and non-maleficence.

• It is the balance between the benefits and risks of 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.

Surg Clin N Am 91 (2011) 481–491

Thank you