Non-maleficence in modern healthcare

Primum non nocere. Do No Harm.

The principle of nonmaleficence is widely considered the primary principle in bioethics. Without this fundamental principle, the other principles cannot hold. I go so far as to suggest that this principle can be regarded as a human quality – humanity’s innate desire to keep one another safe.  This principle is the driving factor for many professionals to choose healthcare. Providing care that positively impacts patients’ lives is precisely what most healthcare workers aspire to in their careers. Unfortunately, harm can occur in healthcare, even when procedures are performed correctly; however, damage and suffering are minimized by upholding the principle of non-maleficence. To ‘do no harm’ means to provide care that incorporates all other principles. So, to achieve the best patient outcomes, physicians strive to balance each principle. If physicians follow this approach, they adhere to moral reasoning and achieve long-lasting results that satisfy the patient’s reasoning towards their health.

The non-maleficence principle is characterized by carefully balancing the benefits and burdens of treatments, avoiding inappropriately burdensome treatments while selecting the most beneficial course of action for the patient. Non-maleficence becomes particularly relevant in challenging end-of-life care decisions, such as withdrawing life-sustaining treatment, managing pain, and alleviating symptoms. Ethical dilemmas have arisen when discussing the contradictions between non-maleficence and autonomy or in public health discussions. Another interesting area of discussion is epistemic injustice.

When discussing end-of-life care, the discussion of assisted dying begins. Assisted dying is the action taken by a physician that assists the patient in death. This can be seen as an injection; this would need a voluntary and informed consent for it to happen, and is being discussed among patients with terminal long-term chronic illness, or this can be the medical professional’s action to turn off equipment that keeps the patient alive. Either way, ethical end-of-life care is needed to respect the individual when performing such actions. In the cases of assisted dying, bioethicists argue that allowing terminally ill patients to choose a dignified death minimizes harm. In contrast, others believe it contradicts the traditional medical duty to avoid causing damage. In my opinion, assisted dying and the outcomes of our discussions and evaluation of our misfortunes are where we can learn how to manage the mysteries of our collective psyche. This involves recognizing the dying as individuals and giving them the autonomy to decide.

As for epistemic injustice, this is a type of injustice that occurs when individuals are dismissed by healthcare providers even when the patient is willing to express their autonomy. In other words, when healthcare providers dismiss the patients’ experience and knowledge of their illness. This is relevant to chronically ill patients and the need to take their experiences seriously. The healthcare community should take these cases seriously, as the repercussions can undermine trust in the healthcare system. Since these patients seek healthcare services the most often, they can impact society’s trust in physicians by sharing their experiences with other community members. These patients have experience in healthcare that other members of society listen to, as they have more knowledge navigating the healthcare system. When they share their experiences with others, their complaints can ripple, affecting those they did not know they would. This can be viewed as a positive for patient advocacy groups and other community members fighting for more patient autonomy. However, on the other hand, this disruption can continue to erode the trust in the healthcare system, which ultimately causes more harm to the general population than to the individual level.

Trust is the cornerstone of a well-functioning healthcare system and a necessary component of effective public health policy. In societies that lack trust in healthcare systems, individuals tend to regard public health as less critical, prioritizing their autonomy over the equitable distribution of resources for public health among the general population. This is seen in cases where vaccines are mandated. The patient’s autonomy is chosen over the well-being of the collective, which causes further injustice in the healthcare system. This is argued to contradict the principle of non-maleficence, and to an extent, I would agree. The public’s health must be considered when dealing with tightly situated populations. Historically, vaccines have been mandated and have had an incredible effect on the longevity and health of youth populations. Vaccines have been a saving grace for the global child mortality rate, nearly eradicating diseases that primarily affect children, and should be seen as an achievement for humanity [Vaccines have saved 150 million children over the last 50 years – Our World in Data]. Instead, we have propaganda and disinformation that have attacked these achievements, causing a snowball effect of mistrust towards physicians who promote vaccines on an individual level. Now, on a personal level, with the cases of vaccines, it is logical to allow autonomy to be used as the primary principle for decision-making. Still, in the cases of vaccines, the evidence outweighs the people’s concerns, and I would argue that, where possible, educating the patients is the best possible solution for this problem. But for the most part, the education of the general population is the government’s responsibility. As for the physician dealing with this ethical dilemma, the principle of non-harm is being held when vaccines are mandated, as non-maleficence is to ‘do no harm,’ and allowing vaccine-preventable diseases to spread causes harm.

As someone who deeply believes democracy is truly understood and upheld by individuals who understand their autonomy, I pivot to explaining how autonomy is the guiding principle of bioethical discourse in a healthy society. Imbalances in bioethical discussion could be addressed with the principle of autonomy and their involvement in decision-making. However, there are healthcare situations that require physician to make decisions without the patient’s involvement, or otherwise the patient’s autonomy cannot be expressed. If the outcome of this care results in harm, the best course of action is to discuss the physician’s intentions when making decisions.

This is where the doctrine (or principle) of double effect can be used in bioethical discourse.

“The doctrine of double effect is often invoked to explain the permissibility of an action that caused serious harm, such as the death of a human being, resulting as a side effect when promoting some good end. According to the principle of double effect, sometimes it is permissible to cause harm as an unintended and merely foreseen side effect (or “double effect”) of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end” Doctrine of Double Effect (Stanford Encyclopedia of Philosophy)

The doctrine of double effect recognizes the decision-maker’s intention. This framework helps decide if beneficence was the leading principle in decision-making, even when the outcome was harmful. The doctrine of double effect emphasizes a distinction between causing moral harm as a side effect in pursuing a positive outcome and the cause of harm when pursuing an individual positive outcome. In other words, there is a difference when damage was done unintentionally in pursuing a positive outcome, and harm is the result of pursuing a positive outcome.

The doctrine helps define the intention of the individual who caused harm and whether the result was for the sake of beneficence.

Joseph Managan provided four conditions that need to be met to establish unintentional harm while pursuing a positive outcome.

1. that the action in itself, from its very object, be good or at least indifferent;
2. that the good effect and not the bad effect be intended;
3. that the good effect is not produced by means of the bad effect;
4. that there be a proportionately grave reason for permitting the bad effect;

These conditions help determine whether an individual’s actions can be seen as good and, therefore, whether the harm done can be morally justified.

The doctrine of the double effect is used in ethical discussions, Whether it is euthanasia and pain relief or abortion and hysterectomy, the doctrine allows for a humanistic approach to ethical cases. Focusing on the intention while reviewing ethical dilemmas allows the decision-maker to grow from their actions. This is part of an individual’s moral growth.

Even so, I argue that this doctrine can be used to solve the dilemma that professionals face: an individualized approach vs. standardization

Ethical dilemmas can happen when the standard approach to an individual does not lead to the intended positive outcome, leaving the patient and/or healthcare professional in an ethical dilemma. Since ethics heavily relies on the capability of moral reasoning, it is to be expected that there will be misjudgment and harm during an individual’s practice. Ethical reasoning is a complex skill involving years of practice and mistakes. To avoid discouraging professionals from applying moral reasoning to an individual approach, the Doctrine of the Double Effect can be used by the healthcare professional. 

I’d like to argue that if the doctrine of double effect were integrated into a healthcare provider’s practice, they could mitigate the constant use of protocols. Although protocols are beneficial for the patient and their use has increased the quality of healthcare worldwide, there are discussions in the general population about the negative effects of protocols. When cases emerge and an ethical dilemma between beneficence and non-maleficence arises, it is easy to side with protocol, prioritizing caution over moral justice. Siding with the established system and not accounting for the patient’s welfare can not be viewed as a free pass from causing harm. On one side, with the safest route, ethical principles might not be the primary focus for healthcare workers, thus creating an imbalance in the system and disrupting the principle of justice. To find a middle ground in such ethical dilemmas, applying the doctrine helps determine the intention and, therefore, the moral reasoning behind an action.