BIOETHICS

BENEFICENCE / 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 • “I will follow that system of
for the good of my
patients according to my
ability and judgment and
never do no harm to
anyone”
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 possess

skills 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 – Limits
1. 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 – Limits
2. 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 – Limits
3. 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 • Limited guidance since many
therapies interventions also entail
• From acting maliciously or serious risks and side effects.
selfishly • Standard care

• [If no benefit, at least do not • [If benefit equals harm, do not

harm or make situation worse] 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 the
parents 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