Beneficence Versus Nonmaleficence
A middle-aged nurse recounts an incident that she believes relates to the principle of nonmaleficence. As a senior nursing student she was responsible for the care of a man who had a shotgun wound to his abdomen. Surgery had been performed, and the surgeon was unable to adequately repair the damage. The man was not expected to survive the day. He was, however, awake and strong, though somewhat confused. He had a fever of 107° Fahrenheit. He was receiving intravenous fluids and had continuous nasogastric suction. The man begged for cold water to drink. The physician ordered nothing by mouth in the belief that electrolytes would be lost through the nasogastric suction if water were introduced into the stomach. The student had been taught to follow the physician’s orders. She repeatedly denied the man water to drink. She worked diligently—giving iced alcohol baths, taking vital signs, monitoring the intravenous fluids, and being industrious. He begged for water. She followed orders perfectly. After six terrible hours she turned to find the man quickly drinking the water from one of his ice bags. She left the room, stood in the hallway, and cried. She felt she had failed to do her job. As a result of the gunshot wound, the man died the next morning. Today her view of the situation is different.
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Think About It
Weighing Harm Against Benefit
· Was this patient harmed? Discuss your answer.
· What was the benefit of the nothing-by-mouth order?
· Discuss whether the harm of thirst or the benefit of maintaining nothing by mouth should take precedence.
· What other ethical principles are relevant?
· Why did the student experience such extreme distress?
The principle of nonmaleficence is related to beneficence. Whereas beneficence requires us to prevent or remove harm, nonmaleficence requires us to avoid actually causing harm. Included in this principle are deliberate harm, risk of harm, and harm that occurs during the performance of beneficial acts. Most ethicists today tend toward the Hippocratic tradition that says to first do no harm (the principle of nonmaleficence), placing this principle above all others. It is obvious that we must not commit acts that cause deliberate harm. This principle prohibits, for example, experimental research when it is fairly certain that participants will be harmed, and the performance of unnecessary procedures for economic gain or solely as a learning experience.
Nonmaleficence also means avoiding harm as a consequence of doing good. In such cases, the harm must be weighed against the expected benefit. For example, sticking a child with a needle for the purpose of causing pain is always bad—there is no benefit. Giving an immunization, on the other hand, while causing similar pain, results in the benefit of protecting the child from serious disease. The harm caused by the pain of the injection is easily outweighed by the benefit of the vaccine. In day-to-day practice, we encounter many situations in which the distinction is less clear, either because the harm caused may appear to be equal to the benefit gained, because the outcome of a particular therapy cannot be assured, or as a result of conflicting beliefs and values. For example, consider analgesia for patients with painful terminal illness. Narcotic analgesia may be the only type of medication that will relieve very severe pain. This medication, however, may result in dependence and can hasten death when given in amounts required to relieve pain. Cammon and Hackshaw (2000) offer another common example. Orders for patients to have nothing by mouth before procedures and tests are common practice, unquestioned by most nurses. The authors cite examples in which elderly patients were denied food for up to 6 days as tests and procedures were completed. The consequences of starvation in the elderly are unquestionable, yet the practice of following NPO orders for long periods of time is seldom questioned. As nurses, we must be alert to situations such as these in which harm may outweigh benefit, taking into account our own values and those of patients.
The principle of beneficence means to do good. It requires nurses to act in ways that benefit patients. Beneficent acts are morally and legally demanded by the professional role (Beauchamp & Walters, 2007). The objective of beneficence provides nursing’s context and justification. It lays the groundwork for the trust that society places in the nursing profession, and the trust that individuals place in particular nurses or health care agencies. Perhaps this principle seems straightforward, but it is actually very complex. As we think about beneficence, certain questions arise: How do we define beneficence—what is good? Should we determine what is good by subjective, or by objective, means? When people disagree about what is good, whose opinion counts? Is beneficence an absolute obligation and, if so, how far does our obligation extend? Does the trend toward unbridled patient autonomy outweigh obligations of beneficence? Veatch (2002) asks whether the goal is really to promote the total well-being of the patient or to promote only the medical well-being of the patient. We must keep these questions in mind as we practice.
The ethical principle of beneficence has three major components: do or promote good, prevent harm, and remove evil or harm. (See Figure 3–2.) Beneficence requires that we do or promote good (Beauchamp & Childress, 2008). Even with the recognition that good might be defined in a number of ways, it seems safe to assume that the intention of nurses in general is to do good. Questions arise when those involved in a situation cannot decide what is good. For example, consider the case of a patient who is in the process of a lingering, painful, terminal illness. There are those who believe that life is sacred and should be preserved at all costs. Others believe that a natural and peaceful death is preferable to an extended life of pain and dependence. The definition of good in any particular case will determine, at least in part, the action that is to be taken.
The principle of beneficence also requires us to prevent or remove harm (Beauchamp & Childress, 2008). In fact, some believe that doing no harm, and preventing or removing harm, is more imperative than doing good. All codes of nursing ethics require us to prevent or remove harm. For example, the International Council of Nurses (ICN) Code of Ethics for Nurses (2006) says, “The nurse takes appropriate action to safeguard individuals, families and communities when their care is endangered by a co-worker or any other person.” Similarly, the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses (2008) says, “Nurses question and intervene to address unsafe, non-compassionate, unethical or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care to those to whom they are providing care, and they support those who do the same” (p. 9).