Most practicing physicians learn the four principles of biomedical ethics at some point during medical school or residency training. Despite the original intent of Tom Beauchamp and James Childress when they first described the four principles as co-equal in importance, we physicians tend to think first about patient autonomy and view it as the most critical of the four principles. The least understood and appreciated of the four principles is nonmaleficence. (Even my word processor wants to change it to malfeasance, and so do many medical students I teach).
The reason nonmaleficence is misunderstood, and therefore often ignored, is that the duty to “do no harm” seems impossible to follow. Beauchamp and Childress are clear that harm is anything that counts as a setback to a patient—any pain or injury is therefore a harm—and practically everything we do to our patients is in some sense a harm. The duty to nonmaleficence must be more complicated that simply doing no harm or it would be a duty to stop practicing medicine.
A better way to understand the duty to nonmaleficence is that physicians must always seek to reduce harm and risk of harm whenever possible. Now we have a principle with real-world implications, and I would like to make it even more concrete by offering a brief case scenario to illustrate how this principle can come into play in everyday practice. I recently saw a woman in her 40s with menorrhagia and dysmenorrhea, but with a normal ultrasound and endometrial biopsy. She was not anemic. She declined medical therapy, declined a levonorgestrel-releasing IUD, and refused an endometrial ablation. Would you do the hysterectomy that she requests knowing she is choosing the procedure with the greatest risk of harm to herself? What if I added that she has had a myocardial infarction three months ago, has uncontrolled type II diabetes, and is morbidly obese? If autonomy is the only principle that matters in bioethics, then as long as she is making an informed choice, you have no reason to refuse to perform the surgery. But the duty to nonmaleficence seems to suggest that sometimes the more ethical response may be to say “no” to our patients when what they are requesting presents too much risk, and too little benefit. Furthermore, we should perhaps not even offer options when the risk/benefit ratio is too unfavorable.
This is not as outlandish or paternalistic as it may appear. None of us offer hysterectomies to teenagers with menorrhagia from anovulation, nor do we offer prolapse surgery to elderly frail women with prolapse that could be successfully managed with a pessary. We all know that it is good medicine to seek to reduce the risk of harm to our patients. It is also good ethics, even if the patient feels differently. Respecting patient autonomy is important, but so is reducing the risk of harm to patients, and it is the actual facts of the situation that should dictate which principle is more important in a given circumstance. This is the “balancing” required of ethical decision-making: determining which principle is most important for each patient encounter and ethical question that we face.