The Principle of Non-Maleficence
from Christianity and Modern Medicine: Foundations for Bioethics
by Mark Wesley Foreman and Lindsay C. Leonard
My favorite Disney villain is Maleficent from 1959’s Sleeping Beauty. I don’t think Disney ever imagined a more evil and corrupt individual.[1] All she wanted to do was to cause harm to everyone around her. The King and Queen, Princess Aurora, Prince Phillip, and the three fairies, Flora, Fauna, and Merry- weather, all suffered under her influence. Her desire to harm is understood given her name, for the term “maleficence” means “to cause harm, evil.” The principle of non-maleficence is the obligation to avoid harming or injuring others either intentionally or through negligence. It is, by far, the most universally recognized moral principle and almost all serious moral thinkers agree that we have a duty not to unjustly harm others. Concerning medical treatment, it is expressed in the classic phrase primum non nocere: “above all, do no harm.” Hippocrates of Cos (460–370 BC), considered the father of West- ern medicine, wrote seventy treatises and in one of the early ones, Epidemics I, he wrote one of the earliest ethical statements about medicine of which physicians “have two special objects in view with regard to disease, namely, to do good or to do no harm.”[2]
Hippocrates’s statement raises the question, which of the two is a stronger obligation, helping or not harming? Most ethicists agree that the stronger obligation is to not harm. One reason is that not harming is a negative obligation, like respect for autonomy. In general, one can fulfill this obligation by doing nothing. One must usually go out of one’s way to intentionally cause harm. Also, the duty to do no harm is more universal in its application than the duty to help. Everyone should avoid harming others, but not everyone has an obligation to help.[3] Therefore, of the two obligations, not causing harm is the stronger obligation to keep.
There are three aspects in which this principle will come to play in the medical context. First is the general aspect, wherein everyone recognizes the overriding moral requirement that medical practitioners strive to serve the well-being of their patients and that this involves not harming them or placing them at risk in situations in which they could be harmed. The good of medicine is in its aims and goals which are to treat and cure disease and suffering, to make patients feel better and live more satisfying lives. Causing harm seems to be the exact opposite of everything medicine is about. This seems so obvious as to not even need to be stated. However, the problem is that health-care workers often find themselves in a conflict in which the only way to achieve the ultimate goal of good health is to cause a certain amount of harm. It would be incorrect to state that medical practitioners never cause harm. They do so on a regular basis. In order to save lives and restore health, they often have to remove organs, amputate limbs, inject harmful drugs in chemotherapy, bombard the body with radiation, and undertake a host of other activities necessary to fulfill their primary obligation of treatment.
When such procedures are necessary, there is a second aspect of the principle of non-maleficence to consider, the weighing aspect. Medical intervention often involves trade-offs of certain risks or harms for benefits. Therefore, one needs to go through a process of weighing specific risks or harms in light of the particular benefits one might achieve. Two kinds of assessments are necessary. A risk/benefits assessment evaluates the risk of harm compared to the possible benefit of a particular medical procedure. In performing a procedure, the physician may realize from training and experience that there might be byproduct results that are unfavorable. The likelihood, quality, and magnitude of these byproducts need to be appraised and a determination made whether to continue with the procedure. For example, if surgery is to be performed on someone’s ear but there is a risk of a certain amount of deafness, the physician and patient will need to weigh the likelihood of the deafness, its magnitude, the quality of life should it occur in light of the likelihood and quality of the intended benefit the patient will experience from the surgery. If it is determined the risk is too great, the patient may decide to forgo the procedure.
A harms/benefit assessment (also called a cost/benefit assessment) is necessary to assess the known harms compared to the possible benefit of a particular medical procedure. In many cases, physicians and patients are aware that in order to perform a particular procedure, certain unintended but foreknown harms will occur. If a patient has a severe case of endometriosis, it may warrant a hysterectomy in which she will lose her ability to have children. This is a known harm that might be necessary to avoid more serious harms, including death. Physicians and patients together must make the assessment to determine if the benefit of a known harm outweighs the harm itself. In one sense, almost all medical procedures are going to cause some harm or cost, even if just financial or minimal. In most cases, such as the discomfort of receiving an injection, we consider the cost/harm to be justified in light of the potential benefit. However, it is not uncommon for patients to reject a procedure that might be beneficial, but the cost or harm is considered too burdensome. For example, many advanced cancer patients might reject further chemotherapy or radiation treatments if the discomfort is deemed too great and the potential for benefit minimal.
It is important that both types of assessments be performed by trained and experienced professionals and the information should be as accurate and precise as possible so that patients can make an appropriate informed decision. While complete certainty is rarely attainable in making these assessments, all effort should be made to avoid allowing bias to affect one’s results and undue pressure should not be placed on patients to make a specific decision.
A third aspect of the principle of non-maleficence is the specific aspect. This is the heart of the principle when it comes to medical treatment and we refer to is as maintaining standard due care. Standard due care is a moral and legal obligation to act in a careful and professionally reasonable manner in cases where one needs to impose risks on others. Due care involves at least three elements: the professional is trained in the specific procedure being applied in this situation, the professional has a demonstrable skill in performing the procedure, and the professional is acting in a diligent and careful manner when performing the procedure.
In general, standard due care is met when first, the goals sought are weighty enough to warrant the imposition of certain risks or harms on others. This means one’s assessment has been properly performed. However, once the assessment is done and it is determined that the goals outweigh the risks or harms, then the second requirement of standard due care comes into play: due care is taken to keep these risks and harms at a minimum level. So, the first aspect is concerned with deciding to perform the procedure and the second is in the actual performance itself.
There have been cases in which this standard has not been met. While some cases were intended violations of maintaining standard due care, most cases were not intended. This is known as negligence, which is defined as the unintended failure to maintain standard due care by failing to guard against risks of harm to others. Negligence usually occurs due to a lack of one or more of the three elements mentioned above necessary for maintaining standard due care. The professional performing the procedure is either not trained, lacks the skill, or is not being diligent in their performance. Charges of negligence can lead to further charges of malpractice and may involve civil or even criminal proceedings.[4] It is important to note that one cannot charge a medical professional with negligence simply because a harm was done. If the assessment discovered a risk or harm and the patient was informed of the risk or harm and consented to the procedure, the patient cannot charge a professional who acted in accordance with the elements outlined above with negligence just because the harm came to fruition.
What does it mean to “harm” an individual? Broadly, harm can be defined as the obstructing, defeating, or hindering of the interests of one party by the invasive actions of another party. This would include the infringement or violation of any autonomous area. Harm goes beyond physical pain to include any occasion where one’s interests are obstructed or hindered. Harms come in degrees of magnitude and may be physical or non-physical. Some harms can be minor, such as unintentionally causing offense, to serious, including taking life. The continuum is wide ranging. What determines a harm as minor or major is often dependent on the context and the perception of the individuals involved, though there are extremes where almost all serious moral thinkers find agreement. Harms can also be intentional or unintentional. Just because a harm was not intended does not mean it did not occur nor that one may not be culpable for it. If one accidentally backs into another car, a harm has occurred and the driver is culpable even though he did not intend it. While intention may play a significant role in tempering one’s judgment of blame for a harm (we tend to be more sympathetic and understanding towards those whose actions cause unintended harms), it does not erase all responsibility for harm. This is the often the case in negligence.
An important distinction must be made between harm and hurt. While these terms are often used synonymously, many ethicists draw a distinction between them. Harm is the actual and real obstruction or defeating of an individual’s interests; hurt is an awareness of harm, such as pain and suffering (whether physical or psychological). Under this distinction, it is possible to harm someone without hurting them. One can be harmed and never be aware of it. For example, a person may go behind an individual’s back and say something that might obstruct some benefit for the person. If Marty is up for a promotion at work and Janet tells the boss some negative information about Marty so he does not get the promotion, Janet has harmed Marty as she has obstructed an interest Marty has to be promoted. Marty may never even know he was up for a promotion or that Janet destroyed his opportunity, but he was still harmed by Janet’s action. So, while it is true that what you may not know may not hurt you, what you may not know can still harm you. The principle of non-maleficence is “do not harm,” not “do not hurt.” Awareness of harm has little to do with keeping the principle.
Finally, like all principles, the principle of non-maleficence has prima facie standing. Not all invasions of another’s interests are wrong. At times, infringing on another’s interests might be necessary. This was observed during the discussion of the weighing aspect of the principle. Sometimes, one must infringe on the principle in order to obtain a greater good, as in amputation to save a life. Whenever it is necessary to infringe on the principle, it must only be done so when another moral principle has greater weight, whether it be respect for autonomy, beneficence, or justice. Such times need to be considered in the context of a situation.
Raising the question of necessary harms in order to achieve good introduces us to a well-known tradition in ethics appealed to by many called the principle of double effect. The principle of double effect is the idea that there exists a morally relevant difference between the intended effects of a person’s action and the non-intended, though possibly foreseen, effects of the action. Many actions have more than one effect. Some effects are beneficial, and some are harmful. Under double effect, the beneficial effect is direct and intended while the harmful effect is indirect and unintended, though perhaps a foreseen and unfortunate side effect. By “indirect,” this means it is not intended as a means to an end nor as an end in itself, a very important point in applying this principle. Because there is a moral distinction between these effects, one is not held morally blameworthy of an unintended, even if foreseen, harmful effect.
A common example of double effect is the removal of an unborn child due to an ectopic pregnancy (a pregnancy where the child has attached itself outside of the uterus). One can foresee that removing the child will result in its death as it is not capable of living on its own outside of the special environment of the mother’s body. However, if left to develop, the child will most certainly do significant damage to the mother, possibly even causing her death. Double effect is a way to allow the mother’s life to be saved and not be held morally culpable for the death of the child. If the intention is to remove the child to save the mother’s life, and this is the only way to save the mother’s life, then double effect allows the action to take place and the physician would not be held morally culpable for the death of the child even if it is foreseen that removing the child will result in the child’s death. The key points are that the death of the child was not intended, just its removal, and the death of the child is not the means by which we are saving the life of the mother, its removal is. If there was a way to remove the child and maintain its life, morally we would be obligated to do so. Currently, there is no way to maintain a child this early in the pregnancy when it is just a few weeks old. In the end it is better to save one life than to have two lives perish.
Double effect cannot be applied in just any situation where we want to achieve some good that might involve adverse effects. Some have tried to apply double effects to other situations such as giving a patient an overdose of morphine to end her suffering knowing that the overdose will also kill her. The problem here is that often the intention is the death of the patient as a means of ending her suffering. Even if death was not intended, the death of the patient is still how her suffering has been ended. Double effect cannot be appealed to as justification for such an action. For double effect to be applied as a means of justification the following criteria must be in place:
- The intended action itself must not be intrinsically wrong.
- The agent must intend only the good effect and not the bad effect (the bad effect may be foreseen and even tolerated, just not intended).
- The bad effect must not be a means to the end of bringing about the good effect.
- The good that results must outweigh the evil permitted.
Not everyone agrees that double effect draws a legitimate distinction between intended results or actions and results that are foreseen and unintended. Many think that proponents are just drawing semantics and that if one is aware of the bad results, one is therefore responsible for them. However, there is a long tradition within Christian ethics to hold that intention does often matter when it comes to moral culpability. If one is intending a good effect, and a bad side effect might result (assuming the other criteria hold, especially if the bad effect is not intended), then it seems double effect might be a legitimate means to resolve a difficult issue.
The principle of non-maleficence is so universally regarded as valid and justifiable that it seems almost absurd to question its biblical basis. Believers are often exhorted to avoid harming others. In his letter to the Romans, Paul urges, “Do not repay anyone evil for evil. Be careful to do what is right in the eyes of everyone. If it is possible, as far as it depends on you, live at peace with everyone” (Rom. 12:17). In his letter to the Ephesians, he encourages Christians to “Let all bitterness, wrath, anger, quarreling, and slander be put away from you, along with all hatred. And be kind to one another, compassionate, forgiving one another just as God has forgiven you in the Messiah” (Eph. 4:31–32). And in his letter to Titus, Paul exhorts followers of Jesus “to slander no one, to avoid fighting, and to be kind, always showing gentleness to all people” (Titus 3:2).
[1] I have in mind the Maleficent of the animated motion picture, who was truly evil, and not the more recent live action film, Maleficent (2014), who was just “misunderstood.”
[2] Hippocrates, Epidemics 1.2.4, trans. Francis Adams (London: Easton, 1849).
[3] We will discuss the obligation to help under the principle of beneficence.
[4] Malpractice is regarded as broader than negligence and can include intentional as well as non-intentional harm. Also, malpractice must result in an injury to a patient, whereas negligence can occur if no actual harm was done, but merely a genuine risk of harm was present.
This post is adapted from Christianity and Modern Medicine: Foundations for Bioethics by Mark Wesley Foreman and Lindsay C. Leonard. If you are interested in adopting this book for a college or seminary course, please request a faculty examination copy. We will also consider requests for your blog or media outlets.
Raises and considers issues common to medical professionals in order to cut through the moral fog in medical science
Christianity and Modern Medicine raises moral questions that were merely hypothetical just decades ago. Moreover, traditional moral models are being challenged incessantly by the medical community at large, shifting the conversation to patient and societal rights within a framework of moral relativism and rendering the decision-making process morally vague and confusing.
In Christianity and Modern Medicine, bioethicist Mark Wesley Foreman and attorney Lindsay C. Leonard delve into the major ethical issues facing today’s medical professionals with the purpose of providing principles and guidelines for making critical ethical decisions where medical knowledge, technologies, and capabilities are constantly evolving. Topics covered include:
- procreational ethics
- abortion
- infanticide
- euthanasia
- physician-assisted suicide
- genetic ethics
- medical research
- clinical ethics
- legal issues
- and more
While Christianity and Modern Medicine is designed especially for students planning careers in the medical field, it is accessible to any Christian interested in steering more clearly through the moral fog in the practice of medicine today.
Mark Wesley Foreman (PhD, University of Virginia) has been teaching bioethics at Liberty University for almost thirty years. He has a doctorate in which he concentrated on bioethics, studying under James F. Childress, who is recognized as one of the fathers of the modern bioethics movement in this country.
Lindsay C. Leonard serves as Assistant Attorney General for the Commonwealth of Virginia and is adjunct instructor for the online bioethics course for Liberty University.
