PRINCIPLES OF BENEFICENCE AND NONMALEFICENCE

PRINCIPLES OF BENEFICENCE AND NONMALEFICENCE

The Principle of Proportionality: provided the action does not go directly against the dignity of the

individual person (the intrinsic good), there must be a proportionate good to justify permitting or risking an

evil effect.

Focus Question: Once a patient has requested a physician to control their pain as a priority, can that

physician increase a dose of morphine as needed to control pain even if that might cause the patient to stop

breathing?

INTRODUCTION

In its most general form, the principle of beneficence says no more than “do good.” Similarly, the principle of

nonmaleficence tells us to “avoid evil.” Unfortunately, these formulations are so general as to be useless. This

becomes painfully clear when we realize that we cannot do all good or avoid all evil. The tension between

autonomy and beneficence is a difficulty here as well. It is a very difficult experience for a physician or nurse

to be prevented from aiding a patient because the patient has refused consent to the very good that the health

care provider has spent his or her entire life learning to provide. These tragic conflicts show us why we need

more specific formulations to help us to sort out the possibilities and make ethical choices.

The Impossibility of Doing All Good

The impossibility of doing all good arises from the nature of time and space, which create the context for our

own limitations and the limits of the instruments available to us. There is just so much time in a day. Indeed,

there never seems to be enough time to do all that we want to do or plan to do. The limits of time restrict us no

matter how efficient we become. Space, too, hems us in. We cannot directly and immediately do good to those

who are far away. Indeed, because we can only be in one place at one time, most of the people in the world are

beyond our direct touch, and so we cannot help them personally.

Our own limited talents further limit our ability to do good. Not everyone has the intelligence to be an atomic

physicist or a designer of supercomputers. Some have better health than others, some greater strength, and

some better coordination. The relative strength of intellect, body, and coordination thus puts limits on what a

person can do. It should be noted, however, that even those who have enough intelligence to master any given

task do not have enough time to master all tasks. The person who is both physician and lawyer is rare; the

person who is physician, lawyer, electrical engineer, mechanical engineer, nuclear physicist, biophysicist,

anthropologist, chemist, paleontologist, carpenter, plumber, bricklayer, and agronomist seems as real as a

winged horse. Even if such a person did exist, time and space would still limit the good he or she could do

since one cannot do all these activities at once.

Finally, our ability to do good is limited by the state-of-the-art in a given area, as well as by the availability of

state-of-the-art tools. Not every health care facility can afford to have all the up-to-date technology, and often

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decisions have to be made regarding what can be afforded and what will be let go. Some treatments are easily

done by nurses or general practitioners, while others require highly trained specialists. Not every facility can

have highly trained specialists in all the specialties. Often health care providers are also limited in the good

they can do by the inability of the patient, or the refusal of the insurer, to pay for the care. That could be as

complex as a heart transplant or as simple as a medication to lower blood pressure.

Our obligation to do good is also limited by our obligation to avoid evil. In other words, the principle of

nonmaleficence limits the principle of beneficence. The sight of a child drowning in a raging stream filled with

floating ice urges one to attempt a rescue. But one stops after realizing that a rescue attempt would threaten

one’s own life, and one would probably not be able to save the child in any event. The evil involved is a price

to be paid for attempting a rescue, but in these circumstances the evil is too great and too likely to warrant the

rescue. Although we might praise the rescuer as a hero, we would not say she or he had a duty to jump in.

Indeed, we call such people heroes because they do not have a duty, but do more than could be normally

demanded. In health care ethics, this is the basis for the distinction between ordinary and extraordinary care,

where ordinary care does not present excessive risks or burdens for the patient, while extraordinary care might

help the patient, but the odds are poor or the risks and burdens are very high (see discussion later in this

chapter).

Clearly, more specific formulations of the principle of beneficence are needed to help us decide what we

should do. It should be clear, too, that doing good and avoiding evil will not simply be a question of principles,

but of practical wisdom weighing the relevant aspects of the factual and social situation, as well as the concrete

meaning of human dignity in a particular time and place.

The Impossibility of Avoiding All Evil

Nearly everything we do has some undesirable side effect or at least the risk of some evil. When you cross the

street, you run the risk of being hit by a car. When you take aspirin, you risk stomach problems or possibly

Reye’s syndrome. When you undergo major surgery, you risk your life. Life is inherently risky. If we tried to

avoid all risk of harm, we would have time for nothing else. Indeed, if we tried to avoid all risks by staying in

bed, we would risk bed sores, muscle deterioration, and stationary pneumonia. There is no escape from all risk,

and so there is no escape from all evil.

Quite aside from the inherent riskiness of human life, we must also face the fact that, because life is social, we

are involved in actual evils to a greater or lesser extent. We are members of a society that, despite considerable

progress, still oppresses minorities and women. Many people work for companies that are destroying the

environment. Some teach in schools where at least some professors are grossly unfair to students. A few are

employed in hospitals that tolerate incompetent physicians or nurses. By continuing to cooperate with groups

that cause or permit evil, we are to some extent tainted by evil. Yet we cannot avoid all this evil. If we isolate

ourselves as hermits, we cut ourselves off from the benefits of social life and increase the risk to our lives and

even our sanity. Worse yet, our flight from evil often leaves the villains in charge and the victims in worse

shape than before. There is no easy way out. We need specifications of the principle of nonmaleficence that

will enable us to make at least rough judgments about what evils to avoid