Nonmaleficence: Making Ethical Decisions About Life Support

Theoretical normative ethics attempts to define reasonable normative principles that can be used as the basis of moral arguments. It is important here to distinguish such principles from the formal principles of moral reasoning that we considered in the last chapter, such as the principle of universalizability. Formal principles determine only the general structure of valid moral reasoning without any consideration of particular moral values – such as honesty, justice, etc. – that enter into the content of moral reasoning. On the other hand, normative principles express those moral values that provide the moral criterion by which one can determine whether a given act is right or wrong. The five principles, autonomy, justice, beneficence, nonmaleficence, and fidelity are each absolute truths in and of themselves. By exploring the dilemma in regards to these principles one may come to a better understanding of the conflicting issues.

It is common for health care providers to deal with the complex and difficult issue of withdrawing advanced life support. The patient is always the key source of authority in these decisions. The most important ingredient in end-of-life decision making is effective communication. It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient’s behalf. The concepts of beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making. Numerous legal precedents have laid the groundwork for end-of-life decision making. Most state courts have supported withholding and withdrawing life support from patients who will not regain a reasonable quality of life. The recent Patient Self-Determination Act encourages patients to fill out advance directives that state their desires. When continued intensive care is futile, advanced life support should be withdrawn. However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions. It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent. During the withdrawal of advanced life support, terminal or rapid weaning is preferable to extubation. Combinations of opiates, benzodiazepines, and other agents help provide comfort to patients who are suffering.

The principle of nonmaleficence is an obligation not to inflict harm intentionally. Most persons who choose a health care career only want to help people, not harm them, so this principle would seem easy to apply. Further, the obligations of not harming are generally considered more stringent than those of helping. One way to remember the meaning of this principle is to think of the phrase in the Hippocratic oath, “To first do no harm.” Usually issues of nonmaleficence are discussed when patients are at the end of life. We often must decide if continuing treatments cause the patient more harm than benefit.
Since nonmaleficence is often a consideration in end-of-life decisions, physical therapists are not often involved in the actual decision-making about withdrawing or withholding life-sustaining treatments on patients. Yet physical therapists and assistants often provide treatments to patients who may discuss these treatment options with them. Patients, family members or surrogates may talk with you about whether they want a feeding tube or a respirator continued. Since therapists often spend significant amounts of time with patients, they may confide in you their wishes regarding end-of-life care. Patients may express a desire to be left alone to die without all of the tubes or they may tell you that they are waiting for a certain family member to arrive. As a member of the health care team you should provide this information to the physician or nurse. Physical therapists who often treat dying patients should seek to be on the institutional ethics committee so that their patients’ wishes can be made known as decisions are made.

Specific physical therapy treatments may also be uncomfortable to patients. It is a difficult ethical decision whether to continue treatments on patients who may not receive much long-term benefit from the treatment. The patient’s quality of life and the patient’s wishes should be considered, not necessarily what the physical therapist believes is “right” for the patient.
Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.
Nonmaleficence means, “above all, do no harm.” It is easy to see how gossiping about a student’s poor performance exemplifies doing harm as a teacher. Each student comes to class to be taught, even graded, not to be harmed by gossip. Analogously, a faculty member comes to a developer in order to improve his or her teaching, and sometimes to remedy a concern arising from a perceived weakness. The instructor discloses the perceived weakness in order to improve, not to have the confidence used against her or him later in an evaluation. If a developer carelessly conveys the private exchanges to third parties, the developer has risked violating nonmaleficence because he can’t guarantee what the third party may do with the information.

Developers who’ve been faced by deans or provosts seeking information about a problem faculty member know that nonmaleficence can be a two-edged sword. Almost certainly, the dean is trying to minimize harm – to students – and, thus, the challenge: In such a case, would a breach of confidentiality decrease or increase harm to the community? Looking at the larger picture, while solving the dean’s short-term problem is tempting, such an action will certainly become common knowledge, and it will discourage faculty from seeking needed help in the future. As soon as a developer explains that solving the immediate problem will cause more long-term harm, most deans and provosts will have the wisdom and maturity to see the issue in perspective, and stop asking for the information. In essence the dilemma tests the strength with which all parties hold the conviction that faculty development is as vital and important as academic freedom. Unless that conviction forms the foundation, any ethical framework will be a house of straw.

Since faculty development has grown in stature and intellectual sophistication in the last thirty years, fixing problems and patching up weaknesses are by no means the only reason faculty become involved with the faculty developers on their campuses. Work with the teaching and learning center might well be something a faculty member would like noticed in a merit review. Thus, one means of preserving nonmaleficence would be to ascribe complete ownership of all information to the faculty member. If a faculty member chooses to use the developmental consultation as evidence of merit, that’s their prerogative. In either case, it keeps the developer from doing the harm that would arise if she slipped from the role of consultant into the role of informant.

Nonmaleficence has a further implication. It obliges every developer to advocate only practices well documented as being effective. Pressures to adopt practices or technologies of dubious value sometimes arise from external or internal authorities. Becoming complicit in foisting quack pedagogies onto faculty violates nonmaleficence. It consumes faculty time and resources to no benefit. Ethical practice obligates a developer to find the best information available on proposed innovations, to speak out for instructional schemes with substantive proof supporting their value, and to strongly question the value of schemes that lack such proof.

The first principle is the concept of the sanctity of life. Life is considered to be precious and should always be preserved. Life has its purpose and meaning regardless if it is physically normal or challenged. Life does not happen accidentally. Thus this principle upholds that life is to be cherished and respected. not to be treated lightly or inadvertently. After all, life is created in the Image of God according to Judeo-Christian tradition. It is dignified and should be respected.

Since life is sanctified, a physician, as stated in Hippocratic Oath , can never use treatment to injure or wrong the sick”. ” Not to harm patients” becomes health professionals’ obligation. If a physician cannot benefit someone, at least he/her should do no harm to them. Harm can be variously defined in terms of death, disability, distress or the deprivation of freedom and pleasure. However defined, harm has always to be weighed against hoped-for compensatory benefits. All medical treatments have some side effects . Nonmaleficence means health professionals cannot intentionally inflict harm on patients. How is this principle to be observed? The concept of Double Effects has been presented to explain that what to do must not be evil or wrong. The pain which may be caused, is for the benefit of patients therefore, tolerable.

This is the positive dimension of nonmaleficence. This principle claims that physicians have duty to help others further their interest. It refers to a positive duty of promoting the health and welfare of patients above other considerations. As the pledge of the American Nurses Association clearly stated: the ” nurse’s primary commitment is to the health, welfare and safety of the patient.” It suggests that the primary duty of the health professionals is to benefit the patients. Usually this means attempting to preserve the patient’s life. Health care providers have the duty to do their best for the patient under any circumstances and not to harm the patient.

Copyright 2003 Texas Physical Therapy Association. All rights reserved. This page may be printed SOLELY FOR YOUR PERSONAL USE. This page may not be copied or redistributed under any circumstances. Printed copies of this course are available for purchase. Contact the Texas Physical Therapy Association at 800 Brazos Street, Suite 430, Austin, Texas 78701, 512-477-1818 FAX 512-477-1434
www.tpta.org/Ethics03/nonmaleficence.htm.
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University of Colorado at Denver
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OJNI
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