Limits to Nonmaleficence

D. John Doyle MD PhD

April 2004

djdoyle@hotmail.com

It has been suggested that we bear some obligation (by the principle of nonmaleficence) to prevent harms that are occurring by means of personal "actions of rescue" that intervene in the situation. How far does this duty go? Where does duty end -  at what point or at what cost to the ethical individual? These issues are addressed in this essay.

The principle of nonmaleficence is one of the basic principles of the “Georgetown School” of bioethics, often also known as “principlism”. Essentially, the principle of nonmaleficence requires that clinicians should "do no harm" when caring for their patients, just as Hypocrites originally taught. Some individuals have modified this principle to state "do no net harm", since many clinical interventions such as surgery always involve at least a small element of harm but usually also produce a large degree of good.

Many philosophers argue that if an individual can prevent something harmful from occurring to someone else with relatively little personal sacrifice that they are under a moral obligation to do so. Indeed, some philosophers such Peter Singer extend this view to require that we help individuals who may very distant from us in geographical terms, and suggest (for example) that spending $1000 on a luxury designer suit is immoral when that same $1000 would sustain the lives of (for example) five starving Ethiopians for an entire year.

In such instances, in failing to act the individual does the moral equivalent of harm. That is, failure to prevent harm, at least when it involves little personal sacrifice is said to be morally equivalent to doing harm.

Such a position can be supported by both consequentialist (utilitarian) and deontological views. The former view demands that we do no harm because doing so leads to unhappiness or goes against a person’s preferences. The latter view demands that we do no harm because it ignores a person’s human rights and violates them as persons.

Consider the following simple example. A person just seen in the emergency department (ED) needs a mere $1.00 to get together enough money to buy a needed prescription costing $75.00. Providing the needed $1.00 is a small sacrifice that most ED doctors would be glad to carry out. However, most would not give the person the full $75.00 for the prescription even if they were convinced that the money would actually go to fill the prescription and not for some illicit purpose.

Consider another example. A bystander knowledgeable in CPR might be quite willing to perform mouth-to-mouth rescue breathing in a victim if the rescuer happened to be carrying a barrier protection device like that shown below.

However, if the rescuer happened not to carrying the device, carrying out mouth-to-mouth rescue involves a much greater sacrifice (as I can attest to from personal experience!) and involves at least some theoretical risk to the rescuer.   Even more extreme is the case where the victim is known to have a disease like TB and where the rescuer would ordinarily be placed on a long course of prophylactic antibiotics if rescue breathing were attempted (as happened to one of my colleagues).

In this context it is useful to distinguish between ordinary ethical acts carried out in the course of meeting one’s ordinary ethical obligations, and “extraordinary” ethical acts that extend “above and beyond” ethical obligation.  For example, calling 911 on your cell phone when you see a person being viscously attacked by a gang of thugs in a distant alleyway would be an ordinary ethical obligation, while personally attempting a rescue of that individual at great personal risk would extend “above and beyond” the requirements of ethical obligation.

The same approach can be used in discussing our obligations to patients. A physician bystander would reasonably be expected to offer aid to an accident victim, but would not be expected to cover the hospital bills should the victim be penniless.

How far, then, do one’s ethical obligations go? Peter Singer argues that we should give until it hurts.  But even he would agree that all this is a matter of judgment – that there are no “hard and fast” rules. Perhaps all that can really said is that we are morally obligated to provide interventions which involve little sacrifice on our part, but as the degree of sacrifice increases these interventions gradually change from being ordinary to being extraordinary.