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Thursday, November 24, 2011


Concept of Non-maleficence
Non-maleficence came from Latin term, non meaning “not”, mal meaning “bad” and ficence meaning “do or make”, so, non-maleficence is mean help patients if nurses can do, but making them avoid from worse. (Hall, 1996).  The Hippocratic Oath expresses the duty of nonmaleficence together with the duty of beneficence: ” I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”. Generally, the concept of nonmaleficence is associated with the maxim premium noncore which has wide currency in discussion of the responsibilities of health care professionals, particularly physicians (Beauchamp & Childress, 2001). Most ethicist today tend toward the Hippocratic tradition, first do not harm (the principle of non-maleficence), placing this principle above all others (Burkhardt & Nathaniel, 2002).
Nonmaleficence requires us to act in such a manner as to avoid causing harm to patient. Included in this principle is deliberate harm, risk of harm that occurs during the performance of beneficial acts. This principle is the other side of the coin of the principle of beneficence it state that we should not harm patient in most situation this principle at nothing useful to the principle of beneficence. Most treatments have some chance of doing more harm than good. It does not follow from this that such treatments should be avoided on the grounds that avoided harming at patient should take priority over doing good. Rather, the potential goods and harms and their probabilities need to be weighed up at the same time to the side what overall is in the patient’s best interest. The main reason for the retaining the principle of nonmaleficence is that it is generally thought that we have a prima facie duty not to harm anyone, whereas we owe a duty of beneficence to a limited number of people only. (Hope, Savulescu & Hendrick, 2008).
For example, William Frankena holds that the principle of beneficence includes four elements: (1) One ought not to inflict evil or harm (what is bad); (2) One ought to prevent evil or harm; (3) One ought to remove evil; (4) One ought to do or promote good. We can see that for number one is talking about do no harm (nonmaleficence) and number 2, 3, & 4 about beneficence (Beauchamp & Childress, 2001).
Nonmaleficence involves two terms. First, it must be distinguished from nonmaleficence, which describes a moral attitude or virtue rather than a moral action. Second, nonmaleficence is frequently explicated by the terms”harm” and”injury”. Both terms are somewhat ambiguous. Injury may refer to harm, disability, or death, on the one hand, or to injustice or wrong, on the other. For example, view not injuring others as a synonym of nonmaleficence and includes under the duty of nonmaleficence a number of prohibitions of harmful activities drawn from the Decalogue, such as the rules against killing, stealing, committing adultery, and bearing false witness
The principle of nonmaleficence can give rise to several specific moral rules. According to Bernard Gert, rules prohibiting harmful actions form the core of morality and include the following: don’t kill, don’t cause pain, don’t disable, don’t deprive of freedom or opportunity, and don’t deprive of pleasure.
Through a long history, primarily but not exclusively in the Roman Catholic tradition, the principle of double effect has been invoked to support claims than an act having a harmful effect, such as death, does not always fall under moral prohibition, such as murder, suicide, or abortion. The harmful effect is seen as an indirect, unintended, or merely foreseen effect, not as the direct and intended effect of the action. Double effect refers to two types of consequences which may be produced by a single action, and in medical ethics it is usually regarded as the combined effect of beneficence and nonmaleficence.
The principle of double effect involves four conditions: (a) The action in itself must be good or at least morally indifferent,  (b) The agent must intend only the good effect and not the evil effect, (c) The evil effect cannot be a means to the good effect, (d) There must be a proportionality or favorable balance between the good and evil effects of the action

Relationship among Non-maleficence, codes of ethics, law, patient’s rights and socio-cultural factors
Nonmaleficence and codes of ethics
Nurses are expected to maintain certain standards of ethical conduct in professional activities. These standards are usually described by their professional codes of ethics (such as the international council of nurses’ code of ethics for nurses, 2000) and may be supported by law (Fry & Johnstone, 2002). The code for nurse is based on belief about the nature of individuals, nursing, health, and society. Nursing encompasses the promotion and restoration of health, the prevention of illness, and the alleviation of suffering. The statement of the Code and their interpretation provide guidance for conduct and relationship in carrying out nursing responsibilities consistent with the ethical obligations of the profession and quality in nursing care.
American Nurses Association code for nurse:
1.      The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2.      The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
3.      The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
4.      The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.
5.       The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6.      The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
7.      The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
8.      The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
9.      The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Copyright: American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, Silver Spring, MD: American Nurses Publishing, 2001.

Based on code of ethics for nurses by American Nurses Association that have relationship with nonmaleficence is number 3, & 4. Nonmaleficence is the concept of preventing intentional harm. Both of these ethical concepts relate directly to patient care. In the American Nurses Association Code for Nurses, there is a specific charge to protect patients by specifying that nurses should report unsafe, illegal, or unethical practices by any person. Nurses are often faced with making decisions about extending life with technology, which might not be in the best interest of the patient. Often the concept of weighing potential benefit to the patient against potential harm is used in making these difficult decisions, along with the patient's own stated wishes (Ellis and Celia , 2001).
Nonmaleficence and law
Selfish of nurses give treatment to patient with doing no harm and doing good, keep in their professional values. The self interest nurses have in doing no harm is the same interest they have in doing good (beneficence), they feel good, are seen as good and adhere to professional value. No harming enhances the individual’s self esteem as a valued member of society. If nurses no hurt other, they are less likely to be hurt by other in turn. Nurses who do not harm other avoid breaking law made to punish people who hurt (either intentionally or negligently). If nurses do hurt other people, criminal prosecution could cost liberty and even life and civil lawsuits could cost psychic pain and money.
The malpractice suit is a result of the value (of doing good and doing no harm) not being adhered to. The people as a society want to compensate the patient if the practitioner fails to do good things. The people, through lawsuits, may also punish the practitioner who “intentionally” does harm.
Non-maleficence and patient’s rights
A patient’s Bill of rights
1.      The patient has the right to considerate and respectful care.
2.      The patient has the right to and is encouraged to obtain from physicians and other direct caregivers relevant, current and understandable information concerning diagnosis, treatment and prognosis.
3.      The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical.
4.      The patient has the right to have an advance directive (such as a living will, helath care proxy or durable power of attorney for health care) concerning treatment or designating a surrogate decision that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.
5.      The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy.
6.      The patient has right to expect that all communication and records pertaining his/her care will be treated as confidential by the hospital.
7.      The patient has the right to review the record has pertaining to his/her medical care and to have the information explained  or interpreted by law.
8.      The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to request the patient for appropriate and medically indicate care and service.
9.      The patient has right to ask and be informed of the existence of business relationships among the hospital, educational instructions, other health care provider, or payers that may influence the patient’s treatment and care.
10.  The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent.
11.  The patient has right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care option when hospital care is no longer appropriate.
The patient has the right to be informed of hospital polities and practices that related to patient care, treatment, and responsible

Ethical dilemmas related to nonmaleficence
A commonly cited example of this phenomenon is the use of morphine or other analgesic in the dying patient. Such use of morphine can have the beneficial effect of easing the pain and suffering of the patient, while simultaneously having the maleficent effect of hastening the demise of the patient through suppression of the respiratory system.
It is often thought that the administration of a high dosage of opioids is sometimes allowed for the relief of pain in cases of terminal illness, even when this can cause death as a side effect. This argument played a great part in the 1957 acquittal of suspected serial killer Dr. John Bodkin Adams, a case which established the principle in British law. Hold that this concept is morally different from deliberate euthanasia for the relief of pain. In addition, support for the view that palliative care and euthanasia are close companions is based on the assumption of a fine line between pain relief, or relief of severe distress, and causing death. In practice, opioids have a very wide safety margin when used appropriately and in the context of pain relief that is titrated (adjusted) to the individual patient. Similarly, sedatives are not lethal when used only to relieve distress and at the lowest dose to avoid dangerous adverse effects. Today, palliative care experience and research has shown that it is possible to manage pain or distress without hastening death (see opioids) and double effect is not viewed as being part of palliative care practice.
The others examples are frequently cited in cases of pregnancy and abortion. A nurse who help the doctor believes abortion is always morally wrong may nevertheless remove the uterus or fallopian tubes of a pregnant woman, knowing the procedure will cause the death of the embryo or fetus, in cases in which the woman is certain to die without the procedure (examples cited include aggressive uterine cancer and ectopic pregnancy). In these cases, the intended effect is to save the woman's life, not to terminate the pregnancy, and the effect of not performing the procedure would result in the greater evil of the death of both the mother and the fetus.

Nurses’s role in ethical decision making based on the principle of nonmaleficence
We have incorporated the work of Van Hoose and Paradise (1979), Kitchener (1984), Stadler (1986), Haas and Malouf (1989), Forester-Miller and Rubenstein (1992), and Sileo and Kopala (1993) into a practical, sequential, seven step, ethical decision making model. A description and discussion of the steps follows (Miller & Davis, 2011):
1.      Identify the Problem.
Gather as much information as you can that will illuminate the situation. In doing so, it is important to be as specific and objective as possible. Writing ideas on paper may help you gain clarity. Outline the facts, separating out innuendos, assumptions, hypotheses, or suspicions. There are several questions you can ask yourself: Is it an ethical, legal, professional, or clinical problem? Is it a combination of more than one of these? If a legal question exists, seek legal advice.
Other questions that it may be useful to ask yourself are: Is the issue related to me and what I am or am not doing? Is it related to a client and/or the client's significant others and what they are or are not doing? Is it related to the institution or agency and their policies and procedures? If the problem can be resolved by implementing a policy of an institution or agency, you can look to the agency's guidelines. It is good to remember that dilemmas you face are often complex, so a useful guideline is to examine the problem from several perspectives and avoid searching for a simplistic solution.
2.      Apply the ACA Code of Ethics.
After you have clarified the problem, refer to the Code of Ethics (ACA, 2005) to see if the issue is addressed there. If there is an applicable standard or several standards and they are specific and clear, following the course of action indicated should lead to a resolution of the problem. To be able to apply the ethical standards, it is essential that you have read them carefully and that you understand their implications.
If the problem is more complex and a resolution does not seem apparent, then you probably have a true ethical dilemma and need to proceed with further steps in the ethical decision making process.
3.      Determine the nature and dimensions of the dilemma.
There are several avenues to follow in order to ensure that you have examined the problem in all its various dimensions are (a) Consider the moral principles. Decide which principles apply to the specific situation, and determine which principle takes priority for you in this case. In theory, each principle is of equal value, which means that it is your challenge to determine the priorities when two or more of them are in conflict, (b) Review the relevant professional literature to ensure that you are using the most current professional thinking in reaching a decision, (c) Consult with experienced professional colleagues and/or supervisors. As they review with you the information you have gathered, they may see other issues that are relevant or provide a perspective you have not considered. They may also be able to identify aspects of the dilemma that you are not viewing objectively, (d) Consult your state or national professional associations to see if they can provide help with the dilemma.
4.      Generate potential courses of action.
Brainstorm as many possible courses of action as possible. Be creative and consider all options. If possible, enlist the assistance of at least one colleague to help you generate options.
5.      Consider the potential consequences of all options and determine a course of action.
Considering the information you have gathered and the priorities you have set, evaluate each option and assess the potential consequences for all the parties involved. Ponder the implications of each course of action for the client, for others who will be effected, and for yourself as a counselor. Eliminate the options that clearly do not give the desired results or cause even more problematic consequences. Review the remaining options to determine which option or combination of options best fits the situation and addresses the priorities you have identified.
6.      Evaluate the selected course of action.
Review the selected course of action to see if it presents any new ethical considerations. Stadler (1986) suggests applying three simple tests to the selected course of action to ensure that it is appropriate. In applying the test of justice, assess your own sense of fairness by determining whether you would treat others the same in this situation. For the test of publicity, ask yourself whether you would want your behavior reported in the press. The test of universality asks you to assess whether you could recommend the same course of action to another counselor in the same situation.
If the course of action you have selected seems to present new ethical issues, then you'll need to go back to the beginning and reevaluate each step of the process. Perhaps you have chosen the wrong option or you might have identified the problem incorrectly.
If you can answer in the affirmative to each of the questions suggested by Stadler (thus passing the tests of justice, publicity, and universality) and you are satisfied that you have selected an appropriate course of action, then you are ready to move on to implementation.
7.      Implement the course of action.
Taking the appropriate action in an ethical dilemma is often difficult. The final step involves strengthening your ego to allow you to carry out your plan. After implementing your course of action, it is good practice to follow up on the situation to assess whether your actions had the anticipated effect and consequences


Beauchamp, T & Childress, J (2001). Principles of biomedical ethic, 5th edition. New York: Oxford University.
Ellis, J R. and Celia L H.(2001). Nursing In Today's World: Challenges, Issues and Trends, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins Publishing
Holly F M & Thomas D. (2011). American Counseling Association. A free publication of the American Counseling Association promoting ethical counseling practice in service to the public.
Leahy, J, M & Kizilay, P, E (1998). Foundations of nursing practice, a nursing approach. Philadelphia: Saunders company.
Fry, T, S & Johnstone, M, J (2002). Ethic in nursing practice, a guide to ethical decision making, 2nd edition. USA: Blackwell publishing.

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