Ethical Issue: The Delicate Balance Among the Principles of Autonomy, Beneficence, and Nonmaleficence.

This posting will contrast the principles of nomaleficence and beneficence including a risk assessment and cost-benefit analyses of a course of action.  From the ancient maxim of professional medical ethics, “Primum non nocere: First, do not harm,” came the principle of nonmaleficence.  This principle implies an obligation not to do harm, thus a physician not technically competent to do a procedure should not do it, and medical students should not harm patients by practicing on them without consent. A medical error may in some sense violate the very foundation of the Hippocrates Oath in which physicians have practiced and continue to do so, and the non-disclosure of error exacerbates the situation (Edwin, 2009; Jonsen et al., 2010; Pence, 2008).

In contrast with nomaleficence, the principle of beneficence implies moral obligation to act and to offer help for the benefit of others – and although not all beneficence acts are obligatory, this principle establishes an obligation for healthcare professionals to help others (Edwin, 2009). For physicians, beneficence can be seen both as a fulfillment of principle or moral virtue (Pence, 2008).

 Nonmaleficence and beneficence can get in conflict with the principle of autonomy. For example, physicians have a moral responsibility to listen to the patient’s wishes (if autonomous) or to the patient’s surrogates (if non-autonomous), but they also have the responsibility to do what is “good” for the patient.  What is good for the patient was derived from the principle of beneficence – “one ought to do or promote good,” and from nonmaleficence – “do not harm” (Beauchamp & Childress, 2009, p. 151). Further, it comes from the appreciation of the patient’s values and of the knowledge and skill of medicine. Moreover, the patient’s surrogates may accurately convey the patient’s consent, but these consents are subject also to the information available that only the physician can provide (O’rourke, 1991).

 An example provided by O’rourke (1991) justifies the argument presented above. A young man named Sam had a car accident and was admitted in a coma at a hospital. His parents conveyed his wishes not to be given life support. The doctor convinced the parents that he had seen worse conditions than Sam and able to walk out of the hospital.  After four months, Sam recovered and was able to get out of rehab soon enough. The issue of this case is not on the success of the treatment but rather the decision to be made when caring for the incompetent (O’rourke, 1991).        

Two of the most widely used formal analysis tools in public health, safety, and medical technologies are risk assessment and cost-benefit analysis. According to Beauchamp and Childress (2009), risk assessment involves the analysis and probabilities of negative outcomes for any course of action. Risk assessment involves first the identification of the risks, followed by the estimation of the risks, and then the evaluation of the risks. Following these stages is the process of risk management which is the set of individual, institutional or policy assessing for the risks including the decision to reduce or control the risks   (Beauchamp & Childress, 2009).

 Risks perceptions are also different between the experts and of the public.  However, public’s subjective perceptions of harm are given importance especially when formulating public policy.  An example taken from Beauchamp & Childress (2009) is the public’s perception of HIV/AIDS versus of the Hepatitis B virus. People fear the exposure to HIV/AIDS more than the exposure to Hepatitis B, although both carry an equal rate of overall risk of death.  The probability of acquiring Hepatitis B is at 25%, while HIV/AIDS is at 1%.  The stigma of fear behind the HIV/AIDS is the certainty of death once one acquires the disease, while survivability from Hepatitis B is higher (Beauchamp & Childress, 2009). 

 Beauchamp and Childress (2009), have defined cost benefit analysis (CBA) as a measuring tool for both the benefits and costs in monetary terms.  For example, CBA measures first all the different quantitative units such as the number of accidents, statistical deaths, and the number of persons treated, then converts these items into common monetary figure, thus theoretically, it provides for a measurement tool to compare various programs that saves lives.

 In conclusion, there is a delicate balance among the principles of autonomy, beneficence, and nonmaleficence. When a patient exercises his or her autonomy by not letting the physician do an intervention but wants the physician to get rid of the pain, in effect the patient is telling the physician, “ I want you to help me (beneficence) with this but not with that.”  It is “catch 22” for the physician.  In the same line, if the physician declines to treat the patient, then within the principle of not harming (nonmaleficence), the physician is not adhering to the principle (Beauchamp & Childress, 2009).  These principles (autonomy, beneficence, nonmaleficence) may conflict with each other and that their use in medical ethics is controversial, moreover the advocates for the principles above do not tell us how to resolve conflicts and balance them to find the best possible solution to a case (Pence, 2008).     


Cesar Aquino