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ETHICS IN MEDICINE   University of Washington School of Medicine

2. The Principle of Nonmaleficence:
Illustrative Cases

In the course of caring for patients, there are some situations in which some type of harm seems inevitable, and we are usually morally bound to choose the lesser of the two evils, although the lesser of evils may be determined by the circumstances. For example, most would be willing to experience some pain if the procedure in question would prolong life. However, in other cases, such as the case of the patient dying of painful intestinal carcinoma, the patient might choose to forego CPR in the event of a cardiac or respiratory arrest, or the patient might choose to forego life sustaining technology such as dialysis or a respirator. The reason for such a choice is based on the belief of the patient that prolonged living with a painful and debilitating condition is worse than death. It is also important to note in this case that this determination was made by the patient, who alone is the authority on the interpretation of the "greater" or "lesser" harm for him.

There is another category of cases that is also confusing since a single action may have two effects, one that is considered a good effect, the other a bad effect. How does our duty to the principle of nonmaleficence direct us in such cases? The formal name for the principle governing this category of cases is usually called the principle of double effect. A typical example might be the question as to how to best treat a pregnant woman newly diagnosed with cancer of the uterus. The usual treatment, removal of the uterus is considered a life saving treatment. However, this procedure would result in the death of the fetus. What action is morally allowable, or, what is our duty? It is argued in this case that the woman has the right to self-defense, and the action of the hysterectomy is aimed at preserving her life. The unintended consequence (though undesired) is the death of the fetus. There are four conditions that usually apply to the principle of double effect:

  1. the action itself must not be intrinsically wrong, it must be a good or neutral act.
  2. only the good effect must be intended, not the bad effect, even though it is foreseen.
  3. the bad effect must not be the means of the good effect,
  4. the good effect must outweigh the evil that is permitted.

The reader may apply these four criteria to the case above, and find that the principle of double effect applies and the four conditions are not violated by the prescribed treatment plan.

Other problems arise when the primary patient cannot decide for himself and others must determine what is in the best interest of the patient, or what constitutes the lesser harm. In Washington State, the law actually guides the surrogate to offer "substituted judgment" if known, or to follow the course of action that will serve the "best interests" of the patient as determined by reasonable judgment (see also Advance Directives, Advance Care Planning, and Informed Consent).


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Last date modified: April 11, 2008