Ch. 3, Principles of Beneficence and Nonmaleficence
Beneficence = doing good, usually to
another person or persons
Nonmaleficence = avoiding evil, usually
to another person or persons
We are typically thought to have duties of
beneficence and nonmaleficence; in
some circumstances these ethical
duties are important enough that they
generate legal duties … examples?
See here.
Ch. 3, under the titles
• The Impossibility of Doing All Good, and
• The Impossibility of Avoiding All Evil,
the book suggests our inability to do all good
for others, and avoid all evil for them,
excuses us from an obligation to do all good
and avoid all evil.
The principle assumed but not discussed
directly is the Ought Implies Can principle,
which says:
For it to be true that S has an obligation to do X, S
must be able to do X.
So, the book notes, p 58, that space and time limit our duties …
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time keeps us from being obliged to help, say, Abe Lincoln
space keeps us from being obliged to help folks in other states
or countries (or across the street)
our talents limit us
available technology limits us, and even
personal risk limits us.
These are all limits on beneficence.
p 60 (4th ed. 59) discusses how our inability to avoid risks limits our duties to avoid
risks …
Risks to self:
 Crossing the street (getting hit by a car)
 Taking aspirin (Reyes syndrome)
 Even staying in bed (bedsores)
Risks of condoning the unethical:
 Living in a country that is unfair to minorities
 Joining a company that pollutes
 Joining a hospital that employs bad doctors or nurses
These are all limits on nonmaleficence.
Not only does the inability to help others limit our
duties of beneficence, so does fair distribution.
Does it make sense to try to meet the mere desires of
some while the needs of others are unmet?
To help address that question, the book defines
Necessary Goods = goods required for
 remaining human
 maintaining dignity
The list of necessary goods …
 Nourishment
 Shelter
 Clothing
 “membership in social groups necessary for
the psychological growth of the person”
 Health care?
The book puts off questions about health care
till chapter 4.
Consider Peter Singer’s model of giving 1/5th
of your income to world hunger relief. Who
bears the burden, exactly, of providing
these ‘necessary’ goods?
What does
“membership in social groups necessary for the psychological
growth of the person,”
at the bottom of page 60 (4th ed. 59), mean?
P 61 (4th ed. 60), bottom:
“most of the goods we have to do are specified by social
agreement, whether through law or custom, as well as
through relationships, roles, or agreements.”
So, for children: family, primary and secondary
education; for adults: citizenship & professions
In health care, benefits professionals are obliged to
provide are specified in part by their
• relationship (doctor/patient)
• role (from custodian to doctor or administrator)
• agreements (from formal contracts to ‘may I help you
into that chair?’)
Near the end of the section:
“the physician or nurse cannot
profess to do more than their
particular education and skills
permit, nor can they do more
than the patient agrees to....
These two limits or
specifications—one by talent,
the other by agreement—must
be kept in mind at all times in
health care ethics.”
The quotation above leads
naturally into specification of
nonmaleficence (as in, trying to
do more than your talents
permit might produce injury)…
The first principle of nonmaleficence is:
Primum Non Nocere (prē-mu̇m -nōn-nȯ-kā-rā):
First, do no harm
The phrase is attributed to Hippocrates in various
forms. While the principle is not controversial, the
question of what constitutes harm in particular
circumstances and when to trade harm for other
benefits complicates its application.
P 62-63, the book rejects Thomas
Aquinas’ principle of double effect
(read the last paragraph) in favor of
the principle of proportionality; we’ll
focus on the latter principle.
Principle of Proportionality:
Provided the action does not go directly
against the dignity of the individual person
(the intrinsic good), there must be a
proportionate good to justify risking the
evil effect.
4 factors that aid in assessing proportionality:
1. Alternatives (always choose the path to a good that
produces the least evil as a byproduct)
2. The level of good and evil (recognize that some goods
are better than others, some evils worse than others)
3. The probability of the good or evil (unlikely goods and
evils count less than certain ones in calculating
proportionate reasons)
4. The causal influence of the agent (what level of
contribution your actions make to the evil produced in a
group setting)
P 66: Under Preliminary Summary:
Reformulation (from “do good”?) of
principle of Beneficence:
 Do good unless the consequences of doing
good produce a disproportionate evil
Reformulation (from First, do no harm?)
of the principle of nonmaleficence:
 Avoid evil and evil consequences unless
you have a proportionate reason for risking
or permitting them
What results from the previous
discussion for the patient’s
obligation of beneficence and
nonmaleficence regarding their
own health?
 Take care of your health as long as, all
things considered, this does not
produce more harm than good – p67
Why the qualifier ‘all things
considered’? … (next slide)
The book includes the qualifier because patients have
many obligations that compete with their obligation
to their own health (say, the health of their children,
service to their country, etc.).
Only the patient’s obligation, stated in a principle of
beneficence and nonmaleficence, includes the
qualifier ‘all things considered’; the health
professional and or surrogate cannot weight the
patient’s obligations for them.
The health care provider’s obligations regarding
beneficence and nonmaleficence are guided by
the Medical Indications Principle:
 Granted informed consent, the physician should do
what is medically indicated, such that, from a medical
point of view, more good than evil will result
Consider:
Kid A hurt his arm when pushed down the stairs by a
bully at school (presents with a bruise and acts
aloof)
Kid B hurt his arm playing on the monkey bars (has
trouble raising arm, but can do so)
Kid C hurt his arm doing a stupid stunt on a
skateboard, illegally (has a scary looking lump and
discoloration mid forearm, can’t lift his arm)
Also, Kid C is in the most pain, B second most, A in
very little pain
Following the Medical Indications Principle, only kids
B and C qualify for x-rays, say. How do you decide
who goes first between Kids B and C?
Is pain a medical indicator?
Is the kid’s responsibility a medical indicator?
Skip to page 76-78 and read discussion of
Beneficence and the Right to Refuse Patients
Read / consider #1 in the ‘Cases for Analysis’, p. 79
Ideally, the surrogate simply presents
the patient’s judgments when the
patient can’t speak for him or
herself, therefore, the first principle
of surrogate obligation is called:
 The Substituted Judgment principle
Complications arise when doubts
about surrogate accuracy enter.
Studies show surrogates are
regularly wrong. (p 71, Ethics)
When patients were never competent, or were
competent but failed to make their wishes known,
two principles guide surrogates:


The Best Interests principle, and
The Rational Choice principle
The best interests principle says to do what is in the
patient’s best interests excluding the interests of even
family, loved ones, and friends
The rational choice principle, in contrast, expands
relevant considerations to include everything the
patient might consider in making their decisions
(concern for family and friends, duties to family
and friends, desires that conflict with their own
personal welfare, etc.)
Compare the application of these principles, p 72,
Ethics.