What takes precedence, beneficence (doing good) or non-maleficence (doing no harm), when weighing treatment benefits and risks?

Balancing Beneficence and Non-Maleficence in Clinical Decision-Making

When weighing treatment benefits and risks, non-maleficence (avoiding harm) takes precedence over beneficence (doing good) if the risks and burdens outweigh potential benefits for the patient. 1, 2

Understanding the Ethical Principles

Non-Maleficence

• Defined as "the duty to refrain from inflicting harm" which is "at least as fundamental as the duty to benefit patients" 2
• Establishes boundaries on actions to prevent harm 2
• Requires physicians to withhold treatments when risks outweigh benefits 1, 2
• Serves as a filtering mechanism for treatment options before beneficence is considered 3

Beneficence

• Involves maximizing potential benefits for patients 1
• Tied to the patient's best overall interests 3
• Requires providing appropriate treatment following medical indication 1
• Considers "overall benefit" including quality of life and psychological well-being 1

Decision-Making Framework

1. Risk-Benefit Assessment

   • "If the risks and burdens of a given therapy for a specific patient outweigh the potential benefits, then the physician has the obligation of not providing (withholding) the therapy" 1
   • Each decision must be made on an individual level, considering disease impact, quality of life, and psychological well-being 1

2. Time Horizon Considerations

   • Consider whether the time horizon to benefit exceeds the patient's projected life span 1
   • Treatments with benefits that would occur beyond a patient's life expectancy may increase risk of polypharmacy and drug interactions without providing benefit 1

3. Trial-Based Approach for Uncertain Interventions

   • "In case the feasibility or efficacy of artificial nutrition is uncertain it is advisable to administer the therapy on a trial basis" 1
   • If complications arise or desired success is not achieved, the trial should be discontinued 1, 2

4. Regular Reassessment

   • "The continued medical justification for [treatment] must be reviewed at regular intervals, determined in accordance with the patient's condition" 1
   • This ensures ongoing appropriateness as the patient's condition changes 1

Clinical Application

When faced with treatment decisions involving both potential benefits and risks:

1. First, evaluate whether the treatment might cause harm (non-maleficence)
2. If potential harm outweighs benefit, withhold treatment
3. If harm is minimal or uncertain compared to potential benefit, proceed with treatment
4. Continuously monitor and reassess the benefit-risk balance

Special Considerations

Patient Autonomy

• A competent patient has the right to refuse treatment after adequate information even when refusal may lead to death 1
• Tension can arise between non-maleficence and patient autonomy when patients request treatments physicians believe may cause harm 2
• Patient autonomy does not mean a patient has the right to obtain every treatment they wish if it's not medically indicated 1

Scope of Practice

• Physicians should practice within their scope of training and expertise 2
• Exceeding one's scope of practice can violate non-maleficence by increasing risk of harm 4

Common Pitfalls to Avoid

1. Prolonging Life as the Sole Goal

   • "Prolonging of life may never be the sole goal and always has to be put in relation to the wellbeing of the patient" 1
   • Avoid treatments that "only prolong the suffering or the dying phase" 2

2. Ignoring Quality of Life

   • Treatment decisions should consider overall benefit including quality of life, not just survival 1
   • This is particularly important for patients with multiple chronic conditions 1

3. Failing to Discontinue Ineffective Treatments

   • Non-maleficence requires discontinuing trial therapies when complications arise or desired success is not achieved 2
   • Regular review of medical justification for ongoing treatments is essential 2

4. Neglecting Patient Values

   • While non-maleficence takes precedence when risks clearly outweigh benefits, patient values and preferences should inform the assessment of what constitutes benefit 5
   • Understanding the patient's view of their own good is an important component of wellbeing 5

By prioritizing non-maleficence when risks outweigh benefits, while still considering beneficence within those boundaries, clinicians can make ethical treatment decisions that best serve their patients' interests.