What is non-maleficence (do no harm)?

From the Guidelines

Non-maleficence is a fundamental ethical principle in healthcare that means "do no harm" and healthcare providers should prioritize avoiding actions that cause harm to patients, even when attempting to help them. This principle requires balancing potential benefits against risks when making clinical decisions, as emphasized in the 2020 European Association for Palliative Care task force expert position statement 1. For example, when prescribing medications, physicians must consider both the benefits and risks of treatment, such as pain relief benefits and risks of addiction or respiratory depression. Non-maleficence extends beyond avoiding direct harm to include preventing foreseeable negative consequences of treatments.

Some key aspects of non-maleficence include:

• Recognizing the potential for significant patient benefit is often linked with the potential for significant complications, side effects, or other harms, as noted in the code of ethics for emergency physicians 1
• Weighing the anticipated benefits and harms of tests and treatments in the context of the patient’s prognosis and health care-related goals, as discussed in the 2020 palliative care guidelines 1
• Informing patients about their diseases and prognoses, and the risks, benefits, and alternatives to tests and treatments, to respect patient autonomy and involve them in shared decision making, as recommended in the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline 1
• Staying current with medical knowledge, recognizing limitations, obtaining informed consent, and carefully documenting decision-making processes to minimize harm and ensure that risks are justified by potential benefits, as emphasized in the code of ethics for emergency physicians 1 and the 2020 palliative care guidelines 1.

In practice, healthcare providers should prioritize non-maleficence by seeking to maximize the benefits of treatment and minimize the risk of harm, as stated in the code of ethics for emergency physicians 1, and by considering the principles of beneficence, autonomy, and justice in their decision-making processes, as discussed in the 2020 palliative care guidelines 1.

From the FDA Drug Label

Stop use and ask doctor if • pain gets worse or lasts more than 10 days • fever gets worse or lasts more than 3 days • new symptoms occur • redness or swelling is present These could be signs of a serious condition. If pregnant or breast-feeding ask a health professional before use. The principle of non-maleficence (do no harm) is indirectly supported by the warnings to stop use and ask a doctor if certain conditions occur, or to ask a health professional before use in pregnant or breast-feeding women.

• The drug label for acetaminophen (PO) 2 advises to stop use if signs of a serious condition are present, which suggests an effort to avoid harm.
• The drug label for acetaminophen (PO) 2 also advises to ask a health professional before use if pregnant or breast-feeding, which implies caution to prevent potential harm to the fetus or baby.

From the Research

Definition and Application of Nonmaleficence

• Nonmaleficence is a principle that requires medical actions to be weighed against all benefits, risks, and consequences, occasionally deeming no treatment to be the best treatment 3.
• It applies to performing tasks appropriate to an individual's level of competence and training in medical education 3.
• The principle of nonmaleficence is tied to the patient's best medical interests only, whereas the principle of beneficence is tied to the patient's best overall interests 4.

Relationship with Other Ethical Principles

• Nonmaleficence takes priority over the principle of beneficence in that it filters the treatment options that are appropriately subject to the principle of beneficence 4.
• There are conflicts between ethical principles, especially between beneficence and autonomy, which can be resolved using a systematic approach to ethical problem-solving 5.
• The four principles of medical ethics, including nonmaleficence, beneficence, autonomy, and justice, provide a good basis for good medical practice and good medical ethics 6.

Practical Implications

• Nonmaleficence can be applied in clinical practice by considering alternative treatments with lower risks, such as cognitive behavioral therapy for chronic pain instead of long-term opioid analgesic therapy 7.
• Understanding the principles of nonmaleficence and beneficence can help clinicians avoid mistakes in thinking about their duties to patients and make informed decisions about patient care 4.