Nonmaleficence and Beneficence - Jones & Bartlett Learning

1 CHAPTER3 Nonmaleficence andBeneficenceLove and kindness are never wasted. They always make adifference. Barbara De AngelisPoints to does the principle of Nonmaleficence affect the healthcareadministrator s (HCA) role in the organization? can you avoid causing harm to employees? does the principle of Beneficence have to do with operating ahealthcare organization?Words to RememberThe following is a list of key words for this chapter. You will find themin bold in the text. Stop and check your understanding of AND DEFINITIONSThis chapter presents two parallel principles of ethics: nonmaleficenceand Beneficence . Some ethics writers view these principles as inseparablecousins. Others argue that Nonmaleficence is the strongest obligation ofthe two. Whatever the relationship, these two areas are central to atrust-based healthcare system because they are assumed by society 9/11/09 7:43 AM Page 4748 CHAPTER3 Nonmaleficence ANDBENEFICENCE individuals to be its pillars of practice.

2 This has been the case as far backas Hippocrates, who recognized these duties in his oath of what do these words mean? Nonmaleficence involves an ethicaland legal duty to avoid harming others (Beauchamp & Childress,2008). It is based on the Latin maxim primum non nocere or First, dono harm. This principle involves areas of healthcare practice includingtreatment procedures and the rights of patients. In addition, it has animpact on how you treat employees in your practice as an HCA. Youwill read more about these applications in this chapter s section health care, you go beyond avoiding harm to people. Your obliga-tion is to create benefit and contribute to optimum health for individu-als and the community at large. This obligation is called includes the obligation to help those in trouble, protectpatients rights, and provide treatment for people who need it.

3 Kantiansagree that these obligations exist because you are dealing with the basicneeds of humanity and because all people have value. However, in day-to-day healthcare decisions, the utilitarian view of Beneficence is oftenused. This involves balancing benefits of a healthcare decision against itsharms. Avoiding the absolutes of Kantian logic, practice or policy deci-sions are made on this reciprocity. You will read more about benefi-cence and its implications for you as an HCA later in this IN HEALTHCARE SETTINGSF irst, do no harm. How can this be part of the principles of ethics intoday s technology-centered healthcare system? Do you not have to causepatients pain and suffering to cure them? Should you not use invasivediagnostic tests and blood work to provide optimal care? Should we con-sider the emotional pain of receiving a diagnosis?

4 Certainly this first, donot harm concept does not mean that you cannot ever cause harm topatients in order to treat them. Sometimes harmful action is necessary,but it should never be automatic. The benefits that you provide throughyour procedure should outweigh the suffering that you has been upheld in both the ethical and legal prac-tices of health care. Using utilitarian logic, the benefit of procedures isbalanced against the harm. If there is greater benefit, the act is viewed asan ethical one. In fact, you have a duty to provide appropriate care toavoid further harm to the patient under what some legal texts call a duecare standard. This basically means that you have taken all necessaryaction to use the most appropriate treatment for the condition and haveprovided that treatment with the least amount of pain and suffering pos-sible.

5 From an administrative standpoint, the care should be provided byprofessionals with appropriate levels of education and training. 9/11/09 7:43 AM Page 48 Nonmaleficence in Healthcare Settings49for safety and protection of the patient s physical health and dignity areapplied to avoid harm. Infection control and other environmental prac-tices are also part of the process of providing care and avoiding , your patients receive care with a trust that it will not causethem harm even if some pain and suffering is many other areas of health care, Nonmaleficence is complicatedwhen advanced technology is part of the regimen. Issues around with-holding or withdrawing life support, extraordinary measures, and deathwith dignity involve decisions about avoiding further harm to the indi-vidual. For example, healthcare professionals and family members seemto be more comfortable with withholding ( , not starting) treatmentthan withdrawing it.

6 Somehow, what has come to be called pulling theplug seems more harmful to the patient than not starting the technol-ogy to support life. The line between extraordinary and ordinary carehas become murkier with the advent of advanced life-sustaining tech-nology. The now classic Terri Schiavo case is an excellent example ofthis level of complexity. It used to be that health care did not go toextraordinary efforts when there was no hope of benefit. However,family members, educated in the marvels of modern medicine, changedthis view. The family might see what used to be called extraordinarymeasures as ordinary and appropriate for their loved one. Even somephysicians who see death as a failure might advocate for care that pro-longs some form of life but increases the suffering of the does your work affect Nonmaleficence for patients?

7 Of course,you are not actually treating the patient, but you create an environmentwhere this principle can be applied. For example, if advance directivepolicies are not in place and are not clearly written, you may beinvolved in policy development or refinement. If they are in place, youcertainly will be involved in making sure that they are implementedappropriately. This responsibility will include periodic staff educationso that staff members are clear about their responsibilities and addition, you might be working closely with an ethics committeewho can advise you when challenging situations and StaffThe application of the principle of Nonmaleficence is not restricted topatient treatment. It also must be considered when dealing with anymember of the healthcare staff. You have an ethical obligation to pro-vide a working environment that is safe and does not harm youremployees.

8 Such an environment allows for discussion of concernswithout fear of reprisal. It should also be a positive environment wherevalues are respected and employees can do their best work on behalf ofthe patients they serve (this is the I-YOU relationship). This environ-ment should be free of harassment, imposition, and discrimination forall employees, regardless of their status in the 9/11/09 7:43 AM Page 49 Creation of a positive environment or climate of trust can go a longway to ensure the implementation of the principle of nonmaleficencefor employees. However, situations can occur that are potentially a vio-lation of this principle. Certainly, downsizing has a potential to causethe staff great personal and professional harm. How can you imple-ment a layoff plan and cause the least amount of harm to employees?

9 The American College of Healthcare Executives (ACHE) gives yousome assistance through its Policy Statement Ethical Issues Related toa Reduction in Force(ACHE, 2005). This statement urges you to con-sider both the long- and short-term impact of this decision, not only onthose who will lose their jobs, but also on those who will remain in theorganization. Survivor guilt can often be destructive to a positive work-place and ACHE also stresses the need for frequent and accurate commu-nication with all those involved in the layoffs and the provision of asmuch support as possible for those who lose their jobs. Often, adminis-trators try to avoid communication about layoffs because they fear dis-ruption and loss of productivity. In keeping information from affectedemployees, they are trying to balance their view of benefits versus of what is to happen is kept to a select group.

10 Inevitably, therumor mill will take over for the void in accurate communication andmake the situation worse. Even though it might seem to make your bur-den easier in a difficult situation, silence is truly not golden and cancause unnecessary is equally important to remember those who remain after a can be an administrative attitude of You should think yourselflucky to have a job and a lack of empathy for the feelings of attitude causes unnecessary harm because it fails to acknowledgethe human reaction of Why them and not me? or survivor guilt. Careshould be taken to acknowledge what has occurred and allow time forprocessing the feelings associated with it. This can be done through sev-eral channels of communication including meetings, newsletters, and e-mails. In addition, communication needs to be ongoing regardingworkload expectations and the potential for any future reductions inthe an administrator, you will be dealing with diversity on many lev-els.