Which is appropriate for the nurse to include in the education of the ethical principle of Nonmaleficence to a group of nursing students?

What is non-maleficence and why is it a fundamental pillar of ethics? Find out what it means and how to approach any ethical scenarios you are given in your Medical School interview.

What Is Non-Maleficence?

Non-maleficence is the sister to beneficence and is often considered as an inseparable pillar of ethics.

Non-maleficence states that a medical practitioner has a duty to do no harm or allow harm to be caused to a patient through neglect. Any consideration of beneficence is likely, therefore, to involve an examination of non-maleficence.

How Is Non-Maleficence Different to Beneficence?

Non-maleficence differs from beneficence in two major ways.

First of all, it acts as a threshold for treatment. If a treatment causes more harm than good, then it should not be considered. This is in contrast to beneficence, where we consider all valid treatment options and then rank them in order of preference.

Second, we tend to use beneficence in response to a specific situation – such as determining the best treatment for a patient. In contrast, non-maleficence is a constant in clinical practice. For example, if you see a patient collapse in a corridor you have a duty to provide (or seek) medical attention to prevent injury.

 Non-Maleficence Example

One of the best ways to understand the difference between non-maleficence and beneficence is by looking at an ethical example:

A 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife.

From a beneficence perspective, successful removal of the appendix in situ would certainly improve the patient’s life.

But from a non-maleficence perspective, let’s examine the potential harms to the patient:

• The environment is unlikely to be sterile (as is that manky pen-knife) and so the risk of infection is extremely high
• The surgeon has no other clinical staff available or surgical equipment meaning that the chances of a successful operation are already lower than in normal circumstances
• Assuming that the surgeon has performed an appendectomy before, they have almost certainly never done it at the roadside – and so their experience is decontextualized and therefore not wholly appropriate
• Unless there isn’t a hospital around for miles, this is an incredibly disproportionate intervention.

Again this is a rather silly example but it is important to remember that before leaping to action, we need to consider the implications and risks of intervening at all.

Discussing Non-Maleficence At Interview

Ethics will come up in your interview, and you need to think about non-maleficence. You should consider:

• What are the associated risks with intervention or non-intervention?
• Do I possess the required skills and knowledge to perform this action?
• Is the patient being treated with dignity and respect?
• Is the patient being put at risk through other factors (e.g. staffing, resources, etc.)?

Non-Maleficence Questions

Some questions you could be asked at an interview include:

• Does euthanasia have a place in modern medicine?
• What are the ethical issues with abortion?
• What are the ethical issues if a 14-year-old patient asks her GP for the oral contraceptive pill?

You can find the answer to these questions – and more – in our ethics questions and answer guide.

Hot Topics

Some hot topics that would apply to non-maleficence include:

• The inequalities suffered by the BAME community
• Public health interventions
• Mental health services
• Medicinal cannabis prescriptions

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of ethical practice in order to:

• Recognize ethical dilemmas and take appropriate action
• Inform client/staff members of ethical issues affecting client care
• Practice in a manner consistent with a code of ethics for registered nurses
• Evaluate outcomes of interventions to promote ethical practice

Ethics, simply defined, is a principle that describes what is expected in terms of right and correct and wrong or incorrect in terms of behavior. For example, nurses are held to ethical principles contained within the American Nurses Association Code of Ethics. Ethics and ethical practice are integrated into all aspects of nursing care.

The two major classifications of ethical principles and ethical thought are utilitarianism and deontology. Deontology is the ethical school of thought that requires that both the means and the end goal must be moral and ethical; and the utilitarian school of ethical thought states that the end goal justifies the means even when the means are not moral.

The ethical principles that nurses must adhere to are the principles of justice, beneficence, nonmaleficence, accountability, fidelity, autonomy, and veracity.

• Justice is fairness. Nurses must be fair when they distribute care, for example, among the patients in the group of patients that they are taking care of. Care must be fairly, justly, and equitably distributed among a group of patients.

• Beneficence is doing good and the right thing for the patient.

• Nonmaleficence is doing no harm, as stated in the historical Hippocratic Oath. Harm can be intentional or unintentional.

• Accountability is accepting responsibility for one's own actions. Nurses are accountable for their nursing care and other actions. They must accept all of the professional and personal consequences that can occur as the result of their actions.

• Fidelity is keeping one's promises. The nurse must be faithful and true to their professional promises and responsibilities by providing high quality, safe care in a competent manner.

• Autonomy and patient self-determination are upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values and beliefs. Nurses encourage patients to make their own decision without any judgments or coercion from the nurse. The patient has the right to reject or accept all treatments.

• Veracity is being completely truthful with patients; nurses must not withhold the whole truth from clients even when it may lead to patient distress.

The most commonly occurring ethical issues and concerns in healthcare include the allocation of scarce resources and end of life issues.

Bioethics is a subcategory of ethics. Bioethics addresses ethical concerns like those that occur as the result of advancing science and technological advances. Some of the most common, current bioethical issues revolve around stem cells, cloning, and genetic engineering.

Recognizing Ethical Dilemmas and Taking Appropriate Action

Nurses have the responsibility to recognize and identify ethical issues that affect staff and patients. For example, providing nursing care for clients undergoing an abortion may raise ethical and moral concerns and issues for some nurses; and some patients may be affected with a liver transplant rejection because donor livers are not abundant enough to meet the needs of all patients who request it.

Many hospitals, medical centers and other healthcare facilities have multidisciplinary ethics committees that meet as a group and resolve ethical dilemmas and conflicts. Nurses should avail themselves to ethicists and ethical committees within their facility when such ethical resources and mechanisms are present in order to resolve ethical concerns and ethical dilemmas.

In addition to utilizing these resources, the nurse can take appropriate actions when faced with an ethical dilemma by understanding and applying the ethical guidelines provided in the American Nurses Association's Code of Ethics, the American Medical Association's Code of Ethics, the World Medical Association's Code of Ethics, the American Nurses Association's Standards of Care and Standards of Practice, American Nurses Association's position papers such as that which describes the ethical use of narcotic analgesics at the end of life even if this medication hastens death, state board of nursing declaratory statements, and the International Nurses Association's Code of Ethics.

The steps of the ethical decision making process, like the problem solving process, are:

• Problem Definition. Problem definition is the clear description of the ethical dilemma and the circumstances revolving around it.

• Data Collection. During this phase of the ethical decision making process includes a review of ethical codes, published evidence based practices, declaratory statements, professional position papers and the professional literature.

• Data Analysis. The collected data is then organized and analyzed.

• The Identification, Exploration and Generation of Possible Solutions to the Problem and the Implications of Each. All possible solutions and alternatives to resolve the ethical dilemma are explored and evaluated.

• Selecting the Best Possible Solution. All potential solutions and alternatives are considered and then the best and most ethical action is taken.

• Performing the Selected Desired Course of Action to Resolve the Ethical Dilemma

• Evaluating the Results of the Action. Like the evaluation phase of the Nursing Process, actions to resolve ethical issues are evaluated and measured in terms of their effectiveness to resolve the ethical dilemma.

Informing the Client and Staff Members of Ethical Issues Affecting Client Care

Nurses have the responsibility to identify ethical issues that affect staff members and patients; and they also have the responsibility to inform staff members and affected clients of ethical issues that can and do affected client care. For example, providing nursing care for clients undergoing an abortion may raise ethical and moral concerns and issues for some nurses; and some patients may be affected with a liver transplant rejection because donor livers are not abundant enough to meet the needs of all patients who request it.

Although a rare occasions, a patient may, at times, ask you to do something that is not ethical. For example, a patient may ask a nurse to assist in their suicide at the end their life or they may inquire about another patient in terms of their diagnosis. When something like this occurs, the nurse must inform the client that they cannot do it for ethical and legal reasons.

Clients may also need information about ethics can affect the care that they choose or reject. For example, a client may ask the nurse about whether or not it is permissible ethically and legally to reject CPR at the end of life or to take pain medications even if it hastens their death.

Practicing In a Manner Consistent with The American Nurses Association's Code of Ethics and Other Ethical Codes

As previously discussed, nurses are expected to apply the ethical guidelines provided in the American Nurses Association's Code of Ethics, the American Medical Association's Code of Ethics, the World Medical Association's Code of Ethics, the American Nurses Association's Standards of Care and Standards of Practice, American Nurses Association's position papers such as that which describes the ethical use of narcotic analgesics at the end of life even if this medication hastens death, state board of nursing declaratory statements, and the International Nurses Association's Code of Ethics.

The American Nurses Association's Code of Ethics, for example, contains elements that emphasize and speak to advocacy, collaboration with others, the maintenance of client safety, the dignity and worth of all human beings, the prohibition of any discrimination, accountability, the preservation of patient rights, such as dignity, autonomy and confidentiality, and the provision of competent, safe and high quality care of nursing care.

Evaluating the Outcomes of Interventions to Promote Ethical Practice

As with all other aspects of nursing care, the outcomes of the interventions to promote ethical practice are evaluated and measured.

Some of the evaluation criteria that can be used to determine and evaluate the outcomes of the interventions to promote ethical practice can include one or more of the following:

• Is staff knowledgeable about ethics and ethical practice?
• Is staff effectively applying ethical principles to their daily practice?
• Are clients and staff fully knowledgeable and informed about ethics and ethical practice?
• Were all appropriate professional resources, including codes of ethics and the professional literature, employed to resolve the ethical dilemmas?

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

• Advance Directives 
• Advocacy
• Assignment, Delegation and Supervision
• Case Management 
• Client Rights
• Collaboration with Interdisciplinary Team
• Concepts of Management
• Confidentiality/Information Security
• Continuity of Care
• Establishing Priorities
• Ethical Practice (Currently here)
• Informed Consent
• Information Technology
• Legal Rights and Responsibilities
• Performance Improvement & Risk Management (Quality Improvement)
• Referrals

SEE – Management of Care Practice Test Questions

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Alene Burke, RN, MSN

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

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