Non-Maleficence

In this series of articles, medical students from across the country will discuss a range of topics from medical ethics to the NHS to public health to medical conditions to clinical governance.

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The non-maleficence pillar of medical ethics is based upon “Primum non nocere”, which is the Latin phrase meaning “first, do no harm”. The Hippocratic Oath, which is the oath of ethics historically taken by physicians, similarly includes a promise “to abstain from doing harm”.

Medical practitioners must therefore ensure that their actions are not intended to do harm or bring harm to their patient’s. The pillar is used to remind medical practitioners to consider the possible harm that any medical intervention might cause.

The sister pillar of medical ethics to non-maleficence is beneficence. Beneficence is the medical ethics pillar to “do good” and promotes the well-being of patients. As a medical practitioner abiding by these two pillars, you must act in a manner that cultivates benefit for your patient, and at the same time protects them from harm.

🧬Clinical Example

An infant with Edwards’ syndrome (trisomy 18). Edwards syndrome is a genetic disorder sadly considered incompatible with life. Using the ethical pillars of nonmaleficence and beneficence as a guide, clinicians can suggest a palliative care plan which minimises harm to the infant and prevents prolongation of futile treatment. For example, it is not in the infant's best interests to be having unnecessary blood tests, which could be uncomfortable/painful. However, it is important to consider that the family may request continuation of interventions and this should be respected and further advice should be sought on this.

💉Medical Negligence

To be negligent towards your patient’s is to go against the non-maleficence pillar of medical ethics. Medical negligence is a composite legal finding, comprising three essential parts.

The person bringing the action, the complainant (formerly known as the plaintiff) must show that:

1. The defendant doctor owed the complainant a duty of care

2. The doctor breached this duty of care by failing to provide the required standard of medical care

3. This failure actually caused the plaintiff harm, a harm that was both foreseeable and reasonably avoidable

❌Breast Surgeon - Ian Paterson

Consultant surgeon Ian Paterson was jailed for 20 years in 2017 for 17 accounts of wounding with intent. He was found to have subjected more than 1,000 patients to unnecessary and damaging operations. He harmed his patients through unregulated “cleavage-sparing” mastectomies, where he left breast tissue behind, meaning that the disease returned in many of his patients.

He subjected many of his patients to not only physical harm but psychological harm by performing surgery on patients who did not require it – they found out years later that they did not have cancer.

⚖️The Bolam Principle

When a medical negligence claim is not as clear-cut as the case of Ian Paterson, the Bolam test can be used to decide the outcome. The Bolam test was established in 1957 following the decision of the court in Bolam v Friern Hospital Management Committee, in which the court concluded that a doctor might be able to avoid a claim for negligence if they can prove that other medical professionals would have acted in the same way.

📜Useful Links:

• BJA education - Duty of care and medical negligence MDU - Clinical negligence: your questions answered

• BBC News - Ian Paterson: Surgeon wounded hundreds amid 'culture of denial'

• Law Teacher - Bolam v Friern Hospital Management Committee

• Oxford reference - Bolam Test