Two Moral Norms: Beneficence and Nonmaleficence

Two moral norms have remained relatively constant across the various moral codes and oaths that have been formulated for health care providers since the beginnings of Western medicine in classical Greek civilization. They are beneficence, which is the provision of benefits, and nonmaleficence, which is the avoidance of doing harm. These norms are traced back to a body of writings from classical antiquity known as the Hippocratic Corpus. Although these writings are associated with the name of Hippocrates, the acknowledged founder of Western medicine, medical historians remain uncertain whether any of them, including the Hippocratic Oath, were actually his work. Although portions of the Corpus are believed to have been authored during the sixth century BC, other portions are believed to have been written as late as the beginning of the Christian era. Medical historians agree that many of the specific moral directives of the Corpus represent neither the actual practices nor the moral ideals of the majority of physicians of Ancient Greece and Rome.

Nonetheless, the general injunction “As to disease, make a habit of two things: (1) to help or, (2) at least, to do no harm” was accepted as a fundamental medical ethical norm by at least some ancient physicians. With the decline of Hellenistic civilization and the rise of Christianity, beneficence and nonmaleficence became increasingly accepted as the fundamental principles of morally sound medical practice. Although beneficence and nonmaleficence were regarded merely as concomitant to the craft of medicine in classical Greece and Rome, the emphasis upon compassion and the brotherhood of humankind, central to Christianity, increasingly made these norms the only acceptable motives for medical practice. Even today, the provision of benefits and the avoidance of doing harm are stressed just as much in virtually all contemporary Western codes of conduct for health professionals as they were in the oaths and codes that guided the health-care providers of past centuries.

Traditionally, the ethics of medical care has given greater prominence to nonmaleficence than to beneficence. This priority was grounded in the fact that, historically, medicine’s capacity to do harm far exceeded its capacity to protect and restore health. Providers of health care possessed many treatments that posed clear and genuine risks to patients and that offered little prospect of benefit. Truly effective therapies were all too rare. In this context, it is surely rational to give substantially higher priority to avoiding harm than to providing benefits.

The advent of modern science changed matters dramatically. Knowledge acquired in laboratories, tested in clinics, and verified by statistical methods has increasingly dictated the practice of medicine. This ongoing alliance between medicine and science became a critical source of the plethora of technologies that now pervade medical care. The impressive increases in therapeutic, preventive, and rehabilitative capabilities that these technologies have provided have pushed beneficence to the forefront of medical morality. Some have even gone so far as to hold that the old medical ethic of “Above all, do no harm” should be superseded by the new ethic “The patient deserves the best.” However, the rapid advances in medical technology capabilities have also produced great uncertainty as to what is most beneficial or least harmful for the patient. In other words, along with increases in ability to be beneficent, medicine’s technology has generated much debate about what actually counts as beneficent or nonmaleficent treatment. Having reviewed some of the fundamental concepts of ethics and morality, let us now turn to several specific moral issues posed by the use of medical technology.