Biomedical ethics are often traced all the way back to the Hippocratic Code, which admonishes us, “…to help, or at least do no harm.” The first great work of the modern era, written by Thomas Percival in 1803, provided the first wide-ranging and inclusive treatise on the topic. Percival argued that beneficence and nonmaleficence (the physician mandates to help others and to do no harm) were the two most important ethical principles in medicine, and that the drive to optimize these two factors may supersede the need to preserve autonomy.¹

In 1979, Beauchamp and Childress published their first edition of their landmark work, Principles of Biomedical Ethics, which fully delineated and justified the principles of respect for patient autonomy and justice as sharing equal importance to the principles of beneficence and nonmaleficence, is central to any discussion of modern medical ethics, and required reading for anyone with more than a passing interest in the field.²

First and foremost, the trauma practitioner has the responsibility to seek out the wishes of injured patients and to honor them whenever possible. The challenges associated with fulfilling this responsibility are countless, and are found in every phase of the process: ascertainment of such wishes, determination of relevance and practicality, and implementation.

To claim that we are doing something, “…for an individual’s own good” when such an action would directly violate a patient’s express wishes, is rarely a defensible or reasonable course of action. The key to this principle is an understanding of what it means to be autonomous, and acquiescence to the idea that few individuals want to be cut out of life-altering decisions or the process of self-determination.

Central to the concept of autonomy, as it is described by Beauchamp and Childress, is the notion that to be autonomous an individual must have: (a) liberty, that is, freedom from controlling influences and (b) agency, or the capacity to act with intention and understanding.³ Therefore, an individual who is befuddled by mental illness, ignorance, incapacitation, immaturity, or addiction cannot be said to be fully autonomous, and therefore, each patient request in such circumstances must be weighed against what is the standard of what is safe and practical. More controversial is the idea that autonomy calls for an individual to be able to subvert certain basic desires in order to promote higher order ideals, that is, be capable of reasoning beyond the primary desires for thirst, hunger, and comfort, but this standard is more stringent, and as a result, more controversial.¹

Patients have a right to autonomy, but not a duty to exercise it. Therefore, a patient may reasonably confer medical decision-making power to friends, spouse and family, or even in some rare circumstances to a physician. The responsibility of the physician is to promote autonomy through education, relief from suffering, and support, to optimize the patient’s capacity for self-determination.⁴ Finally, even when it is unsafe or unwise to allow for patient self-determination because of mental illness, ignorance, or irrationality, patient wishes and preferences should be weighed individually and implemented wherever possible if such wishes are not overly disruptive to the delivery of care and are reasonably safe.

To address the need to minimize harm to others seems superfluous, however, the practice of medicine, including treatment of the sick and injured, is full of mitigable opportunities for harm. Indeed, there are probably at least 100,000 potentially preventable deaths from medical misadventures each year in the United States.⁵ The moral duty of the clinician is to minimize risk to the patient, and to prevent iatrogenic harm wherever possible.

A more challenging area of nonmaleficence, on the other hand, involves withholding and withdrawal of treatments. Treatments that are ineffective in treating a patient’s condition, including such interventions as mechanical ventilation, dialysis, and surgical procedures, can be reasonably not offered (or even withdrawn) when such treatments promote suffering or offer minimal hope of cure or palliation. For example, a patient with brain death cannot benefit in any way from initiation of dialysis—the treatment cannot cure or palliate the patient, and as such, should be withdrawn or not offered. Most examples in the daily practice of medicine are not this clear-cut, although the same principles apply in weighing whether to offer or withdraw aggressive medical interventions: Each must be considered in light of its capacity to cure the patient’s primary disease process or palliate their symptoms, and not in the light of whether it will merely replace a failing organ system.

A more difficult distinction can be found in the discernment as to whether intravenous and enteral feeding constitutes medical interventions, or basic human care, and, whether such treatments prolong dying rather than promote living. In a landmark case in 1976, the Supreme Court of New Jersey allowed the guardians of a patient in a persistent vegetative state from anoxic brain injury to disconnect the ventilator with the express intention of preventing the suffering induced by the mechanical intervention, and allowing the patient to die.⁶ When the patient subsequently survived for several years thereafter receiving tube feeds, the guardians reasoned that the ventilator had contributed to suffering, whereas the tube feeds did not.⁷ The boundaries between basic sustenance and medical interventions are indistinct and certainly shaped by an individual’s philosophic and spiritual beliefs, experiences, and convictions. However, medical nutrition and hydration is reasonable to administer when, at least according to one prominent author, they offer, reasonable hope of benefit and are attainable without excessive expense, pain, or inconvenience.⁸

A discussion of physician-assisted suicide probably has no place in a textbook related to care of the injured patients. However, very often we are called on to administer treatments that cause harm as a secondary effect to their intended primary clinical benefit. Examples of this are easy to find, but none perhaps more controversial than the use of narcotics during withdrawal of care from fatally injured and terminally ill patients. Minor alterations in the dose of an intravenous narcotic can determine the difference between humane care and active euthanasia. Safe moral ground can be attained in such circumstances when an intended action is at least morally neutral and the clinician, although understanding and anticipating the bad effect, intends only the desired effect. For example, when giving narcotics to reduce pain and suffering, a clinician may realize this action has the capacity to hasten death, but just so long as the physician does not administer the medication for this purpose, but instead doses them to provide for relief from suffering, the “rule of double effect” renders the action ethically justifiable. Coexistent with these requirements is the need for the good (desired) effect to not come about as a result of the bad (undesired) effect, that is, halting suffering with death.⁹

Beneficence refers to our duty to take action for the benefit of others. We are morally responsible to protect and defend others from abrogation of their rights and harm, to assist those in need, and to rescue those in danger, but with what limitations?

Morally, where one finds conflicting duties to beneficence, one must discern which one takes precedence, and also weigh the potential for benefit against the collective physical, financial, emotional costs of the action under consideration. Where giving to others unreasonably lessens the future capacity of the healer or the institution to help others and to fulfill prior and competing obligations to aid, continuation or escalation of intervention ought not to be undertaken. In the end, the total potential for good must be weighed against the sum potential for harm.