What's Wrong with Nonmaleficence? Updating an Ancient Injunction

AbstractThis article argues that the ethical principle of nonmaleficence, to "do no harm," has become conceptually thin. Harm in medical settings is ubiquitous and typically in balance with beneficent intent, making nonmaleficence subsidiary to beneficence. Other independent applications of nonmaleficence have lost some of their original force. We propose to expand the conventional concept of nonmaleficence to add the obligation and the goal to avoid harm to the medical relationship. We offer scenarios demonstrating how connecting nonmaleficence to the ethics of care and relational autonomy helps to address key weaknesses in conventional principlism. We pose these relational obligations in prohibitory form because optimal clinical relationships remain context dependent, varying by setting and condition. In addition, this reframing of nonmaleficence foregrounds the risk of relational harm posed by an increasingly fragmented and compartmentalized medical realm that still relies heavily on trust, open communication, and confidentiality between clinicians and patients.