Nonmaleficence, Revisited

Did you hear the one about the $18,000 drug test? How about the $6,000 ice pack? Far from punch lines, stories like these are the punch in the gut for people who sought help from the U.S. healthcare system (here and here, respectively).
You can’t discuss U.S. healthcare without discussing the costs to individual patients. In 2016, the New York Times and Kaiser Health News (KHN) collaborated on the first detailed survey of Americans struggling to pay medical bills, with alarming results. 1 in 5 people under the age of 65 with health insurance reported trouble paying their medical bills in the past year. Even one visit to the hospital can have a permanent negative effect on someone’s finances, even if that person has health insurance. Just this past week, KHN found that surprise medical bills are what Americans worry about most in terms of their healthcare. Medical debt is the most common reason for people to be contacted by a debt collector according to the Consumer Financial Protection Bureau. I may not have an MD after my name yet, but it seems like dealing with a debt collector wouldn’t be part of the recovery I’d recommend for a patient just discharged from the hospital.
Medical schools differ in how much they emphasize medical ethics in their curriculum, but I expect that every medical student at some point learns the four basic principles of bioethics, if only because yes, they will be on the test. The four principles are autonomy, beneficence, nonmaleficence and justice. Let’s look at some examples to illustrate these ideas:
- Autonomy: Patients are allowed to control their own lives, so if an adult who say, has insulin-dependent diabetes wants to stop taking his insulin and has intact decision-making capacity, he’s allowed to. On the test and in real life, this is why adult Jehovah’s Witnesses can refuse blood.
- Beneficence: Often simplified to “do good.” Doctors have a special duty to act in a patient’s best interest. If a patient comes in with a stomach ulcer, you give them the recommended treatment for it. This is also the reason why coding patients are intubated and get CPR if their wishes are unknown.
- Nonmaleficence: The famous “do no harm.” We don’t prescribe drugs to a patient that they’re allergic to, we don’t make surgical incisions just a little bit wider than they need to be so that the medical student can see the liver, and we don’t provide care when the risks outweigh the benefits.
- Justice: The trickiest of the four principles, since it requires us to distribute resources in a fair and equitable way. The best example is patient triage.
With that covered, let’s explore nonmaleficence a little bit more. Right now, I’m taking a gap year between my third and fourth years of medical school. The most common reason to do this is to do research so that you can be more competitive for residency applications, and is practically required for aspiring dermatologists, neurosurgeons and plastic surgeons. While I’m indeed doing research, I’m quite sure that I don’t want to go into any of those extremely competitive fields (much to the disappointment of my dentist, who stans for dermatology whenever my ability to respond is severely hindered by a cleaning). Instead, I have an ulterior motive — I’m worried about nonmaleficence. While I don’t doubt my ability to provide excellent clinical care to my future patients as a resident, I do doubt my ability to do so without causing other harms — namely, financial and emotional.
I spent the summer after college working in a nonprofit at the University of Chicago Medical Center. That August, one of the most interesting researchers at the hospital, Dr. Vineet Arora, published an article in JAMA with some of her usual collaborators that would change the course of my interests. Even the title was startling: “First, Do No (Financial) Harm.”* To this day I think it may be one of the most important and helpful articles I’ve read. It’s a simple argument, really: financial well-being is inextricably tied to health, and if physicians are committed to the health of their patients, then they have a duty to at least try to ensure that the care they provide will not cause undue financial harm. However simple though, the argument is also radical. It calls for an end to the “not my job” mentality around physicians and cost.

And so, one of my reasons for taking a gap year is to learn how to resist becoming a cog in the machine of medical financial harm. From what I’ve seen, residents (the junior doctors in a teaching hospital who are responsible for most of your care) are expected to carry out their jobs without making a fuss. They’re usually so overworked and exhausted that they don’t have the energy to pay attention to “non-medical issues,” as one surgery intern told me. If the rise of the ‘medical bill narrative’* over the last few years has showed me anything, it’s that such a mindset is unacceptable. How can I live by the principles of beneficence and nonmaleficence if my care causes a family to declare bankruptcy, or is a direct cause of the emotional and physical harms of poverty? To be sure, such problems extend far beyond the scope of a single doctor’s care, but don’t we then have a responsibility to also work towards justice? Towards a healthcare system where resources are distributed in a way that maximizes benefits and minimizes risks? After all, medicine without ethics is simply assault.
- Moriates C, Shah NT, Arora VM. First, Do No (Financial) Harm. JAMA. 2013;310(6):577–578. doi:10.1001/jama.2013.7516. Available: https://jamanetwork.com/journals/jama/fullarticle/1709839
- Some of my favorite ‘medical bill narratives’: Kaiser Health News’ “Bill of the Month” series; Vox’s Uncovering ER Bills series, Molly Osberg’s astonishing “How to Not Die in America” at Splinter, and NPR’s “Why Your Health Insurer Doesn’t Care About Your Big Bills”
