Nonmaleficence is the principle that actions or practices are right insofar as they avoid producing bad consequences.5 This is the foundation of all health care and describes the first obligation that every health care provider embraces — do no harm. In Latin the term is primum non nocere which means first, do no harm. Patients who seek dental services place themselves in the care of another person and, at a minimum, should expect that no additional harm will result from that act. The patient grants the clinician the privilege of access to a portion of his or her body for an explicit purpose, a privilege founded in trust. Fundamental to that trust is that the health care provider will do no harm to the patient.
The Hippocratic Oath instructs the health care provider to promise to keep the sick from harm and injustice. In reference to nonmaleficence, the ADA Principles of Ethics and Code of Professional Conduct, states “the principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist’s primary obligations include keeping knowledge and skills current, knowing one’s own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.” For example, practitioners are required to maintain their level of knowledge and skill through participation in appropriate continuing education programs. Thus a dentist who has not performed an endodontic procedure since graduation from dental school 20 years ago would be expected to refer patients to a colleague for root canal therapy. Likewise, a dental hygienist also has an obligation to stay up-to-date with the changing standards of care in the profession. A hygienist who is unfamiliar with local anesthesia techniques should refer or defer performing that service until achieving competency.
Over time nonmaleficence has evolved to include preventing and removing harm. Therefore, health care providers have an obligation to do no harm as well as to prevent harm. Prevention of harm clearly is a domain of dentists and dental hygienists as great emphasis is placed on educating patients about preventing dental caries and periodontal disease.
A narrow interpretation of this principle would hold that complete avoidance of any pain and suffering in patient care must be maintained. Such strict interpretation would mean that invasive diagnostic tests to locate disease, as well as intraoral injections could never be performed. Consequently patients would never benefit from treatment that would alleviate current pain, and they could not benefit from the prevention of future pain and suffering — and this is unrealistic. A clinician may not always be able to avoid harm. In fact, causing some degree of harm when that harm will lead to a greater good—restoring a patient to health—maybe desirable as well as necessary. This conflict is referred to as the principle or rule of double effect, and it requires the health care provider to consider the risks and benefits whenever treatment is provided.
This principle is referred to in such complex situations as saving the life of a pregnant women or her fetus and in the difficult end of life choices. To be morally acceptable, the clinician intends only the good effect. Frankena clarified that delineation between harm and good in the following classification system.6
One ought not to inflict harm.
One ought to prevent harm.
One ought to remove harm.
One ought to do or promote good.
The first classification refers to avoidance of harm which takes precedence over the second, third, and fourth entries, which define beneficence, or the promotion of good. This hierarchy of nonmaleficence and beneficence provides the clinician with a guideline to follow in sorting out dilemmas in practice. Not inflicting harm takes precedence over preventing harm, and removing harm is a higher priority than promoting good. Ideally, the clinician would be able to implement all four parts of this hierarchical relationship; however, when faced with constraints and conflict, prioritization would be necessary. Avoiding harm and promoting good in the practice of dentistry and dental hygiene are not always possible.
Recent understanding of the challenges to health care professionals has focused on the need for self-care and cultivation of well-being. The clinician must attend to their own physical and mental health in order to provide care of the highest standards. Thus an aspect of nonmaleficence is the responsibility to be attentive to burn-out and fatigue.7