During one of my clinical blocks in my 4th year of physiotherapy, I was faced with a very difficult case. The patient was a 10-year-old girl with 35% full thickness flame burns. She sustained burns on the posterior parts of her body from the back of her head to her upper thighs and affected her shoulder, hip and trunk ranges. She struggled with a lot of activities of daily living (ADLs) as well as with emotional well-being. Due to the trauma the patient also suffered from depression.
Some of my short term goals for the patient was
- Prevent contractures of the shoulders and hips and also to maintain their ranges.
- Educate care givers on passive stretches.
- Improve functional activities such as walking, sit to stand, rolling in bed etc.
Therefore, my treatment included active movements of joints affected to encourage movement. It also included practicing of functional activities, scar massage and passive stretches. However, the patient found the treatment boring and almost never participated fully in her treatment. She also developed a fear for the gym and treatment session as she associated it with pain. This was due to the passive stretches which she found very painful. When you do these stretches the inelastic burned skin stretches which causes the patients a lot of pain. I felt so bad for the patient and I did not want to cause this very intense pain and difficulty for the patient every day of the week.
The patient then developed procedural pain due to the passive stretches that was causing a very painful situation for this patient. The procedural pain can be defined as, that related to wound care or stretching of the patient’s scar tissue, activities that seem to cause the worst pain for burned patients (Von Baeyer & Tupper, 2010). This led to me thinking of the principle of non-maleficence, because was it really causing no harm to the patient? How would one know this? Non-maleficence means to do no harm, or to inflict the least harm possible in order to reach a beneficial outcome (European Patients’ Academy, n.d.).
Furthermore, a single action may have two effects on the patient; one that is considered a good effect, the other a bad effect. The formal name for this principle that can be given to this category of cases is the principle of double effect.
According to Beauchamp & Childress (2013), there are four conditions that usually apply when considering cases that include the principle of double effect:
- The nature of the act. The action itself must not be intrinsically wrong; it must be a good or at least morally neutral act.
- The agent’s intention. The agent intends only the good effect, not the bad effect, even though it is foreseen.
- The distinction between means and effects. The bad effect must not be the means of the good effect,
- Proportionality between the good effect and the bad effect. The good effect must outweigh the bad effect.
The benefits of passive stretches are that it prevents contractures and maintains range of motion of joints that is covered with inelastic skin. Therefore, the nature of this act is not intrinsically wrong and the agent’s intention is only the good effect. The good effect being that the stretches will allow more mobility for the patient as well as prevent future surgical procedures. The bad effect on the other hand is that the stretches are very painful for the patient. The pain then causes fear for her treatment sessions and can lead to future problems if the patient refuses treatment later on in her life. However, I think the good effect outweighs the bad effect. It is painful now but it is of great benefit for the patient to prevent future secondary problems.
To conclude, the case was a very difficult case as she was not participating in the treatment and I as a person felt bad to cause this 10-year-old girl these intense painful situations every day. However, I thought of one of the principles of ethics in clinical practice; Non-maleficence. Understanding what it meant and going through the four conditions that usually apply when considering cases that include the principle of double effect, helped me to know that the stretches is actually a good thing to do even though a bad effect is created at the same time. I will therefore use these 4 conditions in my future clinical practice when faced with a similar problem as it helps you to reason your treatment techniques and consider the patient’s feelings as well.
References:
Beauchamp T, Childress J. (2013). Principles of Biomedical Ethics, 7th Edition. New York: Oxford University Press.
https://global.oup.com/academic/product/principles-of-biomedical-ethics-9780199924585?cc=us&lang=en&
European Patients’ Academy. (n.d.). Non-maleficence. Retrieved 16 September, 2019, from
https://www.eupati.eu/glossary/non-maleficence/
Von Baeyer, C. L., & Tupper, S. M. (2010). Procedural pain management for children receiving physiotherapy. Physiotherapy Canada, 62(4), 327–337.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958071/
3 thoughts on “Non-Maleficence in the clinical setting”
Hi Agatha,
Thank you for sharing this piece.
Firstly the topic is relevant to ethics and to clinical practice, I liked how you linked the topic of ethics to your clinical experiences. I see there is a linkage between non-maleficence and empathy, maybe you can add something about empathy and how that influenced your decisions with regards to this patient because I see you mentioned how you felt about this incident.
I liked how you included the 4 conditions, I did not know about those and I learnt something that I can definitely use within the clinical setting in future practice.
References: They are all relevant, just remember to hyperlink them
corrections:
The first sentence is a bit confusing maybe change it:
“During one of my clinical blocks in my 4th year of physiotherapy, I was faced with a very difficult case.”
“she also developed a fear for the gym”
“This was due to the passive stretches which she found very painful” start a new sentence or add a “,”
‘To conclude, this case was a very difficult case”
“and I as a person felt bad to”
Thank you for sharing
Thank you for sharing your piece.
I think this topic is very relevant to us as physiotherapists as all we want to do is help patients get better however some means of us doing so can inflict pain onto the patient. Our intentions behind treatments are always to benefit the patient however it doesn’t always come across that way for a patient especially when we inflict pain as you have described in your writing.
I like how you have linked non-maleficence to a clinical experience and clearly defined what the term means. I would suggest that you join paragraphs 4 and 5 where you talk about procedural pain and non-maleficence. Consider linking your clinical case with these definitions. Explain that by you doing passive stretches and other physiotherapy treatment techniques is causing procedural pain for the patient.
I like how you used literature and added the 4 conditions when looking at a double effect, I would suggest that you link your case more specifically with some of these points to strengthen your argument.
In the second last paragraph you talk about the “good” effects of your treatment, I would suggest that you add the “bad” effects of the treatment (the patients point of view) and shift the paragraph into a mini argument to show both sides of the case.
Reflecting on this experience, what will you do differently if you were faced with a case similar to this again?
Corrections:
Paragraph 1 “She sustained burns on the posterior parts of her body from….”
Overall a relevant and interesting topic that sparked a lot of thoughts when reflecting on my own experiences in clinical practice.
Hello Agatha, thank you for sharing your story and personal experiences. It’s personally a relatable situation.
Content: Your writing was good, everything was a smooth read and it all linked to your heading. I understood your story and why you chose your facts and references. I like the connection between your heading, argument and picture. Possible consider placing the picture on the top and not at the end?
Argument: You stated quite a few claims and you where able to support them with relevant references. Your structure is good and I was able to follow the flow of your argument without having to reread a few times. I enjoyed reading your piece, it is of much relevance to a lot of students daily ethical issues working in pediatrics care. Your treatment goals where accurate and I understand your struggle with causing a double- effect.
References: Strong references used. Correctly formatted in text and in the reference list. Possible consider adding in links to your references so the reader could have direct access to your sources?
Writing: Grammatically correct. Good sentence structures. Paragraph lengths are correct, not to long. As mentioned in your first comment, there are a few incorrect sentence structures and some typos. Please just reread your work again before submitting the final.
Once again, great piece to read and relatable. I do hope you can use the feedback for some good.
Wiana Muller