Nonmaleficence in Internal Medicine

Nonmaleficence in Internal Medicine: Contemporary Perspectives on "First, Do No Harm"

Dr Neeraj Manikath , claude.ai

Abstract

Nonmaleficence, the principle of "first, do no harm," remains foundational to medical practice yet faces unprecedented complexity in modern internal medicine. This review examines the theoretical underpinnings, practical applications, and contemporary challenges of nonmaleficence for internists. We explore the tension between nonmaleficence and beneficence, discuss common scenarios where harm occurs despite good intentions, and provide actionable strategies to minimize iatrogenic injury. Special attention is given to polypharmacy, diagnostic cascade, overtreatment, and implicit bias as modern threats to nonmaleficence.

Introduction

The Hippocratic injunction primum non nocere has guided physicians for millennia, yet the exponential growth in medical capabilities has paradoxically increased opportunities for iatrogenic harm. Internal medicine, with its complex patient populations and multimorbidity, presents unique challenges to maintaining nonmaleficence. Studies suggest that adverse events occur in 10-20% of hospitalizations, with approximately half being preventable.[1,2] This review synthesizes current evidence on nonmaleficence, providing practical guidance for the modern internist.

Theoretical Framework

Defining Nonmaleficence

Nonmaleficence obligates physicians to avoid causing harm to patients. Unlike beneficence (actively promoting patient welfare), nonmaleficence is a negative duty—a requirement to refrain from harmful actions. Beauchamp and Childress distinguish these principles while acknowledging their frequent overlap in clinical practice.[3]

The principle encompasses several dimensions:

• Avoiding harmful actions
• Minimizing unavoidable harms
• Preventing harm from occurring
• Removing conditions that cause harm

Pearl: Nonmaleficence is not absolute but proportionate—acceptable harm must be justified by proportionally greater benefit, the foundation of therapeutic privilege.

The Harm Threshold

Determining what constitutes "harm" requires nuanced judgment. Harms range from physical injury and pain to psychological distress, loss of dignity, and opportunity costs of pursuing ineffective interventions. The European Society of Cardiology defines medical harm as "unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death."[4]

Contemporary Challenges to Nonmaleficence

Polypharmacy and Prescribing Cascades

Polypharmacy, typically defined as concurrent use of five or more medications, affects over 40% of adults over 65 and increases exponentially with age.[5] The prescribing cascade—where adverse drug reactions are misinterpreted as new medical conditions prompting additional medications—represents a particularly insidious violation of nonmaleficence.

Classic Example: Metoclopramide prescribed for nausea causes drug-induced parkinsonism, leading to initiation of carbidopa-levodopa, causing orthostatic hypotension, prompting fludrocortisone prescription.

Hack: Implement routine medication reconciliation at every visit using the "brown bag review." For each medication, ask: "Is this still indicated? Is the dose optimized? Could this be causing current symptoms?" Consider the STOPP/START criteria for potentially inappropriate prescribing in older adults.[6]

Oyster: Before adding a new medication for a new symptom, systematically review whether existing medications could be causative. The timeline of symptom onset relative to medication initiation is crucial.

The Diagnostic Cascade

Diagnostic cascades occur when incidental findings or screening tests lead to sequential investigations, each carrying risk without improving outcomes. Thyroid nodules discovered on carotid ultrasound, pulmonary nodules on CT angiography, and adrenal incidentalomas exemplify this phenomenon.[7]

Pearl: The probability of benefit from investigating an incidental finding depends on pre-test probability, not simply the finding's existence. A 6mm lung nodule in a lifetime nonsmoker under 40 requires different consideration than in a 70-year-old with smoking history.

Hack: When encountering incidental findings, explicitly calculate the number needed to screen/investigate to prevent one adverse outcome versus the number needed to harm. Document your reasoning. Use the Fleischner Society guidelines for pulmonary nodules and ACR white papers for other incidentalomas.[8]

Overdiagnosis and Overtreatment

Overdiagnosis—detecting abnormalities that would never cause symptoms or death—has emerged as a major source of medical harm. Thyroid cancer, DCIS, prostate cancer, and chronic kidney disease Stage 3a represent conditions where many diagnosed patients experience no benefit but all experience labeling, anxiety, and potential treatment harms.[9,10]

The United States Preventive Services Task Force downgraded numerous screening recommendations based on growing recognition of overdiagnosis harms. Screening for ovarian cancer, neuroblastoma, and prostate cancer (in older men) now carry "D" recommendations specifically due to harm exceeding benefit.

Hack: Practice "slow medicine" for chronic conditions unlikely to cause immediate harm. For borderline abnormal labs, trend over time rather than immediately intensifying therapy. Most Stage 3a CKD patients die with, not from, their kidney disease.

Pearl: The number needed to treat (NNT) to prevent one outcome must be considered alongside the number needed to harm (NNH). When NNH approaches or exceeds NNT, the intervention violates nonmaleficence unless patients strongly prefer treatment after informed discussion.

Implicit Bias and Disparate Care

Implicit bias causes both undertreatment and overtreatment across demographic groups, violating nonmaleficence through unequal application. Black patients receive inadequate pain management and delayed cardiac catheterization, while simultaneously experiencing higher rates of certain invasive procedures of questionable benefit.[11,12]

Women present a paradox—both less likely to receive evidence-based cardiovascular interventions yet more likely to undergo low-value screening tests and procedures. This represents systematic failure of proportionate care across populations.

Hack: Implement structured decision tools and checklists to reduce practice variation. Audit your own prescribing and referral patterns by demographic variables. Ask colleagues to review your cases for potential bias blind spots.

End-of-Life Care and Aggressive Intervention

Intensive care unit admissions in the last month of life, chemotherapy in the last two weeks, and CPR for patients with multiorgan failure represent areas where nonmaleficence frequently yields to other pressures. Multiple studies document that aggressive end-of-life care reduces both survival and quality of life compared to palliative approaches for many terminal conditions.[13,14]

Pearl: The question is not "Can we do this intervention?" but "Should we?" Consider the patient's physiologic reserve, prognosis, and values, not just the availability of technology.

Oyster: Earlier goals-of-care discussions prevent crisis decision-making that defaults to maximum intervention. Document not just patient preferences but the clinical context that triggered the discussion—this helps future clinicians understand decision-making rationale.

Practical Strategies for Upholding Nonmaleficence

Medication Safety

1. Beers Criteria and STOPP/START: Systematically review for potentially inappropriate medications in older adults quarterly
2. Anticholinergic Burden: Calculate cumulative anticholinergic scores; burden >3 significantly increases delirium, falls, and cognitive impairment risk[15]
3. Renal Dosing: Verify dosing for all medications in CKD; medication errors are the leading cause of preventable adverse events
4. Drug-Drug Interactions: Use clinical decision support, but recognize that alerts have poor specificity—override rates exceed 90% for some systems

Hack: Create a personalized "high-risk medication list" for each patient noting specific vulnerabilities (e.g., "falls risk—avoid benzodiazepines, first-generation antihistamines").

Diagnostic Restraint

The Choosing Wisely campaign identifies numerous low-value diagnostic tests.[16] Key principles:

• Avoid daily labs in stable hospitalized patients
• No imaging for uncomplicated acute low back pain within first 6 weeks
• No routine annual ECG or chest X-ray in asymptomatic patients
• Avoid screening for asymptomatic bacteriuria (except pregnancy)
• Don't order continuous telemetry without indication or continue >48 hours without re-evaluation

Pearl: Every test carries downstream consequences. Before ordering, ask: "What will I do differently based on results? What is the probability of actionable findings? What harms might result from positive or false-positive results?"

Preventable Hospital-Acquired Conditions

Hospital-acquired conditions represent clear violations of nonmaleficence:

• Catheter-associated UTI: Remove urinary catheters daily if no clear indication
• Hospital-acquired pressure injuries: Risk-stratify and implement prevention bundles
• Falls: Minimize sedating medications, avoid physical restraints (paradoxically increase injury)
• Delirium: Use ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment, prevention and management; Early mobility; Family engagement)[17]

Hack: Use structured daily rounds checklists addressing these preventable harms explicitly. Make catheter removal, mobility plans, and medication review standing agenda items.

Therapeutic Inertia Versus Overtreatment

Balancing undertreatment and overtreatment requires individualized risk-benefit assessment. The American College of Physicians emphasizes less intensive targets for glycemic control, blood pressure, and LDL in older adults and those with limited life expectancy.[18]

Framework for Individualization:

• Life expectancy: Does time-to-benefit exceed likely survival?
• Comorbidity burden: Do competing risks outweigh treatment benefits?
• Functional status: Can the patient tolerate and benefit from intervention?
• Patient preferences: What outcomes matter most to this individual?

Pearl: For patients over 75 or with life expectancy under 10 years, consider relaxing targets: HbA1c <8%, BP <140/90, LDL <100 mg/dL may be appropriate depending on individual factors.

Communication and Shared Decision-Making

Informed consent extends beyond procedures to medication initiation, testing, and screening. Effective communication about harms requires:

1. Absolute risk presentation: "This reduces heart attack risk from 4% to 3%" rather than "25% relative risk reduction"
2. NNT/NNH transparency: "100 people need to take this for 5 years to prevent one heart attack; 5 will experience side effects"
3. Time-to-benefit discussion: Many interventions require years to show benefit—irrelevant for patients with limited prognosis
4. Opportunity costs: Treatment burdens (appointments, monitoring, medication burden) represent real harms

Hack: Use decision aids from the Mayo Clinic Shared Decision Making National Resource Center or MAGIC evidence ecosystem foundation. These present evidence in accessible formats facilitating genuine informed choice.

System-Level Approaches

Individual clinician vigilance cannot overcome systemic factors promoting iatrogenic harm. Institutional commitments include:

• Electronic health record optimization: Reduce alert fatigue through smart alert design; default orders to evidence-based choices
• Deprescribing protocols: Systematic medication reduction programs for anticholinergics, sedative-hypnotics, and medications without continuing indication
• Multidisciplinary rounds: Pharmacist integration reduces adverse drug events by 66%[19]
• Morbidity and mortality conferences: Analyze systems factors, not individual blame
• Quality metrics aligned with nonmaleficence: Track prescribing cascades, falls, delirium, polypharmacy

Future Directions

Artificial intelligence and clinical decision support offer promise for enhancing nonmaleficence through pattern recognition identifying potential adverse events before they occur. Predictive algorithms for delirium risk, fall prediction, and adverse drug reaction identification are under development.[20]

Precision medicine may reduce iatrogenic harm by tailoring interventions to individual risk profiles, though equity concerns persist regarding algorithm development and validation across diverse populations.

Conclusion

Nonmaleficence in modern internal medicine requires moving beyond passive harm avoidance to active cultivation of restraint, vigilance, and individualized care. The exponential growth in medical capabilities demands proportionate growth in clinical wisdom—knowing when not to intervene carries equal importance to knowing when to act. By systematically addressing polypharmacy, diagnostic cascades, overtreatment, and implicit bias while implementing structured approaches to medication safety and preventable harms, internists can honor the foundational principle that has guided medicine across centuries: first, do no harm.

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