Beneficence vs. Nonmaleficence in Clinical Ethics: Examples

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Beneficence is the active obligation to do good on behalf of the patient by promoting their welfare and improving their health, while nonmaleficence is the duty to do no harm by refraining from harmful actions and protecting patients from preventable risk. Together with respect for autonomy and justice, they form the 4 foundational principles of Western medical ethics described in the AMA Journal of Ethics (the American Dental Association adds veracity as a 5th principle). In clinical practice, failing to act or educate a patient is an error of omission that violates both principles, even when no procedure is performed. Sources: AMA Journal of Ethics: Health Coaching (April 2013), AMA Journal of Ethics: Nonmaleficence in Sports Medicine (July 2014), AMA Journal of Ethics: Risk Management Ethics and Safe Discharge (November 2020). Last checked November 3, 2026.

Beneficence vs. nonmaleficence: side-by-side comparison

Both principles put the patient's well-being first, but they pull your clinical thinking in different directions. Beneficence asks what positive step you can take to help the person in front of you. Nonmaleficence sets the safety boundary you cannot cross, even when a patient asks you to cross it.

To practice answering ethical dilemmas out loud under a timer, Confetto runs AI mock interviews for medical, dental, nursing, PA, pharmacy, and residency interviews and gives rubric-based feedback on your reasoning. Start your free week.

Here is how the American Medical Association (AMA) and the American Dental Association (ADA) separate the two duties across everyday clinical decisions.

Beneficence vs. nonmaleficence in clinical ethics
Dimension	Beneficence	Nonmaleficence
Core meaning	Do good: act for the benefit of others and promote patient welfare	Do no harm: refrain from harming the patient and protect them from harm
Nature of the duty	Active promotion of health, timely care, and disease prevention	Restraint from unsafe actions and active protection against preventable risk
How clinicians fail	Failing to provide competent, timely care or failing to help patients understand and apply evidence	Errors of commission (active mistakes) and errors of omission (failing to educate on or prevent risk)
Relation to patient autonomy	Overriding a competent patient's wishes to do good for them is paternalism	Trumps autonomy when a competent adult requests an action that will directly harm them
Day-to-day obligations (ADA and AMA)	Timely evidence-based care, health coaching, preventive care, community service, and reporting abuse or neglect	Keeping skills current, knowing limitations, referring to specialists, supervising auxiliaries, never practicing impaired, and never abandoning patients
Public health scope	Serving the public at large, promoting community health, and sharing research benefits	Postponing elective procedures during a public health emergency when elevated risk to the patient or public cannot be mitigated

What is beneficence in clinical ethics?

Beneficence is the obligation of healthcare professionals to act for the benefit of others and do everything possible to improve people's health. In Section 3 of the ADA Principles of Ethics and Code of Professional Conduct, the most important part of beneficence is the competent and timely delivery of care within the bounds of the clinical circumstances, while giving due consideration to the patient's needs, desires, and values.

That duty stays the same whether a clinician works in a fee-for-service practice, a managed care group, or a hospital contract. Contract rules never excuse a clinician from putting the patient's welfare first.

In medicine, beneficence is often equated with evidence-based care, but writing an evidence-based prescription is only half the job. A 2013 analysis in the AMA Journal of Ethics breaks evidence-based medicine into 5 steps: research uncovers the evidence, clinicians learn it, clinicians use it to build a care plan, clinicians make sure the patient understands the evidence, and clinicians do everything possible to encourage the patient to bring that evidence into daily life.

When steps 4 and 5 are skipped during a rushed 15-minute primary care visit, beneficence fails on a population scale. That 2013 AMA Journal of Ethics paper reported that 50% of patients in the United States with hypertension, 43% of people with diabetes, and 80% of people with hyperlipidemia had not reached the clinical goals set by national practice guidelines. In cited studies from the same article, 3 of 4 physicians failed to give clear instructions on how to take prescribed medications, 50% of patients did not understand how their medication was prescribed, and patients asked to restate their physician's instructions got them wrong 47% of the time.

Closing that gap is a direct act of beneficence. Using the teachback method (asking a patient to state in their own words how they will take their medication tomorrow), teaching diabetic patients their ABC numbers and goals (such as an A1c of 7, blood pressure of 130/80, and LDL cholesterol of 100), and setting collaborative action plans all turn abstract clinical knowledge into actual patient benefit. In an intervention study cited in that 2013 paper, patients encouraged to participate actively in their clinical visits reduced their average hemoglobin A1c from 10.6% to 9.1%, while the control group's average A1c rose from 10.3% to 10.6%.

Relieving pain and suffering: AMA Opinion 5.6 states that a duty to relieve pain and suffering is central to the physician's role as healer and is an obligation physicians have to their patients.
Safe discharge planning: AMA Opinion 1.1.8 states that promoting the well-being of individual patients includes collaborating on a safe discharge plan without regard to socioeconomic status, immigration status, or other clinically irrelevant factors.
Preventive care and community health: AMA Opinion 8.11 commits physicians to preventing disease, educating patients on modifiable risk factors, recommending vaccinations and screenings, and asking openly about transportation, work, and home barriers.
Identifying abuse and neglect: Under ADA Code Section 3.E, beneficence obligates clinicians to know the signs of abuse and neglect and report suspected cases to the proper authorities consistent with state laws.
Workplace culture: Under ADA Advisory Opinion 3.F.1, maintaining a respectful, collaborative workplace is part of beneficence because disruptive behavior undermines team relationships and lowers the quality of patient care.

What is nonmaleficence in clinical ethics?

Nonmaleficence is the duty to refrain from harming the patient and to protect the patient from harm. If beneficence is the engine of clinical care, nonmaleficence is the guardrail.

Applicants in healthcare interviews often talk about nonmaleficence as if it only applies to botched surgeries or wrong-drug mistakes. The AMA Journal of Ethics points out that clinical harm comes from two sources: errors of commission and errors of omission.

An error of commission is an active step that causes injury, such as prescribing a contraindicated drug or performing an unnecessary procedure. An error of omission happens when a clinician fails to act, such as failing to make maximal efforts to ensure a patient understands the risks of uncontrolled blood sugar, blood pressure, and cholesterol and how to lower those risks. Leaving a patient in the dark about preventable cardiovascular complications violates nonmaleficence even if you never lay a hand on them.

Section 2 of the ADA Code of Professional Conduct translates nonmaleficence into concrete professional rules that apply across clinical settings.

Keeping knowledge and skills current (Section 2.A): Because professional status rests on knowledge, skill, and experience, letting your clinical training go out of date puts patients at risk and violates nonmaleficence.
Consultation and referral (Section 2.B): You must know your own limitations and refer to a specialist whenever a patient's welfare will be safeguarded or advanced by someone with special skills, knowledge, or equipment. Upon finishing care, the specialist must return the patient to the referring clinician unless the patient chooses otherwise.
Supervising auxiliary staff (Section 2.C): You may assign only duties that can be legally delegated to qualified auxiliaries, and you must prescribe and supervise the care they provide.
Never practicing while impaired (Section 2.D): Practicing while abusing controlled substances, alcohol, or chemical agents that impair ability is unethical. Clinicians with first-hand knowledge that a colleague is practicing while impaired have an ethical duty to report that evidence to the professional assistance committee of their society.
Bloodborne pathogen postexposure duty (Section 2.E): If a patient is exposed to blood or potentially infectious material in the office, the clinician must immediately inform the patient of the need for postexposure evaluation, refer them to a qualified practitioner, and provide the source individual's pathogen status and testing.
No patient abandonment (Section 2.F): Once you start a course of treatment, you cannot discontinue it without giving the patient adequate notice and the opportunity to find another clinician, making sure their health is not jeopardized in the transition.

When beneficence and nonmaleficence collide with autonomy

Ethical principles are straightforward when they point to the same action. When you give the right antibiotic for an infection, beneficence, nonmaleficence, and autonomy all agree. Interviews test what you do when those principles pull apart.

Autonomy is the right of an adult of sound mind to make decisions about their own body and accept or refuse any recommended medical intervention, per AMA Opinion 1.1.3. Even when a refusal is expected to lead to death, AMA Opinion 5.3 states that a patient with decision-making capacity has the right to decline or stop life-sustaining treatment, and there is no ethical difference between withholding and withdrawing a treatment.

When a clinician decides that beneficence outweighs a competent patient's autonomy, making decisions on the patient's behalf to further their best interests, the AMA Journal of Ethics defines that as paternalism. In modern clinical ethics, overriding a competent adult's informed refusal out of paternalism is generally not accepted. Instead, clinicians honor autonomy while using shared decision-making and ask-tell-ask communication to make sure the patient actually understands their options.

The rule flips when a competent patient demands an intervention or medical clearance that will actively harm them. As a 2014 sports medicine analysis in the AMA Journal of Ethics explains, nonmaleficence trumps respect for autonomy. Harming a patient is not permissible simply because the patient is of sound mind and asks you to do it. A patient has the negative right to refuse care, not a positive right to compel a clinician to inflict harm or sign a dishonest medical clearance.

Concrete clinical examples across medicine, dentistry, nursing, and veterinary ethics

When an interviewer asks you to compare beneficence and nonmaleficence, naming a real clinical scenario beats reciting definitions. These cases come directly from the AMA Journal of Ethics, the ADA Code of Ethics, and the American Nurses Association (ANA) frameworks, along with a veterinary ethics application.

Sports medicine clearance (nonmaleficence vs. autonomy): In a 2014 AMA Journal of Ethics case, 18-year-old soccer player Alison tears her ACL before a national championship that could affect her college scholarships. She is a legal adult of sound mind and asks Dr. Robles to sign a school clearance note stating that Alison accepts all liability. Dr. Robles refuses. Playing a cutting and pivoting sport with an ACL-deficient knee risks irreversible damage to the articular cartilage and menisci. Nonmaleficence forbids the physician from clearing her for harm, and truthfulness forbids writing a misleading note.
High-risk hospital discharge (beneficence, safety, and autonomy): In a 2020 AMA Journal of Ethics case, a 32-year-old man with end-stage multiple sclerosis is weaned from a ventilator after 80 days in the ICU. Regaining decision-making capacity, he refuses further machines and asks to go home alone. His mother and sister agree to limit life-sustaining orders, his father threatens to sue if he is not resuscitated, and the hospital risk manager says going home alone is unsafe and recommends a skilled nursing facility. Under AMA Opinion 1.1.8, the physician must resist discharge requests likely to compromise patient safety while discussing the patient's goals and values under Opinion 5.1. If disagreement persists over the risks and benefits of the discharge plan, the physician should consult the hospital ethics committee.
Palliative surgery in late-stage illness (balancing benefit and harm): According to a 2021 AMA Journal of Ethics article, roughly 12.5% of all surgeries are palliative, aimed at relieving physical, emotional, psychological, or spiritual suffering in symptomatic patients rather than curing disease. Palliative surgery carries the risk of death, especially in late-stage cancer. Clinicians balance beneficence (Opinion 5.6 on relieving pain and suffering) with nonmaleficence by clarifying goals of care under Opinion 5.5, involving the patient's surrogate early, and consulting a multidisciplinary palliative team. A 2018 study cited in that article found that 76.1% of colorectal surgeons had received no formal training in palliative care, showing why active consultation matters.
Elective dental care in a public health emergency (public beneficence vs. individual wishes): Under the ADA Code of Ethics Advisory Opinion on Elective and Non-Emergent Procedures During a Public Health Emergency, a dentist's ethical duty to protect the public during a communicable disease crisis can supersede duties to an individual patient. If a patient asks for an elective procedure during a public health emergency, the dentist must weigh the elevated risk to the patient and the public and postpone the procedure if the risk cannot be mitigated. If the patient has an urgent infection or risks losing tooth structure and function, balancing those duties may justify treating them.
Amalgam removal requests (nonmaleficence and veracity): Under ADA Advisory Opinion 5.A.1, removing amalgam restorations from a non-allergic patient solely at the dentist's recommendation to allegedly remove toxic substances from the body is improper and unethical. Doing so subjects the patient to unnecessary dental work without scientific basis, violating both veracity and nonmaleficence.
Nursing advocacy and the 6-step nursing process (ANA Code of Ethics): In the 2025 ANA Code of Ethics for Nurses, Provision 3 establishes the nurse's duty to build trust and advocate for the rights, health, and safety of care recipients (protecting from harm), while Provision 4 holds nurses accountable for promoting health, preventing illness, and providing optimal care (doing good). Registered nurses carry out both duties through the 6-step nursing process defined in the ANA Scope of Practice: assessment, diagnosis or problem identification, goals and outcomes identification, planning, implementation, and evaluation.
Veterinary ethics interviews (balancing animal welfare and client constraints): In veterinary MMI scenarios, you can apply the same distinction between doing good and avoiding harm when a client requests convenience euthanasia of a healthy animal or declines a costly surgery. Nonmaleficence supports declining to harm a healthy animal simply because an owner requests it, while beneficence calls for relieving pain and offering practical treatment or rehoming alternatives that protect the animal's welfare within the owner's financial limits.

A 5-step checklist for ethics interview stations (our framework)

This checklist is our team's step-by-step plan for answering MMI and traditional interview questions where beneficence, nonmaleficence, and autonomy clash. Use it to structure your thinking during your reading time before a station starts, and see our guide to MMI practice questions with answers for more station examples.

Step 1: Name the exact conflict in your first two sentences. State what clinical benefit you want to achieve (beneficence), what specific harm you are trying to prevent (nonmaleficence), and how those interact with what the patient is asking for (autonomy).
Step 2: Check capacity and understanding before judging the patient's choice. Ask whether the adult patient has decision-making capacity right now and whether the team has committed an error of omission by failing to explain the risks in plain language. Use teachback to verify understanding.
Step 3: Draw the line between refusing treatment and demanding harm. Remember the AMA rule: a competent adult has the right to refuse any medical intervention (even life-sustaining care), but a patient cannot compel you to perform a harmful procedure, prescribe an unsafe drug, or falsify a medical clearance.
Step 4: Look for a collaborative middle option that lowers risk. Before declaring a deadlock, ask what barriers are driving the patient's request (cost, fear, transportation, home support) and bring in team members such as health coaches, palliative specialists, or social workers.
Step 5: Escalate to institutional resources when disagreement persists. If the patient, family, and care team still disagree on whether a treatment or discharge plan is safe, state clearly that you would consult the hospital ethics committee (per AMA Opinions 1.1.8 and 10.7).

How the AMA, ADA, and ANA codes frame these duties

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If you are interviewing at a medical, dental, or nursing program, knowing how your specific profession's code is organized helps you use accurate language.

The AMA Principles of Medical Ethics open with dedication to competent, compassionate care (Principle I), state that a physician must regard responsibility to the patient as paramount while caring for them (Principle VIII), and conclude with supporting access to medical care for all people (Principle IX). The AMA Council on Ethical and Judicial Affairs interprets these principles through numbered Ethics Opinions.

The ADA Code of Ethics is built around 5 fundamental principles: Patient Autonomy (Section 1), Nonmaleficence (Section 2), Beneficence (Section 3), Justice (Section 4), and Veracity (Section 5). The ADA notes that these principles can overlap and compete for priority, and that ethical obligations often exceed legal duties.

The 2025 ANA Code of Ethics for Nurses organizes nursing ethics into 10 Provisions across nurse-to-patient, nurse-to-colleague, and nurse-to-society relationships. Alongside patient advocacy (Provision 3) and optimal care (Provision 4), Provision 5 establishes that nurses have moral duties to themselves, including an expectation of a safe workplace.

Ready to test how you apply these principles under time pressure? Confetto gives you realistic MMI and traditional ethics scenarios with instant rubric feedback and follow-up questions. Start your free week.

Practice question

An 18-year-old high school soccer player comes to your clinic with a newly torn ACL two days before a national championship game. College scouts will be watching. She is a legal adult of sound mind and asks you to sign the school's medical clearance form, offering to sign a waiver taking full responsibility for any knee damage. How do you respond?

See an example answer

Example answer written by our team. The applicant is invented. I would sit down with her, acknowledge how much she has worked for this championship and the college scholarships tied to it, and tell her clearly that I cannot sign the clearance form. This scenario is a direct clash between patient autonomy and nonmaleficence. Even though she is 18, of sound mind, and willing to accept the risk, playing a cutting and pivoting sport like soccer on a torn ACL carries a high risk of irreversible damage to her meniscus and articular cartilage. In clinical ethics, nonmaleficence overrides autonomy when a patient asks a clinician to cause direct harm, and truthfulness prevents me from signing a medical note that says she is safe to play when she is not. Before she leaves, I would make sure I do not commit an error of omission. I would explain in plain terms what early osteoarthritis and cartilage loss would mean for her ability to play in college, and I would ask her to explain those risks back to me. Then I would offer a concrete way to help her (beneficence): with her permission, I would help her talk with her coach and family about surgical repair and rehabilitation timelines, or provide medical documentation of her injury she can share with college scouts so they know her absence is due to an acute, treatable injury.

It commits to a clear decision in the first sentence, names the exact ethical rule from the AMA Journal of Ethics (nonmaleficence and truthfulness override autonomy when a patient asks for a harmful medical clearance), avoids an error of omission by using teachback, and offers a practical beneficent next step for the athlete's college prospects.

Frequently asked questions

What is the main difference between beneficence and nonmaleficence?

Beneficence is the positive obligation to do good on behalf of the patient by actively promoting their welfare and improving their health. Nonmaleficence is the obligation to do no harm by refraining from actions that injure the patient and protecting them from preventable risks.

What are the 4 pillars of medical ethics, and how does dentistry differ?

In Western medical ethics, the 4 foundational principles are beneficence, nonmaleficence, respect for autonomy, and justice, as outlined in the AMA Journal of Ethics. The American Dental Association (ADA) Code of Ethics uses 5 fundamental principles by adding veracity (truthfulness) as its fifth pillar.

Can a clinician violate nonmaleficence without performing a procedure?

Yes. According to the AMA Journal of Ethics, harm comes from both errors of commission (active mistakes) and errors of omission, such as failing to make maximal efforts to ensure patients understand the risks of uncontrolled blood sugar, blood pressure, or cholesterol and how to minimize them.

What is paternalism in clinical ethics?

Paternalism occurs when a clinician decides that beneficence outweighs respect for a competent patient's autonomy and makes decisions on the patient's behalf to further their best interests. Modern clinical ethics prefers shared decision-making, which honors autonomy while improving adherence and outcomes.

Does patient autonomy ever lose to nonmaleficence?

Yes. While a competent adult has the right to refuse any medical intervention under AMA Opinion 1.1.3, nonmaleficence trumps autonomy when a patient requests an action or clearance that will actively harm them, such as clearing an athlete to play on a torn ACL or amputating a healthy limb.

What should a physician do when a patient and family disagree on a safe discharge plan?

Under AMA Code of Medical Ethics Opinion 1.1.8, physicians must resist discharge requests that are likely to compromise patient safety and collaborate on a plan that considers the patient's needs and preferences. If disagreement over the risks and benefits of a treatment or discharge plan persists, the physician should consult the hospital ethics committee.