Nonmaleficence

“First do no harm” is likely one of the most well-recognized ethical mandates in medicine. In its basic application to pain care, this mandate translates to considering treatment choices which have the highest potential to benefit the patient and avoiding risk of potential harm. Sometimes, completely avoiding risk is a luxury that many medical treatment options do not often provide. Virtually every medical intervention carries some level of risk, including risk of adverse consequences or “side effects.” This fact underscores the importance of the informed consent process, which as mentioned in other chapters, is the process of ensuring that patients understand the risks and benefits of any suggested treatment option. The management of pain with opioid analgesics illustrates the need to mutually determine if they are an appropriate treatment option that has the potential to be the safest and most effective for the individual, employing the ethical principle of nonmaleficence. This chapter explores how the ethical principle of nonmaleficence plays a vital role in pain management, not only in avoiding potential risk of harm to the patient, but uniquely also to avoid potential risk to other members of the household, the community, and to society. The risks of nonadherence to a pain treatment plan that includes opioid analgesics are discussed, along with potential harms associated with forced tapering and discontinuation of opioids due to fear of regulatory scrutiny. Additionally, this chapter details risks associated with non-opioid pain treatment options, including nonsteroidal anti-inflammatory drugs and acetaminophen, which are frequently recommended by regulators as safer, alternative pharmacologic treatment options due to concerns associated with opioids including aberrant drug-related behaviors and addiction.