Beneficence Nonmaleficence Whose Needs Come First

When the counselee is trying to balance the benefits and harms of a particular decision against one another, there may be a tendency to emphasize the benefits over the harms. In some cases, the benefit or beneficence for the counselee(s) may mean maleficence or harm for the child. If parents who know they will have a child with a serious genetically determined disease decide to go ahead because they believe they have a "right to bear children," they may benefit in having their own biological children. At the same time they might not be judged "responsible parents" because they may not have given serious enough consideration to the suffering and discomfort their offspring will suffer. Even if this factor has been considered, the parents may justify their decision on the religious grounds that they are merely following the dictates of a higher power, leaving it to God to determine whether or not they have children.

In some cases it may be difficult for counselor and counselee to agree on what constitutes a benefit and what a harm, since such determinations are often rather subjective, governed primarily by the counselee's values. For example, abortion of an affected fetus might be considered a benefit to some and harmful to others, depending on whose needs are considered primary. Providing information that there is a high probability that a counselee at risk to inherit a serious genetically determined disease of late onset has in fact inherited it might seem a beneficent act by some who value knowledge of any sort, and a maleficent or harmful act by others who value information only when it leads to the prevention or correction of harm. In the tension between these contrasting ethical principles, medical ethical tradition suggests that nonmaleficence should be weighted more heavily than beneficence in cases where they are in conflict. This position is consistent with the maxim ofprimum non nocere, first do no harm (Beauchamp and Childress), since providing information without clear benefit has the potential for causing social and emotional harm.

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