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JMBR: A Peer-review Journal of Biomedical Sciences

June 2005 Vol. 4 No.1 pp-22-30

Obligation of non-maleficence: moral

dilemma in physician-patient relationship
Peter F Omonzejele

This paper highlights the principle of non-maleficence from sections of the Hippocratic
oath and those entailed in various declarations of medical ethics and conduct. The
moral dilemmas associated with adherence or efforts at adherence to the principle
were indicated with the use of prepared cases. The centrality of the paper is the moral
conflict encountered by physicians in their efforts at maintaining the fiduciary
relationship that they have with patients. The concepts of dignity, identity, harm and
the definitions of brain death as different from biological death, ordinary and
extraordinary health care and the principle of double effect were analysed in an attempt
to resolve the moral conflict in physician-patient relationship. Cost-benefit analysis,
detriment-benefit assessment and the notion of justice were also brought to bear in the
effort to resolve the moral dilemma in physician-patient relationship as it borders on
the obligation of non-maleficence.

INTRODUCTION kinds of relationships could be entered into

as a result of the demands of professions and
Relationships between two or more persons
duties, as is the case with the physician-
depict some sort of connection that is beyond
patient relationship.
mere exchange of pleasantries or show of
In the course of duty and relationship with
civility. Rather, it indicates some sort of
patients the physician must adhere to certain
intimacy that usually emanates from contact
principles of medical ethics (autonomy, non-
and communication. Relationships are freely
maleficence, beneficence and justice), rules
developed amongst individuals such as the
(fidelity, confidentiality, privacy and veracity)
cultivation of friendships and acquaintances,
and virtues (compassion, kindness, respect,
while other relationships are not as freely
etc). A physician may be sanctioned if he
cultivated. In contrast, they are determined,
breaches the principles and rules of medical
such as relationships between brothers and
ethics, but he may not necessarily be liable
sisters, cousins and relatives in general. Other
or compelled to uphold the virtues entailed
KEY WORDS: Hippocrate, justice, ethics, physician,
in his line of practice and duty. It is, however,
patient morally upright (but not obligatory) for a good
physician to be compassionate, kind and to
Correspondence: Peter F. Omonzejele, Department of show respect for his/her patients. Respect for
Philosophy, University of Benin, Benin City, Nigeria. patients and the wishes of patients are two
Tel: 2348043271636, 2348043271722; E-mail:
different issues that must not be confused.
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Obligation of non-maleficence: moral dilemma in physician-patient relationship 23
The principles and rules of medical ethics While the International Code of Medical Eth-
are derived from the Hippocratic oath and ics (English text) states that:
various declarations (Declaration of Geneva
A doctor must always bear in mind the
as amended in Sydney 1968, Declaration of
obligation of preserving life.
Tokyo 1975, Declaration of Oslo 1970,
Declaration of Helsinki 1975, etc) regulating In other words, the duty and obligations of
medical practice. Despite the Hippocratic oath physicians to their patients remain unequi-
and various declarations, a certain aspect vocally that of beneficence and non-maleficene.
(non-maleficence) of the oath and declaration The principle of non-maleficence revolves
is sometimes breached in what seems to be in around the concept of harm. Harm brings
the “interest” of patients in circumstances that about pain and pain brings about distress.
constitute moral dilemmas. Harm may be incidental, intended and
intrinsic. 1 According to Thomasma and
PRINCIPLE OF NON-MALEFICENCE Graber, incidental harm is brought about
The physician-patient relationship is through carelessness and negligence,
fiduciary. The patient believes and trusts that intended harm is calculated and inflicted pain,
the physician would apply his professional while intrinsic harm is such that harm is
expertise in his/her (the patient’s) interest and directly brought about. They explained further
benefit. Even more importantly, the patient that to kill a person deliberately has the
believes that his/her physicians (based on the intrinsic effect of harming (the patient), thus
principle of non-maleficence) would do it violates the negative duty not to harm.
nothing to harm him/her. The principle of Physicians’ obligation not to harm is reflected
non-maleficence runs through from the in various codes and declarations of medical
Hippocratic oath to current versions and ethics.
amendments of medical ethics. In the Non-maleficence in general, and medical
Hippocratic oath (in the translation preferred non-maleficence in particular, recommends
by the British Medical Association), the aspect that one ought not to inflict evil or harm. 2
that is instructive and serves as guide to Albert Jonsen in his work Do no Harm
physicians in respect of non-maleficemce itemised medical non-maleficence into four
states that: categories: physicians must (a) dedicate
themselves to the well-being (not harm) of
I will follow that system of regimen, which,
according to my ability and judgment, I patients; (b) provide adequate care; (c) properly
consider for the benefit of my patients, assess the situation, that is, risk/benefit
and abstain from whatever is deleterious analysis; and (d) make proper detriment-
and mischievous. I will give no deadly benefit assessments. 3 The physician’s
medicine to anyone if asked, nor suggest provision of ‘standard due care’ is central to
any such counsel. the avoidance of harm. According to the
American Law Reports, elements inherent in
In the declaration of Geneva, and as amended due care may be said to be violated and harm
in Sydney 1968, physicians were expected inflicted when and if the: (1) professional
and indeed mandated to: (physician) has a duty towards the affected
... maintain the utmost respect for human party (patient); (2) professional (physician)
life from the time of conception; even breached that duty; (3) the affected party
under threat, ... not [to] use medical (patient) must experience a harm; and (4) this
knowledge contrary to the laws of harm must be caused by the breach of duty. 4
humanity. Based on these elements, the obligation of
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24 Journal of Medicine and Biomedical Research
medical non-maleficence could be defined as 1. The action itself (independent of its con-
not imposing risks of harm as well as not sequences) must not be intrinsically
inflicting actual harm. 5 Veatch explains wrong (it must be morally good or at least
further that it is the responsibility and duty of morally neutral).
physicians (and based on the fiduciary 2. The agent must intend only the good effect
relationship between physician and patient) and not the bad effect. The bad effect can
to keep patients away from harm.6 Mason and be foreseen, tolerated and permitted but
McCall Smith also indicated, in line with must not be intended; it is therefore
Veatch, that based on their ability and allowed but not sought.
knowledge, physicians must not engage in 3. The bad effect must not be a means to the
medical procedures that may be harmful to end of bringing about good effect, that is,
their patients.7 This is because, and based on, the good effect must be achieved directly
the obligation of non-maleficence, the by the action and not by the way of the
responsibility of physicians is to maximise bad effect.
health and not to inflict harm. 4. The good result must outweigh the evil
In real life situations physicians do inflict permitted, that is, there must be propor-
harm on patients but generally for the purpose tionality or favourable balance between
of achieving some kind of good. According to the good and bad affects of the action.9
Beauchamp and Childress, a harm we inflict
such as a surgical wound may be negligible Beauchamp and Childress explained
or trivial yet necessary to prevent a major further that some ethicists currently
harm such as death. 8 emphasise some of these conditions while
Infliction of harm (that is, negligible harm) they downplay others. However, traditional
purposed at arresting harm for the purpose of moralists still require that all conditions
realising good does not constitute a moral should and must be met before double effect
dilemma. This is because negligible harm is treatments may be justified. It is important to
usually inflicted by physicians based on state that the conditions indicated for the
detriment-benefit analysis in favour of justification of double effect treatments have
patients. However, infliction of harm is not not eliminated the moral dilemma associated
always negligible. Sometimes, and increasingly with the principle, as it pertains to the
regularly, physicians inflict fatal harm with physician-patient relationship and the
the use of double effect medications in what obligation of non-maleficence.
seems to be in the patient’s interest as well as
to his/her benefit. The moral dilemma is this: MORAL DILEMMA
could the infliction of fatal harm that breaches In order to address the question raised, that
the obligation of non-maleficence ever be in is, if the infliction of fatal harm could ever be
the interest and benefit of patients? in the interest of the patient, it is appropriate
The principle of double effect attempts to and for proper comprehension to use prepared
differentiate intended and non-intended cases. This situates the moral dilemma with
effects of an action. The intended effect is good which physicians are faced in real life
and primary; however, associated with the circumstances.
intended effect is the necessary but bad and
unintended (secondary) effect. According to Case one
Beauchamp and Childress, the principle of Okeke suffered from advanced and terminal
double effect must satisfy certain conditions
skin cancer, which had resulted in extensive
for it to be morally justifiable, and these
destruction of his body. He was constantly in
conditions are:
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Obligation of non-maleficence: moral dilemma in physician-patient relationship 25
acute pain. If his physicians continued with dignity. Dignity is an integral part of all
the current and standard line of treatment, he humans that must be retained at any point of
would live for about a year and probably our existence, even at the moment of death.
more, but all the time he would be in acute However, it is argued on the other side of
and unrelenting pain. However, and to relieve the divide that physicians must at all times
Okeke of pain and suffering, his physicians adhere to the code of medical ethics not to
(based on Okeke’s consent) decided to give inflict harm, that is, the obligation of non-
doses of strong pain killers that had the maleficence. Based on Kant’s duty ethics, it is
unintended effect (principle of double effect) argued that what is good is good in itself, since
of shortening Okeke’s life span by about six good is without qualification.13 Perhaps, this
months. Harm inflicted on Okeke (though argument could be pursued further to state
unintended) seemed to contravene the that what is good (if it is really good and good
obligation of non-maleficence, which was in itself) cannot and is not capable of
indicated in the Hippocratic Oath (and other producing evil, except if the good was
amendments and declarations) that: “I will corrupted, in which case it was not really good
give no deadly medicine to anyone if asked, in the first instance. In other words, it is wrong
nor suggest any such counsels.” Herein lies to inflict harm (even if unintended) whatever
the moral dilemma associated with double the reason(s) for the primary and initial
effects medical treatments (such as Okeke’s). intension. This is because what is good is
The argument usually made in favour of unconditionally good, hence, action done
physicians when they help to relieve pain and from duty has its moral worth, not from the
suffering with double effect drugs that hasten results it attains or seeks to attain, but from a
death is that it is the physician’s obligation to formal principle of doing one’s duty whatever
alleviate pain and suffering. Patients (and that duty may be.14
indeed everyone) have the right not to suffer The duty and responsibility physicians
when it can be avoided. According to Cassell, owe to patients and society is to do well
it was the responsibility of physicians to (beneficence) and not to inflict harm
manage pain and suffering of terminally ill (maleficence). Ironically, Kantian ethics could
patients. 10 Liebeskind and Melzack posit also be used the other way round to support
further that by any reasonable code, freedom the principle of double effect (infliction of
from pain should be a basic human right, harm) if one focused on just duty or act and
limited only by our knowledge to achieve it.11 ignored the consequences in line with
Pellegrino indicates that relief of pain deontological ethical theories. This is because
should not generate much moral debate, (and according to Kant) our actions have
arguing that if a physician is unable to moral worth in themselves, in which case it
achieve cure he should at least be able to would seem that only physicians’ intended
relieve suffering.12 The inference is that it is actions should be morally evaluated in double
unfortunate, if in the physician’s efforts to effect treatments and the unintended
alleviate pain and suffering, some kind of consequence (e.g., hastened death) should be
harm (even if fatal and unintended) may be ignored as of no moral consequence or even
inflicted on patients. Physicians cannot, relevance.
therefore, be held morally responsible as their Christian moralists urged strict physicians
first line of duty to patients is to relieve pain to adhere to the obligation of non-maleficence
and suffering. Perhaps it should also be added based on their perception of freedom.
that double effect treatments (as in the case of According to this perception, man does not
Okeke) do not just relieve pain but also enable have the freedom to decide when to return back
patients die (even if death was hastened) in to his creator, as no one (neither physician
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26 Journal of Medicine and Biomedical Research
nor patient) ought to play God.15 Hence, it was requested that his physicians withdraw the
morally wrong for any human to decide to feeding tubes and other life support equipment
embrace death, or for anyone to assist so that he could be given a befitting burial in
someone else in embracing death when God line with African burial rites. These very
has not occasioned or determined it. They important rites cannot be undertaken while
therefore argued in addition that human life he remains on life support. After the
is sacred and must not be terminated, that physicians reviewed Bode’s case, they obliged
pain and suffering are not enough reasons for the request of his family members and
anyone to play the role of the creator.16 Based withdrew the life support equipment and he
on Christian theology, meaning could be died quietly. The moral question is: Did Bode’s
derived from pain and suffering, as suffering physicians breach the obligation of non-
gives man the opportunity to participate in the maleficence? Surrogate decision-making, as
suffering of Christ. 17 However, eastern was the case in Bode’s situation, or advance
theological perspectives (Buddhism, Confu- directives such as a living will, if Bode had
cianism, Hinduism, etc) are not in agreement made his decision known while he was
with the views expressed by most Christian healthy, do not change the moral question
moralists. They support and encourage inherent in withholding and withdrawing life
physicians to relieve pain and suffering by support fluids and equipment from PVS
whatever means, even if such medications patients.
have the unintended effect of hastening death. What is crucial in responding to any
In most traditional African religions, pain and alleged breach of the obligation of non-
suffering are to be stoically endured to the maleficence (as in Bode’s case) should start
very end. This may be connected with the from the concept of personhood in relation to
strong belief in reincarnation, ancestral PVS patients. Persons have certain values,
worships and second burial rites. Anyone who rights and privileges by the very nature of their
hastens his/her death, or gives consent for his/ personhood. These values, rights and
her death to be hastened, is not entitled to privileges are not usually associated with
second burial rites and would consequently non-human beings such as animals. Hence,
not be allowed into the ancestral realm. in analysing the concept of person, Edge and
Grooves asked, “What types of beings can be
Case two thought of as humans.”18 In response, Fletcher
Bode, a 50-year-old truck driver, was involved and Feinberg provided an answer as to what
in a near fatal accident, and although Bode they thought were the criteria that qualify a
survived, his brain artery was ruptured. Bode person as a bearer of rights, which are:
was taken to a teaching hospital where he (a) Possession of certain beliefs, values and
underwent unsuccessful surgery. He intuitive awareness.
eventually slipped into coma and persistent (b) One for whom something could be in his/
vegetative state (PVS). Bode’s family members her interest.
consented to gastronomy for him. PVS (c) Possession of the concept of time, that is,
patients could survive on life support of past, present and future.
equipment for many years without hope of (d) Ability for social interactions with
regaining consciousness. After a few days, others. 19 20
Bode’s family members thought it was
senseless for their loved one to remain in this In other words, when these vital criteria
state. According to one of his family members, are no longer present in humans, they do not
he was neither alive nor dead. Hence, they have rights and privileges usually associated
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Obligation of non-maleficence: moral dilemma in physician-patient relationship 27
with persons; in which case physicians may be made available. According to Pope Pius XII,
not be considered to have breached the obli- life may be prolonged with the use of ordi-
gation of non-maleficence when they either nary care, subject to the circumstances of per-
withhold or withdraw life support from PVS sons, places, time and culture. He explained
patients. However, it is not in dispute or in further that ordinary health care should not
contention that the physician has inflicted constitute grave burden to self or another.
harm, whether compassionate or unintended While extraordinary health care, which may
harms. It contravenes the International Code involve intravenous fluids, nasogastric
of Medical Ethics, which states that “... a feedings, etc, for PVS patients may be regarded
physician must always bear in mind the as optional, ordinary care may be regarded as
obligation of preserving human life.” Moral obligatory. It would seem that extraordinary
dilemma once again surfaces in physician- care begins where ordinary care has become
patient relationship. useless and of no benefit. It seems, however,
Efforts at resolving the moral dilemma in that the demarcation of ordinary care from
withholding and withdrawing life support for extraordinary does not really resolve the
PVS patients may be found in the definition moral dilemma inherent in the physician’s
of death. Death may be defined from two obligation of non-maleficence in physician-
perspectives: brain stem death and biological patient relationship, as what constitutes
death. Brain death may be defined as a extraordinary care still remains unclear. For
condition of unreceptivity and unrespon- instance, what may constitute extraordinary
siveness, no movement or breathing, no care in developing countries may be regarded
reflexes and flat EEG of confirmatory value.21 as ordinary care in developed countries.
However, brain dead patients could be
sustained on life support equipment, such as Case three
a ventilator, feeding tubes, IV fluids, for years. Omole, seven days old, with extensive
In which case biological organs remain physical deformities coupled with severe
functional in so far as life supports remain in mental retardation and other health
place and not withdrawn, but the patient complications was born to Mr. and Mrs.
would never regain consciousness. The Kimba. The couple had no formal education
moment artificial life support equipment is and were casual factory workers who earned
removed the patient dies biologically. In other about N20,000 a month (about US$150) with
words, biological death is when bodily organs which they sustained themselves and their
cease to function. It means one could lose three children (besides Omole) aged five,
intuitive awareness in its entirety (brain seven and nine years. According to Omole’s
death) and yet retain some sort of existence physicians, if he was kept on special diet and
that could be sustained artificially. It is the given monitored health care, all the while he
inability to definitely resolve the concept of must remain in hospital, he would probably
death that gears some physicians to resort to have lived to his fifth birthday but not more.
extraordinary care while others do not and the The Kimbas would be required to pay about
moral dilemma remains. What is to be done? N15,000 a month (about US$115) for Omole’s
To resolve the question, it is mandatory upkeep and health care (Nigeria and indeed
for one to demarcate where ordinary care ends most African countries have no national
and when extraordinary care begins. Perhaps health insurance schemes). If Omole must live
this would assist physicians to arrive at to see his 5th birthday, the options open to
decisions regarding withholding and with- the Kimbas are: (a) sustain Omole in hospital,
drawing life support. Loosely defined, ordi- in which case their other children must have
nary health care has to be beneficial and must
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28 Journal of Medicine and Biomedical Research
to drop out of school, move to a one-bedroom be in danger from malnutrition. The physicians
apartment and considerably reduce the qual- may even stretch their arguments further, that
ity and quantity of their diet; (b) request that it is morally wrong for Omole’s siblings to bear
the physicians allow Omole to die since (i) the consequences of their parents’ decision
Omole could never really live a normal life, to prolong Omole’s life, and if anyone must
and (ii) his brief existence would only bring bear the consequences it should be the couple
more grief and distress for everyone, that is, alone and not their children (Omole’s
to himself and family members. The Kimbas siblings). Their children’s interests should not
decided to take option B, which they be undermined if they decided to bear the
communicated to Omole’s physicians. The consequences of prolonging Omole’s life, and
physicians consented to his parents’ request, since it seemed that nothing could be done
medication was discontinued and Omole died without undermining the interests of Omole’s
two days later. Could Omole’s physicians be siblings, then Omole should be allowed to die
said to have breached the obligation of non- in order to protect the interests of the other
maleficence? children. Consequently, the physicians may
Attempts to make a moral judgment of the have concluded that they acted justly and
physicians’ role in Omole’s death should take morally under the circumstances. However,
into account the concept of justice based on it is not in doubt that Omole’s physicians
utilitarian and Kantian ethics. From a Kantian inflicted harm, even if on compassionate
perspective, an action is morally evaluated to grounds, hence, the moral dilemma remains.
be just if approval of that action could be
universalised for everyone. 22 While utilitar- CONCLUSION
ian ethics focuses on the greatest happiness Efforts at resolving the moral conflict or
for the greatest number in evaluating moral dilemma associated with PVS patients must
and just actions, the idea of justice in tradi- be accompanied with conscious efforts at
tional, and to a great extent contemporary, resolving the lacuna that exist between brain
Africa is essentially interpersonal and social death and biological death. Without bridging
with a basis in human welfare. 23 In the light this lacuna, the moral dilemma associated
of these definitions, was Omole justly treated? with withholding and withdrawing artificial
Omole’s physicians may have acquiesced to life support for PVS patients would always
Omole’s parents because it was the just thing
remain contentious as far as the physician’s
to do based on utilitarian ethics, which pro-
obligation of non-maleficence remains total
motes the interest of the majority over that of
and binding on all physicians under all
the minority; in this case, the welfare of
circumstances, that he shall respect human
Omole’s parents and siblings over Omole’s
life and studiously avoid doing it harm. 24
Perhaps it should be added that even if the
The physicians’ position and judgment
developed world with functional and viable
may be further strengthened based on the low
health insurance schemes could afford almost
quality of Omole’s life. Again, in line with
classical utilitarianism, they may have indefinitely to sustain PVS patients on life
evaluated that it would be morally wrong for support, it would be morally wrong for
the Kimbas to sustain Omole’s interest (an physicians in developing countries, where
individual who would with luck on his side health resources are scarce, to embark on ex-
probably live to see his fifth birthday) over traordinary healthcare, when the same
those of five persons. This is because, for resources could be more beneficially used for
Omole’s sake, his siblings would not only ordinary care in line with cost-benefit
have to drop out of school; their lives may also analysis. This means that physicians in
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Obligation of non-maleficence: moral dilemma in physician-patient relationship 29
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