First, Do No Harm

By Darcy Cowan 21/03/2012

Primum non nocere

A while ago I was accused of advocating that doctors should break the Hippocratic oath. That the cardinal rule of “First, do no harm” should be ignored. Setting aside that this phrase does not appear in the Hippocratic oath, what do we mean by harm in the context of medicine?

I was reminded of this by a post on Science Based Medicine by David Gorski in which he muses over the measure of patient satisfaction as a proxy for how well hospitals meet their obligations with regard to patient care. To kick it off the good doctor notes that many interventions used by modern medicine cause harm, often direct harm.

Does this mean that doctors are throwing out their obligation not to harm patients? No, because we recognise that the concept of harm in this case includes those harms that would occur were we to withhold treatment as well as recognising that the total harm is reliant on the amount of benefit obtained by the patient.

The accusation against me was in the context of my arguing against the claims of anti-vaccinationists that vaccines do more harm than good. I don’t want to rehash that argument here but I do want to dwell a bit on our concept of harm and how it applies in the medical arena.

One of the themes that return to over and over again on this blog is that of risk vs benefit. The amount of harm or risk can only be appropriately assessed in light of the benefit accrued. As pointed out by doctor Gorski there are many procedures that hurt, they hurt a lot. Should a doctor refuse to perform them then? Even if they could save a patient’s life?

Of course not.

It is plainly ridiculous to assert that short term harm out weighs long term benefit, it might but that calculation has to be made in each case. In many cases the benefit will be clear, in others less so. If a patient undergoes a painful procedure that is relatively short lived and then makes a full recovery then the choice is fairly simple. If the recovery is likely to be only partial and the patient’s quality of life is ever after severely reduced then we may weigh up the benefits of that treatment differently.

What then of treatments that are good for most but may harm a few? These are the tricky cases and it depends on a few variables. One is can we identify the persons that will be harmed,  second, how much harm are they likely to suffer and what percentage of the treatment population do they make up? Finally what total benefit will accrue to the population if treatment is green lit?

I listed these variables in the order of importance I estimate they have. If we can identify prospectively harmed persons then they may be removed from the treatment group, harm avoided. If this information is unavailable then we may move to the next criterion: how much harm will they suffer? If this is likely to be relatively mild then all to the good. If the harm is considerably more serious then we may stop the treatment altogether in order to avoid these instances. The last two variables may switch in order depending on the situation or individual values.

Should a vital treatment be withheld from the general population if a very small percentage with be greatly harmed by it? Frankly I don’t know. Help – is there a Medical Ethicist in the house?

Often I’ll find that the people who oppose modern medicine will emphasise the risks of medicine while over-hyping the benefits of alternative medicine. The claims that iatrogenic (caused by medical treatment) harms are enormous abound. This point of view seems completely ignore the benefits received by individuals and society by medicine in it’s current form*.

This seems perverse to me, the idea appears to be that any risk is unacceptable – a completely untenable position to my mind – every action carries risk. I take my life in my hands every time I drive to work, but the risks a relatively low and the benefits are more important to me – and the majority of other drivers I suspect. To argue that we should abstain from automotive transport until it is completely safe misses the point entirely. As does decrying the risks of the majority of medical science in the face of the undoubted benefit received.

To conclude this ramble, harm or risk is part of the human condition. Arguably the complete removal of risk is not only impossible but not even desirable**. We have to live with risk and harm, the key is to ensure we balance these against the good that comes from acting in the world to oppose even greater harms.


*This is quite an extreme view and I would hasten to add that I don’t think the majority of alternative medicine users (however you may break that group down) would subscribe to it, but it exists.

** Depending on how this might be achieved. Possibly we could make ourselves impervious to harm rather than removing everything that might harm us.

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Filed under: Alternative medicine, Medicine, Psychological, Sciblogs, skepticism Tagged: Alternative medicine, David Gorski, harm, Health and Medicine, Primum non nocere, Risk

0 Responses to “First, Do No Harm”

  • I agree that many times medicine does harm in order to do good. I thought it may help discussion to give a few examples:

    1. A person with a ruptured aortic aneurysm. Treatment is by replacement of the leaking aorta with an artificial graft. The surgery is extensive and takes many months to recover fully, and often there is some long term disability after recovery. Death rate during surgery can be up to 50%, depending on the patient, surgeon and institution. Death rate without surgery is 100%. The medical team and patient have to balance the risk of death or long term disability from the surgery against the certainty of death without surgery.

    2. A person with ischaemic heart disease. One of the most effective interventions is low dose aspirin therapy, which has been repeatedly proven to reduce the incidence of future heart attacks. Unfortunately, there is also a long term risk (less than 1%) of major gastro-intestinal bleeding from the aspirin, even to the point of death. Again, the risk of harm is balanced against the proven benefit of the medication.

    3. Vaccination. There is almost always some pain (“harm”) from the injection of a vaccine. The benefit is that the person is then unlikely to get the illness that the vaccine is designed to prevent. The risk of drowning whilst swimming, or death whilst driving between adjacent towns, is higher than the risk of major side effects from the vaccination. Medicine balances the short term discomfort from an injection against the long term benefits of prevention of specific diseases or illnesses.

    No-one says that medical intervention does not cause harm; part of the art of medicine is the balancing of immediate minor harm or even potential long term harm against long term benefits to an individual. In the case of public health medicine the benefits are to the community as a whole, and of course the community is composed of many individuals.

    Even if a person shuns medicine completely and decides to visit a homeopath they are accepting the risk that they will die in a traffic accident during travel to and from the homeopath. Allowing chiropractic manipulation of the neck means that the person has accepted the risk of vertebral artery stroke inherant with the technique.

    All I can do is repeat that nothing we do is without risk. Even sitting and doing nothing has its risks; deep venous thrombosis, lightning strike, earthquake injury for example.

    Once we have minimised risks of an activity then we have to balance the benefit of performing the activity against the risks inherant with the activity. Medicine is no different than any other activity in life in having to balance the risks.

    A final note is that not all medical graduates take the Hippocratic oath as it is not a requirement of any medical school that I am aware of. The decision to take the oath is usually left to individual graduates. My own class elected as a whole to take a modern version of the Hippocratic oath as we graduated; this was apparently the first time for many years that it was done at that particular medical school.

  • hear, hear stuart.

    Thanks for the examples, I didn’t want to flog too much the obvious one of cancer treatment.

    I did read that the oath is not a requirement but as it was just a jumping off point I decided not to include that info so thanks for making that point for me.

  • I agree, cancer treatment can be controversial. Dr Gorski covered the topic well on SBM, much better than I would feel able to.

    For what it’s worth, I’ve seen the whole spectrum of cancer. I’ve diagnosed and treated cancers by various methods but these days am more often involved with palliative care than active treatment. I hasten to add that palliative care is not specifically a part of cancer care but is an option for anyone who has a terminal illness, no matter what its nature.

    I’ve also had a parent and child who have had the diagnosis of cancer made and have gone through different methods of treatment. Yes, they were both “harmed” by the teatment, but both are now fully well following treatment with no more detectable disease. The initial “harm” is more than balanced by their current wellness.

    It helps with cancer to bear in mind that over half of the patients diagnosed with cancer can now be treated so there is no more detectable cancer. I hesitate to use the word “cure”, because oncologists also hesitate to use it, but “no more detectable cancer” is actually a pretty good definition of cure in my book.

    In treating cancer we have to balance the immediate “harm” of treatment (surgery, radiotherapy, chemotherapy, immune modulation, hormone manipulation, etc) against the long term aim of a disease free normal life. Even those who do not become cancer free usually gain both quality of life and life extension. It’s up to the individual to judge how much these gains are worth.

  • Stuartg,

    Thanks for the fascinating examples and info. I had no idea that not all doctors took the Hippocratic oath. Thanks for some excellent examples outlining risk vs benefit in medicine – risk isn’t a concept that is easily understood.