First, Do No Harm

 Anne-Louis Girodet de Roussy-Trioson: Hippocrates refusing the gifts of Artaxerxes, 1792

“First, do no harm”. It’s a litany that is heard quite often in malpractice circles. The common conception is that this is a premier part of the Hippocratic Oath that aspiring physicians are supposed to take at the beginning of their careers.

But there are some aspects of this common wisdom that aren’t quite accurate. First of all is the notion that every med student takes the Oath. Truth is, many med schools no longer give it to their incoming classes (but that’s a topic for another day).

Next is the Hippocratic Oath itself. It originates in the writings of Hippocrates, famous physician of Classical Greek antiquity, and sets a framework for medical ethics. The meat of his oath actually was to respect one’s teachers and the knowledge that had been gained by our predecessors; to keep things told in confidence, secret; and to abstain from deliberately causing death. It does contain statements against causing harm, though these are not given any kind of primacy over anything else. We are not specifically told that our first priority should be to not do harm, that, in effect, it is somehow better to do nothing, than to do something and risk it being the wrong thing.

Medicine is all about managing the risks. Anything a doctor can do can go wrong – even doing nothing. Make no mistake, sometimes it’s valuable to know when to keep your hands off of a problem until it develops further, or just goes away (we call that ‘treating with a tincture of time’). But we didn’t get into this line of work so we could stand by until we had an absolute guarantee of diagnosis and plan. There is only one guarantee in this field. Putting a rule in place of doing no harm above any other course action is futile and counterproductive.

This makes sense, actually. There are plenty of times one must inflict damage in order to address a health problem. If you’ve ever had to remove a splinter from a child’s finger you know what I’m talking about. And there’s a reason we refer to incisions as ‘surgical wounds’. And consider the sometimes brutal side effects of chemotherapy, which can be so bad people will literally choose (not to be blunt, but…) death. (Sometimes it’s just better to end with three good months, rather than twelve bad ones.) And quite often it just isn’t possible to treat one health problem without making another one worse.

This is one thing that sets physicians apart from any other health care folks: the development of what’s been described as a ‘necessary inhumanity’. It’s also been called ‘clinical detachment’, but I prefer the former term; it seems better suited to showing there needs to be a face-to-face relationship between the doctor and the patient. We’re in it, and we know it hurts, but we also know how important it is. And yes, we are going to look at ourselves in the mirror later, and ponder…

A better interpretation of the original Greek of the Oath would probably be ‘to alleviate suffering’. This recognizes that sometimes we must harm in the process of healing. Alleviating suffering without engaging in futile efforts to improve health is the basis of palliative care as well as mass-casualty triage. It recognizes that sometimes there just isn’t anything to be done to make things better that isn’t going to leave some kind of scar, on the patient, their loved ones, or fellow victims.

Still, this doesn’t let us off the hook for working hard, to know our craft, and to apply our best reasoning. It doesn’t give us an excuse to be lazy or cavalier, or to put our wants above our patients’ needs. Unfortunately that does happen. Doctors are people, too, and there are all kinds in the mix. But it’s important to know what the priorities are, for everyone involved.