Do No Harm

Do No Harm.

Three short, easy to pronounce words, but when linked, open a vast world of interpretation and consequences.

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Breaking down the phrase:

DO: Verb – Commanding in its tone promoting action.

NO: Adverb – Sign of a negative.

HARM: Noun – Damage or injury, both physical and mental, when related to a person.

This phrase is most often associated with medicine and is from Hippocrates. In some medical schools, students during graduation after receiving their diploma are asked to recite this or take a similar oath and follow this idea. In the Hippocratic Oath, there is a part that states, “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.” From Hippocrates’ Epidemics, he says: “The physician must be able to tell the antecedents, know the present, and foretell the future – must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.” 

And to clarify, the specific phrase primum non nocere, “first, do no harm,” is not part of the Hippocratic Oath.

A physician, as a general, is not in the mindset of wanting to cause a problem. The physician is interested in helping someone to get better or improve an outcome. They do this after taking a history of the problem and of the patient, after doing an exam, and after synthesizing this information, along with tests and results, to come up with the perceived best path to bring a patient into an improved state of health and wellbeing. Perceived being the opinion of the physician and/or medical establishment.

However, to paraphrase the medieval satirist Walter Map, “No good deed goes unpunished.”

Doing good and doing harm can seem very clear, but more often is a razor thin edge. It depends on the side you look at to determine good or harm, both subjective terms, by the way. What the physician thinks is a good thing may not be what the patient or patient advocate thinks is right. The physician thinks the child has a cold and doesn’t need antibiotics, but the parent wants some. Some physicians will not prescribe the antibiotics based on general standards and some will placate the parent since “it is just antibiotics”. There are benefits and harms in both situations. In the first, the benefit is in not treating a virus with an antibiotic. The harm may be to the physician parent relationship. In the second, the benefit is a stronger relationship, but potential harm to the patient by giving antibiotics that are unnecessary. Yes, there can be harm. First, not taking the entire prescribed course can cause antibiotic resistance. You’ve killed off the weak ones but left the stronger ones behind by not taking the full dose or not for the full time. Second, there is a reinforced incorrect idea that you can treat a virus with antibiotics.

Another example is chemotherapy. These incredible potentially life saving medications take cells that are growing out of control and by taking advantage of this rapid growth, target these cells, and for all intents and purposes, eradicate the cancer from a human body. But. There are other cells that grow fast, like hair, which leads to the classic depiction of balding. Depending on the medications, the patient can have long-term permanent changes to heart, liver, kidney, and reproductive systems, and these are not positive changes. Reduce cancer and maybe heart disease? Reduce cancer and get kidney damage? Reduce cancer and you might not have children. These are more extreme, and some people do not suffer from long-term problems. There is still the risk though.

What about medical trials testing out a medicine or procedure? There can be unintended consequences. Unexpected adverse effects. Someone could get injured. And someone could die depending on the extreme of what is being tested and looked at. At the end, some people might develop problems, but the majority could be healthier, perhaps cured. The one or the many?

From not treating a cold to life saving medications, how much harm in the right way is enough to be good? Or how much good can be achieved by needing to cause harm?