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‘Primum non nocere’ (‘First, do no harm’) doesn’t actually appear in the Hippocratic Oath, but it’s what most people will think of first if you ask them about it. It certainly seems more sensible than much of what actually does appear in the original oath, which includes a commitment not to perform abortions, undertake any kind of surgery or – by a strict interpretation – provide first-aid classes.
Which is odd, really, because actually as a doctor I feel I often do a great deal of harm. More, anyway, than I’d expect to get away with in day-to-day private life. Outside work, I almost never stick a needle in somebody, or persuade them to swallow things which will make them feel sick, or tell them something which is going to ruin their day, if not their year.
On a bad day, practising medicine can feel like doing people an unending series of small harms. Every painful procedure, however necessary, every item of bad news broken, however unavoidable, every drug side-effect, however necessary the drug – they all do harm.
And that’s leaving aside the more profound harms we all hope to avoid inflicting: the missed diagnosis, the surgical complication, the treatment delayed or mis-prescribed.
Of course I know that’s not really what ‘First do no harm’ is supposed to mean. Perhaps ’Do no net harm’ would be more accurate? Except even that isn’t always quite right – what about the patient who dies of neutropaenic sepsis from the chemo that didn’t, in the end, buy them any extra time? The neonate who struggles through three painful weeks of invasive care and then doesn’t make it after all? However you reckon up the balance, we haven’t done them much good.
Over a career, naturally, we all hope to do more good than harm. In medicine, though, the good is often hard to quantify, while the harm is painfully clear-cut.
If you managed your patient’s chronic conditions so well that they didn’t have a stroke, you’ll never know it. Even when someone recovers from a serious illness, it’s hard to allocate the credit between medicine and the natural healing process. There’s no ambiguity, though, about the wince when you insert the ABG needle.
So how about this, instead: accept the harm you have to do, but never take it lightly. Think carefully, for every patient, about what you can really give them, and what it might cost them to receive it.
Remember that medicine’s licence to inflict harm in a good cause is an integral part – perhaps the central part – of the unique trust society reposes in our profession. No-one can practise medicine without doing harm, whatever Hippocrates might say, and no doctor should ever forget it.
By the Secret Doctor. Read the blog and follow @TheSecretDr on Twitter and on Facebook
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