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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
All valuable insights and as a first step can I suggest never asking junior doctors to do tests'as a routine' including ABGS that often add nothing to clinical management
As Italian I know hyppocrates’ oath and after our medial school we swear on it in our body regulator site. Unfortunately the modern medicine is far away from the ethic and moral medicine of Hippocrates because we are not free to decide the best treatment for the patient but we have to obey the rules and NICE guidelines. We are not free to choose wheather that treatment suits our values of the life. We are not free to cure all the patients regardless their age and prognosis because we have to follow the financial resources of the trust. Hyppocrares’s oath says “life is always to be preserved”. The modern medicine is just slave of the burocracy.
Primum non nocere’ (‘First, do no harm’) - I guess we need to check what it actually really means
If it means 'The first principle of medicine is to do no harm (ever)' then I guess it is non sensical for reasons outlined
but what if it means First be a human being, show compassion and empathy and then offer the interventions that most likely will do good for the patient (rather than make the most profit for the doctor etc ) then I cant argue with it at all
Any Latin scholars out there?
Why this blog is promoted in BMA site and why not other blogs by doctors, which could be of better or same quality, is the question.
As a seasoned patient and doctor I can attest to the fact that anything other than kind speech is harmful.
Nice point, but a convoluted course in reaching it! Indeed the oath does not contain 'primum non nocere'; WHS Jones' translation is: 'I will use treatment to help the sick according to my ability and judgement, but never with a view to injury and wrong-doing', which is non-maleficence - as you have explained (so why reference the oath, then infer that you have reached a different conclusion)?
One swears not to undertake surgery as it is a physician's oath, not a surgeon's oath (and this separation and bias towards physicians is still evident today: one attends 'medical school', and qualifies in 'medicine' - compare this to being a 'surgical student', attending 'medical and surgical school')!
By the way - for the lovely Italian poster - you do not have to 'obey' the 'rules' and NICE guidelines. Some very clever and experienced people have self-publicised what they think might be a good way to proceed for many (not all) patients, in an effort to improve sub-standard practice - not to restrict expert judgement. Guidelines do not take away your complete autonomy (and thus responsibility for your actions) - you are free to choose what to do, with patient consent and hopefully following the non-maleficent principles above. Pretending that we have to follow 'rules' (are there any?) both overestimates the competence/confidence of medical/surgical knowledge as a whole, and destroys the autonomy entrusted to you by your patients and colleagues (which is the fundamental point of a doctor, versus a centrally-controlled worker). Always think and act for yourself, and use guidelines to inform yourself of experts' opinions (then read how they came up with the guidelines, and the dispute/uncertainty on the road therein). This is why they are called 'guidelines', why they have disclaimers, and why non-physicians (or non-surgeons!) are not allowed to take your place!
For those of us asked by the CQC to do endless clinical harm reviews a nice read
Correct to highlight the emotional harms from receiving and delivering medicine
An excellent article let down by the statement suggesting that there is a unique trust in society for your profession. They simply have no choice.
That statement clearly shows that you have no idea of the distrust so many of us have in your profession!.
Perhaps you should mention openness, honesty, communication, informed consent, patient rights and last but most importantly, empathy.
Many of us do not trust you, thanks to a dishonest and/or incompetent complement. Very sad!.
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