Intended for healthcare professionals

Editor's Choice

Think harm always

BMJ 2004; 329 doi: (Published 01 July 2004) Cite this as: BMJ 2004;329:0-g
  1. Richard Smith, editor (rsmith{at}

    How do you deal with something unpleasant? The commonest way is not to think about it. That, I suspect, is why medicine has paid so little attention to the harm it may cause—despite the ancient instruction “first, do no harm.” Many people try to deal with death by not thinking about it, but Montaigne advises us to do the opposite and think about it all the time. The same advice might apply to thinking about harm: every intervention by a doctor, even a throwaway comment or a test “just to be sure,” carries the potential for harm, whereas many of those interventions have no possibility of bringing benefit. This long overdue theme issue explores some of the many ways in which health care might result in harm.

    Very few people attend a doctor thinking that they may come out worse than when they went in. But many do. When referring a patient to hospital should a doctor say: “I must warn you that the simple fact of being admitted to hospital means that you have something above a one in 10 chance of suffering an adverse event and a one in a 100 chance of dying”? I put this point to the Helsinki meeting of the World Medical Association, a body that has made its name (and possibly created harm) by promoting informed consent. The audience looked quizzical, and I've never heard of a doctor issuing such a warning. But doctors will regularly warn patients of much less common risks attached to particular interventions.

    Imagine an applicant to medical school answering the universal question of “Why do you want to study medicine?” with “My main ambition is to try to do less harm than good” or “I'd like to devote myself to exploring the harms caused by doctors.” The applicant would be thought very odd even though he or she would be enlarging on “first, do no harm.” Yet the balance between doing good and creating harm in a lifelong medical career undertaken with commitment and compassion may be fine. The harm is omnipresent, the benefit sometimes fleeting.

    As a junior doctor I dutifully prescribed lignocaine to many patients who had had heart attacks. The logic was, I believe, that the drug would prevent the arrhythmias that might kill patients. It never occurred to me that this might kill patients rather than save them, but I learnt years later that the result of my hard work was more not fewer deaths. As my parents took me to hospital as a 7 year old and left me alone (on the hospital's instructions) to have my tonsils removed they never for an instant thought that the harm of the procedure might outweigh the benefit—but it probably did. The hospital admission certainly made me miserable and caused me to miss my big break playing the Archangel Gabriel.

    Hard and uncomfortable as it may be, we need to think about harm all the time.

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