First do no harm: the impossible oath
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4734 (Published 19 July 2019) Cite this as: BMJ 2019;366:l4734All rapid responses
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As we are beginning to understand much that is done in the name of "medical practice" can have unwanted outcomes that we call " side effects/unwanted effects ". For the past 10 years or so of my work as a GP patients would very frequently ask when I prescribed a medication : "are there any side effects doctor?" In my mind's eye I would see the words "of course there are" flash before me but I would say to the patient "I think this will help" but please read the patient information leaflet before you start the medication. So many patients do not do this and some regret this omission later.
However, this is not my reason for writing today as this is an issue that needs much more consideration. Rather my reason for this response is to remind everyone that medical practitioners very often become responsible for so called "sins of omission" . Doing things such as "prescribing" , "operating" , "conducting procedures" can for sure sometimes cause harm but we must not forget that "omitting to give information" can also lead to considerable harm. Many of our patients with disabilities and a wide range of "conditions" inherited or otherwise are fully entitled to "benefits" financial or for instance special shoes for skeletal abnormalities of the foot. However, research tells us that that £millions go unclaimed year after year because patients and carers have not been told of the benefits to which they are entitled.
This situation renders the political effort of our MPs and campaigners to be null and void. Might the BMJ work closely with colleagues such as Mark Gamsu on this topic so that omissions of this kind - that cause such harm - can be avoided.
Mark Gamsu | Local Democracy and Health
https://localdemocracyandhealth.com/mark-gamsu
Competing interests: No competing interests
I think the distinction between damage or pain and ‘harm’ is important and, because this is insufficiently appreciated by many of today’s doctors, has led to much harm being caused in spite all actions being legally sound and defensible.
Competing interests: No competing interests
Self-harm is prolific and protean. Its self-deceptive, sadomasochistic manifestations include injuries, accidents, addiction, tattoos, body-piercing, promiscuity, infidelity, fanaticism, cruelty, crime, and violence. What should we do? We should understand that we all have both a life wish (libido) and a death wish (mortido). And we should be alert to the mortido, because it never rests, and it’s always with us.
Competing interests: No competing interests
First do no harm: the impossible oath?
Kamran Abbasi’s thoughtful, yet provocative Editorial prompts me to offer this comment.
First, it should be clarified that the ”first do no harm” citation, does not belong to the text of the Hippocratic oath.
The Greek text ὠφελέειν ή μὴ βλάπτειν (poorly and inappropriately translated into Latin as primum non nocere) is a passage from the Hippocratic treatise on Epidemics (First book, second part, paragraph 5); "In illnesses one should keep two things in mind, to be useful rather than cause no harm".
In Kuhn’s compilation of the works of Hippocrates, the Latin translation of the same passage reads [1]: "Duoque ista elaboranda sunt, ut in morbis commodes aut ne quid offendas".
A commentary to this passage is attested to Adamantios Corais (1748 – 1833, Ἀδαμάντιος Κοραῆς in Greek) the Greek physician and scholar born in Smyrna and a graduate of the medical school of the university of Montpellier. Corais, in his 'Impromptu Reflections' encourages his young physician-colleagues and compatriots to adhere in their practice of medicine, to this acclaimed precept of the Hippocratic tradition [2].
In the First book (there are seven in total) on Epidemics, Hippocrates describes the atmospheric conditions that prevailed during a four-year period (three of these on the island of Thasos, opposite Abdera) and the diseases that were diagnosed under the said atmospheric conditions. Epidemics, therefore, is not used in this treatise of the corpus strictly in its contemporary meaning of disease prevalence.
This is emphasised by Emile Littré (1801-1881) the physician, translator and publisher of Hippocrates, in his introductory comments to the treatise. Littré’s translation of the relevant passage reads : "avoir, dans les maladies, deux choses en vue : être utile, ou du moins ne pas nuire" [3].
In the Hippocratic tradition, the patient’s benefit has been and should remain the focus of clinical practice. Indeed, the Hippocratic oath does include two categoric statements that demand the physician’s beneficent intervention [4]: “I will apply the regimens of treatment according to my ability and judgment for the benefit of my patients and protect them from harm and injustice,” and “Into whatever house I enter, I will do so for the benefit of the sick...” (translation into English by Nicholas Dunkas, MD).
Can harm always be averted even with the most beneficent of intentions? Probably not, but the intention to be useful to the receiving patient, rather than cause no harm, should continue to guide medicine. Perhaps the Hippocratic oath remains possible, even in our times!
Spyros Retsas MD FRCP
Consultant Medical Oncologist (Rtd)
References
1. Hippocrate /Kuhn, Karl Gottlob (ed). Magni Hippocratis Opera Omnia (tomus III, 395) Leipzig: Car. Cnoblochii, 1827 BIU Santé (Paris). http://www.biusante.parisdescartes .fr/histmed/medica/cote?hippokuhnx03
2. Hippocrates: Omnia OPERA. Volume I (Pournaropoulos G. K. Editor) page 72 (In Greek) Athens, Greece, Martinos A. 1967.
3. Hippocrate. - Oeuvres complètes / Littré vol. 2, 634-637 Paris : J.-B. Baillière, 1840. BIU Santé (Paris).
4. Retsas S. Treatment at Random: The Ultimate Science or the Betrayal of Hippocrates? JCO. 2004. VOLUME 22 NUMBER 24 5005-5008. DOI: 10.1200/JCO.2004.01.044
Competing interests: No competing interests