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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:l4734

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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

22 July 2019
Spyros Retsas
Retired Consultant Medical Oncologist
Formerly Charing Cross Hospital, Department of Medical Oncology, Melanoma Unit
Loughton, Essex