“First do no harm” is the opening word of the Hippocratic Oath, and virtually everyone is familiar with it, as it is quoted at least once a season on TV medical dramas. We tend to think that this oath had a great impact on medical training and practice when it was written around 400 BC. Still, it was of limited applicability, as it only applied to students trained in Hippocrates’ style of medicine, and Hippocrates’ school for medical doctors was only one of many. Even today, the oath likely holds more significance for the general public than for physicians, and has been superseded by more modern oaths.
Healers of that time, and for centuries thereafter, had little to offer their patients but herbs, poultices, and comfort. And “harm” was a simple concept that concerned only one’s patient. Hippocratic physicians were forbidden to perform surgery, hasten the death of their patients, and offer poisons, all of which were considered harmful. Now the term is more complicated because it does not refer to just one patient of hers, but also to a class of patients and to the health of the general public.
What if, by providing treatment to a patient, the treatment, rather than the disease, caused harm? For example, oncologists are tempted to use experimental drugs on patients for whom all standard treatments have failed. This treatment has shown mixed results. When effective, it can greatly extend life, but it has side effects that can end a patient’s life faster than an untreated disease, and that is about the same number of patients saved by treatment. occurs in patients with So would the use of this drug be of potential benefit or potential harm to the patient? In particular, does he/she indicate that he/she wants to live as long as possible?
Or what if the doctor provided the requested medication even though the patient had no medical indications? shortages, and many patients who need the drug are not getting it. Some have died! The drug can also cause side effects in healthy patients and cause permanent liver damage requiring a transplant. Apart from this side effect, should a doctor also consider that providing this drug, even anonymously, could harm another individual and refuse to write a prescription?
or if a health insurance company’s medical consultant refuses to apply the treatment because the prescribed dose exceeds the guidelines without trying to understand why the treatment is used in this way. What happens? They rarely look at supporting documentation and never call a patient’s primary care physician to determine the rationale for treatment. There are many decisions that pay less, but there are more profitable activities to spend your time on. A reviewer’s refusal is considered detrimental if a higher dose is needed to control a patient’s disease, but the patient cannot afford it, and the pharmaceutical company does not consider lowering the price or provide it for free. Does contracting with an insurance company impose a fiduciary responsibility to the patient? If so, does a cursory review and refusal amount to at least default (negligence) or, at worst, fraud (willful negligence)?
Even then, population damage may occur. For example, doctors in Florida sold fake COVID-19 vaccination certificates to parents to comply with public health laws of the time requiring school-aged children to be vaccinated, but the children were vaccinated. did not receive This could endanger many other students and staff, their families and the general public, especially those who may have compromised immune systems.
The concept of harm can be extended to gender and racial inequalities in health care. These apply to fellow physicians, residents, and situations where patient care is affected. One form of this harm, characterized as personal prejudice, can result in unequal treatment (e.g., black women receive lower postoperative pain medication doses, female doctors are treated received). This is nothing new, but it probably started shortly after Homo erectus and Neanderthals first discovered each other and concluded that they were inferior to them based on their physical differences.
Another form of this evil, systemic inequality (for example, slaves in Greece had no right to health care), began later with the development of communities and regulations. These probably stemmed from personal prejudices, but they acted to reinforce them, and systemic inequalities became cultural norms. Only recently has the perception of both types of inequality, especially systemic inequality, become accepted as a reality, especially in medicine. Today, you cannot read a magazine issue without at least one of his articles on inequality, regardless of your area of expertise. Some of them are reasonable, others border on absurd, theatrical and racist, and are in print only for our current interest in the topic.
If Hippocrates were alive today, he might have found the phrase “do no harm” so complicated that he might have chosen a different word at the beginning of his oath.
M. Bennett Broner is a medical ethicist.
