Ethical Dilemmas in Emergency Medicine part 3: Is Primum non nocere timeless or ridiculous?

If you haven’t been following this series, you can also find part 1 and part 2 on the blog.

Part 3: Primum, non nocere

Reconciliation by Scott A. Harvest.  http://www.elfwood.com/~scotimus/Reconciliation.3197669.html

Reconciliation by Scott A. Harvest. http://www.elfwood.com/~scotimus/Reconciliation.3197669.html

When I was a green young House Officer working stupidly long hours quite a few years ago, I can remember the sense of nervous excitement I got when the nurses would page me to see an acutely unwell patient.  As the pockets of my starched white coat bulged with the numerous Oxford Handbooks I clutched to like a toddler clings to their teddy, I’d race down the corridors with what I felt was a stylish and contained urgency (but that probably looked like complete and utter panic to everyone else).  All the time I’d be reciting the relevant mantras in my head. Me as an idealistic young doc Some of them would be specific to the case I’d been called to see – such as the causes of metabolic acidosis with a raised anion gap; daily fluid & electrolyte requirements; the differential diagnosis for acute postoperative dyspnoea.  But one of them recurred, over and over, for every case I ever went to see: ‘Primum non nocere’ or (for those of us who prefer English to Latin) ‘first of all, do no harm’.

I guess that most doctors recited the Hippocratic oath when they graduated.  This notion of ‘first of all, do no harm’ isn’t actually part of the Hippocratic oath but it’s derived from it.  And it’s certainly on the tip of most doctors’ tongues.  Who could argue with it?  It’s obvious.  Iatrogenesis is quite a burden – it’s estimated to cause almost a quarter of a million deaths each year in the United States alone.  Surely our first priority has to be to make sure we don’t actually do something that will cause harm.  It’s a basic principle of medical ethics: we should achieve beneficence (benefit) and avoid maleficence (harm).  Well, I certainly bought that.  As a junior doctor I lived in this idealistic bubble for a while.

As a Senior House Officer, working life was still pretty tough.  The hours I had to work were a bit less onerous – we started working shifts instead of 72-hour (or more) on calls.  But there was still a single SHO in charge of a busy Emergency Department at night, and I remember certain nights where I had to deal with 65 new patients arriving in a single shift.  Perhaps that’s what made me so bitter and twisted as to think about rejecting such a wonderful ideal as ‘first of all, do no harm’?

Brass scales by Toby Hudson

Brass scales by Toby Hudson

Actually, it was a single case that did it.  It was a 50 year old man with a STEMI.  He was given thrombolysis, perfectly appropriately.  But then he had an intracranial haemorrhage, and he died.  Of course, everything had been done right.  The doctor treating him had taken informed consent, including an explanation of the 1-2% risk of intracranial haemorrhage, and they’d documented it.  They hadn’t intentionally caused any harm.  But they did.

How does this fit into ‘primum non nocere’?  Did that doctor violate this universal principle?  Was giving thrombolysis a bad thing to do?  Surely not!  Surely, we can hide behind the fact that we didn’t mean to cause harm – it wasn’t our intention.  So that makes it OK, right?

 

 

So we didn’t mean to do it.  Perhaps that makes it all OK.  But hang on – we did.  We meant to give a treatment that had these risks.  We knew that the treatment would cause intracranial haemorrhage in 1-2% of patients, and we fully intend to give the same treatment again in a similar situation in future.  In fact, if we had 100 patients just the same we’d give it to all of them, knowing that 1 or 2 of them will be given an intracranial haemorrhage – i.e. that we’ll actually harm 1 or 2 patients.  So we did intend to harm some patients, after all.  You can’t hide from that, right?

We did it, knowing that some patients will be harmed, because there is a greater good.  Of those 100 patients we treated, we’ll save perhaps 3 or 4 lives.  So, overall, we derive a benefit.  Great!  That’s what we did – it’s not ‘primum non nocere’ but it’s all fine after all!

Of course, we do this sort of thing all the time in medicine, don’t we?  We’ve bought into Jeff Kline’s test threshold concept

Medicine: a double edged sword

Medicine: a double edged sword

– the probability of disease below which the harms of investigation outweigh the benefits (even accepting that some important diagnoses might be missed).  We make decisions about doing whole body CT, giving anticoagulation and undertaking an RSI or a cardioversion all the time.  For each of those decisions we weight the risks against the benefits for our patients – and if there’s net benefit we go ahead, right?

If you’re with me on this, you’re essentially admitting that you’re (at least in some shape or form) a utilitarian.  What you’re really interested in is maximising the good – not avoiding harm at all costs.  If you’re not with me on this, I’m not sure if you really practice medicine!  Absolutely everything we do for our patients comes with a risk (or even a certainty) of harm.

Take IV cannulation, for example.  It hurts – that’s a certainty.  It scars veins and makes future cannulation a little bit more difficult.  That’s certain too.  There are also some possible harms – infection, bruising, thrombophlebitis, failure.  If you cannulate enough patients, you’re accepting that some of those patients will experience these risks as actual harm.  But you cannulate because you expect a net benefit – it’s basically another form of utilitarianism.

Mention that you’re a ‘utilitarian’ to anyone with an interest in moral philosophy and they’ll probably scowl at you.  They may even accuse you of being a Nazi.  In fact, I’ve been on the receiving end of just that sort of response – in the medical literature, in fact.  Here are the links to the paper written by me and Bernard Foex and the response (which may seem a tad harsh but was actually from a really great bloke, Giles Cattermole!).

Why does it get this reaction?  Well, if our aim is simply to maximise the net benefit, lots of things might become ‘desirable’.  We might, for example, justify a gang of 20 yobs battering a young boy and causing serious injury, because the net benefit of the ‘great laugh’ that the yobs had outweighs the suffering of the young boy.  Or we might even justify killing people to transplant their organs in the interest of ‘net benefit’.

Heck, you might even justify stroke thrombolysis – allowing a few patients to die early on to achieve the net benefit of improved quality of life for those who survive longer term.  ;-)

Clearly, that’s not a world we really want to live in. I don’t advocate utilitarianism from a moral perspective (some things are just morally wrong, even if they bring apparent net benefit) but is medicine different?

cyberscooty-computer-solutionsThere has to be a solution.  Medicine can’t be all bad.  We (as clinicians) can’t be all bad.  And, while we do want to maximise the benefit accepting some risks of harm, there are also some rules we wouldn’t break.  Perhaps we’re really ‘rule utilitarians’.  There are some things that are clearly just wrong, and we would never do them.  But there are other situations where we’d feel that it’s appropriate to recommend a course of action that (on the balance of probabilities) will benefit our patient.

Perhaps the saying isn’t ‘first of all, do no harm’.  Perhaps it’s actually ‘First of all, don’t do anything that’s morally wrong.  Then, do what’s most likely to benefit your patient’.

It’s a drastic over-simplification as it doesn’t emphasise how central compassion needs to be, and it doesn’t include anything about sharing decisions with patients. But is it more realistic than ‘primum, non nocere’?

Right now, I’m just putting this out there.  I imagine that some people will have something to say!  Please do comment below.  These ‘ethical dilemmas’ are all about the discussion they stimulate.

Until next time!

Rick

 

Comments

  1. says

    Ok, so colours on the mast – I’m a utilitarian. I think the bloke with a sore cut finger should put up with his pain for a bit longer so I can (maybe) save the life of the chap with the obstructed airway. But there are rules to my utilitarianism; I draw the line at actively killing random people on the street to harvest their organs for transplant. So who makes those rules; what moral compass do we base them on? Can they change dependent on circumstance? And how do we (or should we?) reach a consensus on them?
    Just putting it out there ;-)

    • Michael Stewart says

      Another great post, and a challenge. My own experience is I’m fairly happy with the ethics of what I do, but trying to define it is difficult. The closest I’ve been able to get is the statistical term ‘given that’.

      Given that someone is going to die whatever I do, it is ethical to consider using their organs to save other lives; it is not ethical to harvest organs from healthy people, regardless of the net aim.

      Given that two people need treatment, it is ethical to make the one with the less serious condition wait in favour of the critically ill; it is not ethical to make someone wait just for the sake of it.

      Given that a person has a better chance of surviving their sepsis with IV access, it is ethical to cause discomfort with cannulation; it is not ethical to cannulate someone who does not need vascular access.

      It’s not perfect, but it’s the best way I’ve found so far to express my moral framework.

      • says

        Thanks a lot for such great comments, Kirsty and Michael. I think both of your comments about triage are really pertinent – I’ll make that the focus of Ethical Dilemma 4! It’s interesting how thinking about utilitarianism in medicine instinctively leads you to thinking about morals. If you asked most people the basis for their moral framework, they’d probably be quite unlikely to advocate for utilitarianism. But practising medicine is unavoidable without at least being something of a utilitarian.

        I guess that, even in everyday life, most of us have to be a bit utilitarian – we take little risks with our own lives every day because of the likely benefit. If we didn’t, none of us would even drive a car! I’m not sure how much people think about that. Perhaps it makes us feel too uncomfortable to do so.

        Thanks again!

        Rick

  2. Segun says

    Great post Rick!

    Does this mean that there are moral absolutes in medicine? Or life as a whole, for that matter?

    DOI: rule utilitarian also :)

    • says

      Thanks for your comments!

      One of the most interesting tweets I’ve had in response to this post was from Alan Bailey:

      I’d be really surprised if there is any doctor that has managed to practice without causing any side-effects or without in some way increasing the suffering of even a single one of their patients. It’s inevitable when you think about it – no matter how good you are. But if that’s OK (and all of us who are still doctors clearly think it is) then we’re being utilitarians.

      Personally, I don’t think that means that we’re moral relativists. There can still be moral absolutes – and I think there are. In terms of the ‘rules’, I’m not so sure that there are, for example, 10 commandments specific to modern medicine (although the originals are still going pretty strong). But I do think that, if everything we do is guided by compassion, backed by hard work and accompanied by careful thought, we can’t go that far wrong.

      Now that’s probably the deepest thing I’ve ever written on St. Emlyn’s. Time to watch some footy! :-)

      Rick

      • says

        Interesting – so what are the moral absolutes? Not killing? What about war? Or physician assisted suicide? Having respect for others (including thy father and mother), not stealing – we can probably agree on them. Adultery, keeping the Sabbath sacred – I think they’ve gone to all intents and purposes (although I have some”old-fashioned” views on adultery as a form of dishonesty). And coveting – isn’t that just being aspirational?

        No offence intended to anyone of any religion here, I just wanted to illustrate that even those things we might consider as absolutes at some point seem to be able to shift.

        So each of us may have our own moral absolutes, but I’m not sure that as a society we have such a unified view.

      • says

        Hi Kirsty,

        I can see that we’re going to have to try and resist being drawn into a debate on moral philosophy here – my DOI is that I am a moral absolutist but I’m going to spare you any more details. While I’d love to have this debate, I think it might be better if I resist – at least on this forum!

        Physician assisted suicide, you say? Perhaps that should be the focus of a future ethical dilemma – but can you take me seriously now that I’ve stated my DOI?! :-)

        Rick

  3. Nicola jakeman says

    Thanks Rick. Thought provoking post. I wonder if we become more utilitarian in our approach when our decision making is increasingly time constrained. Following the ‘Rules’ which are derived from studies looking at population risk, rather than personalising the management of the patient in front of you…just a thought…

    • says

      Thanks a lot for the comment, Nicola! I absolutely agree – I think that’s a really important point. Time is a really precious commodity. Particularly when it’s busy, we don’t have much of it to give to our patients – and I think that itself can cause harm and suffering (usually inadvertently, I’m sure). It would be really interesting to ask patients about this shortly after they’ve left the ED.

      Thanks again,

      Rick

  4. says

    Thanks to everyone who’s commented on this ethical dilemma so far. There have been so many thoughtful comments – and they’re far better than the post itself – please keep them coming!

    I also want to draw your attention to another great comment from Julio Marchini, who tweeted…

    And wrote a great, detailed response at this link… https://medium.com/p/233b30810416

    I’d really like to reply to that comment, so I’ll do that here.

    First of all, I think that Julio’s making some really great points – and I imagine that many people heartily agree with Julio. For a patient with STEMI, prescribing no treatment yields a higher risk of death – so the harm is greater. Julio points out that this still fits in with ‘primum, non nocere’.

    I’d love that to be true. However I have to admit that, while it’s uncomfortable to think it, this is still utilitarianism. The concept of ‘least harm’ is the same as ‘most benefit’ and that’s unavoidably utilitarian in nature. We can’t escape the fact that some patients with STEMI will be harmed by thrombolysis. Take this little scenario to illustrate that point…

    If we have a 50 year old man with STEMI (who has no contra-indications to thrombolysis) and PCI is not available, would you give him thrombolysis? Yes – I’m sure you would. So would I. On the whole, that course of action leads to the greatest net benefit or the least probability of net harm.

    So, if you saw 100 such 50 year old patients with STEMI who are all exactly the same as this man, would you give them all thrombolysis? Of course you would. Nothing has changed – it’s the same scenario times 100.

    BUT here’s the crux of the matter. If you’re prepared to give thrombolysis to 100 patients with STEMI, you must *know* that you’ll save the lives of perhaps 4 patients while *causing* intracranial haemorrhage in at least 1. Yes, you *caused* it. They wouldn’t have had the haemorrhage otherwise – it was your intervention that caused it.

    And you intended to do it, too – because (after treating 100 patients) you knew it would happen to someone but you also knew that you’ll have saved more than you harm.

    So what does that say about medicine? Can we really hide behind ‘primum non nocere’ when in fact (if we face the harsh truth) we give certain treatments firm in the knowledge that, while the population as a whole derives net benefit, some patients will actually receive more harm than benefit?

    That’s uncomfortable – for any doctor, including myself (a bit of an idealist, if I’m honest). It took me a long time to accept it – but the facts are there, I couldn’t hide from this truth any more.

    Having realised this, the question is what the implications are for our practice. Should we pack up our medicine bags and simply hold patients’ hands? Well, no – that’s not usually what our patients want and it’s probably not what we would want for ourselves as patients or relatives. They key, as I’ll touch on in future instalments, is surely to put the patient and their interests firmly in the centre of the decision-making process – not ourselves. We’re merely peripheral informants with a duty to do our very best for our patients’ interests. But (in my opinion) we should never pretend to patients that ‘primum non nocere’ is an achievable ideal. To do so actually obliterates the possibility that any consent we ever take is truly informed.

    Rick

  5. Kevin Reynard says

    Thanks Rick, Just caught up with this- great article.

    To take your thoughts re harm in thrombolysis further, most patients treated will not receive any mortality benefit, and at time of selecting therapy it is impossible to identify which lives will be saved. The vast majority of patients will survive their STEMI without any dangerous treatment. Therefore in electing to thrombolyse all of the 100 patients we are consigning one to death who would probably have survived. Despite trying I still have not found a way of explaining this sensitively and accurately when consenting a patient for thrombolysis for STEMI (and most likely never will as I cannot remember the last one I did)

    • Pik Mukherji says

      Also just caught up with part 3 after having viewed 1 and 2 previously.

      Totally agree that Do No Harm is a crock. You can’t do no harm unless you touch no one. And then you could argue that your inaction is causing net harm. So really it’s “Do as little harm as possible” while trying to practice good medicine. In the examples we have a lovely and easy net #s analysis. Bleed in 1 vs. Saved life from MI in 4. Great. And what about the unintended consequences of our actions? Not the side effect profiles, not the risks of HIV from blood transfusion, but the not on the radar consequences? Well, since you can’t know those, how do you add them into the math?

      Doctors are likely to overestimate the benefits of their treatments and underestimate the harms. After all, we wouldn’t be advocating the treatment if we thought it was a bad idea, right? So our own bias is to reduce our cognitive dissonance. To minimize this bias, it’s important to keep in mind those that we harm, predictably, albeit unintentionally.

      “The last thing I want to do is hurt you. But it’s still on the list.”

      -pik

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