Part 3: Primum, non nocere
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. 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’?
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
- 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?
There 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!