Letters to the Editor

The Lie of Primum non Nocere



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Am Fam Physician. 2001 Dec 15;64(12):1942.

to the editor: In the Latin phrases that get tossed about by physicians, “primum non nocere” (“first, do no harm”) is perhaps the best recognized. “Primum non nocere” is a Hippocratic albatross that today's physicians have come to understand subconsciously in its appropriate context. Every weapon in the physician's armamentarium is double-edged; every cure has a potential harm. As physicians we hide this fact in statistical nomenclature in phrases like “percentage of side effects” and other obtuse phrases that try to hide the fact that physicians are not immune to harming. We, as today's physicians need to allow our patients to understand why and how it is no longer possible to “first, do no harm.”

For every patient I have seen, I have had to rewrite the law. Every drug used, every prescription written, and every procedure has risk; risk of harm, or even death. Today's physicians interpret “primum non nocere” in a more amicable light: “may the benefits outweigh the risks.” When I reach for a prescription pad, I understand that I might be harming the patient. When I feel that the benefits outweigh the risks for the patient, I continue writing. Often, with God's help and blessing, I have been helpful to the patients who have come my way. But, I have not always been helpful. I will never forget the pair of kidneys that I harmed with gentamicin. This patient understood something that I did not understand then, and what I am now trying to explain. My patient did not expect that I could cause no harm. He expected me to try to help. When he had acute renal failure from the medication that we used, he understood that bad things happen. We tried something, we failed. After three months, he finally was able to stop dialysis.

Most physicians understand this subtlety and practice accordingly. However, many patients and all malpractice lawyers still cling rigidly to “first, do no harm.” If there is an untoward outcome in a treatment, then wrong was done, and damage will be repaid. In that line of logic, if a physician gives a prescription and harm is done, and the patient is hurt, then the prescription should never have been given. If surgery is performed and the patient dies, then the surgery should never have been done. It is only in not doing that we can give a 100 percent assurance that we will not harm.

I propose that the medical community continue to uphold the same high standard of excellence in caring for patients. I propose that the medical community continue to use therapies only when the potential risks are outweighed by the potential benefits. I further propose that we abandon the outdated lie of “primum non nocere.”

editor's note: Dr. LeCroy makes an interesting point that I think bears emphasis. In addition to his contention that the tenet “primum non nocere” can be misapplied, it is also widely misunderstood. First, it is often mistakenly thought to be part of the Hippocratic oath, an assertion that I see made regularly in the lay press. For one thing, the phrase is Latin, not Greek. But, more importantly, the statement is usually taken out of context and misconstrued.

The original Greek text translates loosely as: “As to diseases, make a habit of two things: to help, or at least do no harm.”1 In a scholarly exegesis of the text, Jonsen notes that the Latin term “primum” (implying “first” or “above all”) is not supported by the Greek text at all, and that its origin is obscure. Furthermore, the emphasis on helping seems to have been superseded by a more modern notion of avoiding harm. This notion seems influenced by an idealistic, even unrealistic, sense of attaining desirable outcomes while avoiding any risk of harm. Shelton has recently lamented the harm of “doing no harm,” and acknowledges how this concept can ethically tie a physician's hands.2

It would be better to embrace the meaning of the original text, which seems to say: “Try to help your patients when you can, and when you can't, at least try not to make things worse.”

 

REFERENCES

1. Jonsen AR. Do no harm. Ann Intern Med. 1978;88:827–32.

2. Shelton JD. A piece of my mind: the harm of “first, do no harm”. JAMA. 2000;284:2687–8.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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