The Harms of “First, Do No Harm”

Often misquoted as a component of the Hippocratic Oath, “first, do no harm” has become a mantra of the medical profession. These words are repeated daily at conferences, in textbooks, on blogs, and in conversations worldwide. They are treated with reverence, as if they provide some great insight. I think they are insulting, misguided, and harmful.

The insult is obvious. These words imply that I might intentionally harm my patients if I am not occasionally reminded not to. I have never met a healthcare provider who would intentionally harm a patient. (If such a person exists, I doubt that a catchy phrase is going to be what stops them.) Those words tarnish the daily toil we all endure, focused entirely on our patients’ well being.

However, the insult isn’t what bothers me. I am a thick skinned emergency doctor and it takes a lot more than a few words to hurt my feelings. The real reason I would like to see those words banned from the medical corpus is that I think they perpetuate a misguided understanding of medicine that results in millions of patients coming to harm every year.

Medicine cannot be practiced without causing harm. Those supposedly sacred words, right from the outset, were a lie. Any treatment that has an effect, will also have side effects. In order to benefit there must also be harm. That is a basic rule of medicine.

This is so often overlooked, I am going to repeat myself. Any intervention that is capable of altering the wonderfully complex machinery of the human body, will have multiple consequences, some beneficial and some harmful. It is the balance of those consequences that makes the medicine. Those four silly words establish a culture of medicine that is forced to ignore this delicate balance of harms and benefits. We are supposed to be perfect. Harms become taboo, and are therefore downplayed.

This minimization of harms in medicine is clearly evident in another common medical phrase: “the risks and benefits”. We talk about the “risks and benefits” of surgery, or the “risks and benefits” of a medication, but this is an inherently unbalanced equation. Benefit is stated as a given, whereas harm is only mentioned as a possibility.

Unfortunately, benefit is almost never a given in medicine. We like to think that all our actions help, but our dirty little secret is the number needed to treat. This is a statistical term that all doctors are familiar with. It describes the number of patients we need to treat in order for one patient to benefit. If every patient benefitted, the number needed to treat (NNT) would be 1, but that is essentially unheard of. In our very best medicines, like using steroids for children with asthma exacerbations, we see NNTs of about 8. That is a great benefit, but it means that for every 8 children treated, only 1 sees a benefit, while 7 are unaffected. Usually, the numbers are much worse. The NNT to save a life by taking a statin (cholesterol medication) after having a heart attack (people at high risk) is 83. In other words, out of every 83 patients for whom a cardiologist prescribes a statin, 82 will never see a benefit.

We balance these ‘certain’ benefits by talking about the ‘risk of harm’. Sure, there might be side effects, but those only happen in a handful of people. What does that matter when we are assured a benefit?

The culture of ignoring harms extends beyond the bedside and into research as well. Studies are designed to search for benefits. Therapies are approved based on research that only reports benefits. We then rely on postmarketing surveillance to try to identify harms. Every doctor knows that initial reports of new therapies systematically overestimate benefits and underestimate harms, and yet we rely on these reports to guide our practice. We can’t talk about the potential harms, because we, as doctors, must “do no harm”.

Finally, the culture of “do no harm” seeps into our assessments of patients. We suggest tests for deadly conditions, no matter how improbable, because to miss such a condition would be the ultimate harm. We do not tolerate misses, because this culture requires us to be perfect. At the same time, it prevents us from adequately discussing the downsides of this over-testing, because if it were harmful, we as physicians would certainly not be suggesting it.

Doctors understand that every test and every treatment that we offer represents a balance of harms and benefits. Unfortunately, the popularity of those four words has obscured that fact from many of our patients. The culture of “first, do no harm” has generated unrealistic expectations of medical therapy. We believe that antibiotics will always cure this cold, but will never cause harm. We immediately recognize the advantage full body CTs but rarely consider the harms.

There is no such thing as medicine without harm. Medicine is about making hard choices; balancing a potential for benefit against the ever-present potential for harm. “First, do no harm” is either a self-evident cliche, or it is a pernicious distortion of true medical practice. Either way, it should be abandoned.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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