The concept of a “deepity” was, I believe, coined by Daniel Dennet in his great book “Intuition pumps and other tools for thinking”. He says, “a deepity is a proposition that seems both important and true – and profound – but achieves this effect by being ambiguous. On one reading it is manifestly false, but it would be earth-shaking if it were true; on the other reading it is true but trivial. The unwary listener picks up the glimmer of truth from the second reading, and the devastating importance from the first reading, and thinks, Wow!”
The example he gives is the phrase, “love is just a word.” Without further reflection, this seems both true and profound. It is true, in one sense, that love is just a word. Everything is just a word, so long as you are referring to the letters on a page. In that sense, the sentence is true, but entirely trivial. However, the other reading of the sentence is manifestly false. Love is not just a word. We might quibble over exactly what it is – an emotion, an act, a relationship – but we all know that it is a profoundly important state of the human mind, that completely shapes lives, for the better and for the worse. In that sense, “love is just a word” is an incorrect statement. However, because we don’t pause to clarify our definitions, we conflate the truth and the profound, making the statement say something that it can’t.
When someone states “love is just a word”, they are trying to say something more profound than a statement about letters in the dictionary. The statement they are trying to make is patently wrong, but it is given a veneer of correctness through ambiguous grammar.
I think this concept might explain at least some of the gulf between my interpretation of the phrase “first, do no harm”, and the responses from the broader medical community. It may not be a perfect fit, but is has at least some components of a deepity. There are multiple possible interpretations. Some true, but completely trivial. Others sound profound, but are actually impossible or illogical.
Of course doctors don’t want to cause harm. There is a clear truth in that statement, but if you are going to read it that simply, then the statement is so banal it might as well not be said. In the simple and true interpretation of the phrase, the statement provides no value. Or worse, it is downright insulting, as if doctors need to be reminded not to hurt their patients.
But when most people use this phrase, they are trying to say something more profound than simply, “hey doc, try to remember not to hurt that patient.” They want it to mean something. They want it to be a rallying call for the medical profession. They want it to have enough power and meaning to stand as an oath (although, of course, this was never in the oath).
“First do no harm” is a deepity because it is impossible to act in medicine without harm. That apparently profound statement is just wrong. Our best therapies all have significant harms – that is the price you pay for altering the complex homeostasis of human physiology. Aspirin saves lives in MI, but causes GI bleeds as a harm. There are many profoundly helpful surgeries, but all surgery involves immense harm. Sutures cause harm on the path towards healing. Morphine alleviates pain, but also can cause tremendous harm. The only way one could possibly avoid harm is by doing nothing. (In other words, one would have to practice homeopathy.) Pseudoscientific medical practitioners like to jump on that last point, suggesting they are capable of avoiding all harm, but of course their arguments are ridiculous, because they also avoid all benefit (and ultimately cause harm in doing so).
I had never encountered the term before, but I am convinced that “first do no harm” is a deepity. On one reading it is true, but so completely trivial that there is no point in uttering it. Other interpretations make it sound profound, but those interpretations are simply wrong.
Other FOAMed
The Harms of “First, Do No Harm”
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8 thoughts on “Is “First do no harm” a “deepity”?”
Nice reflexion and I understand what you want to critic, but I wouldn’t call trivial a constant and proactive urge trying not to put the patient in a higher risk for than they were before, and I don’t see it so commonly in medicine (for all of the bias you so often and so well discuss).
I would say, if you one wants to formulate it “First, never do more harm than good”, that’s okay, but I think the final goal is the same and it’s just a shortage to the longer phrase.
I think you might be making my exact point. When rephrased in your longer format, it is such a simple and trivial statement that it never needs to be said. (In fact, it is pretty insulting to physicians.)
Hmm, an interesting reflection. I’m not sure I feel insulted by the maxim though. For me, “first do no harm” is a reminder of exactly what you describe – all actions in medicine have a cost, so be conscious of that. And oftentimes we have a tendency to act in medicine, where doing nothing precisely is the right thing to do (you yourself have posted a few articles on this idea – Paxlovid, overdiagnosis, NINJA trial as a few recent examples).
As always thanks for the post!
I think you might be combining both senses of the phrase in your response. Of course there is no reason to be insulted if the phrase is complex but in its complex form it is false. The very simplistic true interpretation really is insulting because it implies that doctors might forget not to hurt their patients.
I have always had the insight into the idea behind the word “deepity”, but I couldn’t find the right terminology until today. I appreciate the focus that goes beyond the obvious.
Finally, I would like you to consider writing a post about flow states.
I understand the point you are trying to make, but I have a different take on this maxim. I see it more as a hierarchical guide for ethical priorities when caring for patients—a compass for making decisions in difficult situations where the balance between good and bad outcomes is very close, and shared decision-making is either not possible or not desired by the patient. In that kind of scenario, it makes sense to prioritize first not causing harm as a rule of thumb.
I think you might be making my point. You are reading way more into this phrase that it actually says. You are not practicing day to day following the apparent sacrosanct advice of “first, do no harm”, because that would be impossible. You are instead reading something into this phrase that doesn’t really exist.
As a side note, I might push back on the concept that this is a good rule of thumb. Imagine a scenario where I have a 21 year old stabbed in the chest and dies right in front of me. He has a low chance of surviving, but his only chance is for me to perform a very invasive thoracotomy. Doing no harm would say I don’t do the procedure, because 8 times out of 10 it is going to cause harm with no benefit. But the right choice is clearly to give this patient a chance.
You can easily come up with endless scenarios that disprove “first do no harm” as an ideal guiding principle. There is no benefit without harm. Changing human physiology always causes harm. We are looking for net benefit, but that is a much more complex concept than the overly simplistic “first, do no harm” can handle. Of course there are examples you can cite where “first do no harm” seems like a good guiding principle, but this is just confirmation bias. Look for the alternatives, and you will see this phrase has no place in modern medicine.
I’ve been thinking quite a bit about that phrase. It is connected to the ‘sin of omission ‘ which I certainly see quite a lot in my daily work. And omission puts patients in danger. It’s a balance, like so often.