Stop saying “first, do no harm”. Seriously, just stop. A moment’s reflection will reveal how inane and unhelpful the phrase is. Might doctors forget and start harming their patients if we don’t regularly remind them not to? However, more than inane, “first, do no harm” paints an unrealistic picture of medicine that actually causes immense harm.
Doctors as idiots
Don’t harm your patients. That seems simple enough. We obviously don’t want doctors purposefully hurting patients, but do we really think that they require the reminder? (And if anyone is psychopathic enough to be hurting their patients on purpose, do we really think that hearing someone say “first, do no harm” is going to stop them?)
Taken at face value, I find the statement insulting. It seems to imply that we are dumb or absent minded enough to require constant reminders not to hurt our patients.
The harms of “First, do no harm”
However, the insult really isn’t what bothers me. The real reason that the phrase needs to be banned from the medical corpus is that it perpetuates a misguided understanding of medicine that, somewhat ironically, results in significant harm.
Medicine cannot be practiced without causing harm. Those supposedly sacred words are a lie. Any treatment that has an effect will also have side effects. Any hope of benefit will also be accompanied by a risk of harm. That is a fundamental, but often overlooked, rule of medicine.
Harm cannot be avoided. Do you withhold aspirin from a STEMI patient because it will occasionally cause a GI bleed? Do you withhold antibiotics in meningitis because of the risk of Clostridium difficile? Do you place chest tubes? Do you intubate? It might be catchy, but “first, do no harm” is consistently ignored in medicine, because every medical intervention will cause some harm.
I would like to assume that no one means for “first, do no harm” to be interpreted in this senseless way. However, at almost every conference I attend, someone seems to pull out the inane “first, do no harm” straw man. “Didn’t you know that succinylcholine can cause hyperkalemia. First do no harm!!” “Thrombolytics can cause head bleeds. First do no harm!” “Thoracotomies cause open chests. First do no harm!!!” Mic drop.
I don’t believe that I have ever heard “first, do no harm” invoked as part of a balanced medical discussion. The phrase is almost exclusively used as an inane rhetorical device; as a way to obfuscate intelligent conversation. (If we were willing to engage in intelligent conversation, we wouldn’t need to parrot thoughtless slogans.)
When harms clearly outweigh benefits (or when benefits clearly outweigh harms), the appropriate action is obvious, and “first, do no harm” is, at best, redundant. When harms and benefits are closely balanced, “first, do no harm” could act as a guiding principle, but it seems to fail both theoretically and practically in modern medicine. Strictly following this advice seems to lead to an incredibly paternalistic practice of medicine, in which physicians judge these difficult decisions independently, ignoring patients’ values, and excluding patients from the decision making process. Perhaps more importantly, I think the evidence is fairly overwhelming that doctors ignore this advice.
Doctors aren’t listening
Doctors consistently overvalue benefits and discount harms. Despite the endless repetition of “first, do no harm”, the evidence suggests that we tend to do the exact opposite. We err on the side of intervention, regardless of the harms.
Consider the use of heparin for NSTEMI. When I read the evidence, I see clear harm without any benefit. However, in the very best light, heparin might cause a small decrease in non-fatal MI, but an equal increase in major bleeding. (Andrade-Castellanos 2014) If “first, do no harm” was truly a guiding principle in medicine, we would give more weight to the harm in this balance, and advise against heparin. Instead, guidelines enthusiastically recommend using heparin, completely ignoring the harm. (Amsterdam 2014) When it really matters, we ignore the words of Hippocrates.
There are endless examples. When harms and benefits are equally balanced, we consistently discount the harms and tout the benefits. PPIs are still widely prescribed for acute GI bleeds, despite no evidence of benefit and some clear indications of harm. We prescribe antibiotics for otitis media. We cast buckle fractures and Salter-Harris 1 injuries. We debride burn blisters. We acutely manage asymptomatic blood pressure. We use adenosine for SVT. We consistently ignore harms and fixate on benefits.
The culture of “do no harm”
Despite being rather inane, “first, do no harm” is repeated consistently enough to influence medical culture. Those 4 silly words establish an expectation of perfection. Harm becomes taboo. When a treatment I prescribe harms a patient, I have violated my oath. (“First, do no harm” is not actually part of the Hippocratic oath, but the feeling is the same.) This culture dissuades us from openly discussing the harms we routinely cause. We spend much less time teaching our medical students about the harms of our treatments than we do the benefits. Our patients often assume that anything we suggest must be perfectly safe, because a doctor would never do harm.
The taboo of harm is ingrained in the culture of medicine. We talk about “risks and benefits”, but this is an inherently unbalanced equation. The benefit is stated as a given, whereas harm is only mentioned as a possibility. We won’t even say the word “harm”.
Studies are powered for benefit and often don’t even look for harms. Systematic reviews always report benefits, but often fail to mention harms. The same is true of guidelines. We have made harm a dirty little secret in medicine.
The constant repetition of this phrase creates a false impression. It leaves medical students, patients, and maybe even experienced doctors with the impression that there are risk free treatments. There are not.
Ironically, the idea that doctors would never do harm underlies the proliferation of harmful practices. “What’s the harm?” is a common refrain in medicine. We offer unproven therapies with little regard for their potential harms. (The COVID pandemic is a perfect example, with medications like hydroxychloroquine being widely prescribed despite no indication of benefit, and plenty of harms.) We see patients undergo invasive angiography, despite a lack of benefit. We see futile rounds of chemotherapy. We see unnecessary surgeries. We see patients demanding antibiotics for their viral illnesses. We routinely order full body CTs in trauma. “First, do no harm” fosters a medical culture in which harm is shameful, thus ignored, and allowed to proliferate.
I will admit, “always ensure that benefits outweigh harms, and if there is uncertainty use your judgement and involve the patient in decision making” is not nearly as catchy. However, “first, do no harm” is either inane, insulting, disingenuous, or misleading. It is either a self-evident cliche, or it is a pernicious distortion of true medical practice. Every medical intervention causes harm. It is impossible to “do no harm”, and by continuing to pretend we can, we are hurting our patients.
References
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130(25):2354-94. [pubmed]
Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Magee K. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014;6:CD003462. PMID: 24972265
Justin Morgenstern. Stop saying “First, do no harm”, First10EM, 2020. Available at:
https://doi.org/10.51684/FIRS.21347
28 thoughts on “Stop saying “First, do no harm””
thanks for the article … how weird … I just finished penning a poem on this very subject .. but looking at it from a slightly different perspective. Thanks for your as always insightful articles … 🙂
The “first do no harm” truism really suffers some blows when you go through guideline recommendations and why studies are powered for benefit and not harms .
Some great (and needed) points!
I use the “Do no harm” mantra when explaining to drug seeking patients why they are not being given any. I tell them that I took an oath not to do harm to my patients and that by abetting their addiction, I would be doing them harm. It seems to lower their anger level.
Meh – usually you are on the mark. Primum non nocere still a useful guide – and one that was shamefully ignored by some colleagues who were taking hydroxychloroquine during the earlier days of covid.
I obviously completely agree with you about the shameful discarding of science during our early response to COVID, but I actually think it is a good example of how useless the phrase is. Everyone has heard “do no harm”, and clearly no one listens.
But I think the most important point is that it is impossible to do “no harm”. Are you going to avoid a possible COVID vaccine if there is the usual 1 in a million risk of GBS or other major harms? That’s what the slogan seems to imply.
I think you can provide high quality, restrained, evidence based care without resorting to cliched slogans.
How was hydroxychloroquine any different than any other drug at that time? At least we knew the slight chance of harm from it.
Your article is not helpful by insulting medical professionals and telling them what and what not to say regarding giving patients the best care. Doctors and other medical professionals are not infallible and we understand this as a basic human nature concept; medical professionals make many important decisions, especially when it comes to performing new surgeries, “promoting” vaccines, and even when it comes to prescribing new medications (w/various side effects) to their patients.
We should all keep in mind the important and necessary precautions that can potentially prevent and help us to make sound, ethical, and vital decisions that impact a patient’s overall health and well-being. Then, perhaps, maybe we can learn more about how we can take some personal responsibility for our own actions in order to provide the best care possible.
Primum non nocere.
“Might doctors forget and start harming their patients if we don’t regularly remind them not to?”
Yes.
It’s more about thinking about your patient and what’s best, and not just your opinion. Not just pertaining to physical harm.
That’s the interesting thing- everyone seems to interpret it differently, even though it seems like a simple statement. If you really want it to mean think about your patients, why not actually have the phrase say that? First do no harm, in most cases I have seen it use, actually seems to exclude to patient from the process.
That may not really be as insulting as you tried to paint it. First, do no harm. that is, even if there is nothing you can do to help, just be sure not to do any harm, at least voluntarily. Do not for bills refuse to help. Let the primum, non nocere guide you. I rather find it Noble rather than insulting. It doesn’t suggest an inherent tendency of doctors to wish to harm a patient. It doesn’t portray doctors as incompetent. Just
Research curiosity should not take precedence over the well-being of patients, a solemn reminder. This can be extrapolated to cover the whole of society
Interesting that you would be so vehemently opposed to a simple statement that prohibits harm, and write a big article about it. Sounds like cancel culture to me. Especially with a GREAT DEAL of harm being dished out by doctors every single day in the name of big pharma. I’ll say that phrase as often as i’d like to, thank you very much.
It would appear that you either didn’t read or missed the entire point of the article.
You have clearly not read past the first three words of that oath. It means we must consider the alternative outcome when not treating the patient. As well as to weigh the risk and potential benefits of performing that intervention. Not “If I give this patient ASA they may develop a GI bleed”. Truly misinformed article I stumbled upon.
What oath are you referring to? “First do no harm” is not part of any oath. You are reading a lot into – which is fine – but nothing you are saying is implied by the words any more than my interpretation. In practice, I have never seen anyone employ your interpretation. When this phrase is used in medicine, it is almost always to overly simplify an argument. If you think the important concept is to ‘weigh the risks and benefits” why not make that your mantra, rather than the inane “do no harm”?
“First, do no net harm.”
Love it, but most clinicians I feel understand the deeper meaning of this phrase. The interpretation presented in this article is as superficial as the workup prior to admission 😅
Thanks for the comment.
1) I am not so sure that most clinicians do understand a deeper meaning to this phrase. Modern healthcare is out of control. We continuously add new tests and interventions with very little evidence of benefit, and ignore potential harms and costs. I think the empirical evidence would be against us “doing no harm” in modern medicine. Personally, I have never seen this phrase used in a helpful context. Of course, I can think of many ways to interpret it in a positive light. But practically, it only ever seems to be uttered as a rhetorical device to shut down conversations about science.
2) If you need to interpret a phrase in order for it to mean something that it doesn’t actually say, I am not sure that is a phrase you should be idolizing as the beacon for medical practice.
I agree with you that the vast majority of usage of the idea is for rhetoric. I also hold the personal belief that as a doctor, I do more harm than good for a myriad of reasons. I perform CPR where there is clearly no hope. I stick children with needles and give them medications that could cause them to stop breathing to move their broken bones around when they would probably heal well anyway. I hand out medications with profound side effects because if I don’t, downstream specialists won’t take my patients (see TXA and PPI in UGIB). I work in a hospital that requires me to give out thrombolytics in stroke despite the horrific evidence, that I have brought forward and discussed and re-discussed with policy makers.
But I use the idea when counselling families, either about end of life care and resuscitation plans, or in those rare instances when I become the unlucky one to diagnose a dread disease. I use the phrase extensively in those discussions, and people tend to then understand the gravity of all the crap we do to eke life out of failing bodies.
Perhaps a thoughtful interpretation of “First, do no harm” would be: don’t be arrogant, presumptuous, entrenched, insensitive, in to big of a hurry to really listen, closed off to new therapies or old therapies. Perhaps it is a philosophy the business side of medicine should follow more closely.
Sadly the noble platitude of do no harm has provided cover in areas such as the management of insomnia, to do no good either. Guidelines have become so prolific that we are governed by the deviation from recommendation as tantamount to being a purveyor of medically negligent practice.
I’m happy that “Do no harm” is a given to you. You will make a good medical professional if this is part of your personality.
Unfortunately not everyone innately shares this philosophy. Many medical professionals get into the industry for money, some for notoriety of the title, and others for job stability.
Living in a society that puts money first, and working with insurance companies that that prioritize revenue over people, we often find thousands of medical professionals who will eventually take a step off the path of altruism and succumb to the daily pressures of medical practice as a money maker.
I’m sorry that you find saying “do not harm” insulting, however that phrase is not there for you, that phrase is there to protect our patients. I’m not insulted that we have laws for seatbelts. It’s a given to me, I don’t get upset that we have seatbelts laws because I know it saves other people’s lives.
I’ve been in the field for a decade and I know dozens of other doctors who would agree with this statement.
Yes, if we truly care about our patients, we 100% need to recite “do not harm”. I’m glad that this is already instilled in your philosophy, you will make a good medical professional.
The thing about philosophy is that it leaves room for discussion. If you take harm in the literal sense of biological harm, than sure have at it. If you take it in the sense that a physician is more than just an agent of medicine, do no harm carries much more meaning. If what we do is an insult to a patients autonomy, then we truly have caused harm. If it were as simple as explaining it in a purely empiric manner then you might as well just throw medical ethics out the window. Just my 2 cents as I still truly believe in such a statement…. then again I like to make things complicated. But I will give a good example. 90 year old pleasantly demented patient presents for ams and ‘diarrhea’ ED pan scans per usual. Incidental findings, possible malignancy. Spoke to patient and family. Discharged before the end of day. If it was cancer, clearly gave the patient a death sentence. Was there harm? I don’t believe so. Patient did not want more tests. Family had POA. Both parties were happy to avoid hospital delirium, invasive tests, time away from grandkids, covid exposure. Letting the patient with probable pancreatic cancer go, clearly harmful correct? Let the spaghetti monster lay judgement on this act of Do No Harm. What comedy of a profession we chose.
I think your case is a perfect example of why this phrase is actually so silly. I have heard people use the argument “do no harm” to do the exact opposite of what you did, based on the idea that missing anything would be harmful. The point is, there is always harm in medicine. Every treatment has side effects. Every decision has consequences. We need to work very hard to make sure we are always doing more good than harm, but I have never seen the motto “do no harm” actually help in the balance. No doctor who is going to make the right decision for the patient, such as you did, would be led astray if they just stopped using the phrase. But I have seen many led astray by the mindless parroting of “do no harm” and the resultant stigma created around discussing the harms we necessarily cause in the routine practice of medicine.
I think everybody here is talking about the same thing. That they can no longer practice medicine like it used to be, when I was a kid, and the doctor did home visits, and said “let nature take its course.” The doctor walked in without knocking. So mothers were anxious to keep the house very neat and clean. The doctor might organise with the local pastor to deliver regular fresh fruit at a home where he reckons the problem is due to lack of proper nutrition. When my mother died, the doctor’s wife arrived at our home with a cake she had baked for us. Back at school the doctor’s daughter, who was my age, sat down next to me at break time and said: “My father said your mother died and I must make friends with you.”
“Might doctors forget and start harming their patients if we don’t regularly remind them not to?”
Let me give you several examples: The Tuskegee experiment where black men with syphillis were slowly observed as they died with no knowledge of what was happening. The forced sterilization of thousands of women. Electroshock therapy. Gay conversion therapy. The pseudoscientific biological racism used to support segregation.
Entirely agree – but that ignores the second part of the argument. Do you really think that same doctors who performed these actions would be deterred by a slogan? Do you think that a doctor performing forced sterilizations is all of a sudden going to stop, because someone misquotes Hippocrates at him? Is there actually any value in parroting these words? (And does that value overcome the tremendous harm that this mindset has caused?)
The phrase shouldn’t be parroted at every opportunity but it holds an important place in medical ethics. Patient consent is often violated in the name of benefit. This goes against the Hippocratic oath. A good example of the oath is sending an terminal patient home to die with their family instead of subjecting them to more tests and the stress of the hospital.