Do No Harm

Hello my Zebras and Spoonies! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I’m going to be talking about medical ethics, specifically “Do No Harm.”

Of all the Hippocratic writings the Oath, in spite of its shortness, is perhaps the most interesting to the general reader and also to the modern medical person. The idea of not doing the patient harm is within the Oath, but the phrase “Do No Harm” is not. Whatever its origin, it is a landmark in the ethics of medicine. It is a declaration that the purpose of medical knowledge is solely for healing. The Oath is the oldest known written work that speaks to Biomedical Ethics. And the idea that it expresses is still at the center of all bio-ethical debates today.

Do No Harm.

This seems so easy and so readily apparent. What is there to discuss? Yet, in the world of medicine, there are many layers to the idea of not hurting people.Defining harm is complex and convoluted. It is part of why ethical questions are difficult to answer.

The question of what is harm has many answers. Some philosophers, such as Epicurus, think harm is necessarily experiential. In other words, you must experience something bad to be harmed.  According to this view, money secretly stolen from a bank account or a symptom-free cancer are only harms if the victim is aware of them. In this view, ignorance is bliss.

Other philosophers disagree with this view. Imagine if your friends were paid actors pretending to be your friends. Despite their behavior, your ‘friends’ actually despise you. If you believe in non-experiential harms, you might say you are harmed by having false friends – even if you never know the truth about their friendship-for-hire. And if this is the case, then you can be harmed by the cancer you never knew you had, or the affair you never discovered.

Is harm a physical thing or does emotional, mental and spiritual harms also fall under this umbrella of doing no harm. Is it a doctor’s responsibility to ensure that their interactions with their patients are ones that are also not harmful to the non-physical self of the patient? The general thought on this is that yes, the doctor shouldn’t be causing their patients any kind of harm even the emotional, mental or spiritual kinds of harm. But this is a pretty big area of grey. It is also an area fraught with problems. Especially when people are engaging with each other across different cultures.

There are many topics that doctors need to discuss with their patients that are emotionally difficult. Conversations about serious diagnoses, poor prognosis, end of life care and futile treatment discussions are all ones that are going to be emotionally difficult and will often cause the patient pain even when those conversations are handled with care and kindness. There is certainly no expectation that these types of important conversations should be avoided in an effort to avoid emotional harm. Yet, there is an expectation that those conversation happen with compassion.

Non-maleficence, which is derived from the maxim “Do No Harm”, is one of the principal precepts of bioethics that all healthcare students are taught in school and is a fundamental principle throughout the world. Another way to state it is that, “given an existing problem, it may be better to do nothing, than to risk causing more harm than good.” It reminds the health care provider that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

But Non-maleficence is not where this ends. Because there are clearly times that doing nothing will cause harm. Medical Neglect is defined as: failure of a health care provider or caregiver to observe due care and diligence in performing services or delivering medicine or other products so as to avoid harming a patient. This can be intentional or accidental, but the result is the same. A person needed care that was not given. Because the care was not provided, harm occurred. This is Medical Malpractice, or the Improper, unskilled, or negligent treatment of a patient.

Most would agree that the first and most obvious implication of “Do No Harm” is the absence of violence. A doctor can’t punch his patient in the face. Nope, doesn’t matter how much of a jerk the patient is. No punching. But what obligation is there to the environment? Is a doctor responsible for keeping his location of practice safe? How far out does this reach? The expectation in America is that we are required to keep our locations of practice safe. It is our duty to prevent violence. That means we can’t allow guns and knives to be carried about. And we can’t allow people to hurt themselves or others while they are on our property.

But what about on a societal level? Do doctors owe something to keeping the community safe? There are some who feel that they do. As providers of care, they hold an important role in the community. Community leadership and education is an expectation even though it is not a legal requirement. But does this fall under the idea of “Do No Harm?” If people do not know what services are available, they will not use them and will have poor outcomes. Harm will be the result.

And there are some who feel it is the doctor’s duty to be an advocate within the political arena. Their patients are often too sick to fight for their own rights. Does that make it a doctor’s obligation then? Some feel that it is. There has been a strong push for doctors to unite in finding solutions for better distribution of health care.

So why does any of this matter to us as chronic illness patients? Medical ethics is a guiding force when providers are making clinical decisions. Understanding how decisions regarding your care are being made can be helpful. The medical system is a complex and difficult beastie to understand and we as patients are often left feeling that we are in the dark. There is rarely time for doctors to explain the rationales behind the decisions that they are making let alone the medical ethics that are driving those decisions.

The more that we understand how medical decision making is done, the better we can engage with that conversation. It allows us to ask better informed decisions. It allows us a foundation to use when formulating our thoughts about our medical care. This can be especially helpful when we are feeling that we are not getting the health care that we need.

Thanks for coming and spending some time with me. I hope that you all find peace and wellness. Until we talk again, you take care of yourselves!

More reading on this topic:
The Oath
Just Distribution of Health Care
Neglect
Do No Harm
Non-Maleficence
Modern Medical Ethics

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