First, do no harm

As an important step to becoming a doctor, medical students must take the oath of Hippocrates. And one of the promises in this oath is "first, do no harm" (or "First do no harm", the Latin translation of the original Greek).

Right?

Wrong.

While some medical schools require their graduates to meet the Hippocratic Oath, others use a different garment - or not at all. And in fact, although "First, do no harm" is attributed to the ancient Greek physician Hippocrates is not part of the Hippocratic oath at all. In reality, it is another of his works called epidemics.

So why the confusion? 
It is true that there are similar language found in two places. For example, here is a line of a translation of the Hippocratic Oath:

"I will follow this treatment system, according to my ability and my judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."

Yes, the applicant must be avoided damage, but nothing that is a top priority. Meanwhile, epidemics says

"The doctor should be able to tell the story, meet present and predict the future - must reconcile these things, and they have two special view of illness, that is, to do good or evil purposes".

Again, there is no clear priority to the prevention of damage to the objective of providing assistance.

It is "First, do no harm" possible? 
The idea that doctors should, as a starting point, will not harm his patients is an attraction. But that does not mean that since the bar low? Of course, any doctor should be set to do something that comes only predictable and preventable damage. We do not need an old ancestor, so respected, or an oath to convince us that!

But if doctors took "First, do no harm" literally nobody would have the surgery, even if it was rescue. We could stop ordering mammograms because they could lead to a biopsy of a non-cancerous tumor. In fact, we could not even require blood tests - pain, bruising or bleeding required to draw blood are clearly avoidable damage.

But doctors do not recommend these things within ethical practice, as the modern interpretation of the "first, do no harm 'is closer to this: physicians should help patients as much as possible by recommending tests or treatments that the potential benefits outweigh the risks of damage yet, in reality, the principle of "first, do no harm" may be less useful -. and less convenient - than you think. 

How convenient is "First, do no harm"? 
Imagine the following situations:

   * Their diagnosis is clear - for example, strep throat - and there is no effective treatment available that carries less risk. Here, "First, do no harm" is not particularly relevant or useful.

   * Its diagnosis is difficult and the optimal conduct of the test or treatment is uncertain - for example, you have back pain or suffer from headaches. It may be impossible to accurately compare risks and benefits concessions from a particular course of action against another. So you can not know in advance whether a test or treatment is "do no harm".

   * His diagnosis is severe - for example, an inoperable cancer - and treatment can cause damage. In this case, the term "First, do no harm" is relevant again. The only reasonable solution is to provide comfort care, support and relief from suffering. This is already a guiding principle of palliative care and is widely accepted.

The bottom line 
The fact is that when you have to make tough decisions in real time, is difficult to apply the "first, do no harm" dictum because estimates of risks and benefits are so uncertain and subject to errors.

But it is a reminder that we need high quality research to help better understand the balance of risks and benefits for tests and treatments we recommend. Ultimately, it is also a reminder that doctors should not overestimate their ability to heal, or underestimate their capacity to cause damage.
By: Robert Shmerling, MD,