First Do No Harm

Sometimes people tell me that treatments like antipsychotic medication and ECT are unethical because they can have side effects. The Hippocratic adage “First Do No Harm” gets quoted as proof that no treatment that could harm someone should ever be prescribed.

And that would be fine, except that’s not what the old saying really means. Doctors would be in a tricky spot if it were. Every single treatment ever given to a patient has held the potential to cause harm – chemotherapy is a horrendous assault on a person; any operation could be terminal. Even taking a blood sample can cause bruising.

In reality, “First Do No Harm” (or “Primum Non Nocere”) is more complicated, and in fact, Hippocrates never even said it. The earliest known attribution is to medieval doctor Thomas Sydenham (1624-89) in an 1860 book by Thomas Inman.

In modern times we associate the famous saying with the two ethical principles of non-maleficence (avoiding harm) and beneficence (doing good). The two principles constantly hang in a delicate balance as we try to decide just how much to treat someone, knowing that every treatment we give has inherent risks. Sometimes it might even turn out that doing nothing is best, if all the available treatments are known to be ineffective or the condition is known to be self-limiting.

So a more authentic interpretation of the phrase might actually be “make sure you consciously try to do more good than harm”, though that wouldn’t look so good in Latin.

This balance between trying to do good and risking harm is no less important in psychiatry than anywhere else. It’s also where the real ethical criticism of some of our treatments can be found – we sometimes get the balance wrong, giving too little thought to risks when we chase improvements. Antipsychotics can be prescribed for too long and in high doses; admissions under the Mental Health Act can drag on long past the point of overall benefit. Thousands of people are given antidepressants for sadness that will pass naturally.

I can understand how this happens. The future is hard to predict; we can never really be sure how well a treatment will work or which side effects will show up. Turning incomplete information into good decisions is not something the permanently biased human brain does well, so we often do something rather than nothing simply because it feels like we’re helping.

But another medical ethical principle could help us out – autonomy. The right of the patient to make decisions for themselves if at all possible is, I think, the most overriding right in medicine. If we involved patients more often in making decisions about their care, by explaining the potential risks and rewards of each option, the best course of action might become obvious. Some would be immediately keen on taking the risk, for others they might have strong personal reasons against it. We could share in the success when things go well and share the responsibility when things go badly.

So “First Do No Harm” doesn’t mean what many people think it does, but perhaps we could still improve on it.

How about “First, Discuss The Harms”?

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

8 Responses to First Do No Harm

  1. Sunseeker says:

    First discuss the possible harm – that has got to be a good path to a treatment plan.
    I was prescribed a SNRI (venlafaxine) and a period of little improvement led to increased doses. I had no knowledge of what this drug was like: the possibility of becoming dependant, the difficulty of withdrawal, the advice that 6 months is the suggested timescale for taking this drug.
    After nearly 3 years it became apparent that the symptoms I was then displaying we’re akin to withdrawal. I had in effect became so “immune” to it that it was having no effect. So the only option, and with the assistance of a new psychiatrist, I started a slow taper and over 5 months I stopped taking the drug. During this time I was so disturbed I was subject to s. 136, I was suspended from work and subsequently lost my job. I have not worked since. I have lost affection for my children which I now know can be a feature of this medication. I feel I am nothing but an automaton.
    Now the logical approach would be to suggest that during these 3 years maybe I maintained a level of functioning that I would not otherwise have achieved. However, I had no idea of the cost of this. And that is the point. I did used to care. I have a child with special needs and two very elderly parents who I also “care” for. Maybe it would have been better to face my limitations with depression earlier on, maybe it was better for me to struggle on and be salaried for those 3 years. But the point is I had no knowledge and no choice.
    I do feel as though harm was done to me and I do feel bitter. I remain now without medication and just long for the day that I die.

  2. Elaine says:

    Thanks, Alex, for another well thought out blog post. I had a discussion on this and similar topics with a couple of psychiatrists some weeks ago. The consensus seemed to be that discussing risks and side effects as part of the process of obtaining informed consent was important, but that in cases where the patient was (or was thought likely to become) subject to compulsion, it was not appropriate to discuss these issues in depth. The doctors concerned felt that, since the patient wouldn’t have a choice, it would be unkind and distressing to leave them facing the possibility of potentially severe side-effects from medication that they couldn’t refuse. I was wondering if you had an opinion on that?

    • Hi Elaine

      I think that there are times when it wouldn’t be the right thing to tell the patient about the state of play and the options. Telling children of a young age and patients who are incredibly distressed and organically confused might often make things worse without gain.

      The key is probably the patient’s capacity to understand. Tell them as much as you think they can understand, in a way that they can understand it. Err on the safe side and try hard even if you’re not sure it’ll get through; I even talk to patients with catatonia as if they were fully aware.

      And no, I absolutely don’t think we should avoid telling detained patients about their treatment when they don’t have a choice in it. It cetainly won’t make things easier and they have a right to know. Though we often think not breaking bad news is for the best, it’s not really our information to withold. It’s about the patient, their body, their mind.

  3. Very useful piece again Alex. It reminds me last year when working on a clinical trial and the discussion with six consultants of HOW to recruit and say actually as long as we do ECGs etc you can take the escitalopram. Very hard as patients are human beings and the minute you start talking about risk/negative side effects etc it adds another dimension into the therapeutic alliance. Needless to say many chose not to take the risk…..However when someone is very unwell a balance has to be taken and yes sometimes there is no choice = not ideal but for the greater good is really important. Not saying creates further problems down the line. .In general medicine these issues crop up all the time ie patients with cancer- a choice between nasty side effects or your life. Mental illness is a shitty nasty illness, psychiatric hospitals not healthy environments beyond acute phases, whatever the diagnosis. Anything that gets you out of hospital and back into a functional place again has a very worthy price tag. .Your writing flows well. Well done!

  4. Nick says:

    I agree about the principle of autonomy given the need to balance risk and potential benefit. It is especially hard in mental health – the data is often so weak even within the scope of what’s constructed and researched as part of medicine and psychology, let alone the un-asked questions and sheer damn-it-all complexity of all the interacting systems. Given the human biases affecting both professional and patient we can at least talk, decide together to minimise regrets and be one-another’s “check” and “balance”. I just wish the pool of data to draw upon was not so tainted and I am not pleased that aspects of financial incentive will further colour the process in a marketised NHS.

  5. Jean Davison says:

    Thanks for this interesting and important post, which raises the question of what people actually mean by ‘First, do no harm.’ Yes, a good point that most treatments (in psychiatry and general medicine) do have potentially harmful side effects. As you say, it may indeed be better to do nothing if there isn’t good reason to believe that benefits are likely to outweigh risks. I don’t disagree with most of what you say in your post, but I’m not sure that ‘First, do no harm’ does not mean what many people think it does.

    When I say ‘First, do no harm’ I mean, if you don’t know how to help someone, best to admit it and err on the side of at least not making things worse. I know patients sometimes demand that a psychiatrist ‘do something’ but that doesn’t mean the psychiatrist should agree to do what is hardly likely to be in the patient’s best interest.

    Yes, ‘First, discuss the possible harm’ would be a big improvement on not discussing it. When I was ‘persuaded’ to consent to ECT as a naive, vulnerable teenager, I was told ‘There are no risks’, and I was told nothing, too, about the debilitating and harmful drugs I received.

    I know that in some situations it’s far from easy to know, or agree upon, what is or isn’t in a person’s best interests. But I can never understand how bombarding a person’s brain with drugs and electric shocks can possibly be expected to help in situations where it’s the person’s circumstances, not their brain, that needs changing. So, ‘First, do no harm.’

  6. judithhaire says:

    Reblogged this on Far be it from me –.

  7. Alex, I want you to know something and to learn it from someone who has been there in person, catatonic herself. WE HEAR EVERYTHING you say. Believe me. We are NOT non compose mentis, no matter how bacterial you may believe we are…When I was catatonic to the point of needing all my bodily functions taken care of for me, I nonetheless was aware of what people said and what was going on around me, and it mattered. Oh, I knew who thought they could either laugh at me or discuss my care in my presence as if I were literally mindless. And I still to this day remember! But I also remember the psychiatrist who understood that I was “in there” and who treated me as if I were a human being who was conscious and alive “in there” and spoke to me not about me when in my presence. It made a world of difference. If you learn nothing from me and my comments on your blog, I hope you learn this one thing. No psychiatric patient that I have ever met has ever been so far gone as to be a vegetable. We are far more conscious and aware of what YOU as a psychiatrist are doing and thinking and saying than you have any idea, apparently, and it behooves you to keep this in mind, every single time you interact with a patient.

    I am sorry, but your post made me furious. How dare you NOT discuss the pros and cons of a treatment with someone who is being forced to have it. How dare you even think to force treatment on anyone? FIRST DO NO HARM…well, do some research into the drug companies that taught you all you know about the drugs you prescribe today, because sure as shooting that is where you got your information about them, where else? No one else does any research about the drugs, so you had to learn about these drugs from the pharmaceutical companies, and they LIE about their drugs to make money…

    As for ECT, tell me, since when has causing a seizure in anyone’s brain been a good thing for them, except in psychiatry? That just makes no earthly sense, except to psychiatrists…But they said that about lobotomy and insulin coma too, so of course they would white wash seizures induced by ECT…why not? They haven’t been shocked themselves and lost short term memory or developed temporal lobe seizure disorders afterwards, so why not support the use of ECT? It is easy and no one is stopping them!

    Oh you student psychiatrists who don’t bother to question the received wisdom of your teachers just make me want to throw up…

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