“First, Do No Harm” – Good Advice? Bad Advice? Meaningless Advice?

By | January 18, 2018 | 0 Comments

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.
– Physicians’ Oath, Hippocrates, c. 460-377 B.C.

When I graduated from medical school years ago, we were given copies of the Hippocratic Oath we had taken. I framed mine, and it is still on the wall of my study. The paper is a bit yellowed with age now, but I can still read it clearly. In fact, unlike most people – even most physicians – I do read it from time to time.

Only a few of the 141 American medical schools still administer the Hippocratic Oath. All the other schools use a variety of oaths, of which only one rejects abortion, only four forbid having sex with patients, and only 25 reject euthanasia – all of which are forbidden by the Hippocratic Oath.

Some medical schools allow students to make up their own oath. These graduates no longer swear to uphold the 2400-year-old traditions of a noble profession, but merely say they intend to put into effect their own ideas. How hard is that?

Despite the fact that the Hippocratic Oath is out of favor with “modern” medical schools, it is still quoted when people think it will support their agenda. The problem is that it is usually quoted incorrectly. How many times have you heard people condemning the death penalty, the war in Iraq, or something else they oppose? How many times have you heard them quote with solemnity, “First, do no harm”?

Read the classical translation of the Oath noted above, the one on my wall. Or read a more modern translation. Where, exactly, does it say, “First, do no harm”? It doesn’t.

In fact, “First, do no harm” is not 2400 years old. It rarely appeared in print till the early 20th century, when most drugs were either useless or actually harmful. To do no harm is a worthy objective. But to put it above all other objectives is confusing at best – and paralyzing at worst. What we should say is this:

Do the most good and the least harm you can, according to your best judgment of the current circumstances.

What the Oath does say is that physicians must not deliberately harm their patients. This idea goes along with the Oath’s forbidding abortion, assisted suicide, and euthanasia. Physicians were told to help their patients whenever possible. When killing people was considered necessary, an executioner was sent for. Killing and healing were kept separate.

Now we have turned the Oath upside down. We are told that it is a good thing for physicians to perform abortions. We are told that it is a good thing for physicians to kill their incurably ill patients, or to help them kill themselves. But at the same time, we are told that it is morally dubious for physicians to serve in the military. In other words, some people read the Oath the same way they read the Bible or the Constitution. These people see whatever they want to see, even if it isn’t there, and they do not see whatever they don’t want to see, even if it is there.

Specifically, they see, “First, do no harm.”

Even if this were in the Hippocratic Oath, how could I obey it? What could I do to be sure I would do no harm? When I was a medical student, I learned that all treatments and medications carry some risk. More complex treatments and more powerful medications usually carry greater risks. But rarely, even an aspirin can cause death.

The most essential substances for life are oxygen and water. But excess oxygen can injure the lungs and cause death. And excess water can be fatal even to a healthy person. Anything I could do might cause harm. So if I put not doing harm “first,” I would tend to do nothing at all.

On the other hand, if I sat and watched TV all day, my patients might die of neglect. Nothing I could do, including nothing, could guarantee I would do no harm. That is, “First, do no harm” is not only poor advice – it is, in effect, meaningless advice.

It is bad enough when people claim to see in the Oath what isn’t there and apply it to medicine. But it is even worse when they try to apply it elsewhere.

Take our war in Iraq. We went into Iraq with four objectives: (1) Remove Saddam; (2) Eliminate Iraq’s ability to threaten its neighbors; (3) Make sure the last of Saddam’s weapons of mass destruction were removed; and (4) Establish a stable government. We have accomplished the first three. Can we accomplish the fourth? I don’t know, and at present things look somewhat promising, but no one can see the future. One thing I can predict, however: You can’t succeed if you don’t try.

Was it a mistake to go into Iraq? Time will tell whether the good we have done outweighs the disorder that resulted. But whatever answer history will give, the question cannot be answered by mindlessly repeating, “First, do no harm.” Yes, we did harm by going into Iraq. But we also would have done harm by not going into Iraq. Not being omniscient, I cannot say which course of action would have been better. No one else can know for certain, either. Like me sitting and neglecting my patients, doing nothing was not the way to be sure of doing no harm.

Or take the situation in Iran. Its leaders deny historical events, declare they want to destroy Israel, and lead mobs in shouting, “Death to America!” Should we trust such people with nuclear weapons? And what about North Korea, which in fact has exploded nuclear and even hydrogen bombs, and is testing missiles with longer and longer ranges?

If we act now to take out North Korea’s nuclear facilities, awful turmoil may result. But if we sit idly and let delusional fanatics build nuclear weapons, even worse things may happen. Not being a prophet, I can’t predict which course of action is likely to produce the most good and the least harm. But no one else can know for certain, either. Again, like me sitting and neglecting my patients, doing nothing is not the way to be sure of doing no harm.

But paradoxically, liberals are quick to declare “First, do no harm” when it comes to military or other conservative policies, but they never say “First, do no harm” when it comes to their own liberal policies. Do some welfare programs exacerbate family breakdown and result in more fatherless children? Does “progressive” education produce graduates who need remedial courses in English and mathematics? Does “bilingual” education produce graduates fluent in neither language? Does “modern” education produce graduates who can’t read cursive writing and can’t make change?

No matter. Liberals see these programs as good in themselves, regardless of actual results. When it concerns their own pet projects, “First, do no harm” is the last thing on their minds. Applying this mantra selectively is a useful political tactic, but it is fundamentally dishonest.

Some people believe the harm that results from our actions is somehow worse than harm that results from our inaction. This notion may make sense in a bureaucracy, where avoiding blame is often the principal activity. In a bureaucracy, “not making waves” may result in a promotion. But in the real world, doing nothing at a critical time can get us killed.

“First, do no harm” is not wise advice. It is often an excuse to do nothing while evil people do their worst. If we sit idly as our nation and our civilization circle the drain, we can blame cowardice, apathy, laziness, ignorance, or stupidity. But don’t blame Hippocrates. He had nothing to do with it.

Contact: dstol@prodigy.net. You are welcome to publish or post these articles, provided that you cite the author and website.


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