ETHICS COMMITTEE
“First, Do No Harm” Melissa Myers, MD FAAEM and Al Giwa, MD FAAEM
W
e all remember standing in ourgraduation robes, hand raised, as we recited the Hippocratic Oath at our medical school graduations. The room would have filled with voices saying the famous phrase “First, Do No Harm.” It seemed very simple to me as a graduating medical student but as the years have passed this has proved to be a more difficult oath to keep than I first thought. “First, Do No Harm” is the basis of the bioethical principle “non-maleficence.” This bioethical principle states that a physician should “act in such a way that he or she does no harm.”1 An obvious example of violating this ethical principle would be to come to work altered or intoxicated. In this case, the physician would be unable to provide medical care without harm to their patients due to their own incapacity. This is an extreme example that I think most of us can say we have either avoided during our careers or sought needed help. There are more subtle kinds of harm, and times when a tradeoff must be made. The second part of this definition is “does no harm, even if her or his patient or client requests this.” Imagine a scenario we all face frequently—perhaps multiple times a shift. A patient presents to the ED with lower back pain, requesting narcotics for their pain. Do you write the prescription? Potentially, your prescription will lead to a narcotic addiction for the patient, surely a type of harm. Or the patient who presents with sinus pain and is requesting antibiotics for what is clearly a viral illness. Do you write the prescription? What if that patient returns with Steven-Johnson-Syndrome or clostridium
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difficil? I would say most practicing emergency physicians have written that prescription once, or perhaps many, times. It’s hard not to in the age of patient satisfaction scores. Holding this principle in mind may help us all to give our patients the care they need, even if it’s not exactly what they want. Closely related to this principle is that of beneficence, which states that not only must a physician not cause harm, but they should also act in a way the benefits their patient.2 As with non-maleficence this is more difficulty in practice than in theory. As physicians, we all believe that we are giving the best possible care to our patients with our extensive training and experience. I would argue that this ethical principle requires us to go farther and confront our own internal biases to improve our care for all
patients. Patients in the United States receive different care based on their race and gender with differences in pain control and maternal outcomes between white and minority patients.3,4 A patient recently arrived to a hospital I work at complaining of abdominal pain. The physician who initially saw the patient described her as “hysterical” and wanted to avoid giving pain medication. Another patient presented with arm pain, and was this time described as “histrionic.” The first patient was diagnosed with a high-grade small bowel obstruction, the second with a humeral fracture. The commonality in these cases was that both patients were women of color, whose race and gender meant that their pain was not taken seriously. To truly do good for our patients, we must avoid perpetuating these differences and learn to avoid our own implicit biases. “Do No Harm” seemed much more straightforward I realized that I left the easy answers behind when I started intern year. Holding to the principles of non-maleficence and beneficence, trying to intentionally apply these principles to our patients on shift, can help us to be the physician we wanted to be as a student.
Do No Harm seemed very simple to me as a graduating medical student but as the years have passed this has proved to be a more difficult oath to keep than I first thought.
References 1. Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Medical Ethics. 2014;15(1):1-10. 2. Beauchamp TL. The ‘four principles’ approach to health care ethics. Principles of health care ethics. 2007;29:3-10. 3. Johnson TJ, Weaver MD, Borrero S, et al. Association of race and ethnicity with management of abdominal pain in the emergency department. Pediatrics. 2013;132(4):e851-e858. 4. Callaghan WM. Overview of maternal mortality in the United States. Elsevier; 2012:2-6.