For those who don't know Latin, this phrase has been variously translated as either: "First, do no harm" or "Above all else, do no harm." It is ingrained into every medical student's brain within a few months of beginning school, and is one of the guiding principles of medical practice.
While popularly thought to be part of the Hippocratic Oath, in truth, such an expression appears nowhere in this oath or in any of the various modern revisions taken by medical students across the country. The origins of the phrase still remain shrouded in mystery, some attribute it to the famous Roman physician Galen (though he, like Hippocrates also wrote in Greek), and a similar phrase appears in the Hippocratic corpus, "As to diseases, make a habit of two things-- to help, or at least to do no harm" (Epidemics, Book I, Section XI)
Regardless of its origins, the idea of "do no harm" is emphasized again and again during our ethics classes throughout our course of study. While the literal meaning of the aphorism cannot be applied practically, since all treatments always entail some degree of risk of harm, the conscientious physician is always to recommend the course of treatment to his or her patient that he believes will maximize the well-being and minimize the potential harm. In no circumstance should an ethical physician prescribe a drug, procedure or other therapy that is known to carry an unacceptable degree of risk for the patient (e.g. prescribing ampicillin for a bacterial infection when the patient has a known allergy to penicillin-like drugs).
Nor should physicians order unnecessary tests or invasive procedures that carry little benefit for the patient or help for the physician in reaching a diagnosis. And, when confronted with a ethical dilemma concerning the management of a patient on a study protocol, the doctor should always consider the best interests of the patient first, even if it means ruining the data collection process.
Finally, when faced with end-of-life considerations, where there is no hope for a cure or rehabilitation, primum non nocere dictates that the best course of action is to relive suffering, pain and allow the patient to die in dignity, rather than performing heroic, costly and unnecessary radical procedures or treatments. Sometimes, the best course of action is do give nothing but reassurance, guidance, and a comforting hand to hold.
Suffice it to say, there's a reason for medical students and physicians to put that "First" there, because when all else fails, one should always remember this guiding tenet above all others. While in practice it isn't always easy or obvious as to what "doing no harm" is, putting one's patient's interests above all other considerations is as close to a commandment as we get in medicine.
Which brings me to this gem, an AP piece on how our Senate Majority Leader, William Frist, MD (as he likes to remind us) considers the fact that there was a leak about secret prisons where torture surely occurs more important than the fact that the United States operates said secret prisons where torture surely occurs.
The money quote:
Frist told reporters Thursday that while he believed illegal activity should not take place at detention centers, he believes the leak itself poses a greater threat to national security and is "not concerned about what goes on" behind the prison walls.
(emphasis mine)
Now, I'm sure that our Majority Leader, a licensed physician (although, I think he's been out of the doctor's office a bit too long given his (mis)diagnosis of Terri Schiavo), knows better than most as to what the medical effects of the CIA's euphimismistically-titled "Enhanced Interrogation Techniques" are. I'm sure he understands firsthand, having gone through that peculiar form of torture that all young doctors must go through (aka residency), what the effects of sleep deprivation are. But at least he also didn't have to deal with being made to feel as though he were drowning, or be subjected to religious humiliation, or placed in stress positions for hours on end. Or maybe such "hazing" rituals are part of the surgeon's training, but if so, I haven't heard of it. And of course, these are just the devils we know from Abu Ghraib and Gitmo, who knows what actually goes on in these Soviet-style gulags the CIA operates.
Regardless of what he should know, let me take this opportunity to remind our esteemed leader what the American Medical Association, hardly a bastion of liberal thinking, suggests to its members about the practice of torture.
From the Code of Ethics (link):
Torture refers to the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment.
Physicians must oppose and must not participate in torture for any reason.... Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great.
(emphasis mine)
So, according to the AMA, torture includes "inhumane" and "degrading" treatments, which I think would include such techniques as stress positions, washboarding, sleep deprivation, etc. And the money quote to me,"Physicians...whenever possible, [should] strive to change situations in which torture is practiced or the potential for torture is great."
So, again, I ask the esteemed majority leader, isn't this a case where your medical background mandates that you recognize this abomination for what it is? Shouldn't you be on the forefront of the campaign against torture? Or have you forgotten your medical ethics? (not that you necessarily had any to begin with, cf. the cat killing episodes)
Unfortunately, I don't think you can lose your license merely for violating "ethical" tenets of medicine, one needs to violate written rules and regulations. But certainly, not condemning torture when you know it is occurring is tantamount in my book to a tacit approval of these techniques. And there's no place for that among physicians.
As I said above, the concept of primum non nocere is the closest thing we have in medicine to a sacred belief. Sometimes, it's a tough call to decide what constitutes harm, but in this case, using pharmaceutical agents, sleep deprivation, physical discomfort, and psychological manipulation to achieve a desired goal is certainly not in the best interest of the detainee, and physicians should have nothing to do with it.
Note: For an excellent discussion on how the DoD is attempting to get around these ethical guidelines for its own medical personnel, see this JAMA piece.
A snippet:
It is clear from the Army surgeon general's report that the engagement of physicians in interrogation remains part of the DoD's policy. The impact of the new DoD ethical guidelines is to justify and rationalize these roles, that is, to continue to allow physicians to support, facilitate, and monitor interrogations that Pentagon officials and lawyers have deemed acceptable but that are contrary to the spirit and letter of ethical guidelines physicians have previously followed.
(emphasis mine)
Basically, the upshot is the DoD distinguishes between physicians engaged in "clinical or treatment-related activities" and non-clinical activities. For the former, the ethical guidelines hold in accordance with applicable law (cf. Abu Gonzalez's memos). For the latter, there are no restrictions in participating in, designing techniques, or monitoring coercive interrogations. Of course, these are exactly the same defenses the Nazi doctors used during the Nuremberg trials.
