First Do No Harm

CHAPTER 1

A NEW
MEANING FOR
‘FIRST DO NO HARM’
I N THE 21ST CENTURY
Heights by great men reached and kept were not attained by sudden flight.
They, while their fellow men slept, were toiling far into the night.
Henry Wadsworth Longfellow (1807–1882), poet and educator

he Hippocratic Oath is an example of outstanding medical
T leadership which has endured for more than 24 centuries. While
some of the principles are more than outdated, many remain steadfast
examples of how we should lead our lives as medical practitioners.

T H E H I P P O C R AT I C OAT H
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the
gods and goddesses, making them my witnesses, that I will fulfil according to my
ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life
in partnership with him, and if he is in need of money to give him a share of mine,
and to regard his offspring as equal to my brothers in male lineage and to teach

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them this art—if they desire to learn it—without fee and covenant; to give a share
of precepts and oral instruction and all the other learning to my sons and to the
sons of him who has instructed me and to pupils who have signed the covenant and
have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and
judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a
suggestion to this effect. Similarly I will not give to a woman an abortive remedy.
In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favour
of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of
all intentional injustice, of all mischief and in particular of sexual relations with both
female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the
treatment in regard to the life of men, which on no account one must spread
abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art,
being honoured with fame among all men for all time to come; if I transgress it and
swear falsely, may the opposite of all this be my lot.1

Since the time of Hippocrates, the practice of medicine as a higher
calling and life career has been based on high ethical standards and
proud traditions. Every day doctors in every country of the world
practise medicine according to a creed that has been handed down
through generations: Primum non nocere, or ‘ﬁrst do no harm’.
In the opinion of some scholars, Hippocrates originated this
creed in his writing on Epidemics in the statement ‘As to diseases make
a habit of two things—to help or at least to do no harm’. The creed
has become an international fundamental principle to remind

1 Translation from the Greek by Ludwig Edelstein (1943), The Hippocratic Oath: Text, Translation,
and Interpretation, Baltimore: Johns Hopkins Press.


A new meaning for 'first do no harm' in the 21st century {3}

doctors to consider possible harm to patients in every interaction and
intervention. It could be argued that the creed is even more relevant
in the 21st century, as many expensive technological developments
in medical, surgical and pharmaceutical treatments risk increasing
human suffering and can create ethical dilemmas, particularly at the
end of life.
In this book, we are advocating for a broader definition of ‘first do
no harm’, to include not just ensuring the safety of our patients but
also doing no harm to ourselves. We can’t be effective doctors in the
long term if we neglect our own health and wellbeing. In challenging
the meaning of the creed, we need to be mindful of the potential
personal challenges of 21st century medicine. These new challenges
include:
New ethical issues in clinical practice related to human
genomics and changes in medical technology.
Keeping up to date with enormous advances in quality patient care.
Dealing with health information overload.
Meeting patient demand for early diagnosis and access to new
expensive health technology.
Balancing the pressures of being the gateway to finite health
resources with the needs of our individual patients.
Pressures associated with medical workforce shortages.
Changes in the roles of women doctors following the significant
influx of women into the medical profession over the last
50 years.
Decreasing patient satisfaction with many aspects of medical
practice.
Increasing litigation.
Health risks such as new infections and the impact of sedentary
lifestyles.
Escalating medical workplace violence.
Increasing government regulation and interference in our
clinical work.
Increasing administrative demands in patient and practice
record keeping and reporting.


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Meeting all the above challenges while still caring for our
patients.
Even with the best intentions, we sometimes find ourselves
suffering unwanted personal consequences as a result of our work as
healers. It seems to be increasingly difficult to retain a commitment
to being a great clinician while leading a balanced life.

BEING A DOCTOR CAN BE
A RISKY BUSINESS
Being a doctor can be a health risk. There are many examples of
doctors being harmed in the course of responding to the needs of
their patients and there are many reasons why doctors experience high
levels of burnout and mental health problems. In the past, suicide
has been reported as being twice as common in male doctors and
four to six times as common in female doctors than in the general
population, but there are very few studies of recent trends.
Unfortunately many of us perceive asking for support from a
colleague as a weakness. Yet many of us experience serious marital
disharmony, mental health concerns or use excessive alcohol or
other drugs. Such is the stigma attached to these issues that very little
research has been conducted on the extent of the problems among
medical practitioners.
We may be forced by medical registration boards to undergo
supervised counselling or treatment if we are identified as being in
crisis, but it is more common for us to deal with health issues by self-
treatment and self-referral and miss out on vital preventive health
care and mental health care. Many of us don’t have our own doctor.
Apparently many of us don’t believe we get sick or deserve high-
quality impartial health care.
On the other hand, if we are proactive about our own health and
wellbeing, we are more likely to be able to provide consistent high-
quality patient care. By doing so, we act in our patients’ best interests


A new meaning for 'first do no harm' in the 21st century {5}

in the short and long term. We participate fully in the medical
workforce for longer. We set a good example for our patients and for
our younger colleagues about the importance of self-care and peer
support.

The new meaning of ‘ﬁrst do no harm’ includes a consideration of ourselves

{ as well as our patients. This is not to be confused with selﬁshness or ‘looking
out for number one’. It is about a long-term obligation to our own
wellbeing, health and safety, which is essential for the competent medical
care of others and our optimal participation in medical life. }


First Do No Harm

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