"First Do No Harm"

This summer, I discovered and got addicted to the TV show, “Nip/Tuck.” A phrase that was thrown around often on the show was “first do no harm,” which was cited to be the cardinal rule of the Hippocratic oath.

I had intended to write a post about how hypocritical the Hippocratic oath is, only to find out through further research on the subject that “first do no harm” does not in fact come directly from the Hippocratic oath, but is merely “adapted” from it.

Like so much in the medical profession, this phrase, too, is a myth…

So what does it actually mean, “first do no harm,” and what is its significance for the chronic illness, if not the entire, medical community? On paper, it sounds great. But as many of us with chronic illnesses have learned, most medical interventions come equally with both risks and rewards - as I have thought about a lot lately, sometimes the medication is worse than the symptoms it was prescribed to alleviate.

For me, “first do no harm” makes me think of the unintended harm that a patient can be caused. I am drawn to the advice on all of my prescription pamphlets:

“Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects.”

I wonder if, both the above warning and the adage, “first do no harm”, apply to subconscious emotional harm, as well as physical harm. What if prescribed medications, the entire chronic illness experience for that matter, change the patient’s self image, and/or brings out feelings and emotions that the patient never knew existed and is not fully able to deal with?

What if, in the process of trying to alleviate symptoms, the patient is caused psychological harm? At what point, if ever, is it the responsibility of the doctor to take note of these changes and respond to them? And at what point is it the patient’s responsibility to just “suck it up”?

There is, of course, a balancing act here. And it is one that is very subjective. There are risks that everyone probably agrees on, like taking medications that greatly increase ones risk of cancer. But what about say, gaining weight from being on prednisone. That might not seem too devastating to a middle-aged, male doctor, but might seem quite bothersome to a teenaged, female patient, even when the drug alleviates some of the symptoms the patient is being treated for.

In the chronic illness experience, then, is it possible, no matter how good the doctors or the medication, to escape unscathed, physically and emotionally? And what does that even mean in the case of chronic illness?

The emotional toll that chronic illness can have, as I have experienced first hand and battle on a daily basis, is really the unseen demon – it’s at the core of what makes me question the utility of “first do no harm”. The physical and the emotional are deeply connected. Even if the physical aspect is going well, the emotional parts can derail everything.

I also wonder if “first do no harm” even applies to the patient at all. Has my doctor ever asked me how I feel mentally, emotionally? When I had to go have steroid infusions for three days, did my doctor ever ask how they made me feel? Physically, yes. Emotionally, no. The physical and the mental work in tandem, but it is the physical that gets all the attention. I’m not in too much pain so that must mean that I am feeling great mentally, as well.

Or are our doctors just trying to protect themselves from harm? I know my rheumatologist is detached because rheumatology is a medical specialty in which good news is rarely given. Remissions don’t last forever. Cures rarely exist. Pain is often a daily experience. And I understand this emotional detachment and have come to expect and accept it. If it didn’t exist, my doctor would probably be a pretty depressed person. I also understand that being overly emotionally involved with a patient can cloud judgment.

But just because the doctor remains emotionally detached, doesn’t mean that the patient does.

I think sometimes our doctors forget that the daily grind of not feeling well, of pushing ourselves to do things that used to feel so easy, of just showing up for doctors’ appointments, is difficult physically, but also emotionally. Doctors can see abnormalities on x-rays and lab reports, physical manifestations in or on the body. But what they don’t see, and often don’t attempt to look for is the emotional pain that many of us suffer.

Chronic illness is neither easy for patients nor doctors. It is not sexy, glamorous, or fun. It is what it is. However, this failure to look at the emotional, as well as the physical, manifestations of disease seems to me to be a gulf in the doctor-patient relationship that needs to be closed. In order for “first do no harm” to mean anything, the patient as a whole person needs to be seen by the doctor.