Friday, August 15, 2008

"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.


  1. In my experience, 20+ years of chronic migraines and other chronic illnesses, more doctors than I can count and actually becoming an RN myself, people who have never experienced chronic pain never do get it. (If it weren't so labels like "drug seeking" and such wouldn't be used so casually.)

    "First do no harm" has been traded for, "first, make sure I can't get sued".

    A psychiatrist, therapist, or possibly a really good pain control RN, or an exceptional RN period, will have your emotional well-being on their radar but No MD I have ever met, even the good ones, with compassion and some first hand experience with pain.

    Sorry this isn't more hopeful, your post struck a chord with me -I feel ya'...

  2. My experience with psychiatrists (seeing my son for severe depression and anxiety) following a head injury) is that really seem to think any complaint of pain is drug-seeking.

    Even the psychiatrists are not willing to consider how constant pain from muscle spasms increases his depression and anxiety.

    So, yeah. They've made him into a drug-seeker, looking for any kind of doc that will prescribe klonopin, which helps with the spasms and anxiety.

  3. Your post makes me think of the surgery I had on my feet called forefoot reconstruction. It was not until much later that I found out it was considered "salvage surgery" and was the end of the line as far as that part of the foot goes.
    No one mentioned that at the time - I had hopes of more improvement

  4. Thank you The Five Nomads for your comment and to Donna B. and Annette for sharing your experiences with me. I think you have all brought up excellent points about about what "first do no harm" means and how it gets translated into actions by doctors. Thanks for that!

  5. i'm all with you on this. when i was diagnosed six years ago, the thing that bit me deepest and still bites deepest was that the medical profession clearly felt i had simply been *erased* as the person i had once been. to the point where they weren't even selfconscious about it, since they clearly felt the previous me wasn't even present enough in there anymore have any opinions, much less lodge a protest :D

    it was awfully subtle and abstract, but from the moment i got the rubber stamp, it was *there*. and the harm it did was enormous - and made even worse by their bland incomprehension when i spoke about it.

    it isn't true, of course. everyone with a chronic illness still continues to be precisely themselves, just with the illness as well. we clearly *don't* all turn overnight into the same cookie-cutter stepford patient they seem to perceive. but there's a really rough period at first where you feel stripped of the only person you ever were or even knew how to be, and you don't know how to be the new person you've begun to become. the covert, subconscious contempt in the medical profession is just so unnecessary and so harmful during that time. anyone diagnosed with a chronic illness has the sudden, massive task of re-inventing themselves against all the additional pressures of actually feeling sick, or exhausted, or fighting pain. they just shouldn't have to also fight the constant subliminal message that as a person, they've just been quietly, completely erased.

  6. Before any mention of specific drug or side effect mentioned ... my mind did a tennis match between the serious consequences of Imuran and weight gain/diabetic risks/osteoperosis type issuse of Prednisone

    For me, it's Myasthenia Gravis and Lupus.
    I was on a safer drug than Imuran ...still risky, but none the less, safer.
    But the insurance decided that since it had the same risks, although they were significantly LESS risky ... there was no difference and refused to pay for the Cellcept anymore and I am back on Imuran.
    The fact that while on Imuran, I needed help dressing, could not walk up a flight of stairs and wore leg braces and couldn't drive more than 6 miles ...
    But on cellcept, could walk up 3 flights of stairs, never thought of someone helping me, could work out 3 times a week and could drive to a town 90 miles a way ...

    Imuran ... is an equal drug ...less effective, higher risk ...but ... it does the same job a 10th of the cost ...

    so .. I'm back on it.

    There is no consideration to what that might do to my life ..or my emotions ...or to my families life ...and what happens if I do go back to where I was when on it before?
    If they give me back the Cellcept ...will it work a second time?

    It's a game that the medical community can afford to play, but's not their body, nor their emotions is it?

  7. "But just because the doctor remains emotionally detached, doesn’t mean that the patient does."
    Brilliant line - this says it all

  8. fabulous. im a chronic illness patient earning my nursing degree and i couldnt agree with every word of this more. it's so hard on the patient side, and it's all too easy to get used to your patients' sufferings from the doctor/nurse side. you put it all so well, and i hope others will continue to "get it"... ive wondered about the phrase myself but sadly, to a lot of doctors it seems to mean "just dont do any major harm ... intentionally... especially if it's even remotely close to a lawsuit" right?? yeah, so we can go on suffering on the meds that help one thing and make 20 other things worse. these comments are all fabulous as well. love your blog.

  9. Thanks Barbara and Amanda for your comments! I'm glad you agree and I hope you keep reading!