Above All, Do No Harm (But it Shouldn’t Stop There)





When it comes to medicine, perhaps one of the most commonly heard phrases is, “Above all, do no harm.”  As everyone (supposedly) knows, those words come straight from the Hippocratic Oath, the oath that physicians have taken upon graduation for many years.  While a somewhat different oath is recited by veterinarians upon their graduation – there’s no mention of “do no harm,” by the way  – fundamentally, the idea that a treatment shouldn’t hurt the individual being treated is a thread that runs throughout medicine (CLICK HERE if you want to read the veterinarian’s oath).

UH-OH, WAIT, SCRATCH THAT:  Did you know that the phrase, “Above all, do no harm,” actually appears nowhere in the Hippocratic Oath?  Here’s what one version of the Oath says:  “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.” (CLICK HERE to see one of the most accepted versions of the original Oath).

Thomas Syndenham

Thomas Syndenham

AND THERE’S MORE:  The so-called Hippocratic injunction to do no harm actually has nothing to do with Hippocrates, which, when you think about it, makes some sense, since the way it’s usually phrased, primum non nocere, is Latin, which is a language that first came to prominence a couple of hundred of years after Hippocrates died.  In fact, the “first do no harm” thing first shows up in English around 1860, coupled with its unique Latin, with attribution to the English physician, Thomas Sydenham, although the origin is also attributed to the Parisian pathologist and clinician Auguste François Chomel (1788-1858).  Admittedly, this is more than you probably wanted to know.

SPEAKING OF THE HIPPOCRATIC OATH:  Did you know that there are many variations, and that it’s been modified many times?  One current popular version was written by the late Louis Lasagna (really), a distinguished pharmacologist who you can read about if you CLICK HERE.  Dr. Lasagna’s oath can be found by clicking HERE.

OH, AND ONE OTHER THING:  While there’s nothing that legally requires medical students to swear an oath when they graduate. 98% of American medical students do.  On the other hand, only 50% of British medical students swear an oath.  I have no idea what this means, but it’s interesting.

CigaretteAdSo, at this point, you might just think, “Oh, just forget it.” But whether it is in the Hippocratic Oath or not, the “first do no harm” idea still holds a considerable amount of psychological power and influence.

Regardless, in my opinion, lately, the spirit of the thing has been turned on it’s head a bit.  Today, the phrase seems to have been modified somewhat.  Now, what you hear is, “It’s not going to do any harm, so I might as well give it a try.”  Otherwise stated, if a treatment can’t be shown to be overtly harmful, then it’s worth foisting on the horse, and, by proxy, the horse’s owner.  Companies that make stuff feel that way, and especially if they don’t have to prove that the products really do anything. Some veterinarians do, too.  Heck, clients may feel that way – they may be willing to throw the proverbial kitchen sink at a horse’s problem (real or perceived), just as long as it “doesn’t hurt.”

And I just think that attitude is just plain wrong.  I think we (“We” meaning not only veterinarians, but anyone who aspires to give some sort of treatment to a horse, including discerning horse owners) can do better.

george_washington_deathWhen the idea of “do no harm” came about, medical treatments were pretty ineffective:  even terrible.  Some of the more popular treatments from a couple of centuries back included bleeding (a treatment to which the death of George Washington is at least partially attributed), or giving mercury salts until signs of toxicity – vomiting and such – started.  As you might imagine, in some cases, the treatment was as bad as the disease.  As a result, most people were not very enthusiastic about seeing a doctor.  I mean, seriously, who would have been, given the nastiness of the treatments and the results?

There were lots of “options” to doctors then, too.  Of course, the options didn’t matter much either because, in fact, just about nobody’s treatments were any good.  When all treatments are equally ineffective, there’s really not much to choose from, but at least you could try to stay away from things that made conditions worse.  In fact, you’d probably be drawn to the one that was most likely to cause problems – the one that would “do no harm.”

WizardOilSo, from a historical perspective, it makes some sense to, “Do no harm.”  But we’ve moved beyond that.  And so should our treatments.

You see, medicine is – or at least should be – more than just “doing no harm.” It should be about doing some good.  Using the, “Well, at least it won’t hurt” rationale to justify the administration of a product or service isn’t good enough.  I think that line of thinking is wrong-headed, and it can be expensive, too.

Here’s an example.  Let’s say that your horse had a case of colic.  And I had a rock.  A colic-curing rock.  With my rock, you could wave it over your horse’s belly, and it might help his colic go away.  Best of all, my rock only costs $15, far less than some of those other colic treatments, which can also cause harm.  Totally natural, too.  There’s no risk of direct harm (that is, the rock won’t do anything bad to the horse).  I mean, it’s just a rock, albeit a somewhat magical one (trust me).  And I can make change for a $20, too.

Is that OK?  I would hope that you’d say, “No.”  And why?  I mean, my magical colic-curing rock will, “Do no harm.” And I hope your response would be, “But it doesn’t do any good!”

pet rockExactly.  The cost of my colic-curing rock is certain – the benefit is not.  And there are a whole lot of rocks being sold to horse owners.

And the “do no harm” admonition can be expanded to have a broader meaning, too.  As it is, people mostly think about what’s known as “direct” harm.  That is, you don’t want a treatment that will hurt the horse as a direct result of treatment.  But what about indirect harm?  Indirect harm doesn’t cause injury to the horse.  It’s more insidious than that.  But it still hurts.

Indirect harm comes when a treatment makes horse owners waste money.  Indirect harm comes when horse care is made to be more complicated and expensive than it needs to be. Indirect harm comes when products and services are sold so as to pander to people’s trumped up fears (e.g., he might be “lacking” in something, or some system might have all the necessary “support”). Indirect harm comes when people are enticed people to pursue worthless treatments, and possibly avoid to therapies that might actually help the horse.  Indirect harm comes when medically ridiculous ideas are advanced in support of worthless therapies.  That doesn’t injure the horse, at least not directly.

The heck with itBut it is certainly harm.  It’s harmful to make caring for horses more expensive than it needs to be.  It’s harmful to promote false ideas.  It’s harmful to make out like caring for horses is excessively complicated.  Why?  Because these sorts of things can make people throw up their hands and say, “Oh, to heck with it.  It’s not worth the bother.” And that’s bad for horses.  Horses need people to bother with them.

In this day and age, we have the means and the methods to see if treatments do any good.  We have the means to do more than assert that treatments can do more than not cause harm.  And, if a treatment is new and experimental, and if we don’t know if it does any good, we can always do good science to see if it does any good. And in my opinion, all of this should be done before a product or service is sold to people.  What do you think?

So, sure, do no harm.  But also do some good.


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