The concept of “First, do no harm,” which is embedded in the oath that kicks off the careers of most new doctors in America, has become something of a surrogate for the practice of medicine. But it’s something of a false promise. Doctors routinely cause their patients harm. The oath we should be taking is, “Help others with as little harm as possible.”
We live in a world of harm — from car accidents to recreational drugs, sexually transmitted diseases, cancer, unhealthy diets, and lack of exercise. The list goes on. In treating the outcomes of these hazards, the goal as a physician should be to reduce harm.
Take obesity as an example. This widespread health risk is an important underlying cause of diabetes, heart disease, cancer, and other chronic conditions. When counseling patients about weight loss fails, as it often does, we turn to interventions like diet pills and gastric bypass surgery. While they can help people lose weight and reduce the risk of developing obesity-related complications, these treatments aren’t without harm. Instead, they can be accompanied by significant side effects and can even by deadly. Nonetheless, we accept these risks as a way to reduce the harm of obesity, compared to the known risk of death and disease associated with morbid obesity.
There are countless other examples. We routinely prescribe insulin, a drug that carries the known side effects of hypoglycemic coma and death, to people with diabetes. The much-applauded drugs that can cure hepatitis C may also cause severe liver failure. Lasix, an essential medication that helps people with heart failure get rid of fluid buildup in the legs or lungs, can also cause kidney failure. And every consent form for surgery, even operations to remove tumors, includes death as a possible complication.
Because harm is inherent in modern medicine, physicians practice harm reduction almost every time we treat our patients. No one, including patients, really gives this a second thought. But when it comes to medical issues that become public health issues, harm reduction becomes remarkably controversial.
We’ve seen this with sex education beyond abstinence-only. There’s no question that the use of contraception reduces unwanted pregnancies and sexually transmitted diseases, yet education in schools on the use of condoms or other methods of birth control are still hotly contested in many states, with critics fearing it will encourage teens to have sex. Clean needle exchange programs, which are not widely accepted despite the known risk of transmitting hepatitis and HIV/AIDS with IV drug use, are yet another example. Current debates centering on the opioid crisis and e-cigarettes further highlight our failure to practice harm reduction.
Tightening up prescribing of pharmaceutical opiates in the name of fighting the opioid crisis, we’ve actually driven patients to using street heroin. Whether to approve naloxone as an over-the-counter treatment to reverse potentially deadly opioid overdoses is still a state-by-state debate. Methadone, a pharmaceutical-grade opioid that helps heroin addicts transition off of street drugs, is still highly stigmatized as “prescription heroin” even though it has been proven to help heroin addicts live productive lives. While methadone is an opioid that, like heroin, can cause death, it has a far safer drug profile than heroin as well as carefully dosed prescribing by specially trained physicians.
E-cigarettes, the ill-named electronic nicotine delivery device that aren’t cigarettes at all, have garnered a similar stigma as methadone. Real (combustible) cigarettes like Marlboro or Camel burn tobacco at high heat. In addition to releasing the nicotine from tobacco, the heat releases tar, carcinogens, and other toxins that get drawn into the lungs. E-cigarettes heat a nicotine-containing liquid at low heat to create an aerosol that is drawn into the lungs. This provides the nicotine that will reduce cravings for smoking without the dose of other toxins.
In the United Kingdom, the official public health policy of harm reduction for smoking includes promoting e-cigarettes as “95 percent less harmful than cigarettes.” In contrast, the e-cigarette debate on this side of the Atlantic is dominated by sexy headlines like “Carcinogens found in urine of e-cigarette users” and the like. Rarely highlighted is the lower exposure to cancer-causing compounds when using e-cigarettes compared to combustible cigarettes, or the possibility that e-cigarettes can help people stop smoking, especially those for whom other smoking cessation methods have failed.
Policy debates like these often pit public health groups against the government agencies that codify the rules and regulations surrounding these issues. But it is health care providers who directly face their real-world effects. We’re the ones putting heroin addicts on life support when they overdose, the ones who treat the first-degree burns of cancer-stricken smokers who light a cigarette while wearing their oxygen masks, the ones who must answer directly to patients when they are knocking on death’s door.
We live in a world of rampant harms and not enough resources in health care to contain them. Our paradigm should evolve from “do no harm” to “reduce harm.” Chained by practicality, physicians don’t have the luxury of shooting for the impossibility of no harm. It’s time for us to embrace, on all topics — sex, drugs, smoking, etc. — harm reduction.
Amy Faith Ho, MD, is an emergency medicine physician in Chicago.
Correction: An earlier version of this article incorrectly stated that “First, do no harm” is part of the Hippocratic oath.
Great article! I tweeted it to the author and on the @stat page. I didn’t see it there?
The Health Policy Era of Cost Cutting has not been put to rest yet. After the shift from the era of support of those who provide are and respect for vulnerable populations, the Era of Cost Cutting has continued strong since 1983 with more years to come. Health care spending has become a primary target. Indeed, runaway health care costs have marginalized budgets at all government levels, of employers, and of most Americans most behind already. Damage is most evident regarding essential spending in areas such as spending important for Basic Health Access.
Low or no access to basic services is clearly harm as health care cannot even begin until care delivery begins. Access barriers impact 35 – 55% of Americans depending upon your geographic marker and the magnitude of the access barrier desired.
Even worse, expansion of health care coverage has become a marker of access. Experts including health access foundation leaders consider expansions of insurance to indicate improved access. Sadly it is only where workforce is overpaid that expansions of worst insurance plans can help access.
Where most Americans most need care, the low revenue and the higher costs of delivery required by expansion plans plus the complexity added by the plans results in even greater harm – closures and compromises of team members resulting from this Triple Threat. Small hospitals, small practices, small ERs, primary care practices, rural practices, and other basics are selectively exterminated by financial design.
It is a great harm to believe that access is about health insurance. Access requires contact with the team members that deliver care. Insurance has become a barrier to this contact. Expansions of high deductible plans do not aid in the support of local primary care, women’s health, mental health, and basic surgical services – 90% of local care for 2621 counties lowest in workforce because of lowest payments for these services, paid 15% less in the private and public plans in these counties. Veterans plans fail for local support where 50% of Veterans are found. Medicare and Medicaid pay too little in these counties and private plans send only 6% of spending to primary care with even less where 40% of Americans have half enough.
Digitalization, certification, innovation, and regulation have reduced the revenue remaining for primary care in 2621 lowest workforce counties from 40 billion a year to 34 billion – a move away from the 70 billion required for sufficient primary care, team members, and access involving primary care. And more cuts are planned that have cut and compromised care most prominently for most Americans most behind and those who attempt to serve them – decade after decade. Incentive based payments widen disparities as the payments are least for those who care the most for this majority of Americans with inherently lowest outcomes – by health, education, economic, social support, and other designs.
Researchers finally are held to higher standards involving beneficent intent, informed consent, and protection of vulnerable populations. The Era of Cost Cutting has consistently violated all human subject protections, often for low or no actual cost savings, and has been discriminatory versus vulnerable populations. The population abused by design is growing fastest with millions added a year and will reach 2800 counties with 200 million by 2040 if not before as housing collapse sends even more from counties highest concentration to counties lowest – by housing design. There is no indication of increasing dollars to support these counties. Indeed their costs of innovation increased, more cuts to come, and the losses of small hospitals and small practices indicate that the nation will have less than 13% of health spending locally where 50% of Americans will be found.
This population has some idea of the harm caused and has become restless – not knowing why their situations continue to deteriorate. Fake news and fake health policy research will only cover up the real deterioration only so long in these places where concentrations of basic health spending are so important along with SNAP, Social Security, disability, child development, CHIP, Veterans benefits, and senior support spending.
Designers should consider this half of the nation where underutilization has resulted in harm – by design.
”When ever any form of Government by design,reduces it citizen to absolute DESPOTISM ,,” it is the right,the duty of the people to alter or abolish it,,,”
mary
I have to agree that e-cigarettes are not probably healthy (especially if you are using nicotine liquids), but it is a lot better than smoking usual cigarettes.
I myself used to smoke for 4 years. I wanted to quit and I understood that I have to do it step-by-step. My friend sent me an article where it told how it is possible to quit smoking using e-cigarettes. Here’s the article, in case someone’s interested: http://ecig-reviews.net/using-e-cigarettes-quit-smoking/
I haven’t smoked a normal cigarette for a long time now, which is a relief for myself. Hopefully I can quit the “methadone” as well.
As a human being,,,i do not see,,allowing a human being to function more,to inter-act socially more ,to lessen physical pain by using MEDICINE not a drug,,but MEDICINE,, that allows them lessen physical pain to feel useful in life,,TO BE ABLE TO WORK,TAKE CARE OF ONES SELF,IE DIGINITY,, ENOUGH MEDICINE TO ALLOW THEM TO LIVE EVERY SECOUND OF EVERY DAY IN LESSEN SEVERE PHYSICAL PAIN,,,i don’t call that harm,,I call that, HUMANE AND IT HONORS THEE OATH ”TO DO NO HARM,”’!!!!!!MARYW
Doctors have do no harm guidelines and attempt to maximize benefit while minimizing adverse outcomes. There is an attempt at informed consent and protection of vulnerable populations. Human subject research protections ascribe to the same. This has been a 50 year pursuit. There are a few people damaged one at a time by doctors and human subject researchers.
To really violate ethical guidelines for millions, it takes a policy design. For decades, health policies have been primarily about cost cutting. Vulnerable populations are exploited rather than protected. Informed consent is missing or is ignored. There are even claims of justifiable harm.
Health policies are not even tested prior to implementation – especially when being cut back as seen since 1983. Researchers at least attempt small scale before increasing the risks to large populations, but not those who design health policy. Major changes in health policy have been implemented using the only available tools – PPS, DRG, and SGR. HITECH, ACA, and MACRA have even been promoted for the good of the nation despite lack of study and known consequences.
PPS and DRG was specific to cost cutting and closures of hundreds of small hospitals. No one questioned lesser pay for smaller providers – the major theme of US payment design for decades. No one considered the challenges of caring for more complex patients in places with fewer resources. No one considered the destruction of health care where concentrations of Medicare and Medicaid patients coincide with other lowest paying health plans.
When the Pay for Performance bandwagon was rolled over the nation, studies had already demonstrated lower payments for providers caring for the most complex that were known to already have lesser outcomes. When studies demonstrated the worst penalties for hospitals where facilities and workforce were at lowest concentrations, the bandwagon rolled on. When MACRA was demonstrated to discriminate against small practices as published by CMS and when CMS exceeded the designs of Congress and their consultant, the Bandwagon rolled on. Major reviews of the evidence basis confirmed the lack of impact of P4P on health outcomes, the discrimination against providers where needed, and minimal improvements in process for Pay for Performance. But there was not even a concern noted as government and insurance payers pushed way past reasonable.
Higher cost of delivery with stagnant payment plus increasing complexity of patient and practice has continued to devastate primary care, mental health, small practices, small hospitals, and basic services where needed. Stagnation of health care is quite obvious for 30 – 40% of the nation – by design.
Being forced into higher costs by HITECH, ACA, and MACRA plus being teased by ACA plus being paid less by MACRA have resulted in serious consequences for those already least paid due to the services they perform, the states where they practice, and the places where they practice in the state.
Over 40% of the nation has been left behind in health access, cash flow, economics, and health outcomes. This lowest physician concentration segment involving 2621 counties will be 50% of the population in 20 or 30 years as more are forced from higher to lowest concentrations by housing designs. The elderly, poor, disabled, fixed income, Veteran, and other populations forced into migration add to complexity and demand where workforce is stagnant by design.
Each year there are more promises of different workforce solutions, more promises of practice innovations, and more failures of practices, hospitals, workforce, and health outcomes by design. But there are no more dollars added locally to support the team members to deliver the care – a decades long deficit in accountability.
It took 50 years to rein in researchers to at least reduce the potential for harm for a few. How long will it take to rein in designers that continue to send more lines of revenue and the highest reimbursement in each line to a 1100 zip codes in 1% of the land area that already have highest concentrations with 45% of physicians and over 50% of health spending despite only 10% of the population.
How many new corporate players will receive special funding as delivery team members receive less and are asked to do more despite greater complexity?
“Because harm is inherent in modern medicine, physicians practice harm reduction almost every time we treat our patients. No one, including patients, really gives this a second thought. ” This patient will sit up until three AM looking at PML lesions in textbooks and nudge a liver panel twice yearly.
The underlying concept, that “First Do No Harm” is not sufficient as a guiding principle, is not new.
In 2002, the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine, published a joint Physician Charter:
http://abimfoundation.org/what-we-do/physician-charter
that addresses many of the associated issues regarding quality of care and the distribution of finite resources.
Bottom line, in this context, if you are not doing any harm, that does not mean that you are providing benefit. If you are not providing benefit, why are you doing it?