T

he 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.

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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.

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  • 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?

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