Our good friend Dana Ullman commented on my last post that doctors are being unethical by NOT prescribing homeopathic medicines because they are breaking one of the most important medical guidelines: “First, do no harm.” Here I do not want to discuss in-depth the nonsense about homeopathy in his sentence, rather I want to focus on the notion that doctors are obliged to foremost do no harm.
The sentence ‘first do no harm’ is supposed to originate from the Hippocratic oath which allegedly all doctors have to take when finishing medical school. This is twice wrong:
- we don’t take this oath – I have read it, and it is something utterly non-applicable to today;
- the famous sentence does not appear in the oath.
But never mind the history and all that! Doctors are nevertheless obliged to ‘first do no harm’ because it is an important principle of medical ethics.
This is also not true, I’m afraid.
If it were true, doctors would have to stop practicing much of medicine instantly. Clinicians do harm all the time. Their injections hurt, their diagnostic procedures can be unpleasant and painful, their medications cause adverse effects, their surgical interventions are full of risks, etc., etc. None of this would be remotely acceptable, if it did not also some good.
And that is why the ethical imperative of doing no harm has sensibly been changed to the imperative of doing more good than harm. Of course, doctors must be allowed to do even quite serious harm, as long as their actions can be expected to generate even more good. In more common medical terms, we speak of the risk/benefit balance of an intervention:
- if the known risks of a treatment are greater than the expected benefits, we cannot ethically prescribe it;
- if the benefits outweigh the risks, we can consider it as a reasonable option.
That is all very well, but it can only apply to treatments where both the risks and the benefits are well-understood. What about the many treatments where there is uncertainty regarding either or both of these factors? This question is impossible to answer in the abstract. We need to look at the best evidence we have for each specific case and, together with the patient, try to make an informed judgement.
Now, let’s please our good friend Dana and do such an evaluation for homeopathy, as one of many examples of an alternative therapy:
- The best evidence fails to show that highly diluted homeopathic remedies have any specific effects.
- As these remedies contain nothing, they also cannot cause any harm.
Therefore, one might argue that the balance of risk versus benefit might not look all that bad. Dana and his colleagues would thus feel that it ethically legitimate to routinely use homeopathy. But this line of thought would ignore an important issue: harm can be done not just by the remedy itself. The harm caused by applying an ineffective treatment for conditions that are otherwise effectively treatable (usually referred to as neglect) can be considerable, even fatal. So, for homeopathy the true situation presents itself as follows:
- no benefit beyond placebo;
- high risk of neglect.
This results in a negative risk/benefit balance which means, as outlined above, we cannot ethically use homeopathy.
… and, of course, Dana’s statement (doctors are being unethical by NOT prescribing homeopathic medicines because they are breaking one of the most important medical guidelines: “First, do no harm.” ) turns out to be wrong on several levels.