The Tribune was wrong. Medicine often involves a risk to the patient. – By Lynn Webster, M.D. – Dec 2018
The Salt Lake Tribune published an editorial on Sunday Nov 12, 2017, “Medical professionals need to play a role in opioid crisis.” The first line reads, “First do no harm.”
According to the editorial, physicians who prescribe opioids to treat pain patients may be violating the Hippocratic Oath, because “a doctor’s first concern is to not do anything to make things worse.”
However, the editorial got it wrong.
In all of life, it often happens that bad situations are made worse in the short run in order to improve them in the long run, for example, like painfully resetting a broken bone or going through labor to birth a child.
As N.S. Gill writes in Thoughtco, many people mistakenly believe that “First do no harm” is a quotation from the Hippocratic Oath. That is not the case.
But, more importantly, the creed does not say that doctors must never provide a clinical intervention that may benefit a patient without also triggering some degree of harm.
If physicians had to live with such a code of ethics, they would be unable to provide almost all treatments offered in medicine.
As Harvard Health Publishing points out, that would mean no one would ever have life-saving surgery.
Doctors wouldn’t be able to
- order CT scans, MRIs, mammograms, biopsies, or other tests that can turn up false positives;
- draw blood for fear of bruising;
- or provide vaccines that might cause side effects.
Even aspirins are potentially dangerous treatments for some people. To avoid risk altogether, doctors would have to limit themselves to providing BAND-AIDs® and soothing words
“First do no harm” isn’t about standing by idly and helplessly while someone suffers needlessly.
And this is exactly the current situation in pain management when doctors are discouraged, and even prohibited, from prescribing opioids.
It is an ideal that is better explained by the principles embedded in the philosophy of the Double Effect (DE).
According to the Stanford Encyclopedia of Philosophy, the Double Effect means that it’s acceptable if harm occurs in the course of trying to make a positive difference.
DE often is used to explain why physicians have prescribed opioids, even knowing they can cause risk to patients.
Doctors prescribe opioids, and sometimes at very high doses, with the intent to provide pain relief (which is “to do good”), because there are few other options available or affordable, and the risks of harm are manageable for most patients.
This is true for all medications and interventions, and not just for opioids.
Opioids are not, themselves, evil agents, despite their somewhat checkered reputation among some laypeople, physicians, and lawmakers.
All the anti-opioid zealots paint opioids as “evil”, generating an unfounded fear of these useful (and even necessary) medications.
PROP leader Kolodny goes so far as to call our life-saving opioid medications “heroin pills”. Labeling a whole class of drugs, illicit and legal, as the worst particular molecular version of opioids is no different from calling a liqueur-filled chocolate a vodka cocktail.
A mischaracterization of the phrase “first do no harm” must not prevent providers from caring for people, including providing them with medication that can adequately provide pain relief with acceptable risk.
Most of the studies on opioids have only been looking at the risk of harm, while ignoring the benefits of pain relief. (See Opioids Blamed for Side-Effects of Chronic Pain)
In fact, most opioid studies do not even consider pain relief as a relevant factor, looking only at opioid dosages without even mentioning that they are prescribed for serious pain.
Lynn R. Webster, MD is Vice President Scientific Affairs for PRA Health Sciences. He is a past President of the American Academy of Pain Medicine. In addition, he is the author of the award winning book, “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us” (Oxford University Press). Visit him online at www.thepainfultruthbook.com. @LynnRWebsterMD