“First Do No Harm” Means Providing Proper Pain Treatment – By Lynn Webster, M.D – July 2020
Many physicians say their ethical duty is to “First, do no harm.” This principle is often mentioned in the context of prescribing opioids.
Some people believe that prescribing opioids to treat people in pain violates the Hippocratic Oath, because, they say, a doctor’s first obligation is not to do anything that could make things worse for a patient.
However, that is a flawed oversimplification of the “First, do no harm” directive.
What Does “First, Do No Harm” Mean?
…the creed does not say that doctors must never provide a clinical intervention that might trigger some degree of harm. If physicians had to live by such a code of ethics, they would be unable to offer almost any medical treatment, since they all carry some risk of harm.
As the Harvard Health Blog points out, ensuring that you always “do no harm” would mean no one would ever have life saving surgery
The Double Effect (DE) Philosophy
“First, do no harm” isn’t about standing by helplessly while someone suffers needlessly.
And this is exactly what authorities are forcing doctors to do.
It is an ideal that is better explained by the principles embedded in the philosophy of the Double Effect.
According to the Stanford Encyclopedia of Philosophy, the Double Effect doctrine means that an action is acceptable if harm occurs in the course of trying to make a positive difference.
An intent to do good or help must be the underlying motive. However, the intention to do good by itself is insufficient. The possible good from the action must sufficiently outweigh the potential for harm.
Often, the Double Effect guideline is used to explain why physicians prescribe opioids even knowing they can pose risk to patients.
Doctors prescribe opioids—sometimes at very high doses—with the intent to relieve pain (which is “to do good”), because there are few other options available or affordable, and the risk of harm is manageable for most patients.
Using Opioids Creates Controversy, Even at the End of Life
Some people believe that opioids should never be prescribed because of the harm they may cause, regardless of their potential benefits to patients.
But not using opioids can also cause harm.
I’m glad to hear this from a respected doctor because I’ve been collecting articles and studies that prove how much collateral damage is caused by ongoing unrelieved pain:
In an American Journal of Law and Medicine scholarly essay this month, Kate Nicholson and Deborah Hillman argue that there is a special duty to a subgroup of patients who are already receiving opioids: doctors must not harm them with forced tapering.
There is also harm, Nicholson and Hillman say, in not treating pain in patients.
Based on a Human Rights Watch study, they believe that doctors who deny patients the care they need “in an effort to protect their licenses or stay under the radar of law enforcement” may be violating their patients’ human rights.
Nicholson and Hillman point out that “First, do not harm” has a different meaning for policymakers than for physicians.
The patient’s need for pain medication, they believe, should be prioritized over society’s need for protection against the harm that misused or diverted opioids can cause.
Even this isn’t correct in my opinion; it should read “protection against the harm that [MAY be caused by] misused or diverted opioids”. Otherwise, it’s saying that for every patient prescribed opioids, there WILL be harm from “misused or diverted opioids”.
Our Ethical Responsibility to Patients
A mischaracterization of the phrase “First, do no harm” must not prevent providers from caring for people, or prevent policymakers from allowing physicians to treat their patients. That treatment must include providing patients with medication that can adequately provide pain relief with acceptable risk.
The physician’s ethos must always be based on what is best for the patient when all factors are considered—not on arbitrary guidelines that impose a one-size-fits-all philosophy.
Author: Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.
You can find him on Twitter: @LynnRWebsterMD.
Doctors have two ethical duties: to cure disease or ease suffering and, also, to do no harm.
The ethical duty to “Do No Harm” has been used to justify two sides of a pendulum swing in the philosophy of opioid prescribing for pain.
In the 1990s, it was invoked to expand prescribing, and more recently to justify dramatic reductions in prescription opioid use.
In this Article, we explore whether prescribing opioids for pain presents challenges that differ from the ordinary mandate physicians face as they balance the call for action with the imperative to do no harm [DNH].
We argue that the treatment of pain differs in three important ways.
1. First, the fact that pain is present and occurring reduces uncertainty about the need for action, and thus strengthens the reasons to act.
If only! But instead, it seems like medical providers are currently very deliberately ignoring patients’ pain. If they did acknowledge our pain, they’d be obligated to do something about it.
They’re understandably reluctant to get involved in trying to treat chronic pain, which is often far more than a symptom, but rather a collection of various complex “pain syndromes”.
2. Second, while DNH applies to both physicians and policymakers, each has distinct duties: physicians have a duty to the individual patient; policymakers have a duty to society.
As a result, harm from drug diversion should weigh little when clinicians decide how to treat individual patients.
Exactly. Even if people are overdosing on the streets around the clinic where I’m being treated for my chronic pain, I should not be denied prescription opioids just because those other people are overdosing on illicit opioids.
Public health officials, by contrast, rightly consider societal effects.
However, in doing so, they must adopt policies that
- mitigate the ethical burdens placed on physicians,
- respect the testimony of patients in pain, and
- pay particular attention to how policy guidance is likely to be implemented by others.
3. Finally, we address what duties are owed to patients who are currently taking opioid medication, given evidence that they are experiencing significant barriers in receiving healthcare.
We argue that once treatment has been initiated, there are special duties to these patients.
As much as I appreciate this handy loophole, it ignores the reality that opioids work so well for so long for some of us.
We need opioids for our pain, not just to stave off withdrawal, but we’ll never be able to prove it. Anti-opioid zealots have always taken advantage of our inability to prove our pain; we have no way to disprove their unfounded accusations of “exaggerating” or downright “faking” our pain.
They have saturated the media, academia, and even the medical profession with myths like this (it’s not pain, it’s withdrawal) that they just make up. The crusade against opioids and those who take them makes people want to believe these glib ideas, so they do.
But let’snot forget another reality: many millions of Americans have used post-surgical opioids without getting addicted.
That’s something I’ve never seen that mentioned.
Kate M. Nicholson is a civil rights attorney formerly with the Department of Justice. She writes and speaks widely about pain, opioid prescribing and the overdose crisis.
Deborah Hellman is David Lurton Massee, Jr. Professor of Law and Roy L. and Rosamond Woodruff Morgan Professor of Law at the University of Virginia School of Law.
First, do no harm – Harvard Health Blog – Harvard Health Publishing – by Robert H. Shmerling, MD Senior Faculty Editor, Harvard Health Publishing – Oct 2015
Is “first, do no harm” even possible?
But if physicians took “first, do no harm” literally, no one would have surgery, even if it was lifesaving.
But doctors do recommend these things within the bounds of ethical practice because the modern interpretation of “first, do no harm” is closer to this:
doctors should help their patients as much as they can by recommending tests or treatments for which the potential benefits outweigh the risks of harm
Even so, in reality, the principle of “first, do no harm” may be less helpful — and less practical — than you might think.
Imagine the following situations:
- Your diagnosis is clear and there’s an effective treatment available that carries only minor risks
Here, “first, do no harm” is not particularly relevant or useful.
- Your diagnosis isn’t clear and the optimal course of testing or treatment is uncertain
It may be impossible to accurately compare the risk and benefit tradeoffs of one particular course of action against another. So you can’t tell ahead of time whether a test or treatment will “do no harm.”
- Your diagnosis is serious — for example, an inoperable cancer — and treatment can only cause harm.
Here, the “first, do no harm” mandate is irrelevant again.
The only reasonable course of care is
to offer comfort, support, and relief of suffering.
This, I believe.