A necessary renaissance of “Primum non nocere”

It is often said that the phrase “First do no harm” (Latin: Primum non nocere) is a part of the Hippocratic oath. Contrary to common belief, the phrase does not appear in the oath. The phrase “primum non nocere” is believed to date from the 17th century.

In Hippocratic Writings, Geoffrey Lloyd points to another equivalent phrase found in Epidemics, Book I, of the Hippocratic school: “Practice two things in your dealings with disease: either help or do not harm the patient.” The exact phrase is believed to have originated with the 19th-century surgeon Thomas Inman (Daniel K. Sokol, 2013).

In the 1960s, the Hippocratic Oath was changed to require “utmost respect for human life from its beginning”, making it a more secular obligation, not to be taken in the presence of God or any gods, but before only other people. When the Oath was rewritten in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, the prayer was omitted, and that version has been widely accepted and is still in use today by many US medical schools:

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

In a 2000 survey of US medical schools, all of the then extant medical schools administered some type of profession oath. Among schools of modern medicine, sixty-two of 122 used the Hippocratic Oath, or a modified version of it. The other sixty schools used the original or modified Declaration of Geneva, Oath of Maimonides, or an oath authored by students and or faculty. All nineteen osteopathic schools used the Osteopathic Oath (2004, Kao and Parsi).

There is no direct punishment for breaking the Hippocratic Oath, although an arguable equivalent in modern times is medical malpractice which carries a wide range of punishments, from legal action to civil penalties (2008, Johnathan Groner, M.D.).

We in the intractable pain community have rightfully adopted and adapted “First, Do No Harm” in an effort to emphasize the disasterous consequences of the 2016 CDC Prescribing Guidelines for Chronic Pain. By declaring an Opioid Epidemic/Crisis, the federal government and many states have made the decision to blindly enforce the CDC recommendations. Within one year, they have sewn the seeds for another devastating watershed: the Opioid Refugee Crisis.

References

1. Lloyd, Geoffrey, ed. (1983). Hippocratic Writings (2nd ed.). London: Penguin Books. p. 94. ISBN 0140444513
2. Sokol, Daniel K. (2013). “‘First Do No Harm’ Revisited” BMJ. 347 (f6426). doi:10.1136/bmj.f6426
3.  Kao, AC; Parsi, KP (September 2004). “Content analyses of oaths administered at U.S. medical schools in 2000.”. Academic Medicine. 79 (9): 882–7. doi:10.1097/00001888-200409000-00015. PMID 15326016
4. Groner M.D., Johnathan (2008). “The Hippocratic Paradox: The Role of The Medical Profession In Capital Punishment In The United States”. Fordham Urban Law Journal Library