Most health professionals have learned, in an ethics or professional responsibility course, the phrase primum non nocere, meaning, "first, do no harm." I've looked in a variety of medical ethics textbooks; most give credit to Hippocrates (c.460-380 BCE) for this phrase. Some authors write that the aphorism is a Latin paraphrase by Galen (c. 130-201 CE) of a Hippocratic aphorism, or they ignore the source of origin. Simply put, this is a bit of common knowledge that does not appear to be true. Let's think about it.
Primum non nocere is Latin (and from what I've read, not proper Latin at that). Hippocrates, from the Greek island of Cos, wrote in Greek, not Latin. Likewise, Galen wrote in Latin. Thus, when I first read this bit of logic, in a letter to the editor in the British Medical Journal, I felt like a dope. Of course, I was no dopier than all the authors over the years who have attributed this Latin phrase to either of two Greek writers. This was so illogical but illustrative of the nature of knowledge. We oftentimes "know" something to be absolutely true, when in reality, our memory has played a trick upon us. Our memory erroneously has assigned a level of confidence to some "fact" that it did not deserve. I come across these kinds of things often and they always make me a bit skeptical about many things I "know" and hear from others as being authoritative.
It appears that Hippocrates did write something similar to primum non nocere. In Greek, it appears he did write Wfelein h mh blaptein (ofelein ee mei vlaptein), which means, "to help, or at least to do no harm." This aphorism purportedly was in his writings - Epidemics, Book I, Section XI.
Smith1 writes that the earliest attribution of primum non nocere is to Thomas Sydenham (1624-1689) in a book by T. Inman (1860). According to Smith, by the turn of the 20th century, the aphorism was in common usage.
This duty to prevent harm is known in ethics as the duty of nonmaleficience. Nonmaleficience can be thought of as one side of a continuum; beneficience (the duty to bring about a good result) is the other end. I think most of us chose to become chiropractic physicians because we wanted to help (i.e., benefit) humans.
Obviously, if one's goal is to benefit humans, causing them pain, injury, etc., is inconsistent with one's values. We doctors are an empathetic bunch, and hurting those we pledge to help can be very psychologically distressing to us.
The first time I knew I had hurt a patient was during my junior year in undergraduate college. This was my seventh year working as a student athletic trainer, and I was cutting the tape off of the thumb and wrist of a football player. This was a mundane task I had done innumerable times. On this occasion, I accidentally cut the dorsum of his hand. It was a very small cut, not even a centimeter long and only superficial. I was devastated, almost on the verge of tears and profusely apologetic. The football player, not the nicest guy on the team, was more than forgiving and gracious, and even tried to console me. Still, it was very hard on me because my goal was, as Hippocrates wrote, "to help or at least to do no harm."
What Is Harm?
If the duty of nonmaleficience means to prevent harm, what is harm?
Some patients definitely equate hurt with harm. This is the essence of what is called fear-avoidance behavior. I'm reminded of the patient with the frozen shoulder of six months duration; I treated her with trigger-point pressure release (similar to receptor tonus technique). For the first time in six months, she could comb her hair with that hand, but instead of being happy, she was quite angry about how badly I had hurt her. To her, I harmed her.
Obviously, an instantaneous clinical response in every patient would be wonderful, but unlikely. Most of you probably have had the patient for whom one adjustment was the "miracle cure." You know - the patient who could hardly walk into the office, and after that one adjustment was completely pain-free. The problem comes months or years later, when there is a recurrence and one adjustment doesn't eliminate the patient's symptoms as it did before. Now the patient thinks you are harming them, by trying to get more office visits out of them. "Didn't make enough money off of me the first time, doc? Now you're going to string me along before you fix it?"
Not helping a patient could be harm. I've heard of a malpractice case wherein the patient was treated for 180 office visits without any change in the symptom that had brought him to the chiropractor in the first place, syringomyelia. This case also illustrates the point that not doing a needed diagnostic test can be harmful. This doctor would have needed to order an MRI to find the syrinx.
Finally, performing unneeded diagnostic tests is harmful. I mentioned in an earlier column that a chiropractor had his license suspended in the U.K. What I didn't say is what action resulted in that suspension. It was taking X-rays when there wasn't an appropriate clinical reason to do so.2
In the end, it doesn't matter if we think of it in Greek, Latin or English; preventing harm is just part of our job as professionals.
- Smith CM. Origin and uses of primum non nocere - above all, do no harm! J Clin Pharmacol, April 2005;45(4):371-7.
- Perle SM. Argumentum ad hominem. Dynamic Chiropractic, July 30, 2005 www.chiroweb.com/archives/23/16/24.html.
Stephen Perle, DC, MS
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