Commentary: The Tribune was wrong. Medicine often involves a risk to the patient.

(Courtesy of the Utah Department of Health) A health department initiative called Talk to Your Pharmacist placed stickers on bottles to prompt prescribers to talk to their pharmacist about the risk of using opioids.

The Salt Lake Tribune published an editorial on Nov. 12, “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.

The Hippocratic Oath is not the origin of the phrase “First do no harm.” 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. 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. An intent to do good or provide help must be the underlying motive. However, intent to do good is not sufficient. The potential for good must sufficiently outweigh the potential for harm.

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.

Most clinicians who treat terminally ill patients, the patients themselves and patients’ families place a priority on a peaceful, pain-free death. Opioids are frequently necessary to provide that scenario at the end of life despite their potential to hasten death.

Providing opioids to ease end-of-life suffering passes the DE test, but it is still controversial. Furthermore, end-life-care is only one area in which the use of opioids is questioned.

There are some people who believe that opioids should not be prescribed because of the harm they may cause, regardless of their potential benefits to a patient.

As physicians, we are trained to heal. We become health care professionals because we want to provide compassionate care to the sick, the frail and the dying. We take an oath, in part, to use our best judgment to evaluate the risk and potential benefits of all interventions. Intending to do good, knowing that adverse effects can occur with every intervention, is our ethical responsibility.

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.

Lynn Webster

Lynn R. Webster, M.D., is vice president of 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

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