Do No Harm

We live in an age of technological medicine, benefiting greatly from its probings and treatments. Yet patients’ encounters with it can leave much to be desired (see “Prescription: Networking”). In addressing those deficiencies, there is no better place to begin than a text produced 2,500 years before the modern technological era.

The work is an essay called “The Art,” produced by Hippocrates and his disciples in ancient Greece. In his time, practitioners of medicine considered their discipline to be an art, not a science. This meant, in essence, that doctors knew they must use their ethical judgment to direct the limited number of interventions in their therapeutic arsenal.

The Hippocratic physicians were concerned that intemperate use of these therapies could have damaging consequences. Applying them inappropriately, to illnesses where they were unlikely to help, undermined patients’ confidence in the treatments, the doctor, and medicine itself. It also transgressed an important principle of the Hippocratic Oath: do no harm. This precept is often misunderstood to mean that doctors must not inflict harm in the process of care. This is frequently impossible: we accept pain and side effects as the price of beneficial treatments. What “do no harm” means, as I interpret it, is that doctors must avoid exposing patients to preventable risks.

The cautions expressed by the Greeks are worth respecting in the medicine of our own day, when technology is too often used without regard for the ideal of avoiding needless risk. A recent study estimated, for example, that about four million Americans have been exposed to a substantial amount of radiation from multiple imaging tests such as CT scans. While such technologies can be important elements of clinical care, doctors are increasingly using them to evaluate patients without clinical symptoms of disease. And each new test adds to the cumulative radiation dose that increases a person’s risk of developing cancer.

The use of imaging tests is part of a larger trend in medicine: interrogating the body intensively and the person minimally in trying to prevent and treat disease. We need to pursue relationships with patients to understand how they live and function, not just use technology to secure biological data about them. To know and treat the disease fully and the person partially is a formula that produces inadequate medical care.

Stanley Joel Reiser is clinical professor of health-care sciences and health policy at the George Washington University School of Medicine and Health Sciences.