First Do No Harm

The principle attributed to Hippocrates has shifted over time, with disturbing consequences

"I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."
- Hippocratic Oath

The principle ‘first do no harm’ is one that can serve us well, although it is not easy to follow. Harm is a broad concept, and not everyone understands it in the same way. Still, making a priority of avoiding harm is a worthy commitment from anyone, for all that we associate this expression solely with doctors. This particular formulation of the Hippocratic Oath appears around the 17th century and clearly descends from the original oath to Apollo and Asclepius attributed to Hippocrates.

Alas, few doctors today follow the original spirit of this principle. In the last century, the Enlightenment version of the Hippocratic principle, ‘first do no harm’, was supplanted by a new approach called health economics, whose governing principle is that ‘medicine is always a balance of risk and benefit’. It is this calculus (rather than the avoidance of harm) that has guided industrial medicine from its outset. While the actual oath sworn by doctors varies from nation to nation, the underlying medical doctrine is now always a matter of risks versus benefits.

Until recently, what constrained health economics were the Geneva Conventions drawn up in the wake of the atrocities of World War II. ‘Informed consent’ became the limiting factor in applying the Hippocratic principle to health economics: no longer ‘first do no harm’, now harm was permitted provided the patient had been appraised of the risks and consented to them. This permitted more dangerous medicines, ones with inherent harms justified by clinical calculations. Patients were invited to bear risks in order to claim plausible rewards. Alas, this constraint of consent was finally eliminated in the last few years, creating a fourth era of Hippocratic principles - from the classical, to ‘first do no harm’, to health economics with informed consent, to imperial technocracy.

What made the transition from ‘first do no harm’ to health economics plausible was a resolute commitment to meticulous scientific investigations, along with a hair trigger for withdrawing unsafe treatments. In the twentieth century, even a handful of deaths were sufficient for a medicine to be completely removed from the acceptable options. In the twenty first, the substitution of mathematics for ethics has destroyed all such checks and balances. Industrial medicine was precarious enough without being shorn away from adequate safety testing, but we have recently switched from gathering five to ten years of safety data to just a few scant months, and from measuring actual clinical outcomes to inventing computer models to ‘prove’ the validity of sometimes quite outlandish scenarios.

We are now living through a grotesque parody of the Hippocratic principles, that might be caricatured as ‘first admit no harm’. Public health agencies around the world have taken to hiding the data on the effects of certain recent treatments. The most generous way of interpreting their behaviour is that officials are afraid that knowledge of problems with one vaccine will collapse trust in all vaccination - but this amounts to claiming that they wish to preserve public trust by lying. Meanwhile, anyone demanding the investigations that a few short years ago were considered absolutely necessary will be accused of being an ‘anti-vaxxer’.... This demonisation takes on a very different tenor when understood as a clash between the second or third incarnation of Hippocratic principles and the reckless greed of technocratic medicine.

Without ‘first do no harm’, without informed consent, the suggestion that our health is still what matters has become farcical. ‘Safe and effective’ used to be the end goal of rigorous scientific testing regimens. Now it is the catechism of those whose fear of disease is so great they are willing to sacrifice drug safety on the altar of quick-fixes. Yet when the purpose of public health institutions becomes shielding pharmaceutical corporations from scrutiny, the role of doctor established by the ancient oath is utterly defiled. ‘First admit no harm’ is not a Hippocratic principle at all - it is merely the craven demand to protect Pfizer’s share price at any and all costs, even at the most ghastly expense of all: human life.