First do no harm: evidence sometimes shows the self-evident to be wrong

‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each instalment is based on one of the 12 RCGP competency domains, this month’s being:

11. Maintaining an ethical approach to practice: practising ethically with integrity and a respect for diversity.¹

‘The true aim of medicine is not to make men virtuous; it is to safeguard and rescue them from the consequences of their vices. The physician does not preach repentance; he offers absolution.’²

INTRODUCTION

Every consultation, however straightforward, superficially contains ethical dilemmas.³ Autonomy, equity, beneficence, non-maleficence, and confidentiality are incommensurable and often mutually exclusive. Shared decision-making may be the ethical norm⁴ but is hampered by the asymmetry between the doctor for whom knowledge is power and the patient in whom illness creates a state of temporary dependency.⁵ Evidence sometimes shows the self-evident to be wrong.⁶ Where evidence isn’t available, compassion justifies pragmatism but not quackery.⁷

HARMING

Confusing autonomy with consumerism, equity with indifference, beneficence with proselytism, non-maleficence with passivity, confidentiality with insularity. Over-riding people’s beliefs and preferences, being bigoted or prejudiced,¹ rejecting people who don’t comply with our conception of the sick role, being rude.⁸ Addressing distress and not disease; addressing disease and not distress.⁷ Treating people as means, not ends.⁹

HEALING

Respecting difference.⁸ Promoting socialised health care.¹⁰ Avoiding conflicts of interest.¹ Furthering scientific knowledge and incorporating evidence into the consultation.⁷ Being courteous.¹ Laughing with the patient.⁷ Treating people as ends, not means.⁹

ATTITUDE

Being alert to the uniqueness of each situation and eclectic in our efforts to find the right thing to do in each set of circumstances.³

KNOWLEDGE

The Quality and Outcomes Framework, despite inadequacies, improves the safety and evidence base for monitoring and prevention of disease.⁷ Beyond it there are areas of our work for which evidence has yet to be translated into widespread practice: mobilisation is good for many musculoskeletal problems;^11,12 the pharmaceutical pain relief produced by opiates or nonsteroidal anti-inflammatories for up to 3 months is less than the relief produced by placebo and after 3 months is unproven;¹³ it’s unclear whether antipyretics in children with fever are beneficial or harmful;¹⁴ and wart treatment is probably no more effective than time.¹⁵

SKILLS

Identifying the ethical dilemmas in the apparently most straightforward of consultations.⁷ Using rules ‘as ballast rather than as compass’.³ Observing before evaluating before judging.¹⁶ Communicating non-violently.¹⁶ Using the Quality and Outcomes Framework to optimise not only profit but also patient care.⁷ Being a vocal citizen of the healthcare community^17,18 by contributing to research, guidelines, peer-reviews, professional organisations,⁷ and the All Trials petition.¹⁹ First doing no harm: beginning with a therapeutic consultation without the dangers of tests and drugs.⁷

Supplementary information

The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html