Doctors code of ethics do no harm

The expression "first do no harm" is a popular term used to express the underlying ethical rules of modern medicine. Although this is generally thought to have been taken from the ancient Greek Hippocratic oath, no translations of the oath contain this language. 

• The expression "first do no harm," which is a Latin phrase, is not part of the original or modern versions of the Hippocratic oath, which was originally written in Greek. 
• The Hippocratic oath, written in the 5th century BCE, does contain language suggesting that the physician and his assistants should not cause physical or moral harm to a patient. 
• The first known published version of "do no harm" dates to medical texts from the mid-19th century, and is attributed to the 17th century English physician Thomas Sydenham. 

"First do no harm" is a popular saying that derives from the Latin phrase, "primum non nocere" or "primum nil nocere." The term is particularly popular amongst those involved in the field of healthcare, medicine, or bioethics, and among popular accounts of the medical field, since it is a basic principle taught in healthcare-providing classes.

The takeaway point of "first do no harm" is that, in certain cases, it may be better to do nothing rather than intervening and potentially causing more harm than good. 

The Hippocratic oath is part of an outline of essential ethics in medicine which is described in ancient Greek literature.

Hippocrates was a Greek physician who lived on the island of Cos between about 460-370 BCE. He wrote many medical texts and is considered one of the most important figures in ancient Greek medicine. He is generally credited with writing the original Hippocratic Oath. 

The oldest extant mention of the Hippocratic Oath was found on a medical papyrus dated to the 5th century CE, one of the many thousands of manuscripts found in the archaeological treasure trove Oxyrhynchus. The oldest extant version is from the 10th century CE. It is stored in the Vatican library. The original is thought to have been a written law of the medical fraternal organization on the island of Cos, of which Hippocrates was a member. Written in Greek about 421 BCE, the oath was originally intended as a pledge between a master (the physician) and his qualified assistants. 

Healers in Athenian society were known as Asclepiads and they belonged to a guild (koinon), to which they inherited their right of membership from their fathers. Hippocrates' father and grandfather before him were members of the guild on Cos. Then, doctors were itinerant specialists who carried their skills from city to city, setting up surgeries. Rather than a promise made by new doctors on joining the guild, the oath was sworn by nurses and assistants in the various surgeries as part of a promise to obey the doctor. 

According to the original Hippocratic oath, these assistants were to respect their masters, share medical knowledge, help patients and avoid harming them medically or personally, seek help from other physicians when necessary, and keep patient information confidential.  

However, there is no mention of the phrase "first do no harm" in the original oath.

Although "first do no harm" does not actually come from the Hippocratic oath verbatim, it can be argued that it does come from that text in essence. That is, similar ideas are conveyed in the text of the Hippocratic Oath. Take, for example, this related section which has been translated as:

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. I will give no deadly medicine to anyone if asked, nor suggest any such counsel, and in like manner I will not give to a woman a pessary to produce abortion. 

In reading the Hippocratic oath, it is apparent that not harming the patient is explicit. However, it is not clear that "abstain from whatever is deleterious" is equivalent to "doing no harm." 

A closer version to the succinct "do no harm" does come (possibly) from Hippocrates, however. "Of the Epidemics" is a part of the Hippocratic Corpus, which is a collection of ancient Greek medical texts written between 500 and 400 BCE. Hippocrates was never proven to be the author of any of these works, but the theories do follow closely with Hippocrates' teachings.

Regarding "first do no harm," "Of the Epidemics" is considered to be the more likely source of the popular saying. Consider this quote:

The physician must be able to tell the antecedents, know the present, and foretell the future — must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm. 

However, according to an exhaustive search of the ancient and historical literature conducted by pharmacologist Cedric M. Smith, the phrase "primum non nocere" does not appear in medical texts until the mid-19th century, when it is attributed to the 17th century English physician Thomas Sydenham. 

At many medical schools, but by no means all, a version of the Hippocratic oath is given to the student on graduation or read to the students in the first year. Different countries have different customs about the oath. In French medical schools, it is common to have the student sign the oath on graduation. In the Netherlands, students must swear to it verbally. 

At graduation, some deans read the oath while the students stand silent. In others, the students repeat a modern version of the oath at the graduation ceremony. However, data on these reports do not tell how often "primum non nocere" is included as part of the oath. 

Crawshaw, Ralph. "The Hippocratic Oath [with Reply]." BMJ. BMJ: British Medical Journal, T. H. Pennington, C. I. Pennington, et al., Vol. 309, No. 6959, JSTOR, October 8, 1994.

Jones, Mary Cadwalader. "The Hippocratic Oath." The American Journal of Nursing. Vol. 9, No. 4, JSTOR, January 1909. 

Nittis, Savas. "The Authorship and Probable Date of the Hippocratic Oath." The Johns Hopkins University Press. Bulletin of the History of Medicine, Vol. 8, No. 7, JSTOR, July 1940.

Shmerling, Robert H., MD. "The Myth of the Hippocratic Oath." Harvard Health Publishing. Harvard Medical School, Harvard Health Blog, Harvard University, November 28, 2015.

Smith, Cedric M. "Origin and Uses of Primum Non Nocere — Above All, Do No Harm!" The Journal of Clinical Pharmacology, Volume 45, Issue 4, American College of Clinical Pharmacology, John Wiley & Sons, Inc., March 7, 2013.

You need to understand medical ethics and be ready to answer ethics questions or tackle MMI stations that focus on this topic. This guide outlines the four pillars of medical ethics and introduces three ethical frameworks that you should know about.

Medical ethics describes the moral principles by which a Doctor must conduct themselves. You need to understand the concept of medical ethics when you’re applying for Medical School, but you aren’t expected to be an expert.

It’s worth being aware that medical ethics is a changing ideal. Something that might have been considered ethical 30 years ago may not be today – and what we think is ethical right now may change in the future.

Why Is Medical Ethics Important?

Medical professionals frequently find themselves facing moral questions and ethical dilemmas in their line of work. Medical ethics provide a framework to help them make judgement calls which are morally sound and right for the patient in question.

It’s essential for aspiring Doctors to have a good moral compass and a solid grasp of medical ethics so they can consistently do what is best for their patients.

The four pillars of medical ethics are:

These four principles represent a framework for analysing the best action to take in a given situation. To use this approach, you must consider whether your actions are in compliance with each of the four pillars.

A good example of an ethical dilemma relating to Medicine is that of surgery.

Imagine that a patient has appendicitis and the surgeons believe that surgery is necessary. Technically, making an incision into the patient’s skin is causing “harm” to the patient; however, this is done with good intent as removing the inflamed appendix eliminates the risk of progression to rupture and peritonitis.

Surgery would be offered to the patient based on their clinical need and they will have the right to make an informed decision. The four principles would, therefore, support performing this surgery.

Consequentialism is an ethical ideology that states the morality of an action is dependent purely on its consequences. A simpler way to phrase this would be that the “ends justify the means”. If your action has an overall benefit, then it does not matter about the action itself.

Example: Your patient has a terminal illness and is not likely to survive the operation she is about to undertake. Just as she is about to be anaesthetised, she asks you: “Doctor, will I be okay?” A consequentialist ideology supports that lying in this circumstance is acceptable, even though lying itself is not a moral action.

Utilitarianism says the best action is that one that brings about the best increase in utility (benefit). Utility is generally considered on a broad scale, often taking into consideration wider society and not just the patient in question. It’s a form of consequentialism.

Example: You have a sum of money to either fund a very expensive treatment for one patient with a rare disease or five patients with a very common and easy-to-treat disease. Utilitarian ethics dictates that treating the five patients is morally superior as a greater overall benefit is achieved.

Deontology is also known as “duty-based ethics”. This ideology states that the correct course of action is dependent on what your duties and obligations are. It means that the morality of an action is based on whether you followed the rules, rather than what the consequence of following them was.

This is in direct contrast with consequentialism.

Example: If your terminally ill patient asks if they’ll be ok after a surgery they’re unlikely to survive, a deontological approach would suggest you don’t lie to comfort them. That’s because according to this concept, lying isn’t morally acceptable because it’s our obligation not to lie – no matter the consequences.

Generally speaking, consequentialism may be the most relevant guide to thinking about the broad aims of healthcare – and deontology-based guidance is the one most commonly seen in Medicine.

How To Develop Medical Ethics Knowledge

One of the best ways to develop your understanding of medical ethics is to practice analysing situations using ethical frameworks and ideologies. You can do this on your own, with a teacher, or with a fellow Medical School applicant who could give you their perspective and share ideas. Try to compare the outcomes given by different frameworks and consider the implications of this.

Make sure you stay up-to-date with the latest health news – and see how these ethical frameworks apply to what’s currently in the news.

At Medical School interviews, medical ethics is a big part of the selection process. It’s highly likely that you’ll be asked ethics questions or face an MMI station designed to test your understanding of these concepts.

Some key medical ethics examples that you should be aware of for your interview are:

When you answer ethics questions, you don’t have to list each of the four principles of ethics and outline these concepts – instead, pick a couple that are really relevant to show the interviewer that you’re aware of medical ethics in general.

And remember – you may not be expected to make decisions yet. The key thing to do in your interview is to show you understand the issues by discussing how the key ethical principles relate to the question. If the interviewer pushes you for an opinion, make sure you can back up what you choose with some ethical reasoning.