Health Care Paradigms

Primum Nocere

One of the principal precepts of medical ethics includes the maxim, “primum non nocere”, or, “First, do no harm”.  The phrase, a version of which is found in the Hippocratic corpus, describes the importance of restraint in the application of medical intervention.

However, the phrase, as it applies to modern medicine, is misleading because it suggests that the application of modern medicine can be anything other than harmful, and this is generally not an accurate representation.  The three primary agents of modern medicine- drugs, radiation, and surgery- are all intrinsically harmful, even when they may ultimately result in overall benefit to the patient.

 DRUGS

America may be the most medicated nation on the planet.  According to the U.S. Department of Health and Human Services, at least half of all Americans take at least one prescription drug, with one in six taking three or more medications.  We spend over $160 Billion dollars per year  on drugs.  Pharmaceutical intervention is a primary tool of modern medicine.

Drugs are harmful.  All drugs have side effects, and most drugs have several side effects.  The term “side effect” itself is something of a misrepresentation: what we are actually describing are harmful effects.  The definition of a side effect is not just that it is not the intent of the medication, but that it is a deleterious event for the patient.  How much more prudence we might exercise in the administration of medicine if we called side effects “harmful effects”!  Of course, the term “side effect” has a higher marketing value, as it tends to diminish the significance of these harms.

RADIATION

Radiation therapy includes both diagnostic and therapeutic uses of many different types of radiation.  MRI’s., CT Scans, x-rays, mammograms and others, all use radiation.  Radiation is intrinsically harmful, as it exposes the body to focused beams of ionization, one of the few things we know with certainty causes cancer.  The harmful effects of radiation are furthermore cumulative, making these harms permanent and irreversible.

SURGERY

The harms of surgery are also obvious: in order to perform it you need to cut into the body.  The body must heal the surgeon’s cut.   It goes without saying that we engage these tools of medicine when we feel that the benefit of the procedure outweighs the harm it inflicts.  However, we rarely hear the term, “Harm/Benefit Analysis”.  Instead we hear “Risk/Benefit Analysis”.  And while we should certainly consider both the harm of a procedure as well as the risk of other possible harms, there is a difference between the concept of “risk” and the concept of “harm”.  The term “risk” implies that the possibility exists for no harm at all.  Describing a Harm-Benefit Analysis, however, more accurately and scientifically describes the process of truly informed decision making in medicine.

Correcting our language when we talk about medicine is an important step in framing the dialogue around medical interventions and the establishment of public health protocols.  Failing to identify medicine as intrinsically harmful enables a system in which medical procedures are overutilized and their harm minimalized.  A good example is antibiotics.  Warnings about excessive prescription of antibiotics have been issued for decades.  Etymologists described the impact on humanity as “the worst case scenario” and “the end of the road” over 20 years ago.  Yet pediatricians have made few changes to their habits, decreasing prescriptions by only 20% in that time period.  Meanwhile, resistant strains have become so powerful that last year over 19,000 people died from MRSA.  That’s more than AIDS.

One complaint that pediatricians give is parents who come into the office demanding antibiotics for their child when the child has a viral infection (for which antibiotics are useless).  Pediatricians yielding to this pressure is one common reason for overprescription.  And while it is clearly true that it is the responsibility of the doctor (who is trained in the proper utilization of drugs) to exercise the necessary moral fortitude in the matter, it is also true that the failure to clearly identify medical interventions, including antibiotics, as intrinsically harmful, empowers this dysfunctional relationship.

A similar situation is happening with another miraculous scientific development.  Vaccines helped exert a controlling force over infectious disease that was rampant in many countries in the 19th and 20th centuries.  However, today the U.S. vaccination schedule seems to have gone off the deep end, administering 69 doses of 16 different vaccines between birth and age 18.  Compare that to far healthier nations like Sweden which administers only a dozen.  The lack of restraint and conservative approach is driven by the illusion that vaccines are intrinsically harmless.  In fact, vaccines are drugs, just like antibiotics.  Many vaccines even contain antibiotics.  The long term, multigenerational effects of these drugs being administered universally to an entire population represents an epidemiological question which will be simply impossible to accurately measure (lack of a control group being one problem).  The fact that adverse effect reporting rates are as low as 1-10% means that solid evidence concerning the effects of these drugs is mathematically unattainable.

Another good example  is the use of painkillers, whose harms are easy to overlook as their benefits are so welcome and immediate.  However, not only are we learning about the short and long term “harmful effects” of OTC drugs like acetaminophen and ibuprofen, but the addictive effects of opiate painkillers and the long term harm to the body of that addiction has become a national emergency.

Understanding medicine as inherently harmful is a critical step in reigning in the rampant overutilization that has affected so many elements of our health care system, and by association, its costs.  The health insurance industry does little to help this situation, as its focus on the short term amelioration of the most superficial aspects of health and disease engenders a system that rewards expensive, dangerous interventions and discourages preventive, proactive care.

Dean Ornish, the world famous cardiologist who developed the first proven  system to reverse heart disease without drugs or surgery (thus raising the question of whether he is practicing medicine at all”¦) said years ago, “If I perform bypass surgery on a patient, the insurance company will pay at least $30,000.  If I perform a balloon angioplasty on a patient, the insurance company will pay at least $7,500.  If I spend the same amount of time teaching a heart patient about nutrition and stress management techniques, the insurance company will pay no more than $150.  If I spend that time teaching a well person how to stay healthy, the insurance company will not pay at all.”  Incentivizing the most expensive, shortest-term, highest harm solution is a tremendous recipe for failure.

When we more realistically appreciate the innate harm of medical care, we can make more well-informed decisions about whether and how to utilize it.  Sugar-coating the tools of medicine serves no one.  The true motto of allopathic medicine should be adjusted to read, “Primum nocere”- First, the Harm.  This is not an insult, but simply embraces the reality that sometimes in order to help someone, you must hurt them first.  Let the world be warned.  This will help us to choose medical interventions more wisely, and hopefully gain the best that modern medicine has to offer (which is a lot) while avoiding the worst.

“You gotta be cruel to be kind,

In the right measure,

Cruel to be kind,

It’s a very good sign,

Cruel to be kind,

Means that I love you, baby,

You gotta be cruel to be kind”¦”

                                  -Nick Lowe

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