Australian Doctor Australia Doctor 18th August 2017 | Page 30

Gut Feelings
T
Guest
Editorial
Professor
Stephen Leeder
30
Is primum non nocere
really achievable?
HE ‘first, do no harm’ rule
for doctors is sensible and
straightforward advice.
As is: “Don’t do things to
patients that damage them.”
But acting on these in the day-to-
day throws of clinical practice is not
always easy. Therapeutic interven-
tions can, and often do, harm. Surgery,
radiotherapy, hospital admissions,
dental work, and even psychotherapy
can cause collateral harm.
As positive outcomes cannot be
guaranteed, we try to communicate
probabilities of treatment outcomes
to patients, but at present they still
consent more in hope rather than cer-
tainty.
However, as more precise under-
standing of disease processes comes
to the fore, uncertainties over the
possible harms of treatment should
be alleviated.
For example, once more data is
in on the genetics involved with
responses to chemotherapy, we can
be more reassuring to patients over
the outcome of chemo and potential
side effects.
Yet, it is not just treatment we are
talking about when it comes to ‘do no
harm’. Prevention measures also have
the capacity to damage patients.
The late Professor Geoffrey Rose,
a UK epidemiologist, drew a clear
distinction between primary popula-
tion-based prevention (dealing with a
well community) and secondary pre-
vention, where a not entirely healthy
individual seeks medical care for, say,
disease risk factors.
And our approach should be dif-
ferent in each case. Avoiding harm
| Australian Doctor | 18 August 2017
is paramount, he argued, in primary
prevention where we are recom-
mending action to well people (for
example, immunisation) or chang-
ing their environment (such as, water
fluoridation).
If we damage well people who
were not in search of treatment, we
will not be doing the right thing.
However, preventing the occur-
rence of illness in those who may have
risk factors, but no clinical disease, is
different. It is complex territory.
We need to tell a patient who is
starting statin treatment, for exam-
pl