The future lies before you like a field of driven snow, be careful how you tread it, for every step will show– Unknown
First do no harm. A popular phrase, often mis-attributed to the Hippocratic oath, which in its original form bears little relevance to the practice of modern medicine. In the modernised form it omits even a specific phrase with similar meaning. The original phrasing of this part of the oath translated was something like: To abstain from intentional harm or wronging. Modern revisions of the oath, which drop the original requirements to share money with ones teacher, refrain from surgery in various circumstances and withhold abortion allude more to viewing the patient with empathy, warmth as having equal or greater weight than medical intervention, treating the patient as a person rather than a symptom and treading carefully in matters of life or death. These revisions reflect attempts to distil the codes of ethics which modern day physicians are bound to. The oath is now primarily merely a trope.
This is not simply a matter of semantics. While it is more the territory of philosophy experts to enter into arguments concerning the ethics of failure to act, even the layperson understands that the only way to maintain certainty of not inflicting harm is to abstain from action altogether, to occupy a negative space- and yet a Doctor or even trained first aider who chooses to stand staring at a wall while a person expires from choking- for fear of breaking a rib, or saving the life of someone who may go on to cause a fatal car accident, punch a security guard, step on a snail- is indeed playing a part in the death of a human being. It is not the medical professionals role to abstain from acting but to consider the risk/benefit balance of any actions they chose to take.
Doctors of course are people too. For all the NICE guidelines, clinical pathways set out to take the burden of decision making from the individual practitioner, few people can fail to consider the risk/benefit to themselves of any action taken, be this risk or benefit emotional, professional, financial or legal.
Those practising the art of medicine in the time of the inception of the oath may have been beholden to Apollo, their tutor and their communities while modern medical professionals apply science in the context of businesses, local authorities and government targets. The role of the self however- the practitioner and their conscience, the practitioner and their career, their well-being, their financial security endures from the age of medical art to the age of medical science. First, do no harm, first applies to that self, and then the patient.
So what of the choice of the patient in this? The medical system in undeniably paternal. Offering or withholding treatment, medication or support in line with the goals of the business, the government, the system of funding, the risk/reward benefit of the decision maker- requires a patient at who is not allowed to bear the burden of the risk themselves, even if they may disagree with the priorities of the decision maker. The emphasis in this decision making tends to fall more heavily on the choice of action, rather than the choice of abstinence from action.
Why these thoughts in a diary post? This week, an individual close to me has become caught between two agencies, while both agree a treatment would be beneficial to them, neither want to bear the responsibility of initiating the treatment due to a specific risk in doing so. The choice of the patient, the power to bear risk, is nullified leading to significant suffering on the part of the patient in question. To be clear, no party disputes that the treatment is suitable and almost certainly of great benefit. The risk however, would become a potential liability to both the prescribing individual and the organisation they work within.
Recently, a baby passed away due to a rare illness. From the perspective of the child’s parents an opportunity to attempt a new, untested treatment was denied to them prior to the damage of the illness becoming too great for the treatment to be of benefit, should it succeed. Here the case is far, far more complex. The medical bodies involved in the decision making applied to the courts to make judgement of the ethics of allowing this treatment. Before the initial ruling was obtained, the illness became sufficiently advanced that the decision making parties involved felt that there could be no benefit to the treatment. The parents, who were under the immense emotional pressure of the prospect of their first child dying before reaching his first birthday, maintained the treatment was worth trying. Later facts which came to light have altered somewhat the general public view of the case. There was no patient here able to advocate for themselves. The court became to an extent, the advocate of the patient, with the parents also advocating for the patient but in opposition to the view of the courts. The risk/benefit weighting here; unimaginably complex- grief, an extremely rare disease and an entirely un-trialled treatment, a hospital traditionally benefiting from a vast amount of public donation, public opinion, the unhelpful weighing in of non-expert but high profile figures. It is not difficult to see how the patient could be lost somewhat in all this, becoming an ideological symbol, a blank canvass for the emotions and ideas of many people. The fact the child was too young to speak, to disabled to express- in fact it was reported that even the immensely experienced Drs working with Charlie were not able to establish if he could experience pain- must have, could not failed to have, made Charlie the ideal subject for the projections of those both around him.
Furthermore, I received a full copy of my medical notes yesterday. I applied for these with a view to preparing supporting evidence with regards to my application for disability benefit. I was not prepared for finding these notes went back as far as birth.
The notes do not follow my history as I remember it. It is well known that people tend to revise and rewrite their stories from a position of retrospect, memory is not so much a record of the past as it occurred, but an interpretation of the past as it relates to the present. Parts are disturbing. At one point I came close to throwing up. Reading from now backwards, or from the beginning forwards, are very different experiences. Oversights, failures to act, are many. Patterns emerge which can only be seen in viewing the quite substantial pile of papers as a whole. It strikes me that, if my current GP was able to provide these,then every general practitioner I have spoken with has had access to my entire medical history, every Dr or medical organisation I have encountered could have viewed them. And yet, there is only one letter in the entire bundle which references historical medical documentation. The oath, from its inception to its current state, is barely reflected in this story.
Many people express feelings of being incomplete. Their partner often described as their other half, their children or their possessions or their hobbies often described as ‘filling a hole’. The medical profession reflects this. A drawing of a limb here, a scan of an organ there, isolated, in its time and cleanly separate from the rest of the body and all its messy history. One widely used attempt at revision of the Hippocratic oath states; I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
What harm might be done to the practitioner if they were to truly follow this creed? The healthcare budget? The bottom line? What is the damage done in a lack of time, in fear of risk, when healthcare resources are stretched to breaking point across every sector, what damage is done due to lack of money, lack of time?
In my story and the story of many other’s it seems to me, where harm is present, inaction came first.