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. (Hippocrates, Of the Epidemics 1.2.5)

“I will do no harm,” states the Hippocratic Oath. This creed was reinvigorated in the seventeenth century by an English physician named Thomas Sydenham (1624-1689), who was likely the first to Latinize the motto, primum est ut non nocere.1 To this day, primum non nocere – “first, do no harm” – remains a pillar of medical ethics.

Since the dawn of medicine, doctors and practitioners have been acutely aware that treating a patient is risky. Every healer is a human, prone to miscalculation, hence the ever-present possibility that a course of treatment might bring about a calamity of counterproductive consequences.

In medicine, the word for unintended and inadvertent harm is iatrogenesis, literally meaning ‘brought forth by the physician’. It epitomizes a doctor’s greatest fear: instead of fostering health and recovery, the patient becomes a victim of yet another infliction – the doctor. Whether a combination of prescribed medications interacts to create an injurious concoction, or a hospital-acquired infection is contracted, or negligence and malpractice are to blame, the recipient of an iatrogenic treatment faces a daunting realization: their present state might be better if they had simply not received medical care in the first place.

The pursuit of ‘not doing harm’ demands that a physician be constantly careful, critical, and ever-learning. The status quo must especially remain under an eye of weary suspicion. For hundreds of years, bloodletting was practiced with the best of clinical intentions: it conformed ‘logically’ to observations of menstruation and secretions (after all, it was abundantly evident that bodily fluids were expelled after their usefulness). For generations, bloodletting was universally understood, accepted, and promoted as an effective remedy. However, over the centuries, the practice severely harmed millions of patients – proving that even the most obvious and conventional strategy to help can actually be detrimental. Bloodletting is a textbook case study of iatrogenics. Just because a practice is universally accepted does not mean it is somehow inherently free of harm.

Unlike physicians, most of us are not charged with the task of making life and death decisions every day. But, like physicians, we are still no less the architects of outcomes we produce today, entirely regardless of the intentions we profess for our actions. An abiding, chronic trait of the human condition is the lingering potential that we can inadvertently cause harm while seeking to foster life. There is never a guarantee that the fruits of our labours will match the intentions of our efforts. In life, as in medicine, this foundational ethic eternally pleads with us to second-guess even our most sacred assumptions: first, do no harm.

  1. Smith, Cedric M. (2005). Origin and Uses of Primum Non Nocere—Above All, Do No Harm! The Journal of Clinical Pharmacology. Volume 45, Issue 4, 371–377, April 2005 

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Shelley, James. (2020). 'Iatrogenesis' (in System Thinker Notebook). Originally published on August 5, 2020. Accessed on October 31, 2020. Licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Permalink: https://jamesshelley.com?p=17168
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