Primum, Non Nocere

‘‘Less Medicine, More Health’’

Sthabir Dasgupta

President Garfield was shot with a 0.44 calibre pistol, from a point blank range, on July 2, 1881. There were two consecutive bullet injuries, one in the arm and the other in the back. The arm injury was not a serious one while the back injury was very serious but not lethal. It had traversed deep tissues, but the bullet stopped just short of major organ and blood vessels. He was hospitalized immediately and a team of doctors led by a surgeon did their utmost. President Garfield had endured the trauma for 11 weeks before succumbing to death on September 19, 1881.

It is interesting to note that Charles J Guiteau, his assassin had defended himself in the court of law by saying that the bullets were fired by him, but he did not kill the president! Then who had killed the 20th President of the USA? The assessment of Dr Donald Trunkey, a famous surgeon and academician almost 100 years later was simple and blunt. He said the president was killed by his surgeon. But how did he arrive at such a conclusion? Was there any lack of medical attention? Was there a conspiracy? Not at all; on the contrary, the medical attention was round the clock and too aggressive.

But then, how and why did he die? Everybody knows that the cause of his death was severe and multiple infections. How did they occur'? It is also known now that the surgeon had tried repeatedly, for several weeks to explore the back wounds with fingers and metal probes in order to feel the position of the bullet so that it could be taken out from his back. He did not bother to wash and clean his hands before doing so, for although the concept of sterilization was known at that time, there were surgeons who did not pay heed to it. The infections therefore, were the only certainties.

President Garfield had died of severe infections resulting in multiple abscesses which were avoidable. The conclusion of Dr Trunkey was therefore obvious, for the infections were introduced in the patient's body by unwarranted intervention. The interventions were unwarranted indeed, because now we know that the bullet should have been allowed to stay where it was and one should have waited till the wound healed by itself. This is because trying to remove it by heroic-measures would be more disastrous. Thus the wound was not fatal but the subsequent actions and knee-jerk response on the part of the surgeon were.

This anecdote is one of many such in a newly published book, "Less Medicine, More Health", by H Gilbert Welch, an academic physician and professor of medicine in the USA. The anecdotes remind us of the first principle of medical practice that says, First, Do No Harm. Such a principle only indicates that while medicine is tremendously useful to us, some of its aspects are harmful as well. A responsible medical man therefore, is asked to be doubly careful and considered while delivering his service to the sick. One may wonder why at all it should be reiterated today.

Yes, it must be reiterated, because the unique development that everybody witnesses to his dismay today is that modern medicine, instead of being more and more professional, has become more and more an investment opportunity. Such an orientation clearly produced more and more urge to treat. This urge indulges one to diagnose more, to order more tests and to intervene into the body and psyche of the unassuming people, even when such interventions serve no fruitful purpose. 'Disease' has to be invented even if there is no trouble or complaint and opinion in favour of treatment has to be manufactured.

One can easily appreciate that in Garfield's case the doctors were under the most compelling situation. The patient was none other than the President of the USA. So, they had to be active, more than it was scientifically required rather than simply supervising a good and efficient supportive and symptomatic care. Or else, they would have been criticized for deficient care. Dr Welch says in his book that the doctors would certainly not have been so over-active had the victim been a common soldier. 'There were numerous Civil War veterans who just a few years earlier had survived bullet wounds of similar severity. What was done for them? Nothing'.

At this point some may argue that the doctors merely failed to control infection which was the real cause of death of President Garfield. Yes, evidently they failed. But the question is how do such infections occur and how do they become so fatal? The answer is that we do such things to our patients in our hospitals that weaken their vitality and their natural power of resistance. This causes infection to be more serious and more and more resistant to treatment. Our over-activism against troublesome infection results in killing of the good bacteria that are responsible to maintain the normal, ecological balance of life.

Today this is termed as hospital care-associated infections. However, it is not a problem of infection only. Our over-activism is not limited to infections only. In the problems other than infection also our over-enthusiasm results in the newer diseases or conditions that were never there before starting treatment. In medical parlance, development of disease or condition due to treatment is called iatrogeny. It is being lamented in various medical journals for the last few decades that modem medicine has become the victim of its own creation: the more you do the less (or the worse) you get!

It goes without saying that there are desperate times when actions even they seem to be rigorous, are immensely required. It is truer however that in many other times, particularly with terminally ill patients they result in disasters. We can demonstrate modern medicine's resuscitative prowess: 'intubation', 'ventilators', 'central lines' and many such. Sometimes there may be a price worth paying if the underlying disease process is reversible, and the life regained in such manner is worth living. But when it is not so, such actions demonstrate a combination of patient's extreme discomfort and medicine's powerlessness.

Although the popular assumption is that action is always better than inaction, the disturbing truth as explained by Dr Welch in his book is that action is not reliably the right choice. In fact, as we were taught earlier in our medical schools that masterly inactivity is sometimes the wisest judgment. We were also taught that the best surgeon is one, who knows when not to do surgery. Similarly, the best doctor is not one who can prescribe easily; on the contrary, it is one who can make considered evaluation. Inaction however, is not synonymous to inactivity. Inaction is a grand strategy of treatment.

This is because sometimes our intended actions complicate the ailment more. In these circumstances inaction serves as the best action. Inaction is against purposeless action. It is to be reiterated that there are some problems which disappear on their own, by time. There are others which may persist, but we adapt to them. There are still others which wax and wane. So, it is a false assumption that healing is not possible without medical care. The fact is that there are many things that can be done, there are some things that should be done and there is precious little that must be done.

Medicine however knew it from its very inception. Hippocrates had had to enunciate four millenia earlier that Primum, non nocere, meaning 'First, do no harm', because it was known that all therapies are inherently pregnant with iatrogeny. Arthur Bloomfield, the outstanding Professor of Medicine, Emeritus, at Stanford University School of Medicine had to plead that every hospital should have a plaque at the entrances stating: 'There are some patients whom we cannot help; but there are none whom we cannot harm'. Can anyone find such a plaque anywhere?

The paradox of modern progress is that we have chosen to ignore what is really beneficial to us. The medical establishment has tried hard and has succeeded to a great extent to confuse the people about the virtue of medicine and modernity. As a result, people's and medical men's faith in the marvels of modern medicine is bought at an enormous psychic and monetary expense. The most obvious force promoting unnecessary and even necessary action today is money. Along with this there are other incentives also, for instance, if we act our patients feel that they are properly heard, we can claim credit for cure or at least a credit for trying.

Health researchers have warned many times that the medical establishment we are so proud of has become one of the leading causes of death today. In fact, reliable data and statistics prove that the medical profession itself tops the list of causes of death followed by cancer and heart attack, in that order of preference! Certainly there are reasons behind this sordid affair. Those reasons might be clear if we go through Dr Welch's latest book. The lay and the learned as well will understand that all risks cannot be lowered and trying creates risks of its own.

They will understand that early diagnosis that the medical establishment is so fond of can needlessly turn people into patients and newer interventions are typically not well-tested and often wind up being harmful. There are seven such popular assumptions which, when put to test prove to be false. Such an understanding is required today, for medical decisions are not simply about science, they also involve value judgment. It is true that today's circumstances are not comparable to those of yesterdays; but still a young medical man will also realize that the medical profession is more a calling and less an investment opportunity.

We must treat the sick. As Dr Welch says, ''This is the most important part of medical care, but it's not what most of medical care is. And much of medical care doesn't reliably lead to better health'. It is time for us therefore to remember that the lexicons trace both the term modern and medicine to Latin—Modus, meaning Measure or Matra in Sanskrit. So, modern medicine is all about a sense of proportion.

Vol. 48, No. 13, Oct 4 - 10, 2015