Think Harm Always
Editor's choice
How do you deal with something unpleasant? The commonest way is not to 
think about it. That, I suspect, is why medicine has paid so little 
attention to the harm it may cause-despite the ancient instruction "first, 
do no harm." Many people try to deal with death by not thinking about 
it, but Montaigne advises us to do the opposite and think about it all 
the time. The same advice might apply to thinking about harm: every 
intervention by a doctor, even a throwaway comment or a test "just to be 
sure," carries the potential for harm, whereas many of those 
interventions have no possibility of bringing benefit. This long overdue theme 
issue explores some of the many ways in which health care might result in 
harm. 
Very few people attend a doctor thinking that they may come out worse 
than when they went in. But many do. When referring a patient to 
hospital should a doctor say: "I must warn you that the simple fact of being 
admitted to hospital means that you have something above a one in 10 
chance of suffering an adverse event and a one in a 100 chance of dying"? 
I put this point to the Helsinki meeting of the World Medical 
Association, a body that has made its name (and possibly created harm) by 
promoting informed consent. The audience looked quizzical, and I've never 
heard of a doctor issuing such a warning. But doctors will regularly warn 
patients of much less common risks attached to particular 
interventions. 
Imagine an applicant to medical school answering the universal question 
of "Why do you want to study medicine?" with "My main ambition is to 
try to do less harm than good" or "I'd like to devote myself to exploring 
the harms caused by doctors." The applicant would be thought very odd 
even though he or she would be enlarging on "first, do no harm." Yet the 
balance between doing good and creating harm in a lifelong medical 
career undertaken with commitment and compassion may be fine. The harm is 
omnipresent, the benefit sometimes fleeting. 
As a junior doctor I dutifully prescribed lignocaine to many patients 
who had had heart attacks. The logic was, I believe, that the drug would 
prevent the arrhythmias that might kill patients. It never occurred to 
me that this might kill patients rather than save them, but I learnt 
years later that the result of my hard work was more not fewer deaths. As 
my parents took me to hospital as a 7 year old and left me alone (on 
the hospital's instructions) to have my tonsils removed they never for an 
instant thought that the harm of the procedure might outweigh the 
benefit-but it probably did. The hospital admission certainly made me 
miserable and caused me to miss my big break playing the Archangel Gabriel. 
Hard and uncomfortable as it may be, we need to think about harm all 
the time. 
Richard Smith, editor 
British Medical Journal  2004;329 (3 July)