Primum Non Nocere

Nonmaleficence exemplified in the Latin maxim ‘primum non nocere” is held up by some to be the most important principle in medical ethics.  Abstaining from harming the patient is usually a good thing to consider given the potential of all medical treatments to damage as well as help but why is the principle considered to be the doctor’s primary concern?

The phrase “primum non nocere” has an uncertain origin. The exact phrase was not used by Hippocrates although he does say things similar such as “the physician must... have two special objects in view with regard to disease, namely, to do good or do no harm”. The “primum” however is nowhere to be seen. The phrase has been attributed to Thomas Sydenham, an English physician born in 1624 and fought for parliament in the English civil war (and incidentally the first to proscribe quinine in the form of cinchona bark for malaria).  However the justification for the nonmaleficence as the sole basis for ethical medicine is probably not for historical reasons.

 In choosing treatments the potential for harm is certainly a factor the must be weighed up against the treatments chance of success. Fixing even simple bone fractures through surgery would be a quick and appealing option if not for the major risks inherent in any surgical operation (and the cost). Even antibiotics have enormous potential to harm especially if used inappropriately when they have a very real risk of leading to the development of antibiotic-resistant strains of bacteria such as MRSA. Whilst the side-effects of any treatment are a serious concern weighing them up does not appear to be more challenging than most of the tasks and issues a doctor has to deal with on a regular basis. Is nonmaleficence unfairly emphasised? Why also are doctors in particular targeted with the responsibility of doing no harm when the roles of, for instance, a soldier or airline pilot have perhaps an even greater potential to cause death and destruction?  

 To some what separates nonmaleficence form other principles of medical ethics for instance beneficence (the duty of doing good) is a matter of scope. Whilst doctors have a duty to everyone to do no harm the doctor’s duty to good is strictly limited to the patients whose treatment he or she is currently involved in.

However just because we have a duty to do no harm to all does not necessarily mean that nonmaleficence has priority when it conflicts with other principles for instance when Nonmaleficence conflicts with respect for autonomy if a patient does not consent to a life saving treatment. Like people’s perception of good and what they seek to gain from a treatment, each patient will have their own perception of risk and harm. Palliative care may be acceptable for some whilst others may want curative treatment options despite major risks involved.  

Whilst nonmaleficence cannot, in my opinion, be the most important principle of ethical medicine I would not goes as far to say that “primum non nocere” deserves to be confined to the history books. The principle of nonmaleficence itself is vital when combined with other ideas such as justice and autonomy in deciding the best course of action.