Friday, September 15, 2006

Primum non credere

Well, I might have done a bit of nocere today.

That's the nocere of "Primum non nocere" - the First Commandment of medicine. Primum non nocere translates as "first, do no harm. "

Like the First Commandment in the Pentateuch, in fact like every commandment and law, it is written down and quoted and sometimes even publically sworn with every apperence of solemnity.

And like every commandment it has had to be written down and quoted and even publically sworn because it's the kind of thing that nobody really wants to do. Like all laws, it exists to stop people doing something that otherwise they'd be doing all over the place.

Doctors have to be told not to hurt people for the same reason that drivers have to be told not speed and the accused has to swear to tell the truth and people have to be told to pay taxes and not pluck peaches from the neighbour's tree.

(Makes you think, doesn't it - if laws are just catalogues of the more common and attractive sins, then there should be a sub-profession of "forensic archaeologists". These would be people who go through the laws of exotic cultures and strange, isolated tribes, (such as the Bantu of South Africa, the Yali of Indonesia and the Doctors of the Emergency Department), looking at the laws of that society and working out what looked to have been their big problems.

If some ancient tribe had lots of laws about how important it was to only worship Snarg, Deity of Buttonholes, and how anything else must be punished, then you could say that Snarg wasn't getting enough, and that s/he obviously had reason to feel insecure. And presumably, for a bronze age nomadic desert people, all living in close proximity, the coveting of the neighbour's ass was indeed a problem, as was working out how closely someone could be related to you before having sex with them became a bad idea).

So why do doctors have to swear, or at least have it drummed into their heads, to do no harm? Are we that homicidal?

Not at all. Those harmed by doctors who are overtly homicidal are few, whereas those harmed by doctors who are neutral, or well-meaning, or even deeply compassionate, are rather too many. For every victim of a Crippen there are thousands maimed and damaged by doctors who are, they say, just trying to do their jobs.

Some of these harmful doctors are inept.
Others are, at the time, bone-acheingly tired.
Others are too ashamed to ask for help before things go wrong, and too afraid to ask once things have started to go wrong.
Others are arrogant, or ignorant, or lazy, and sometimes all three.
One in a very small number is actually cruel.

As for me, it seems that if I did harm (and it's not a big lump of harm, and it's not a big stuffup, and it may have been no stuffup at all) it was a combination of ignorant and well meaning.

The setting was one of Florey's lecture theatres, and I was giving a talk to a group of nurses. I have been doing talks to the nurses and the junior doctors for a few weeks now, and the differences are quite marked. Doctors are able to prescribe medications, and so attract the attention of the pharmaceutical companies. You turn up to the doctor's talks and there's a full meal laid on, and ties and watches and pointless free gizmos litter the desks. You turn up to the nurse's talk and there's a big Tupperware container of boiled lollies and instant coffee, BYO cup.

Anyway, I was there to talk on drugs and alcohol. This is a fairly easy topic to talk on, of more intrinsic interest than renal carcinomas or effective use of the Wells enucleating spoon. It's easy to sprinkle your talk with startling facts ("By this time Mr Ague was drinking five to seven litres of wine a day...") and the whole thing offers listeners either that frisson of the forbidden or the chance to feel better about yourself than someone else - and often both in the course of one powerpoint slide.

Anyway, rather than bang on about heroin for hours, I slanted most of the talk towards the addictive drugs that would kill far more of my audience, and their children and their parents.

Tobacco, so far ahead it's not funny.


A segue onto the whole "does marijuana cause something like schizophrenia" thing (answer - nobody's sure, and those who are really sure probably shouldn't be as sure as they are, and if you've got any history of being what doctors call schizoid and the rest of us call weird, don't smoke marijuana. Sad but true.).

And towards the end, some stuff on what works and what doesn't work when giving up smoking, that kind of thing.

And that was the nubbin of it. I told them safe, effective, useful ways to give up the number one cause of early death in their age-group.

Good medicine, obviously. Basic applied epidemiology, bargain basement harm minimisation, patient empowerment (for a predominantly female, "lower income than me" clientele and so forth. One one hour talk, one nurse gives up smoking one year earlier than she otherwise would have, a cell divides evenly, a cancer does not form, or forms but starves. Ten extra years on her life.

An hour well spent, one would think.

Apparently not. An article in the June issue of the Journal of Consumer Research describes an experiment that suggests that providing information about treatments for diseases* like smoking, injecting drug use, obesity and so on may make it less likely that the patient* will seek treament. The idea goes that both smokers and non-smokers (or both injectors and non-injectors, or both fat and popular /employed people) who hear about successful treatments for their diseases subsequently see their diseases as less serious. They are thus less likely to quit, because, hey, it's not so dangerous after all, and if things do get bad they've got a "get out of jail free" card.

This makes no sense, on one level. However, it certainly took the self-satisfied grin off my face when I came home, too, and it does fit in with something I have been coming across every now and then as I read, something to do with how human beings treat risk - studies that cite observations that drivers drive closer to cyclists wearing helmets than to cyclists without helmets, or that taxi drivers will drive faster in taxis with better brakes.

The idea that ties all this together is called "risk homeostasis". This is the idea that people have an inbuilt level of acceptable risk, and that they will keep running at that inbuilt level despite attempts to make things safer. You make things safer, people take more risks. The plutocrat driving the 4WD/SUV with the airbags and the seatbelts will serenely cruise through the red light, the terrified student hunched over the steering wheel of his 1972 Chevrolet Impaler will not.

I don't know about this. It seems a difficult idea to prove. I suspect that some innovations are pretty much definitely lifesaving - child-proof lids on medicines, for example, and non-flammable clothing. I don't believe that people wearing flame-retardant woolen pyjamas are more likely to burn rubbish during a fire ban than, say, people wearing flammable nylon pyjamas.

And is it not possible that the risk homeostasis is true for a certain sub-group of the population, motocross-riding, base-jumping adrenaline quaffers like our newest social worker, but not for dyed in the wool physical cowards like myself? Leading to a weak, or partial risk homeostasis effect?

Anyway. Maybe I could have saved more lives by standing up in front of the smoking nurses and saying "Smoking. It kills most people who do it, it'll probably kill you. You'll try to stop, but you won't be able to, and when you finally do it'll be too late. You'll drown in your own viscid lung secretions, either in front of your pale and terrified relatives or abandoned by them, after months of swelling, suffocating, unmedicable terror. Any questions? Didn't think so."

Not really me. Anyway, will write more soon. Thanks for listening,

*weird seeing these words used like that, isn't it?


Blogger lauritajuanitasanchez said...

I had a conversation recently w/ a friend (A). I was very concerned about another friend (B) who had gone in for an X ray and they'd found a spot on her lungs. Friend A is a PhD in some biology based field and he said something to the effect of "since B is a smoker, she's got a 1 in 3 chance of dying from it". I was pissed off at A for being so callous, for looking past the person and immediately going into stats. But then, you can't argue that smokers (and I was one myself...managed to quit) haven't been informed of the risks. If they REALLY wanted people to stop smoking, they'd photodocument the deterioration of someone w/ cancer as part of an anti-smoking ad campain.

10:24 PM  
Blogger Niamh Sage said...

LJS: We've had some truly horrifying anti-smoking ad campaigns in Australia, showing smokers' lungs, arteries, etc. Don't you get stuff like that where you are?

9:25 PM  

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