Monday, June 23, 2014

Of Medical Kayfabe

The Hippocratic maxim primum non nocere, "first, do no harm" is a fine pleasantry that offers little practical bioethical guidance. After all, the surgeon's scalpel harms the patient, so does chemotherapy, so does dialysis, and so does the insertion of a Foley catheter. If you've ever seen a code, there's no way you can conclude that no harm is done to a patient when rescuing from supraventricular tachycardia.

Medicine as she is practiced inflicts a little harm to produce a greater benefit. Physicians crack ribs asunder to insert stents, dice flesh to excise tumors, and pump cancer patients full of poison to shrink tumors. The sick and injured are necessarily poked, prodded, pricked, and punctured on the road to recovery. Yet that little phrase lurks in the wings, a wee moral beacon to help with the extremely tough trade-offs faced by doctors and their patients. First, do no harm.

Do no net harm is the easiest rescue of the nostrum. Yes, you may saw off a limb, but it's to prevent the spread of gangrene to the rest of the body. A little harm here to prevent a much greater harm there. Everybody knows that. It's obvious. What may be less obvious is that medicine is always and everywhere a matter of conditional probability. The harm suffered by a patient on the path to wellness is personal and subjective. Likewise, the benefit of improved health, the marginal contribution of a treatment, and the probability of effectiveness are all idiosyncratic, limited to the the best estimates a patient can summon, and always weighed against the opportunity cost of an intervention.

So here's my question. Does primum non nocere perversely influence the delicate economic calculus of medical intervention? If so, how does it bias intervention decisions? Most medical professionals I know opine that diagnostics are oversupplied (too many MRI scans, eg) and drugs are undersupplied (the FDA traps new drugs in approval hell for years while patients suffer and die waiting for a cure that may never come at all). Is the Hippocratic maxim a near-mode guide to help patients and their physicians agree on a course of treatment that almost always by necessity involves at least some harm, or is it a far-mode policy guideline for regulatory bodies imposing a strict precautionary principle?

Which interpretation leads to a greater flourishing of euvoluntary exchange?

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Do you have suggestions on where we could find more examples of this phenomenon?