First, Control the Damage
by, 09-02-2011 at 03:16 PM (2227 Views)
Frankly, I'm getting sick (literally) of doctors and "public health experts" trotting out the "First, do no harm" adage as their justification for aiding and abetting the murder of millions of smokers.
"I can't prescribe something that's harmful." Oh, really? I'd venture to say that a large percentage of the medications listed in the Physician's Desk Reference are substances that often are harmful when used as directed, can be harmful if prescribed for a condition the patient doesn't have, or are harmful when overused.
Nowhere in the Hippocratic oath will you find the exact words, "First, do no harm." Here is the pertinent sentence from the oath:
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
While not harming the patient is explicit, the first concern of anyone who provides medical care must be damage control. Old Joke: The operation was a complete success but the patient died.
In Epidemics, Hippocrates expands on the idea of what it means to never do harm to anyone.He suggests that the goal should be a speedy recovery of health, and the avoidance of prolongation of the disease, or death, or relapses.
But what happens when the patient is shut out of the process? Often that means that the disease is misdiagnosed because the doctor is lacking pertinent information or does not understand (or does not value) the patient's health priorities.The physician must be able to tell the antecedents, know the present, and foretell the future - must mediate these things, and have two special objects in view with regard to disease, namely,to do good or to do no harm. The art consists in three things - the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician.
The Tobacco Control Community has decided that the disease they intend to treat is "tobacco addiction." Framed in that way, "take away the tobacco" is the only treatment possible.
But what if, as Hippocrates suggests, we involve the patient in this process? What if the patient is more concerned about lung disease, cancers, and heart diseases that are not a direct result of the "tobacco addiction" but rather are direct results of the nicotine delivery method, smoking? What if the patient is also concerned about cognitive and emotional health, which are impaired when the patient follows the doctor's orders and becomes nicotine-abstinent? Is it ethical for the doctor to impose his or her set of values on the patient and disregard the patient's pain, distress, dysfunction, and premature death?
Diagnosing the disease as "the health consequences of inhaling smoke" opens up a whole new world of potential treatment options.
In Framing tobacco control efforts within an ethical context, B. J. Fox argues that the tobacco control community should more proactively frame its actions and base that frame upon ethical principles. "The tobacco control community lacks a comprehensive understanding of ethics," he states. "In turn, this has allowed the tobacco control community to be defined by its desire to defeat the tobacco industry, at the expense of its desire to protect the public."
Framing tobacco control efforts within an ethical context -- Fox 14 (suppl 2): ii38 -- Tobacco Control
Ethically, a doctor's first priority needs to be damage control.
Help the patient to stop the damage being done to his or her body, using whatever works! There's plenty of time later on to worry about treating addiction--if that turns out to be necessary to protect the patient's physical, cognitive, or emotional health. Moral health should be left up to the patient's spiritual healers, not to medical doctors or public health officials.