The vast ethical void between primum non nocere and the customer is always right


First, do no harm. For physicians, these are hallowed words. Within religion, they are akin to the Golden Rule and are, in fact, quite similar. In the realm of ethics, Kant’s categorical imperative, to only do what you would have seen done universally to all people, comes to mind as a suitable comparative axiom. Other professions have curious and interesting maxims as well. In politics, when you strike at a king, you must kill him. In literature, show; don’t tell. Carpentry? Measure twice, cut once. Finally, in sales, the customer is always right.

This leads me to the crux of my argument: That in the house of medicine, there is a vast ethical void between primum non nocere and the customer is always right. To begin with, medicine is a difficult art due to its reliance on strict, empirical science and a murky science due to its artistic cultivation in the soil of humanity. It grows toward the light of science but out of the hearts and souls, the jubilant dreams and the dread terrors, the sins, and the struggles of men. It needs light as much as soil; gentle rain as much as dark earth. As such, the most considerate gardener will make mistakes.  What is right in a textbook is often wrong for the patient in front of you and vice-versa. Our work is a hard science and an almost daring art.

The heart of medicine is the relationship between a physician and a patient and is fundamentally of a covenantal nature. A dialectic conversation occurs in which a patient’s hopes and worries are conveyed to the physician, and the physician’s thoughts and potential solutions regarding those concerns are transmitted to the patient. There is much room for shattered expectations and disappointed hopes in such a fraught relationship. Given such considerations, when medicine is forcibly contorted into a business model or an act of legislation, both “customer” and “provider” are bound to be unsatisfied. When these economic and political terms have weaseled their way into the lexicon of medicine it does seem as if something corrupt has infiltrated our sphere of interest. They are like dead canaries in a coal mine: a sad and pitiful warning. Something is rotten in the state of Denmark, indeed.

It is this perversion of an ancient art into a modern corporate or government paradigm that has turned a covenant into a contract, a patient into a customer and a physician into a provider, or even worse, into the infantilizing sobriquet of “team member,” as if we are playing intramural kickball. Behind the commodifying idiocy that such egregious appellations have forced upon us, both as doctor and as patient, lies the corporate mindset of hospital administration. It is this plague that is the source of so many of the modern symptoms that we find ourselves struggling against.

The insanity of extremely broad and non-specific sepsis metrics that mandate massive fluid boluses and broad-spectrum antibiotics for patients within one hour of arrival to the emergency department is one example of a government mandate turned into a corporate directive injuring our patients and damaging our profession. This hurts both individual patients directly and society writ large indirectly (through the excessive and unnecessary use of antibiotics that will inevitably lead to antibiotic resistance for everyone). Disingenuous “provider-in-triage” times that encourage costly, unnecessary, and sometimes harmful testing to patients are yet another symptom. The calumny of Press Ganey patient satisfaction scores and the ever-increasing burden of electronic health record documentation are just a few more instances of such symptoms.

All this and more has led to what has been recently classified as a “moral injury” to physicians. Doctors mistakenly believe that they must go along to get along with administration without realizing that the administration has vastly different goals than they have. But we have a choice. We can protect our covenantal relationship with our patients — what I like to think of as our space of mutual contemplation where shared decision-making occurs respecting a patient’s goals and a physician’s options given those goals — or we can allow rough hands to damage our art, our moral sense of honor and, by default, our patients. If we don’t stand up and fight for our patients we might as well turn in our badge. We will be nothing but tools of a boardroom or instruments of a government fiat. To stand by and tacitly consent to health care by algorithm or medicine by process metrics does indeed cause “moral injury” but it does so through the prism of professional acquiescence, or dare I say it, cowardice. The untoward consequences to ourselves and, more importantly, to our patients will occur regardless of whether they are due to those of us who would support such malignant policies or to those of us who lack the courage to stand up, firmly set our feet in the sand and draw a line that we shall not cross without forfeiting our still noble and honorable craft.

So, my colleagues, what will it be? Our profession as a joy or our profession as a job? Modern medicine wants to turn patients into means for economic and political ends, but we must remember that patients are ends in and of themselves. If we as a profession simply stood up and said we will take care of our patients as their goals and our abilities dictate, who is to stop us? If we could act in concert together as a group with our patients at the forefront of our minds, then we will earn their respect, and our hearts will be reignited with the passion and the joy of our beautiful calling. This strenuous practice of an ancient art and of a modern science is ours to earn the honor of or ours to give away.

We cannot forget that true healing begins at that contemplative place between two people in a covenantal agreement seeking a mutual and individualized goal and that any policy that would violate that trust, or simply bypass it altogether, is one that must intrinsically do harm. This, of course, violates axiom number one of medicine. Sometimes the oldest ideas are still the best. Primum non nocere.

Andrew Ross is an emergency physician and author of The Sweet and Bitter Taste of Moonshine.

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