Monday, December 31, 2007

Primum non nocere

An ancient principle of the practice of medicine is "Primum non nocere" which means "First, do no harm. It seems like a straight forward admonitition, but it is amazing how it has been transformed in a world where modern obstetrics is practiced, where neonatal death rates are low and maternal deaths are measured per 100,000.

I was struck by this when reading a comment on Rixa's blog in response to my claim that babies become "acclimated" to maternal organisms. The poster criticized homebirth advocates for ignoring scientific information, and then, in the spirit of fairness, criticized doctors as well:
It is even more sad that medical professionals cannot see the harm caused by their knee jerk reliance on often unnecessary medical procedures. (Hello -- "First, do no harm" ring a bell?!)
What I find particularly ironic about the comment is that the "often unnecessary" medical procedures are used precisely to prevent harm.

It is instructive to look at the context in which the phrase actually appears. Hippocrates admonishes the physician "to help, or at least to do no harm." For obstetricians, "harm" means one thing above all else: death, of the baby or the mother. The secondary meaning of "harm" is permanent disability such as brain damage of the baby or an obstetric fistula of the mother. Everything that is done in modern obstetrics is done for the express purpose of reducing harm.

Obstetrics has been spectacularly successful in "helping". Neonatal and maternal mortality rates have fallen to levels so low that the average person may never meet someone who has lost a term baby due to labor complications, and will never even hear about a woman who has died in normal labor. Every one of the supposedly "unnecessary" medical procedures has been instrumental in achieving these successes. Obstetrics has been transformed from primarily disaster management, to disaster prevention. Moving from management to prevention has meant the application of technology to women who, in retrospect, may not have needed it. Doing "no harm" in obstetrics, as in the rest of medicine, now means preventing known harms from occuring at all, not waiting until they occur and treating them.

In attempting to "do not harm", aren't obstetricians obligated to offer everything they know that may prevent avoidable harm? There is much that could be changed about modern obstetrics, but reminding obstetricians not to let "harm" come to any patients isn't the problem.

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