Renzo Bruni

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What should be the first law of medicine ?

Many wrongly ascribe "Primum non nocere/Do no harm" to the Hippocratic Oath, although it is NOT really found there. Hippocrates apparently did say that, or write that phrase, but it was in his "Epidemics". Should not the First Law of Medicine rather be "Primum bonum facere/First do good" (et secundum non nocere). Would this not summarize the role of modern physicians, nurses, providers and therapists better than a nostrum ("Primum non nocere/Do no harm") that might be interpreted as to justify holding back on any therapy which has side effects. Does not this new First Law of Medicine justify all interventions which might help, and allow more adaptability to the real situation by admitting that 'helping' is the moral role of providers?

  • Aug 18 2011: Imho the first law of medicine shouldsay something like this:
    "First try to understand the original conditions that caused the illness in the patient. If those conditions can be solved or changed so the illness will be cured, cure the patient in that way. If the conditions cannot be solved or changed, you can only cure the symptons"

    So for example if I suffered from frequent colds, the doctor should be able to find out what originates the problem and tell me "Mr. Gonzalez, the problem is that every night before going to bed you leave the windows opened and it is winter time. You must shut the windows every night before going to bed". The problem is that the doctor won't try to find out anything, he will check the cold and then he will say: "Mr. Gonzalez, everynight before going to bed take this pill and that will fix the cold".

    Doctors don't detect the causes, they most of the times fix symptoms. That should change I think.
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      Aug 26 2011: @ Juan - Excellent points. In fact most medical schools say their goal is to teach these detective skills. In part, and only in part, the way doctors treat symptoms instead of the real diseases has to do with marketing in a competitive environment. Insurance companies determine reimbursement, but doctors tend to feel they must please the patient and keep them coming back (for the profit motive mostly). To some extent doctors (as any living being, even a lab rat would do) push the lever that brings them food, so to speak. If the system rewarded the lab rats differently maybe they would push better levers.
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    Aug 18 2011: ABC

    A always
    B be
    C curing

    always be curing, always be curing!
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    Aug 25 2011: " Never try to play GOD"
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      Aug 25 2011: I certainly get the emotional force of this axiom (I don't think you invented it, did you?)(insert smiley face here) but could you be more precise in what it means in terms of details or specific limitations? Do you think doctors are arrogant? Do you mean that the full application of available technology (stem cells, cloning, anti-onco-gene insertions for cancer, in vitro fertilization, abortions, plastic surgery) is going too far? What is GOD's role, what is man's (or the doctor's)?
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        Aug 26 2011: I thought it up yes, but maybe someone else had the thought as well......I do feel that some Doctors are somewhat arrogant yes, they think they are so good that they alone hold the key to life? application of technology is never the sole factor when it comes to life, although some doctors think so. Just have a look at the bible when it comes to healing. It has a preventative approach, and when it comes to actually healing or curing, it almost never involved medicine.....It involved the hand of GOD. doctors have said before that there is no hope.....then years later the patient still lives a great life after miraculously recovering from the illness.....I was in the emergency services for a couple of years and these days I joined forces with a friend in a business that deals with emergency situations. Altogether me and Wynand have handled probably 20 000-30 000 emergency situations. I have seen people come out of totally wrecked cars with a couple of scratches, and I have seen people die in front of my eyes when the car had only a couple of scratches.....The role of doctors are to intervene when people get sick or injured by their own choices or the reckless behavior of others. When people get sick because GOD allows it, or they are born deformed or disabled because GOD have a mission for them, then there will be nothing any doctor can do for that person....Although there are doctors who ignore this and try in any case. You see when other people are not "normal" in our eyes, then we tend to try and get them there by all means necessary.


        Here is a good example of someone that was born without limbs and discovered the meaning of hes life.....Sometimes there is NO medical REASON for things....
        Nick Vujicic
        http://www.youtube.com/watch?v=dRkUbOLLmYE
        It's a bit long, but do yourself the favour and watch it completely.
        also watch this.....
        http://www.youtube.com/watch?v=4LtCrlXdd2E
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      Aug 25 2011: oh, I thing we are long past that. we are playing god everyday. To begin with CPR - we are resurrecting people. Or maybe you mean that we shouldn't decide who gets to live? well thats basically what the insurance companies are for...
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        Aug 26 2011: No my friend.....GOD has control.....And always will
        Are you a doctor?.....you speak like one.....
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        Aug 26 2011: Your comment ("insurance companies" "decide who gets to live") brought a wry smile to my face. I agree with the force and direction of your sardonic wit, but actually (IMHO) it is society that decides who dies, when and how, by deciding who lives well, who eats at all, who eats right, who gets medical care, and even who gets which disease. It seems that insurance companies make the proximate determination of these things (and they do of course) but it is US who allow it to happen, and therefore 'choose'. When you know it could be different (and better), and still you do not make it better - there, then and in that way you choose (I invented that axiom).
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    Aug 21 2011: The word doctor comes from the Latin word Doc meaning teach or teacher. So to be able to teach his student (patient) about his/her body, the doctor has to know that individual body. For example if the patient has some auto immune disease he could infer that inflammation and other problems associated with that may be a problem to consider in the future. So the doctor would go in depth with the "student" from diet to environmental issues.
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    Aug 18 2011: Defending the right to air, water, food, thought, speech, movement (and I guess sanitation).
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    Aug 18 2011: "Do no harm" leaves grate space for interpretation. It is quite often that in order to help someone a doctor needs to "do harm" e.g. surgery - I imagine one could argue that surgical procedures are in contradiction with this statement.
    But I think it is a good rule as a general statement.

    Salim, too much of empathy is not good either. I think you know dr House series. He likes to say "patients lie" and that is the true. When people come for help they tend to omit many important details, specially if they find them shameful. A good doctor needs to be a skeptic.

    Luke, what you say is unfortunately utopia. In the end someone would have to pay. We could argue how should the costs be distributed among the state, insurance agency and the patient, but the health care is highly expensive and I don't think we, as the society, would ever be able to provide the best health care to everyone.
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    Aug 18 2011: Understand patient & her/his condition best before you decide .... should be the first rule as I feel.
    Only understanding better , will give clue what is good or what is harmful for patient.....

    Well it's my thought only
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    Aug 18 2011: Golden Rule for Medicine:
    Do everything to help the patient no matter the monetary cost.
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      Aug 18 2011: With respect, and just for the sake of debate, I think your point of view is well intentioned...... but,,,,, I understand that in Scandinavia, where all health care is transparently free for everyone, the legislature or board of doctors (or some persons in power) have decided that very old persons (over 70 let's say), who need chronic (lifelong) kidney dialysis, are not eligible for such care. The whole society accepts this as reasonable (I am guessing they do since it hasn't changed) but they accept that such expensive care at the end of life is exorbitant.
      Then in terms of terminal care, I have a dog whom I adore with newly diagnosed high grade lymphoma, but will not consider putting her thru chemotherapy since it is 1) too expensive 2) causes heavy and nasty side effects and 3) does not have a very good cure rate. In Pacific Northwest US and in Holland, terminally ill patients are allowed to chose to die deliberately by their own hand, with a doctor's expert advice and prescriptions. Is that still doing everything for the patient? Is it defensible?
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        Aug 18 2011: Obviously there are still some treatments that are not economical enough to treat and some people who are in extremely bad health but i believe that for a majority of people should receive everything at our disposal. Also almost all first world countries now have universal health care and yet we do not. we let the insurance company decide what is best for us instead of the doctor.
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          Aug 19 2011: the health care is a subject where you can't say "majority of people should receive everything at our disposal". one has to define exactly the rules who gets what and why. there is no place for arbitrary decisions. And in the end you will always get the group that has been excluded and is unhappy about that. That's why from the start everyone has to knot, that health care is expensive and not everything can be provided to everyone.
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      Aug 21 2011: I think a lot of patients coming to get treatment understand their treatment and health about as much as they understand how the meat in the grocery store gets there. It's what's put in front of them and whatever has the right color or flavor they happen to favor is what they are going to pay for.
      I think also that the wide array of tests that are available to doctors has essentially made them shittier doctors.
      Someone said earlier quoting "House" about PT's being liars is a tough one to call. I think some doctors don't talk to the patients enough and give expensive tests to their PT's before the give the the benefit of doubt that they know what is going on with their own body. Unfortunately this is just because so many people don't understand their bodies, and others are ashamed of the way the treat them, so the docs don't trust them.
      fuck house, I like scrubs
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      Aug 21 2011: Also I think Doctors need to appreciate what the patient wants to do to their bodies, educating them the dangers of their behaviors and helping them live the healthiest lifestyle possible regardless if they choose to use their wings to fly too close to the sun.
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    Aug 25 2011: Promote life.
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      Aug 25 2011: Promote life... and living well and fully?
      Would this include social activism such as advocating for abolition of death penalties and illegality of war? Is that a righteous place for doctors and nurses to act?
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        Aug 26 2011: Renzo, for me it would but I think it is unfair for us to put medical professionals in the gap between legislation and social activism.
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          Aug 27 2011: Well, Debra, I don't mean that they should be in anyway required to act in the gap, but isn't it a place where they have a right or duty or the expertise needed to lead us?
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        Aug 27 2011: Hi Renzo, Yes, they do have the abilities and they should lead us, so I do not disagree with your points. My point was that as societies we are trapping them between their own moral choices and the stated law. We need to consciously and legally and legislatively decide what we feel about end of life issues instead of trapping medical professionals and famiilies between being 'humane' and breaking the law. We need to make the hard decisions rather than leaving them unmade so that medical professions are at risk.
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          Aug 27 2011: You are right. I agree. Well said.
          I would go further, in that we let 'lawmakers' (and lobbyists) write the laws. We should seek more input from nurses and doctors, and allied professionals - those with real experience and well reflected observations.
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        Aug 27 2011: We are paying the price as societies for letting the lobbyists. professional bureaucrats, politicians and interest groups decide our moral issues. There is an old adage that says 'We get the government we deserve."

        We have downloaded our responsibilty for creating a living society and we have to change this situation.
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      Aug 25 2011: but at what cost? and I don't mean monetary cost, but think of terminally ill patients who are suffering? should we do everything in our power to keep them alive, knowing this won't bring them back to health and only causes more suffering?
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        Aug 26 2011: Marcin, thank you for your cognent point about the end of life. I recently had an aunt who was terminally ill decide when she would die. She had been on dialysis for many years and developed cancer which spread to her brain. Before she lost her faculties she decided to stop dialyzing and made a dignified, peaceful, graceful and generous end to her life. She spoke to all of us and encouraged us to live good lives. I share this story to make the point that we have to change the way we think about the end of life. Prolonging it when there is no hope of improvement in terminally ill persons should be replaced by helping families get to a better place before the end. Doctors should not be in the position of guessing what the law and the 'right' thing to do is. As societies we should decide how to handle these situations and support the doctors and the patients in these difficult transitions.
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          Aug 27 2011: @ Debra and Marci (both)
          The arguments for focusing on quality and quantity of care at the end of life are appealing, humanitarian and self evident. What however of the application of these same ethics to other medically based problem areas of society: an embarrassingly high infant mortality rate, absent universal prenatal health care, hungry children (one fourth of American children by recent estimates), untreated addictions, birth control, sex education, et et et etc.
          Amartya Sen (Nobel Prize Economics 1998) believes that universal health care in the US is the single biggest contributor to social unrest, crime, political divisiveness and disaffectation (like not voting)(although in truth I am paraphrasing without a quote and from flawed memory, I got the gist of it correct).
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    Aug 25 2011: Side Effects.
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      Aug 25 2011: don't understand - what about them?
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        Aug 27 2011: These are adverse reactions of medicines. When we take medicines like antibiotics along that it kills harmful bacteria it also kills millions of useful bacteria in our body that later it becomes another illness.

        I think doctors usually dont disclose this.
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    Aug 19 2011: This is actually the philosophy in practice in ER medicine. Most ER nurses and docs will tell you that they order their priorities this way, and any ethical hospital in the first world will also behave similarly. Unfortunately, after you are healed and discharged the much less humanitarian bean counters take charge: they can rip the healed flesh right off your sore and sorry bones.
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    Aug 19 2011: I like simple axioms, although I was not expecting to get them back from my proposition. Well spoken! Thank you.
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    Aug 19 2011: First heal then think of charging.
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    Aug 19 2011: LIFE ABOVE RICHES.......
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    Aug 18 2011: This patient is a human being much like you.
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    Aug 18 2011: "For each and every virus there exists a host who is followed by a detonator called drug or medicine."