Do no harm ...

Doctors deal in drugs. Dangerous ones. Not surprisingly, we sometimes stuff up. As the Romans depressingly suggested, Qui medice vivit misere vivit. Who lives medically, lives miserably. Another ancient quote worthy of reflection is Primum non nocere. It means First, do no harm. Those words sum up this article’s message. If you’re time-poor, read no further.

First, do no harm is a favourite dictum of doctors. It is usually attributed to long-dead white males like Hippocrates or Galen but might have first appeared a couple of millennia later in an obscure 1860 book. Hippocrates did, however, write that regarding diseases and treatments a physician should “make a habit of two things - to help, or at least to do no harm”.

Unfortunately, for a doctor to never do harm requires either enormous luck or a very peculiar practice. Competency is not repeating mistakes; incompetency is not recognising them. All doctors occasionally harm patients so a more realistic goal is to “Do more good than harm” or perhaps, in case the doctor is preventing someone else from doing even more good, “Do more good than the alternatives”.

This article was prompted by reports of harm stemming from specialists’ ignorance of prescription drug side-effects. In medicine, it is said generalists know nothing about everything and specialists know everything about nothing. There’s a degree of truth in this, but the avalanche of new information means even conscientious doctors sub-specialising in small, well-defined fields can struggle to keep up with all potentially relevant drug data.

Most drugs have a huge list of potential side effects. Doctors are generally not good at acknowledging or even recognising these. Every week, I probably fail a patient in this respect. There is also plenty of evidence that doctors tend to be too uncritical in accepting drug promotions including dodgy studies and data interpretation. In addition, a psychological leap is required to admit the treatment you have prescribed is possibly worse than useless.

The problem, therefore, is not usually wilful ignorance. The medical profession has been known to illustrate more than one of the Seven Deadly Sins - pride and avarice spring to mind - but, to be fair, sloth is not usually one of them. Anyway, being lazy and ignorant is not a good fit with being proud and greedy.

Napoleon once said one should not ascribe to malice that which is better explained by incompetence. Sometimes, however, incompetence appears an inadequate explanation.

I receive a constant stream of mail from manufacturers saying their drugs do not work as initially advertised. Today’s letter was from GlaxoSmithKline. It stated that excessive use of Polident Extra Hold Denture Adhesive Cream could be dangerous. In fact, “as a precautionary measure GSK has voluntarily stopped the manufacture, distribution and advertising of this product”.

Until the letter arrived, I had never given the slightest thought to Polident Extra Hold Denture Adhesive Cream. In fact, I had never heard of it let alone considered its potential interactions and hazards. It now seems there are reports that the zinc in the product might be responsible for some consumers experiencing “sensory disturbance, limb weakness and difficulty walking”. The company’s letter did not say when these concerns became apparent. A pack of lawyers has probably already diverted from ambulance-chasing to try to find out.

GSK is also currently in trouble over its diabetes drug, Avandia (rosiglitazone). For years, the company downplayed concerns about Avandia’s cardiac safety. Then, on February 20 this year, a US Senate committee released a report based on over 250,000 internal company documents. The US Food and Drug Administration has estimated that the drug caused 83,000 heart attacks between 1999 and 2007.

The Senate report confirmed that GSK’s own experts raised serious questions about Avandia’s safety at least as far back as 2003. When these concerns became public in 2007, it is said that executives deflected them, intimidated critics, orchestrated the early release of favourable data from a supposedly independent study and attempted to continue business as usual. With billions of dollars at stake, this is no surprise. On this planet, people routinely die for far less.