First Do No Harm and DSM - Part I: An empty slogan?
What does First Do No Harm mean?
Posted May 6, 2010
Allen Frances, the head of DSM-IV, emphasizes that we need to be conservative about changes in DSM-5. First and last, he says, the guiding principle should be Do No Harm. We should realize that we are not getting at the truth about mental diseases with our DSM categories, and thus we should emphasize pragmatic consequences. Researchers, like me, are wrong when we worry about whether a diagnosis is closer to "reality" or not; the nature of truth is not absolute, and we should focus on pragmatism and the Do No Harm principle.
I will return to the notion of reality and scientific truth later, but here, in a two-part blog post, I wish to challenge this facile use of the Hippocratic "Do No Harm" concept.
A pragmatic conservative approach to DSM - First Do No Harm - as my colleague supports, is quite different than what Hippocrates meant by that idea. In fact, if DSM is nothing but a pragmatic common language, with little to no relation to real disease, then we can only do harm. ((Most physicians have not read works on or about the Hippocratic tradition firsthand, and instead only repeat the Do No Harm slogan; such study is useful. A prominent recent book is here. I have published a full discussion of these points in relation to Hippocratic psychopharmacology, with scientific references, in a psychiatric article).
Let me agree with the pragmatic problem: Psychiatrists prescribe drugs frequently, probably too frequently. I agree that the Hippocratic tradition is a solution, but we need to understand that tradition correctly, not assume it. The best rationale for psychopharmacology - when to prescribe, when not to prescribe, what to prescribe - is to be found in a rediscovery of the true Hippocratic approach to diagnosis and treatment.
Another fact: the sobering results of the National Comorbidity Survey are that only one-half of persons currently treated by clinicians (mostly with psychotropic medications) have a current diagnosable DSM-IV mental disorder. In other words, in a large group of patients, psychiatrists practice symptom-, rather than diagnosis-, oriented treatment. Already, DSM is not the entire issue; many clinicians ignore it, and simply treat symptoms. This approach, as we will see, is anti-Hippocratic.
There is a general misunderstanding of the term "Hippocratic", often associated with the ethical maxims of the Hippocratic oath, such as "First do no harm," later Latinized as Primum non nocere. (The full original quote was in the maxim of Epidemics I: "As to diseases, make a habit of two things - to help, or at least to do no harm.") The Hippocratic tradition in medicine is thus identified simply with a conservative approach to treatment. While partly true, this popular simplification fails to capture the deeper genius of Hippocratic thinking, for its ethical maxims were not abstract opinions but rather grew out of its theory of disease.
The basic Hippocratic belief is that Nature is the source of healing, and the job of the physician is to aid nature in the healing process. A non-Hippocratic view is that Nature is the source of disease, and that the physician (and surgeon) needs to fight Nature to effect cure. Even in ancient Greece, physicians had many potions and pills to cure ailments; Hippocrates resisted that interventionistic medicine, and his treatment recommendations often involved diet, exercise, and wine - all designed to strengthen natural forces in recovery. If Nature will cure, then the job of the physician is to hasten Nature's work carefully, and at all costs to avoid adding to the burden of illness.
Based on this philosophy of disease, the first step in the Hippocratic tradition is to refuse to treat symptoms with drugs (at least most of the time). The key is to assess symptoms and determine if a disease is present or not. If disease is not present, then no drug treatment is needed, and the patient can be informed that she has no disease, and non-drug treatments or simply watchful waiting (that most effective of medical interventions) would be prescribed.
If symptoms are thought to represent disease, then drug treatment would still not be given in two of three circumstances: The Hippocratics divided diseases into three types: curable, incurable, and self-limiting. Curable diseases require intervention, aimed at aiding the natural healing process. Incurable diseases generally were best left untreated, since treatments did not improve illness and, due to side effects, would only add to suffering. Self-limiting diseases also did not require treatment, since they improved spontaneously; by the time any benefits of treatment would occur, the illness would resolve by itself, again leaving only an unnecessary side effect burden. The concept of Primum non nocere, thus, meant knowing when to treat and when not to treat, based on what kind of disease one diagnosed.
One does not routinely treat symptoms with drugs; and even when disease is present, one only treats two of three types of diseases. This is how you get to First Do No Harm. Not by abstract conservatism, but by taking disease seriously.
It is clear that in the 3rd century BC we knew far less about disease than we do now. Thus this approach allowed the Hippocratic physician to treat patients as little as possible, and as much as needed, given the contemporary knowledge base, and uncertainty, about disease. This approach applies as much today in psychiatry as it did two millenia ago.
If we dismiss concerns about disease as research experts' biases, and identify pragmatism solely with "what works" (a simplistically false interpretation of the philosophy of pragmatism as I will explain in future posts) , then we are going directly counter to the Hippocratic tradition. First Do No Harm only grows out of knowing when diseases are present, and when they are not present. If our knowledge of disease is faulty, then we cannot apply the Hippocratic approach, and we can never reach the goal of First Do No Harm.
First Do No Harm is not an abstract ethical principle about being conservative with treatments and diagnoses. It is a product of an approach to symptoms that emphasizes knowledge of disease. It is an endpoint, not a beginning. The ethics is the result, not the cause; ethics grows out of the science. The ethical principle, standing by itself, is not at all what Hippocrates taught.
So, if my colleague is right, and DSM should be seen as a pragmatic language with very little connection to the reality of mental disease, then we cannot practice according to the Hippocratic tradition of First Do No Harm. The slogan becomes empty and impossible to implement in any scientifically and ethically meaningful way.