Do no harm does not mean do nothing

It is a common misconception that the only principle of being a doctor is ‘Do No Harm’.
The four pillars of medical ethics, beat into us at every exam and interview, are thus;

“Beneficence, justice, autonomy and non-maleficence.”

Let me explain. Beneficence simply means ‘do the best for your patient’, or more simply ‘always act in the interests of your patient’.

Autonomy means ‘respect the individuals right to make their own decisions’, and this often comes into conflict with the first pillar. The best medicine for my patient might not be one they want, or their decisions might bring them to ill health e.g smoking, but that’s their right. Some patients may not have full autonomy- advanced dementia, confusion, even being drunk. Then we act in the best interests of the patient, and do what we can.

Justice means different things to different people, but essentially is ‘treat all patients fairly and equal’, but each decision must be right for the individual patient, and respect their wishes.

Finally, non-maleficence is the infamous ‘do no harm’, but already you see the complexity. ‘Do no harm’ does not mean do nothing.

Take for example an operation to replace a broken hip. Have you ever seen it? A vital, life-saving intervention for an older person who breaks their femur (the long leg bone that ends at the hip)- it starts with a long slash across the thigh, followed by wrenching and cutting through the thick muscles to the bone itself. The head is sawn away and ripped out, the cavity ground down and shaped with power tools, a metal head chiselled and rammed in, then hammered into the existing bone. Blood flies out, cement pours in. It’s one of the most brutal things I’ve ever seen done to a human being. It certainly would constitute ‘harm’, but it serves a higher purpose- the beneficence of the patient, ie a new hip, restored mobility, and a better chance of longer life. The same could be said of nearly everything medicine does- from the needle puncture for a blood test to the toxic side effects, and indeed intended effects, of chemotherapy for cancer. To simply say ‘do no harm’ means ‘take no action’ neglects the fundamental balance of risk and benefit that underlies all medicine.

Every decision therefore is usually a conflicting mix of all of the four pillars of medical ethics, and we must synthesise every part of the law and of our own conscience to act in the best interests of the patient, fairly, safely and in line with their own wishes.

Now apply this view to the next junior doctors full strike, with emergency care juniors walking out as well.

We’ve heard plenty about the ‘do no harm’ argument – the government has lined up everyone on the payroll to give their two cents in the press. Darzi, Stephenson, Keogh, Davies. Some retired guy that resigned as chief medical officer 15 years ago.

But does it actually add up?

Let’s look at the situation on the ground. There are around 44,000 consultants in NHS hospitals, 54,000 juniors Doctors and 10,000 non training and dental staff. On any given emergency day, such as the Royal Wedding, the number of junior doctors that cover emergencies only is around 10-30% of the workforce. So in a full walk out, assuming everyone does walk out, you would need about 5000-18,000 doctors to replace them to provide emergency care. You have 54,000 non-junior doctors, consultants and other non-training doctors, on payroll, who also happen to be the most experienced doctors in the hospital. That’s without preparation. Hospitals are taking proper measures to ensure safety, led by our consultants and managerial colleagues. In fact, with the active movement of additional blood taking and clinical support staff to wards, the deployment of several consultants per striking junior, and proper bed management, some hospitals might even be the safest they have ever been. So the proposition of significant ‘harm’ is logically unlikely.
What about autonomy? The government spin machine would like you to believe we have none, we are ‘misled’ by our union, and we do not have the ability to make decisions ourselves. This movement has been led by the grassroots from the beginning- the hashtag #iminworkjeremy trended nationally in July 2015, from everyday doctors in response to the first shots from government over this contract in the press, not the BMA. Since then it has been the grassroots at the forefront, driving the BMA. Not the other way around. It is our jobs to take large volumes of information, synthesise that and make a complex decision, and then take responsibility for that judgement. To say we act without understanding is ludicrous.

What about beneficence? Much of the public don’t understand this issue, and for that we apologise. It’s about making a workforce cheaper, removing safeguards that cost hospitals money, and stretching lucrative elective weekday work into the weekend. It is, as it always has been, about money for the government, at the cost of safety. We recognise that, and we recognise that this contract will create dangerous conditions for patients, crippling retention and recruitment at a time when the NHS is already on the brink. An A&E in Lancashire closed last week due to lack of staff- we have a long term duty to patients to make sure that doctors have safe working hours and staffing levels.

Lastly- justice. I take this pillar of medical ethics to mean that every member of society should have the same healthcare, should be treated fairly based on need alone. The NHS is one of the most just and equitable healthcare systems in the world, and it is being summarily destroyed. We cannot stand by and watch this happen.

We are trying all we can to avert the next strike- we don’t want it, but it is the only treatment option we have left.

We want to talk- for the past six days doctors have been camped outside the DoH waiting for Jeremy Hunt to open his door and begin negotiations again.

In the fight for justice and beneficence Justice For Health are taking Mr Hunt to court today, issuing proceedings officially at 4pm. Their aim is to have the High Court review the government’s actions on the contract and the NHS and decide if this is safe and rational. A win in the court could avert this whole mess, a step in a new direction to save the NHS.

But they can’t do it without your help- Jeremy Hunt is trying to bully these crowd funded doctors with threats of huge costs, demanding £33,000 up front to even get the case to a judge. He is trying to use the deep pockets of the government to put down a safe, effective and reasonable intervention against a dangerous contract.
Will you help us?
Do no harm does not mean do nothing. If you want justice, for the long term benefit of all of us, do this.

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