Do we forget the first rule of care: ‘first do no harm’? - Veterinary Practice
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Do we forget the first rule of care: ‘first do no harm’?

PERISCOPE continues the series of reflections on issues of current concern

I HAVE no doubt that just as the National Health Service can learn from the way vets provide care to their patients, so we can also learn from them. This was brought home to me recently when Professor Don Berwick, a former adviser to Barak Obama, told the British government that the goal of the NHS should be to cause “zero harm” to patients.

For many people I think that this recommendation came as something of a shock. They, like me, had naively thought that such a goal “goes without saying”. What other function could any doctor or nurse possibly have other than to cause no harm to their patients?

Such a goal is as old as medicine itself and is contained in the four principles of medical ethics: nonmaleficence, beneficence, autonomy, and justice. When it comes to the topic in question, non-maleficence, I can still remember several of my lecturers at university teaching that the first rule of veterinary medicine was “first do no harm”.

As a young and rather rash student, the significance of this statement was lost on me. Surely, I reasoned (though whether I ever “reasoned” about anything in those days is debatable), I would never intentionally harm an animal committed to my care and I didn’t imagine any of my fellow students would either. It therefore seemed irrelevant, almost insulting.

Significance revealed

Knowing what I know now and with many years of experience under my belt, its true meaning and significance has only slowly revealed itself to me. The word intentional is almost certainly deliberately left out of the equation because the law of the land already legislates against a doctor or vet doing intentional harm to a person or animal.

I believe that the real relevance of the statement is that one should do no harm of an unintentional nature. Harm perhaps caused through neglect or a cavalier approach to one’s own knowledge, understanding and ability. Harm that might be caused by one’s own desire to be viewed as a pioneer or “leading light” in one’s chosen field.

Or even perhaps a desire to be seen to be doing something when the patient would benefit more from caution and a conservative approach to the management of its condition. Or harm that might be caused through opting for a treatment of convenience for the owner or vet without due regard to the needs of the animal.

The reason I bring this matter up is because in both human and veterinary medicine I think it is all too easy to forget that vets and medics have before them a whole animal or human that needs to be considered before commencing treatment.

In the veterinary case, an animal may be suffering from a fractured leg or from chronic renal failure but it is still an animal in its own right, not an injury or a disease process to be treated in isolation.

How often when faced with such cases and the decisions that need to be made as to future treatment do we stop and deeply consider the possible costs and benefits to the animal as a whole of the various options?

How often too do we consider the autonomy of the animal (largely delegated to the owner in veterinary medicine) and perhaps encourage the owner to empathise with what might be their pet’s wishes if they could articulate them?

Do we sometimes have a tendency to simply go along with the owner’s choice of treatment to preserve life at all costs with little consideration of the consequences for the animal and the golden rule of “first do no harm”?

A good example of failing to adhere to this golden rule is when procedures are carried out that could be considered of dubious need at best and completely needless at worst.

Spurious reasons

The docking of puppy dogs’ tails was a fine example of this and there are still those who consider it acceptable and attempt to justify its continuance for sometimes rather spurious reasons. But there are other less obvious choices that we make on a daily basis.

Take the issue of radiography, for instance. Could vets and indeed medics be considered cavalier in their approach to subjecting animals and people to radiographic examination? X-rays are not potentially dangerous things, they ARE dangerous things.

Yes they have an important diagnostic role to play and their use has saved many lives over the decades. But is there a tendency these days to consider radiography to be something of a first-line diagnostic tool just to “rule out” this, that or the other.

My 18-year-old daughter was hospitalised earlier this year and unbeknown to me at the time the consultant treating her requested an abdominal CT scan to “rule out” anything surgically untoward. Mercifully, the radiologist refused to do it on such scant reasoning and she made an uneventful recovery but the consultant would do well to ponder in future the golden rule of “first do no harm”.

Cursory thought…

How often do any of us give even a cursory thought to the potential harm caused to the patient by being exposed to x-radiation? And let’s not forget that the effect is cumulative.

Every x-ray exposure increases the risk of genetic damage and the risk of developing a neoplastic condition years down the line when the x-rays will have been long forgotten.

This is not a procedure to be used lightly and perhaps would be used more sparingly if we all stopped and thought for a moment about “first do no harm” and asked ourselves the question, “Is this x-ray or CT scan really necessary?”

The harms caused to human patients in the NHS are both potential and real. A survey in 2012 showed that approximately 5% of all prescriptions written by GPs contained an error of sorts.

Whilst the majority of errors were minor, a small percentage may have led to serious consequences.

Is all our dispensing completely up to scratch, one wonders, and how often do we refresh our memories by looking up the correct dose rates for drugs we have been dispensing for many years?

So, not before time one could argue, the NHS is to adopt the mantra of “zero harm” in all its dealings with patients.

Should we in the veterinary profession follow suit and give this age-old edict the prominence that I believe it truly deserves?

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