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The unwritten oath: First do no harm


Chris Cairns,
Consultant Editor

This, as many know, is a central principle of the Hippocratic oath taken by doctors. As pharmacists we do not have an equivalent oath, but our code of ethics, no matter where we practice, will have some basic principle that means we have a professional obligation not to cause harm to our patients. The concept of causing no harm has a number of strands. First there is an obvious one, which is that we should not carry out a deliberate act that would intentionally cause harm. Here, we primarily think about assaulting a patient or giving them a medicine we know not to be of therapeutic benefit to harm them. In the UK, the example of Dr Harold Shipman, who deliberately killed healthy patients with injections of morphine, comes to mind. It may also cover the situation where we are party to giving patients a medicine against their wishes.

However, the case of Dr Shipman is, fortunately, a very rare exception, and the overwhelming majority of pharmacists and their staff, in the same way as nurses and doctors, come to work to help patients, not deliberately make them sicker. But there are two situations where we can harm patients inadvertently. The first one has been covered in a number of recent issues of this journal: it is where an error in dispensing, prescribing and/or administration occurs. Managing and reducing the risks of these problems happening is a task that occupies a significant amount of the time of many pharmacists and their staff.

The other occasion is when a patient suffers an adverse drug reaction (ADR) or another iatrogenic event. Modern medicines, as well as giving us great benefits, have the capacity to cause great harm. This problem is not new. William Withering, in his discourse on digitalis leaf in the treatment of “dropsy”, published some 200 years ago, recognised that digitalis was not without side-effects (he found a 12% incidence of unwanted effects). As pharmacists, we have a responsibility to ensure that, wherever possible, adverse drug effects are minimised. We can do this at both procurement and selection stages by ensuring that the drugs with the least likelihood of causing a side-effect are used. At the selection stage, we should contribute by considering the patient’s clinical condition so that the drug chosen is one which interferes least with other therapy and pathology. Once the patients have been given the drug, we must advise them on how to minimise the risks of side-effects: taking sedative antidepressants or antihistamines at night, for example, or making sure patients on metronidazole avoid alcohol. Proper use of medicines, including basics such as taking the correct dose at the correct time, is vital to avoid ADRs. Here, careful counselling of the patient or their carer is paramount. Last but not least, we have a responsibility to monitor the effects of the medicine. This applies equally for minor side-effects, such as constipation from narcotic analgesics, as it does for severe ADRs, such as the renal and ototoxic effects of gentamicin.

We work as hospital pharmacists to help ill people get better. We must also make sure that the medicines we use do not make them worse if we can avoid it.

Chris Cairns, Consultant Editor

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