Essay #17: Primum Non Nocere

On December 11, the New York Times featured an opinion piece on the front page of its website entitled “We Must Do More to Stop Dangerous Doctors in a Pandemic” written by Richard A Friedman, M.D., a practicing psychiatrist. The title is a non-controversial statement, to say the least. We should always be working to stop “dangerous” doctors. Those who wield medical titles are afforded a certain amount of trust, and when they abuse that trust for pernicious means, they can hurt people. This becomes especially true during a pandemic. Unfortunately, once you get past the title, the op-ed is little more than another contribution to the crusade for orthodoxy.

Dr. Friedman calls out specific doctors and cites examples where they have brought “quack theories” forward or “promoted pseudoscience”, but this piece is bereft of citations at very curious moments. Here are some phrases that contain no citation:

  • “…he cast doubt on the efficacy of face masks, long after science had confirmed their efficacy.”
  • “…there is indisputable scientific evidence that [masks and social distancing] are effective in preventing or limiting the spread of coronavirus.”

Those are two statements where he references something that is supposedly confirmed by “science”, yet he does not link to the paper or study proving such statements. I believe that masks and social distancing work, and I can reference some articles (I am not scientifically literate enough to read through the papers) that reference papers that indicate as such, but I am also aware that none of this is “confirmed” or “indisputable”. I have no doubt that Dr. Friedman could reference some papers that prove his point, but I suspect he did not because he believes he does not have to. I suspect he believes his audience will scoff, as he may have, at the fact that anyone would question the orthodoxy of social distancing and masks, and it would have been superfluous to reference the science supporting those “certainties”. You don’t reference Isaac Newton’s paper on gravity (is there even a paper for this?) every time you bring up the concept.

Dr. Friedman then proposes that doctors projecting opinions to the public are not exercising their free speech, but rather practicing medicine. He takes that logic a bit further and purports that these doctors promoting “alternative opinion” are in violation of the Hippocratic Oath in which they swore to “do no harm”. Guess what. The phrase “do no harm” is not in the modern versions of the Hippocratic Oath that current medical practitioners swear to uphold. I didn’t know that, and I had to look it up which makes sense because I am not a medical practitioner. Maybe you didn’t know that either. You know who should have known it? Dr. Friedman. Not only is he himself a medical practitioner who has likely sworn to uphold the oath, but he is also privileged with the audience that the New York Times Opinion section affords and chose to write about it! So, in an opinion piece in which he is critical of those irresponsibly spreading false information, he is spreading false information. Did he swear the Hypocritic Oath? Badum-tsssssssssss… I am so sorry.

To steelman Dr. Friedman’s argument, I would be comfortable guessing there are quite a few medical professionals right now who are perhaps motivated by some outside factors and are violating the Hippocratic Oath by knowingly spreading false information (or perhaps did not do their due diligence on the information and opinions they are projecting). Perhaps they enjoy the affection of the Pro-Trump faction when they stand up to present opinions that support Trump’s behavior during the pandemic. Perhaps they see the orthodoxy forming and will take any position to oppose it (a trap I sometimes fall into). However, these “dangerous doctors” are only capable of such a magnitude of danger because an orthodoxy exists, and many people believe that it does not serve their interests. The harder and more viciously an orthodoxy works to protect itself, the more legitimate the alternatives seem, irrespective of whether the orthodoxy is promoting truth.

I will end by quoting Dr. Friedman’s concluding paragraph in which he requests punishment to result from challenging the orthodoxy:

“Doctors should realize that their advice is, in effect, a form of medicine. If they step outside accepted standards of practice, based on empirical evidence, it’s time for the state boards to take disciplinary action and protect the public from these dangerous doctors.”

P.S. It is so disappointing that this kind of opinion piece can make it into the New York Times. I was never an avid reader of the New York Times, and although I read it more now, I am still not enmeshed in the culture of this publication. However, if its reputation is at all merited, this opinion section has been home to some very important pieces, and Dr. Friedman’s op-ed does not belong in such company, in my opinion. And if you guessed I was salty that something of no greater quality than my own work is being featured on the New York Times front page, you would be correct. I do not think that my blogs belong in the New York Times, but if pieces worse than mine are being published it makes me feel a certain way. I do not belong in the NFL, but if NFL teams suddenly started signing people who are even worse at football than me, I would be bummed that I didn’t get a contract. Same-same.

P.P.S. I find it funny that a correction was issued on the day this article was published, but it was not correcting the incorrectly referenced Hippocratic Oath, but rather a misspelled doctor’s name.

P.P.P.S. For those of you who are not fluent in Latin, the title means “first, do no harm”. It is a phrase used by some 17-19th century physicians indicating that their primary purpose was to do no harm. The more modern Hippocratic Oath starts off with the phrase, “I swear to fulfill, to the best of my ability and judgement, this covenant”. All good systems should build in the ability for discretion by those knowledgeable enough to wield it. This opening statement affords the field of medicine the leeway it needs. If doctors were bound by “do no harm”, many medical practices would be out of the question. When there was not enough knowledge about how to fight infections, amputation was common and saved many lives (although it is a brutal practice). Amputation is not only causing direct harm to the patient, but there is also a risk of it not working properly and the patient succumbing to the injury caused by the physician. Chemotherapy works in a similar way. You basically inflict harm in the hopes that the cancerous cells will die before the patient does. Chemotherapy is a brutal practice as amputation was, but it is a miracle of our current iteration of medicine and is our best weapon in the fight against cancer. Physicians cannot be given a simple rule to follow such as “do no harm”. They must be given room to make judgements about the patient’s risk tolerance, the efficacy of treatments, the quality of life post treatments, etc.

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