“First do no harm” is the opening line of the Hippocratic Oath, and virtually everyone is familiar with it, as it is quoted on every TV medical drama at least once a season. We tend to think that the oath was highly influential in medical training and practice when it was written circa 400 BCE. Still, it had limited applicability, as it only applied to students trained in Hippocrates’ style of medicine, and his was only one of several schools of physician training. Even today, the oath likely has more salience for the public than it has for physicians, as more modern pledges have replaced it.

Healers back then, and for many centuries thereafter, had little to offer patients but herbs, poultices, and comfort; and “harm” was a simple concept that related only to one’s patient. Hippocratic physicians were forbidden to perform surgery, to hasten a patient’s death, and/or to provide a poison, as all were considered harms. Presently, this term is more complicated, as it does not only involve a single patient, but can refer to a class of patients, or to the general public’s health.

What if, by providing treatment to one’s patient, harm arises from the treatment, and not from disease? For example, an Oncologist is tempted to use an experimental medication on a patient who has failed all standard treatments. This therapy has demonstrated mixed results; it can extend life significantly when it works, but it has side effects that could terminate a patient’s life more rapidly than the untreated disease, and this occurs in almost as many patients as are helped by it. Would use of this medication then be a potential benefit to the patient or a potential harm? Especially as s/he has indicated wanting to live as long as possible?

Or, what if a physician provides a patient with a requested medication for which s/he has no medical indication? The drug is popular for its convenience, and so many people are using it for this purpose, that a shortage of it has been precipitated, and many patients who require the drug are unable to obtain it; some have even died! Also, the drug may present a healthy patient with a side effect that could result in permanent liver damage, necessitating a transplant. Aside from this side-effect, should the MD also consider that providing this drug may result in harm to another, though anonymous individual, and decline to write the prescription?

Or, what if a health insurance company medical consultant denies coverage for a treatment because the prescribed dose exceeds guidelines without attempting to understand why the treatment is used in this manner? They barely survey the supporting documents and do not call the patient’s physician to determine the treatment rationale. There are many determinations for which remuneration is low, and there are more profitable activities to engage his/her time. If the higher dosing is necessary to control the patient’s disease, but s/he  cannot afford it, and the pharmaceutical company will neither consider a reduced price nor provide it gratis, then could the reviewer’s denial be considered harm? By contracting with the insurer, does the reviewer develop a fiduciary responsibility to the patient, and if so, does the cursory review and denial constitute, at a minimum, nonfeasance (neglect) or, at worst, malfeasance (deliberate error)?

Then too, there could be population harm. For example, a physician in Florida sold false COVID inoculation certificates to parents to meet a then public health edict that school-aged children be vaccinated, though these children were not. This potentially placed many others, pupils and staff, their families, and members of the general public, especially those who may be immunocompromised, at risk.

The concept of harm can even be extended to gender and racial inequities in health care. These apply to situations in which fellow physicians, physician trainees, and patient care are affected. A form of this harm, characterized as personal biases, can result in unequal treatment (e.g., Black women receiving less post-surgical pain medication, female physicians being treated condescendingly). This is not new but likely began shortly after Homo erectus and Neanderthals first discovered the other, and each concluded that the other was lesser than they were, based on physical differences.

Systemic inequities, the other form of this harm (e.g., Greek slaves were not entitled to medical care), started later with the development of communities and regulations. They likely grew from personal biases but, in turn, acted to reinforce them, and systemic inequities then became a cultural norm. Awareness of both types of inequities, especially systemic ones, has only been accepted as real recently, especially so in medicine. One cannot presently read a journal issue, regardless of specialty, that does not contain at least one article on inequity; some of which are well-reasoned, while others border on the absurd, are histrionic and racist, and are only printed because of the current interest in the topic.

If Hippocrates were alive today, he would find that “do no harm” is so complex that he might have chosen a different phrase to open his oath.

M. Bennet Broner is a medical ethicist.