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Psychiatrist Sabooh S. Mubbashar discusses his article, “Why ‘do no harm’ might be harming modern medicine.” He reveals that the principle “First, do no harm,” or Primum non nocere, is not part of the original Hippocratic Oath but a later, misattributed addition that has become a dangerously oversimplified slogan. Sabooh argues that a literal interpretation makes medicine impossible, as every intervention, from surgery to medication, technically inflicts harm. This creates a dissonance for clinicians and can paradoxically lead to overly aggressive care, especially at the end of life, where the pressure to “do everything” causes more suffering than benefit. The conversation explores how the interplay of this flawed mantra with patient autonomy and fear of liability can lead to choices that are legally defensible but ethically and clinically harmful. As a solution, he suggests returning to the oath’s original, more honest language, which calls on physicians to use their “ability and judgment” to weigh risk and benefit, acknowledging that real ethics live not in mottos but in the nuanced, gray areas of clinical practice.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Sabooh S. Mubbashar. He’s a psychiatrist, and today’s KevinMD article is, “Why do no harm might be harming modern medicine.” Sabooh, welcome to the show.

Sabooh S. Mubbashar: Thank you so much for having me, Kevin.

Kevin Pho: All right, so tell us a little bit about your story and the reason why you decided to write this KevinMD article.

Sabooh S. Mubbashar: Sure. Well, I’m a psychiatrist. I trained at Yale.

I’m originally from Pakistan, but I’ve been living in the U.S. for 26 years. I came into psychiatry because I had a very deep interest in neuroscience and psychopharmacology, and I have some basic sciences background in that as well. But I think over the last five years as I’ve gotten older, I have gotten more interested in ethics and models and philosophy of medicine rather than psychopharmacology. Don’t get me wrong. That is still an area of interest for me. But, you know, I think William Osler once said that the young physician prescribes 20 drugs for one disease, and a seasoned one prescribes one drug for 20 diseases.

So I find myself heading in that direction as I get older. I actually, interestingly, work with geriatric patients, with most of them with dementia. The other half of my day, I work with severely autistic kids. And I think I realized early on that the more challenging the patient population is, I think that is where my satisfaction lies.

So it is primarily actually working with geriatric dementia patients where the whole seed of “do no harm” started. The article talks about aggressive interventions and why we don’t stop and think about them, at least in my opinion. What are the risks versus benefits of a statin in a 90-year-old with end-stage dementia or performing CABG in an 85-year-old with advanced dementia?

And I think I realized that, at least in my experience, it’s not like any of my colleagues are not cognizant of this. I felt that do no harm has become such a buzz phrase for us that we are anesthetized from what it actually means, and that was the basis for the article.

Kevin Pho: All right, so you said that you work with the geriatric psychiatric population. What are some examples that you are seeing where do no harm may be called into question?

Sabooh S. Mubbashar: Where I actually feel that harm is being done. I would say probably people with end-stage dementia undergoing hip surgeries, OK, or prostatectomies, or feeding tubes being put in. I think the article also talks about the burden that we place on family members to make those calls.

And sort of that tension between patient and, in this patient population, by extension, autonomy of the health care proxy versus what may or may not be the best clinical path to pursue. You know, I do want to take the time out, Kevin, to talk about this. We are the first cohort of humanity that is dealing with dementia at this scale because we are living to that age.

We are literally the first cohort of humanity. So the rules are actually being written, if they are being written in the first place, in real time. And the rules actually are not being written. We are just navigating our way. And so the rule book has not been defined.

So you can imagine, you know, hip fracture, hip surgery, right? The context of end-stage dementia, hip fracture, hip surgery, I think that needs to be redefined.

Kevin Pho: And not only that, you’re seeing things like prostatectomies in people with end-stage dementia as well. Is that a common scenario, or is that something that you see regularly?

Sabooh S. Mubbashar: Common enough to be disturbing. And then you can imagine, you know, while the surgery may have gone very well, the post-op delirium, which they never recover from, ends up on the psychiatrist’s plate. Hence, the psychiatrist is the one writing this article.

Kevin Pho: So tell me the decision process that’s being made. You mentioned that your colleagues, they must be aware of that dissonance between do no harm and doing all these procedures in this population. So tell me the decision tree that often leads to these patients getting hip procedures and prostatectomies.

Sabooh S. Mubbashar: Yeah, I think it comes down to patient autonomy, but in this case, again, the rules are very different, and they haven’t been clearly defined yet for reasons that I just mentioned. So nobody’s, I think, going to the patient if they want the hip surgery; they’re actually asking the daughter. And, as I’m sure you must have seen as well, if you ask a loved one in a moment of crisis, “Do you want us to do everything?” a good amount of time, the answer is, “I want to do everything.” And I think sometimes, when I’ve, a lot of times actually, when I’ve sat down with family members, the level of guilt that they anticipate by just saying, “No, we don’t want you to do everything.”

And I do think that as physicians, maybe we have moved away a little bit from sitting down and talking about what we really think should happen. So I think the autonomy has swung to one extreme, which may not be very conducive to good health care.

Kevin Pho: You mentioned earlier about that burden that’s being placed on the family members to make these decisions. Tell us more about what you’re seeing, about how they’re feeling that burden.

Sabooh S. Mubbashar: I think something as simple as not realizing that for somebody with even moderate stages of dementia, how they’re going to come out of it after four hours of anesthesia.

They’re going to have a new baseline, which is way worse than the baseline they went in with. And then the infections and the ICU delirium, all of that that goes with it. And the medication side effects and the urinary retentions. How can you expect a non-medical professional next of kin to even think that through?

And I think that is something we are not talking about enough with them because we say, “Well, you know, the hip is fractured. Do you want us to do hip surgery?”

Kevin Pho: Now, are physicians really just asking that question open-ended without any guidance or without getting a sense of that family’s values? They’re simply just asking, “Do you want your loved one to get hip surgery?” I would think that in a lot of cases, I’m an internal medicine primary care physician, so these conversations come up enough where sometimes I can say, “You know, what I would do in that situation,” or I would get a sense of what some of the family’s values are before just simply asking that question. What are you seeing?

Sabooh S. Mubbashar: I think one, and this is nothing to take away from the specialist, I am a specialist myself, I think, you know, you make a great distinction. I think at the primary care level, you know, I think we’re doing a much better job. The more specialized you get, you know, as I like to say, the right-hand surgeon is way less likely to have those conversations, is what I’m finding.

Kevin Pho: So sometimes in the emergency department, if someone fell, you’re asking family members to make these complicated, nuanced decisions in a matter of minutes.

Sabooh S. Mubbashar: Absolutely. Even something like intubation with end-stage dementia with COPD, like, “Do you want us to?” And I do think, I think on a very preventative side, I think we should be talking at a much larger scale about advance directives.

And I think, you know, you’ve hit on something very important. I think this should be one of the goals of care at the primary care level. You are going to a primary care physician at any age; advance directives should be part of your conversation with your primary care physician.

Kevin Pho: So tell us what you think should happen. I completely agree with the importance of advance directives. They are not utilized enough, which leads us into situations like the one that we’re talking about today. Speaking from your perspective as a psychiatrist, and you’ve seen all of these adverse events happen in the geriatric psychiatric population, what would you like to see happen as a path forward?

Sabooh S. Mubbashar: So my response is going to be a little philosophical, so bear with me. I think the first thing that needs to happen, not just for the medical community, but for us as a society, is that we need to first accept the brain as an organ.

Right? The conversations go much better when I say the ejection fraction is 25 percent, or this is end-stage COPD. Right? The brain on the other hand, and the neurodegeneration of it, I think we have a much harder time wrapping our head around it, where this is somebody where the brain is failing as much as your left ventricle, left ventricle failure is happening in real time.

So I think that is the first awareness: that this is an organ, it can fail, probably the most important organ, and can fail miserably. So the same rules need to apply of doing aggressive measures. That is step number one.

I think step number two is that, you know, recently in New York they’re talking about the legislation for euthanasia. And I think the same thing, if the patient has capacity, it’s still leaving out my patient population. Right. Who’s making decisions for those who do not have capacity? And that does still not account for the health care proxy to make those kinds of decisions. So if you are with it and you have end-stage COPD, you can maybe make that decision. If you have end-stage dementia, first of all, you don’t have capacity, and then that’s that.

Kevin Pho: One of the things that you mentioned in your article was the fear of liability sometimes can drive physicians to do everything. So tell us more about that specter of liability that may influence their decisions.

Sabooh S. Mubbashar: I think defensive medicine is real. And I can empathize with my colleagues. I think, you know, this is a journey that I’ve made myself as well. But I think it is probably tied into us not having those larger conversations. I think at a very, very preventative level, it should be as seminal to our conversations as, say, vaccines or better diet habits or, you know, a number of alcohol drinks consumed a week.

I think till that becomes a part of our DNA in the physician-patient interaction, I can totally see why defensive medicine, you know, defensive medicine is reactive. Right, and I think once you start making medicine more and more preventative, there is little room for defensive things.

Kevin Pho: Now, let’s say from the patients’ and their families’ perspective, they’re listening to you on this podcast. They read your article on KevinMD. Now, what kind of questions should they be thinking about, God forbid, if they ever find themselves in the emergency department because of their elderly loved one falling and whatnot? Tell us the issues and questions that they need to think about when confronted with that question from a physician in the middle of the night.

Sabooh S. Mubbashar: I’ll make it very simple. It should be one simple question: What is the quality of life?

Not quantity, quality.

Kevin Pho: And what do you mean by quality of life?

Sabooh S. Mubbashar: Are they? If this was a gentleman, say, a psychiatrist at 50 and the life that he was living, at 90 with advanced dementia or any other advanced medical condition, is he even leading 20 percent of that life?

Right? Things that he enjoyed, things that she loved doing, recognizing family members, or is it being stuck in a chair, high fall risk, completely confused 95 percent of the time, being fed, obviously, just to make a point, giving you an extreme example.

But I think, and I do find in my experience with these conversations over the last 20 years, whenever I have brought up the phrase, “Is their quality of life there?” I have actually seen it instantly click with family members.

Kevin Pho: You’ve seen the cases where people with advanced dementia are getting procedures that may be of questionable efficacy, like those hip procedures, like the prostatectomies. Now you have that perspective as a psychiatrist that a lot of us don’t. Tell us what you’re seeing. How does it affect these patients with advanced dementia when they have to go through these procedures? What does that look like?

Sabooh S. Mubbashar: I think, as I mentioned earlier, they’re coming out of it after five hours of anesthesia more cognitively compromised. They are more delirious. They’re in more pain. And outcomes don’t change with these interventions. I think there is solid evidence to show that, that, you know, it’s not like these interventions are changing outcomes. Yet, we are doing them.

It’s just that, arguably, I would hate to put it like this, they’re probably dying in more pain and unnecessary suffering.

Kevin Pho: We’re talking to Sabooh S. Mubbashar. He’s a psychiatrist, and today’s KevinMD article is, “Why do no harm might be harming modern medicine.” Sabooh, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Sabooh S. Mubbashar: Well, maybe not related to that, but I think a couple of things. One is as I get older and my shift from psychopharmacology to ethics and philosophy of medicine, I think, you know, medicine has a way of humbling you every day.

I’m finding myself getting more and more drawn to the right versus left hemisphere of the way we live our life and how that translates into our practice of medicine in Western culture, where the left hemisphere is the systemizer and the right hemisphere may be a little bit of the empathizer, for the sake of simplicity.

So I think we are increasingly becoming more and more systemizers and less and less empathizers. And I think that right hemisphere needs to enter the equation once again.

Kevin Pho: Sabooh, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Sabooh S. Mubbashar: I appreciate that, Kevin. Thank you.