Redefining How We “Do No Harm”

Weighing the lesser of two evils in a lose-lose situation

The Hippocratic Oath is so ubiquitous it rarely needs further explanation.

First, do no harm.

What is less obvious right now is whether the harm caused by the COVID-19 pandemic is something we’ll recover from. Whether through loss of life, debilitating illness, or financial ruin, we’re staring down the barrel of a loaded gun. We’re being forced to contend with previously unthinkable scenarios, each delivering untold pain and suffering.

“I hope I get it, I want to just get it over with and move on,” a colleague of mine shared on a Zoom happy hour. My dad disclosed in a text message, “A free-for-all reopening of the country scares the hell out of me.” I don’t disagree with either of them, as I’ve caught myself admitting those exact sentiments to myself and others.

What’s harder to admit is that like it or not, whatever the next steps involve, there will be a lot of harm done.

The question is no longer about doing no harm. That ship has sailed, as more than 56,000 Americans have died of coronavirus at the time of this writing. Millions of others are facing the loss of their businesses, paychecks, and homes. Under shelter-in-place orders, reports of domestic violence and child abuse are rising and it’s likely safe to assume everyone’s mental health is suffering to some degree.

The question instead becomes, how do we minimize harm for as many people as possible?

While physicians are historically the profession most associated with swearing by this particular code of ethics, they are not the only medical professionals guided by the concept of “no do harm.” As a dietitian, I abide by a similar code. We are required to complete a mandatory ethics CEU, or continuing education unit, in order to renew and maintain our credentials.

In the centuries since the Hippocratic oath was widely adopted, medical ethics expanded into areas of patient confidentiality, informed consent, non-maleficence, and more. Legal precedents and rulings take it into consideration (such as Roe v. Wade in 1973) and it makes difficult issues like physician-assisted suicide all the more challenging to grapple with.

In 2020, we’re facing another instance where the interpretation is up for debate. What will truly do less harm?

One outspoken voice on this issue is Dr. David Katz. He holds an MPH from the Yale School of Public Health and is board certified in preventative medicine. As the Past-President of the American College of Lifestyle Medicine and the Founder and President of the True Health Initiative, he is arguably among the best qualified to speak to the challenges of reopening the country during a pandemic.

Dr. Katz penned an opinion piece for the New York Times, , that advocated for a phased approach that would “allow most of society to return to life as usual and perhaps prevent vast segments of the economy from collapsing.” Dr. Katz pointed out that initially, yes, total lockdown and strict quarantine measures are necessary to prevent healthcare systems from being overwhelmed.

However, he says the next step of a phased reopening plan must allow for targeted and proactive testing of the most vulnerable among us. If commerce could resume, albeit at limited levels, and healthy individuals could return to some semblance of normalcy, he predicts herd immunity and a restored sense of calm would overtake the virus’s stronghold on the American public.

Dr. Katz , “If all we do is flatten the curve, we don’t prevent deaths. We just change the dates.” Meaning that, if we effectively isolate ourselves to protect against an initial wave of infections, the virus is still circulating, ready and waiting for the time when we flood back into the world. A second wave hits, a new surge claims lives and depletes resources, and we’re basically back at square one.

When I heard that, I couldn’t help but recall the media circus that ensued after Dr. Oz was featured on the Fox News show “Fox & Friends.”

He argued that reopening schools is risky, but keeping them closed might be making a bad situation worse. With estimates that doing so would increase total mortality by 2–3%, he said,

In real numbers, 2–3% of the roughly 56 million schoolchildren in the United States equals 1.1 to 1.6 million students. Unsurprisingly, news outlets and social media lost their ever-loving minds. Righteously so, because suggesting a sacrificial offering of the nation’s youth for the greater good is on par with the most atrocious human rights violations in history.

Most failed to note he said “total” mortality, which is to say that number refers to the total population, not students only.

Dr. Oz later apologized, acknowledging how his statement was confusing and easy to take out of context. He offered clarification, saying, “I am a doctor. I want you to be safer ― I want you to err on the side of being overly cautious, but not at the expense of making decisions that don’t really serve us.”

The part most difficult for me to reconcile is that Dr. Katz, whom I genuinely respect as a physician, seemed to be saying essentially the same thing as Dr. Oz, whom I envision as an over-hyped clown masquerading as a doctor.

The former embodies qualities I’d love to see in my own physician. Calm, cool, and collected, he delivers complex medical info in a way that’s easy to understand. In a time when group-think is commonplace, he challenges us to think critically and not become complacent in our beliefs. He doesn’t grandstand. He remains true to the evidence. He seems like a pretty nice guy.

Dr. Oz, meanwhile, continues to be what amounts to the bane of my existence. He has single-handedly contributed to a breakdown in health literacy, critical thinking, and the collective confusion of an entire society. In my days as an undergrad nutrition major, I remember one of our assignments was to choose a supplement promoted on his show and dig into the evidence (or lack thereof) that supports its use. Needless to say, the research for raspberry ketones remains less than impressive.

The two glasses of wine I enjoyed with dinner that night didn’t make it any easier for me to untangle their statements. Was I really coming to the defense of my nutritional nemesis? Was Dr. Katz’s voice of reason echoing down a misguided tunnel?

I resigned myself to bed, telling myself I’d sleep on it and mull it over with coffee, sans alcohol.

With a fresh outlook the next morning, I returned to ask, which is it? Is a widely revered and respected physician suggesting the same thing as a loud-mouthed celebrity doctor? Or is it possible Dr. Oz misspoke, and instead meant to imply the same thing as Dr. Katz?

I can’t believe I’m saying this, but here goes nothing.

I’m choosing to believe that deep down, Dr. Oz still remembers his Hippocratic Oath to “do no harm”. I’m willing to give him the benefit of the doubt because, despite all the problematic statements he’s made and how difficult it’s been to undo that damage, I truly don’t think he wishes to watch Americans suffer and perish.

This seems to be the case, as he is as saying, “I am a doctor. I want you to be safer — I want you to err on the side of being overly cautious, but not at the expense of making decisions that don’t really serve us.”

Dr. Katz has a more measured and eloquent way of putting it. Which is, that people will die and yes it’s all terrible, but it’s also egregiously inhumane to subject people to the despair of unemployment, poverty, and lost hope.

At first, I rejected statements like, “People die every day in other ways — what makes this any different?” or “Coronavirus has killed XXX people, but [insert other calamity] kills three times as many!” This is comparing apples to oranges. I can’t get on board with flawed logic. So I earnestly agreed with Rachael Hope when pointed out that caring about a pandemic doesn’t automatically negate your ability to care about other social injustices.

But what I am warming up to is the idea that just as we take on calculated risks in everyday life, perhaps taking our chances with this virus is becoming another one.

Hear me out.

This is not, I repeat, not my endorsement of an “every man for himself” approach. I am, however, starting to understand that just as we take on a certain level of risk each time we drive a car, fly in an airplane, walk out the front door, so to will we have to contend with a certain level of risk in a world with COVID-19.

I also believe this is forcing us to redefine “harm” and “suffering”. What’s worse: A continuous uptick in the number of positive cases and confirmed deaths, or the immeasurable toll brought on by the despair of unemployment, poverty, and a tanked economy?

Clearly, this is a lose-lose situation.

We are the collateral damage. And thus, a dividing line has been drawn.

Last week, we started witnessing protests en masse on the steps of state capitals, calling for a return to business. Mayors and governors are operating from different playbooks, with some taking a cautious, calculated approach while others seem bent to the wills of their constituents. And while some of us are more than willing to hunker down, grit our teeth, and do our part to #FlattenTheCurve no matter the personal cost, others sense their civil liberties are under threat and insist this is a full-blown assault on individual freedoms.

As COVID-19 exposes the structural, racial, and personal biases that widen the gap between the privileged and the marginalized, my perception of humanity is laid bare, too. I still feel the same conviction in my own actions as before, but I also feel more compassion for those who cannot or will not compromise anymore.

We’ve all been asked to confront what our tolerance for harm is. For regardless of the success or failure of a national reopening effort, there is more of it coming.

The longer we disagree on our next steps, I fear the worse it will be.

Lover of carbs and puns, call me Cara Carbstreet | Anxious Millennial | Coffee Enthusiast | Non-diet Dietitian

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store