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Monday, May 7, 2018

FIRST DO NO HARM: THE BROKEN OATH BY PHYSICIANS


Corruption in medical fields is more important than the health of patients

Corruption in medical fields is more important than the health of patients


“Primum non nocere” (First do no harm) is one of the standard medical ethics attributed to Hippocrates. This Oath became obligatory for physicians prior to practicing medicine in the 4th century AD. 


Then the Era of vaccination appeared in 1796 when Edward Jenner injects healthy eight-year-old James Phillips first with cowpox, then three months later he is hailed as the discoverer of smallpox vaccine. Yet nobody talked about how disastrous this really was.

Of course, Jenner knew about the Hippocrates' Oad and why a medic should never perform an experiment which might be harmful to a patient even though highly advantageous to science or the health of others.

The mere mention of experimental medical research on incapacitated human beings, like the mentally ill, the profoundly retarded and minor children, summons up visceral reactions, with recollections of the brutal scientific experimentation. 

Even without the planned brutality, we have had deplorable instances of over-reaching medical research in this world causing, for instance, iatrogenic diseases like Aids and Ebola.

Iatrogenic disease is the result of diagnostic and therapeutic procedures undertaken on a patient with the multitude of drugs prescribed to a single patient adverse drug reaction are bound to occur. The Physician should take suitable steps to detect and manage them.


Iatrogenic of a disease, symptoms induced in a patient by the treatment or comments of a physician


Even though Hippocrates claims “First do no harm,” yet stories of medical remedies and scientific experiments causing more harm than good have been recorded from time immemorial.

An iatrogenic disorder occurs when the deleterious effects of the therapeutic or diagnostic regimen cause pathology independent of the condition for which the regimen is advised. 

It would be impossible to provide the benefits of modern medicine if reasonable steps in diagnosis and treatment were withheld because of possible risks.

Diagnostic procedures, mechanical and radiological, therapeutic regimen (drugs, surgery, other invasive procedures), hospitalization and treating doctor himself can bring about iatrogenic disorders. In fact, there is an enormous list of iatrogenic diseases as can be found here;


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923397/


Scientists who publish their research have an ethical responsibility to ensure the highest standards of research design, data collection, data analysis, data reporting, and interpretation of findings. 

There can be no compromises because of any error, any deceit, can result in harm to patients as well harm to the cause of science, as the Wakefield saga so aptly reveals.

We sincerely hope that researchers will keep this ethical responsibility in mind when they submit their manuscripts and not using pencil and rubber in order to adjust the right figures which suits more to the outcome of research as I found out.


Some important adverse effects of diagnostic procedures


Mechanical procedures


Diagnostic aspiration of fluids may lead to hemorrhage, secondary infection, etc. Rapid pleural or peritoneal fluid aspiration and needle biopsies may lead to shock and even death. An endoscopic procedure may cause perforation of a hollow viscus.


Diagnostic Radiology


Reactions to contrast media injected intravenously or intra-arterially may be mild, moderate or severe, and some are potentially fatal. Intravascular contrast media may have a nephrotoxic reaction. 

Cerebral angiography may cause transient or permanent neurological deficits. Radioisotopes are safe except in pregnant mothers or in newborn


Adverse effects of a therapeutic regimen

Adverse drug reactions (ADR)


ADR is defined by the World Health Organization as any response to a drug which is noxious, unintended and which occurs at doses normally used for prophylaxis, diagnosis, and therapy of disease. 

ADR can be classified as predictable (side effects, toxicity, superinfection, drug interactions) and unpredictable (intolerance, idiosyncrasy, allergy or pseudoallergy).

When fewer than six different drugs are given in hospitalized patients, the probability of an adverse reaction is about 5%, but if more than 15 drugs are given, the probability is more than 20%. 

Of the patients admitted to a General Hospital, 2 to 5% is due to ADR and fatality in patients with ADR varies from 2-12%. ADR occurs in the elderly more frequently.

To overcome the inadequacies in the WHO definition, new definition for adverse drug reaction is “an appreciably harmful or unpleasant reaction, resulting from an interaction related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment or alteration of the dosage regimen or withdrawal of the product.” 

They are classified into six types (with mnemonics), dose-related (Augmented), non-dose-related (Bizarre), dose-related and time-related (Chronic), time-related (Delayed), withdrawal (End of use), and failure of therapy (Failure)


Anaphylaxis


Penicillin, other Beta-lactum antibiotics, various types of vaccines sera, and human insulin are the most common agents that cause anaphylaxis. Aspirin and other nonsteroidal anti-inflammatory agents (NSAIDs) cause non-IgE mediated anaphylactoid reactions.


Drug-induced hematological disorders

Megaloblastic Anaemia (MA)


Oral contraceptives, phenytoin, phenobarbitone and primidone cause MA due to folic acid deficiency, colchicines, neomycin, para-aminosalicylic acid (PAS) due to vitamin B12 deficiency and 6-mercaptopurine, 5 fluorouracil, hydroxyurea, acyclovir, and zidovudine by interfering with DNA metabolism.


Hemolytic anemia


Drugs causing hemolysis by direct action are phenacetin, PAS, sulphonamides: by immune mechanism are aminopyrine, chlorpromazine, quinine and tetracycline: and in G-6 PD deficient patients, antimalarials (primaquine) and antibiotics (nitrofurantoin).


Aplastic anemia


Drugs that regularly produce bone marrow depression are busulphan, cyclophosphamide, chlorambucil, vinblastine, and 6 mercaptopurine. Drugs which rarely produce bone marrow depression are chloramphenicol, penicillamine, sulphonamides, isoniazid, NSAIDs, analgin, thiouracil, anticonvulsants, antidiabetics, cimetidine, tranquilizers etc.

The drug-induced liver injury is a potential complication of nearly every medication because liver metabolizes virtually all drugs. Acute (acetaminophen, halothane) and chronic (nitrofurantoin, methyldopa) hepatocellular injury, veno occlusive disease interact with indigenous and prescription drugs. 

The use of indigenous drugs is neither inquired in the drug history nor are the patients advised to avoid such an indiscriminate concurrent use of drugs. Sometimes these factors lead to either a therapeutic failure or a drug interaction or an accentuation of the unknown toxicities of the chemical prescription drugs.


Radiation hazards

Acute and chronic progressive radiation injuries Pneumonitis  Bone marrow depression and Malignancy

Hazards of hospitalization


The prevalence of hospital-acquired infections is around 10%. Urinary tract infections and respiratory infections are the commonest. There is increased chance of infections associated with diagnostic and therapeutic procedures and with antibiotic-resistant bacterial flora.


Physician as the cause of the disease


The harm that a physician can do is not limited to the imprudent use of medicine or procedure but may include unjustified remarks and misinterpretation of investigational data. 

The physician should be aware of the properties of drugs that he prescribes and their potential dangers. Ignorance of the possibility of a reaction is a clear evidence of negligence. The physician should warn the patient of the likely side effects.


The list of drugs given in this article is in no way complete and only examples are given. Readers should look up the references to have more details. Drugs affecting the fetus or breastfed babies are not discussed.

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