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First, Do No Harm [Muldoon]

I've been reflecting lately on my 35 year career as a physician and how that relates to American medicine in the age of COVID and the United States of America at the end of 2021.

Two different, yet interrelated foundational principles have been central to my thoughts. The first is a core tenet of western medicine, the doctrine of primum non nocere or "first do no harm". The second is "Life, Liberty and the Pursuit of Happiness".

Although the concept of primum non nocere is linked in most people's minds with the Hippocratic Oath. The words are not likely his, seeing as how they are Latin and he was Greek, but I digress. Primum, while meaning 'first' also has a hierarchical sense, indicating primacy or being of primary importance. It is not so much in the sense of being 'the first thing on your list' as it is 'the most important thing'.

The Online Etymology Dictionary links nocere (harm, injury, damage) to modern words such as 'innocent' (doing no evil; free from sin, guilt, or moral wrong) and 'innocuous' (harmless, producing no ill effect). But intriguingly, the Latin word 'nocere' is also linguistically linked to the Proto-Indo-European root 'nek-' (death), and part of modern words such as pernicious, necrosis, obnoxious and nuisance. In my view, the sense of nocere in "primum non nocere" includes more than just physical harm or injury, but also a broader meaning of not interfering with the individual's personal domain or autonomy.

The Declaration of Independence positively asserts mankind's God-given rights to Life, Liberty and the Pursuit of Happiness. The first two seem relatively straightforward, but what is "the pursuit of happiness"? I have read that Thomas Jefferson wrestled with the wording of that portion, including substituting 'property' for pursuit of happiness. Happiness, in this context has a sense of fulfillment, satisfaction or self-meaning. What are those things that give you as an individual a sense of purpose in your life? You could say it equates b being master of your personal domain.

So, if we juxtapose those two principles, the phrase "primum non nocere" or "first, do no harm", can be restated in the form "As a primary principle, do not impinge on the individual's self in a harmful way". As a practicing physician I always sought to follow that principle, balancing my knowledge of the science as it related to the patient's condition, with the patient's family situation, resources, culture, and overall identity. My job was not to tell them what they needed to do, rather it was to help them navigate the complexities of their condition, demystify the language, explore treatment options (sometimes including the option of not providing any treatment at all, one of the most difficult decisions a family may face) and empower them to make hopefully wise decisions.

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That brings us to today. For the sake of discussion, let's compare the official reactions to ivermectin versus mRNA vaccines. We have seen numerous news reports of physicians being censored, fired, or losing their medical license for daring to prescribe ivermectin for off-label use. Ivermectin has been approved by the FDA for many years and has been prescribed widely in humans for anti-parasitic uses. In general, physicians in regular practice commonly prescribe medications for uses that are off-label, or not specifically delineated in the FDA's approval. This a well known and widely accepted part of medical practice. Ivermectin has a known track record of safety and a well defined mechanism of action at the cellular level. Where is the harm in trying such a medication, with its anecdotal evidence of beneficial effects in COVID, particularly when compared with the known demonstrable harm of myocarditis following mRNA vaccines?

Recently the FDA blithely approved the Pfizer mRNA SARS-2 vaccine for children as young as 5 years old. This vaccination in some settings is being made mandatory for young healthy children. In making this move, the FDA blatantly dismissed with a wave of the hand or entirely ignored VAERS-documented increases in confirmed cases of myocarditis in teens and young adult males (above anticipated baseline levels). Pfizer had two separate trials of its mRNA vaccine involving a total of a little over 4000 children, of which approximately 3000 received two doses of the active vaccine and the rest received placebo. They reported zero cases of myocarditis within 7 days of receiving the vaccine ( approximately 6000 total doses). The VAERS data on myocarditis reported 21.5 cases of myocarditis per 1 million doses of vaccine, which they calculated to be more than 3 times the expected occurrence in the general population of males aged 12-15 (21.5 vs. expected range of 1 to 7 cases). A single case of myocarditis in a sample size of 6000 doses would equal roughly 170 cases per one million doses. For a condition such as myocarditis that is rare in the general population, a sample size of 6000 is insufficient to be confident that 5 to 11-year-olds do not experience myocarditis at rates substantially higher than the general population risk. Yet the FDA and the CDC both tout the vaccine to be safe and are actively recommending widespread vaccination of young children. Why not take a more even handed approach to both ivermectin and the mRNA vaccines? Why are physicians who recommend ivermectin vilified and politicians and bureaucrats who push a new vaccine technology with an as yet uncertain safety profile praised?

In a context of "first, do no harm", a physician acting in good faith ought to be able to prescribe a medication that in their best medical judgment is safe and may have some effectiveness, until such time as it is shown to cause harm. The FDA's own webpage "Why You Should Not Use Ivermectin to Treat or Prevent COVID-19" does not cite any harm from appropriate doses of human forms of ivermectin, rather it focuses on overdosing of the veterinary forms in individuals who self-administer, and scant evidence of any widespread adverse effects even at that.

Secondly, in a framework of the basic rights of Life, Liberty, and the Pursuit of Happiness", a patient by rights should retain the autonomy to apply their conscience in making their own health care decisions. Yet here we are, in a circumstance where politicians are threatening individuals' liberty and pursuit of happiness on the vague and as yet unproven notion that vaccine mandates, as Surgeon General Vivek Murthy put it, "...our pathway out of the pandemic”. This is a vain hope at best. That "science" most certainly is NOT settled, as natural immunity, cross-immunity and mutation of the virus to more benign forms are all contributors.

Perhaps I'm just a dinosaur, but I believe the precepts of Primum Non Nocere and inalienable rights endowed by our Creator are every bit as valid now as they were when first put forth. I commend those in the medical community who have followed their conscience in advocating for individual rights, at risk to their own livelihood. And I call on the rest of the medical community to wake up and realize where their loyalty ultimately lies. Physicians should actively push back when a third party (employer, government) seeks to inject themselves into the relationship between doctor and patient or to supersede it entirely. They should rededicate themselves to a duty to individual patients rather than a 'greater' public good. Let us rekindle a spirit of "First, Do No Harm".