Non-maleficence (do no harm)…and beneficence

The first, the original, principle I think was non-maleficence, the notion that above all else, you should do no harm. For most of the history of medicine, for 2,500 years, that was really the predominant principle, because medicine couldn't predictably do much good. There wasn't a lot you could do predictability that could benefit people. We didn't understand germ theory until late in the 19th century. We didn't develop any effective drugs until 1935 when the sulfa drugs emerged and Penicillin came into being in the 40's, antibiotics in the 50's. So these drugs make it possible predictably to benefit people, whereas before it was largely a hit and miss affair.

There's a fascinating book about surgery in the American Civil War. That war produced thousands of amputees, something that I was never aware of until I looked at this book. People who had minor flesh wounds, bullet wounds, just minor, would have their arm or their leg amputated because that was the only way people knew how to stop gangrene from setting in. There was no understanding of the mechanism of infection. So they could actually remove a leg in less than a minute on the battlefield. They could take off a guy's leg above the knee in sixty seconds. They had it down to that. And you had thousands of amputees, people without arms or legs, who today would be treated with antibiotics and would be perfectly fine. Which is a graphic example of how late in the history of medicine any ability to benefit people predictably is. So, in essence, the notion of what you have to do is benefit people emerges fairly late. And there's tension, constant tension between these two. Every attempt to do good entails some risk. I had a terrible example of that recently.

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