Recently, as I was perusing The History of Medicine authored by William Bynum, a statement caught my attention that subtly reinterpreted many of our assumptions regarding our profession. Bynum reflects on the progression of medicine, stating: “When in doubt, remember the Hippocratic injunction that health is most likely to be found in the middle way.”

This concept, intricate, humble, and profoundly clinical, seems vastly different from the expression now most prominently linked with the physician’s oath: “Do no harm.”

Many might be surprised to discover that “Do no harm” is absent from the original Hippocratic Oath. The Latin phrase “Primum non nocere,” meaning “First, do no harm,” doesn’t feature in any version of the oath ascribed to Hippocrates. In fact, its likely emergence occurred centuries later, perhaps in the 19th century, often misattributed to Hippocrates himself. The earliest documented use of “primum non nocere” in a medical context is from the 1860s, attributed to the English physician Thomas Sydenham or the American Worthington Hooker, depending on the historian consulted.

Yet, this addition has evolved into the most frequently cited and misconstrued principle in medicine. It is displayed at white coat ceremonies, hospital entrances, and bioethics presentations. It is referenced by both physicians and politicians. It has been simplified into a catchphrase, a symbol of virtue, a moral guiding principle.

However, here lies the contradiction: If taken at face value, “Do no harm” renders medicine unfeasible.

Each instance a scalpel contacts skin, harm is inflicted.

Every time an SSRI is ingested and induces even slight nausea, harm occurs.

Whenever we sedate, inject, biopsy, intubate, irradiate, we are technically causing harm.

So what exactly do we convey when we invoke this expression?

If “Do no harm” were a rule, we would never treat a patient. We would merely observe disease unfold, unimpeded. The reality is: Medicine isn’t focused on preventing harm. It’s about comprehending it, assessing it, and opting for it when it represents the lesser evil.

Why is it crucial to address “Do no harm” at all? The issue stems from the gap between the phrase we have adopted as medicine’s moral motto and the genuine, lived experience of clinical practice. This principle is ingrained from the very start of a clinician’s education, echoed in white coat ceremonies, featured in ethics curricula, and uttered with a near-religious reverence. Yet it bears scant resemblance to the realities of practice, which center less on the ideal execution of principles and more on maneuvering through the complicated landscape of uncertainty, trade-offs, and clinical improvisation.

Often, when a rallying cry contrasts sharply with the work it professes to reflect, an unconscious dissonance begins to take root. The phrase offers clarity; the practice demands ambiguity. Over time, the actual craft of medicine—its judgment, instinct, and human subtleties—becomes disconnected from the slogans that originally inspired it. As it must. For that disconnection is not a betrayal; it is evolution. It encapsulates the realities of what medicine genuinely is: uncertain, contextual, and irreducible to moral platitudes.

However, unresolved dissonance carries a psychological toll. We cease to think critically. We stop reflecting. We recite the phrase without further analysis. Thus, “Do no harm” persists, not as an ethical guide but as an unquestioned ritual, repeated more for reassurance than clarity. It grants us moral justification. It creates the illusion that our intentions suffice, that our ethics are affirmed merely by declaration. Yet in doing this, it may hinder us from the more difficult, essential task: evaluating risk and benefit with each intervention. The phrase comforts us into believing we are cautious, that we are virtuous, while in truth, we might be defaulting to habitual interventions without reflection.

American medicine frequently faces criticism for being overly aggressive, too swift to treat, intubate, or operate. Yet, as is often the case, a profession’s greatest strength can also be its greatest vulnerability. Our inclination towards action, toward doing something—anything—is reinforced by a slogan suggesting we are always grounded in safety. Under the verbal anesthesia of “Do no harm,” we might evade the more uncomfortable reflection: Should we be undertaking this at all?

– Should we consider offering hip surgery to a 90-year-old suffering from severe congestive heart failure, someone already with limited mobility, deeply reliant on assistance for basic needs, and likely to emerge from anesthesia in a more disoriented, delirious state and permanently worse cognitively than before?
– Should we contemplate re-intubating a patient with end-stage COPD, already on maximum oxygen support, for the