First do no harm

Although I know that leading off with an apology is not recommended, in this case it seems appropriate to do so in this case – for having been somewhat erratic in the last few postings, and for having missed last week. The emergency response to Hurricane Sandy (now apparently renamed “Superstorm Sandy”) is winding down and things are a bit less hectic than they have been the last few weeks (last week was especially grueling). In any event, I thought it might be interesting this week to think about an oft-cited principle that is, I believe, not well-understood – the Precautionary Principle.

In a nutshell, the Precautionary Principle states that, if something is potentially harmful and it is not fully understood then we should assume it is harmful until it is proven otherwise. It is akin to the Hippocratic Oath – the part that admonishes physicians to “first do no harm.” But the Precautionary Principle is sort of one-sided as usually applied, and this is what I wanted to explore in this post.

Let’s start off with a rather simple one (and the one I know best) – exposure to radiation. First, there is no doubt that radiation can be harmful – we all know that it can cause cancer and, in higher doses, birth defects and radiation sickness. Most radiation scientists (myself included) would also agree that we do not yet know everything there is to know about radiation’s health effects. So a strict adherence to the Precautionary Principle would seem to suggest that we avoid all radiation exposure – that until we fully understand the impact of low-dose radiation we should simply avoid it altogether. But does eliminating ALL exposure to radiation really minimize our risks? I would suggest not.

Consider medical radiation, for example. When I worked in medical radiation safety we provided support for nuclear medicine, radiology, and radiation oncology. In each of these departments patients were exposed to radiation – which we know to be potentially harmful in sufficiently high doses – in apparent contradiction to the Precautionary Principle. Leaving aside for the moment the fact that a large fraction of physicians can’t quantify the risks of medical radiation to their patients, it’s reasonable to wonder about the possible longer-term health effects of this exposure. Are we putting patients at risk by prescribing these procedures? Should we outlaw medical radiation exposure in deference to the Precautionary Principle? Or is there more to consider?

Obviously the answer to the final question is “yes.” Consider – cancer takes decades to manifest itself, and the risk of developing cancer from radiation exposure is very low (the radiation from a single CT scan – among the highest-dose radiological procedures – carries with it a risk of less than 1/100 of 1%). When my son was x-rayed to try to diagnose the reason he was having problems breathing I accepted this risk gladly because not breathing is far more certain to be fatal, and very quickly fatal at that. My thought was that not breathing is also a health risk and it would be nice to keep my son alive in the short term. Similarly, x-rays can remove the need for exploratory surgery, can help physicians to diagnose disease, and so forth – all of the obvious risks from exposure to medical radiation are matched by obvious benefits. Few would debate the benefits of medical radiation exposure, if used responsibly.

So the Precautionary Principle would seem to be somewhat more complex than phrased above – we can’t simply ask ourselves if something has been proven safe beyond a reasonable doubt. We should also consider the risks of failing to take advantage of something that carries with it a benefit as well as a risk, and we should try to balance these against each other. Or to put it another way, lacking diagnostic information is a risk and, in some cases, this can be a greater risk than the radiation.

Let’s take a somewhat more difficult example – genetically modified organisms (GMOs). On the one hand, while we know a lot about these crops (and there are no indications I know of that links them to human health problems), we don’t know all there is to know. So a number of nations have decided that, in keeping with the Precautionary Principle, GMOs should simply not be sold or consumed within their borders – this way, if research some years or decades hence shows them to be harmful, at least humans were put at risk.

But what if a nation is starving? If genetically modified food is fed to the citizens then they are potentially put at risk – the risk is nebulous and unquantifiable, but it has not been shown to not exist. So many nations have decided that, according to the Precautionary Principle, GMOs should not be fed to even the starving. But withholding food – even genetically modified food – from starving people is certain to cause harm when they succumb to malnutrition and starvation. So what’s a leader to do? Feed his people with food that might make them ill years or decades hence, or withhold potentially risky food from his people? I would argue that, as with my son’s x-rays, the most reasonable course of action is to feed one’s people, even if the only available food is genetically modified. Someone who starves to death won’t live long enough to develop whatever problems might stem from eating genetically modified foods. It would seem to make sense – as with my son – to expose people to an indeterminate long-term risk in order to avert a certain death in the short term.

This makes me wonder if perhaps the Precautionary Principle should be re-formulated somewhat. There is a degree of philosophical purity in simply refusing to allow people to be exposed to a potential threat that cannot be quantified and that might carry a degree of risk. But we might not have the luxury of being philosophically pure, and this degree of purity simply doesn’t hold water when it leads to suffering and death. Weighing a long-term hypothetical risk against a short-term real risk is not easy – but weighing bodies in the street next week against hypothetical patients a few decades hence…that ought to be an easy choice.

Given all this, I’d suggest that the Precautionary Principle might need to be modified somewhat to be a bit less strict and one-sided – to encompass not only the exotic and hypothetical, but also the real and immediate needs of those who might be exposed. Instead of first doing NO harm, perhaps we should simply try to do as little harm as possible.

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8 Responses to “First do no harm”

  1. James Greenidge November 23, 2012 at 3:48 AM #

    Then, the Precautionary Principle can also make one a public health hypocrite. On the industrial mortality rate scale, nuclear plants and facilities — even counting worst rare accidents — make barely a blip on the worker/public death-injury/property damage radar compared to oil and gas facilities whose far more frequent accidents put away whole neighborhoods with barely a peep of horror from people to shut them down. And we’re not even touching the literal millions of fossil fuel aliments incurred over the generations. If we apply the “do no/less harm” mindset, it’d be logical and humanely prudent to replace truly more dangerous oil and gas power plants with nuclear ones without question. This isn’t rocket science, yet the irrational passionate resistance to this notion is dismayingly formidable and illogicalky implacable.

    James Greenidge
    Queens NY

  2. Ganavion November 23, 2012 at 5:18 PM #

    Every possible harm has a price. And every precaution has a price, too.
    When I go out I have some risks. A criminal could want my wallet, or worse.
    I could apply the precaution principle, paying a good escort. How many able and expensive men should I pay for my escort ?
    Oh, my life is one of the most important things in my life :-)
    But I have to do some calculations. Not all risks are worth a price. It depends on how mach should I pay for avoiding that danger.
    That’s the point, imho.
    Global warming mitigation is too expensive, and it is not sure.
    Well, I think it is not worth worrying so much.
    Think of the movements of Earth, their changes, they influence climate much more than CO2 ppm’s
    (think of summer-winter temperature differences…)
    imho

  3. Ben Greenebaum December 3, 2012 at 10:59 AM #

    The precautionary principle, though it is often invoked or viewed in a black/white manner as described by Dr. Y, is more nuanced and isn’t much different from the approach he takes in his examples. It says, in essence, that one should use the best scientific knowledge available at the time and then decide what to do, taking into account the costs and benefits of the various options, including both actions or no action. Costs should be proportional to expected benefits. However, the nuances are often overlooked in the often heated discussions about how to apply it in a specific situation, since in any such discussion there is significant scientific uncertainty about the effects of doing vs. not doing something and often a good deal of emotional investment on one or both sides. Sometimes commercial investment as well.

    The principle is much more formally ingrained in European legislation than the US. A summary of the EU’s approach is at http://europa.eu/legislation_summaries/consumers/consumer_safety/l32042_en.htm

  4. Dr Y December 3, 2012 at 12:36 PM #

    All good – and very thoughtful – points; thanks! Part of the problem is what Professor Greenebaum points out – the media doesn’t make time for a nuanced discussion of any issue, so people speak in sound bites (we’re all going to die; mobile Chernobyl, etc.) rather than in coherent thoughts. This, in turn, can lead to a public debate (and decisions by various levels of government) that also lack nuance. So instead of the Precautionary Principle leading to a critical looks at a problem, it turns into a knee-jerk statement that, if something isn’t proven to be harmless then we must assume it’s bad. When this happens, the public loses, as Mr. Greenridge notes. And, as Gavanion points out, this lack of clarity in our thinking can also lead to spending money unwisely.

  5. Richard Frankel December 3, 2012 at 8:10 PM #

    I might argue that you have stated the precautionary principle too stringently In particular I do not read it as requiring abstension unless knowledge is complete. Rather, it urges caution if information is not complete. In reality, since information is never complete, it can serve as a reminder about caution. But a different way of thinking about at least some cases is necessary when, in particular, adoption of certain GMO crops can make major inroads into endemic hunger and even starvation in certain 3rd world regions. Then the burden of proof should fall on the opponents, to provide evidence of harm commensurate with possible nutritional success.

  6. J. Boling December 4, 2012 at 3:12 AM #

    Precautions may be taken when we know what it is that we don’t know – the uncertainty principle of balancing benefit v. identified risk – and seek resolution of those defined “unknowns.” The danger exists when we really don’t know all that we don’t know (is this sounding familiar?). In atomic research this was a great problem; new “unknowns” were identified as development progressed – each dealt with as it was identified. However, even as identified questions were answered, new ones arose, challenging whether we ever should have “gone down that road” in the first place. The same applies to GMOs and the present sense of uncertainty – we can identify SOME potential problems (and take precautions), but we haven’t even begun to conceive other, more remote, possible outcomes. If saving the lives of starving populations today (short-term benefit) results in human genetic mutations that are (thanks to “globalization”) species-wide in 30-50-or-100 years, will that short-term benefit have been worth the eventual price? [Assuming that the mutations are negative value; flip a coin because they could make us all resistant to every known microbe and virus existant, or they could make us all fat and bald.] The Chicken Littles would deny us any progress in any area based on not knowing what we don’t know. For the most part, that’s just not the way we roll.

  7. Pat Gibbs August 17, 2013 at 9:17 AM #

    A spurious argument. GMOs do not help starving people in impoverished countries. They are designed to maximise profit and the poor cannot afford to purchase them directly or indirectly. GMOs also do not increase crop yields. GMOs are designed to be used in conjunction with crop yields and we have overwhelming evidence that using GMO seeds increases pesticide use and increased pesticide use is unequivocally linked to serious health harm.

    • Dr. Y August 17, 2013 at 10:40 AM #

      I’m not sure I can agree completely with your point. You are correct that companies are trying to make money – in fact, under US law they have a legal obligation to try to make money. And that’s ANY company – not just those that develop GMOs – so every company that you think well of is just as obligated to try to make money as those of which you think ill.

      On the other hand, I think you’ve also overlooked a few points. When the world sent food to Zambia in 2002 to help fight famine (and the food was rejected by Zambia’s government) profit was not the motive – the motive was to help feed the starving. Similarly, the development of “golden rice” to help combat vitamin A deficiency, and the rice was developed by university scientists motivated by a desire to help the poor – not to make a profit from them.

      Of course the profit motive exists – that’s the basis of virtually every company in the world. But there are plenty of examples of GMOs being developed or distributed for humanitarian reasons as well.

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