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I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.From the Hippocratic Oath1
It is astonishing that the Hippocratic Oath—written over 2000 years ago and centuries before medical interventions improved the likelihood of survival—managed to capture so many of ethical principles that remain central to clinical medicine today. However, the Oath generates much myth and misremembering. First, it was probably not written by Hippocrates but by several people who followed him. Furthermore, the oft-repeated phrase ‘primum non nocere’ (first do no harm), widely quoted as being its shorthand summary, appears nowhere in the Oath, though many feel certain it must be in there. But a clear principle of the Oath is recognising the delicate balance between help and harm.
Several articles in this issue of Practical Neurology may help us to manage this difficult balance in our clinical practice. We feature three papers discussing the almost impossible dilemma faced by women of reproductive age with idiopathic (genetic) generalised epilepsy who might consider taking sodium valproate. No issue better illustrates the Hippocratic balance between benefits (‘I will use treatment to help the sick…’) and risks (‘…neither will I administer a poison’). Epilepsy is a life-changing and even life-threatening illness and, for some young women, sodium valproate is their only effective treatment. Yet, it is also a potent teratogen, causing not only major malformations (up to 10%) but also significant and very common (up to 40%) cognitive impairment in children exposed in utero. Valproate potentially gives young women both immediate and long-term benefits—controlling seizures and so enhanced quality of life, reduced risks of epilepsy-related death and improved opportunities for education and work. But the risks of harm to a future child are also very significant and lifelong—although these remain abstract risks until the woman becomes pregnant. What is the right way forward? The failure of simple advice and recommendation has compelled the European Union’s regulatory body to change valproate’s marketing authorisation. Sanjay Sisodiya (for the Association of British Neurologists’ Epilepsy Advisory Group) discusses the major practical impacts on our practice ( see page 176 ), John Craig discusses the risks of fetal injury ( see page 219 ) and Charlotte Lawthom argues for valproate remaining an option for young women ( see page 222 ).
The Hippocratic Oath provided medicine’s first ethical standards. However, we mostly practise neurology without having to consider the ethics of our various decisions. We can do so because we work within a framework of regulations and guidelines that have been developed to include an ethical dimension. Thus, medications are licensed only if they are safe—or if their benefits outweigh their risks—and the guidelines help us know when an intervention’s benefit is worth the risk (and when it is too risky). Some clinical situations present us with a more dramatic series of options—to treat or to withdraw treatment for example—often in patients with impaired capacity, giving a very definite ethical dimension. How should we approach these decisions? Most hospitals do not have an ethicist (though some do, and some even have on-call ethicists). Daniel Tan and colleagues highlight one approach to this—moral case deliberation—which aims to help us make better decisions in the moment ( see page 181 ). Gareth Llewelyn highlights another approach—the Schwartz round—which allows discussion and reflection on difficult situations that can help us and our teams in the future ( see page 179 ).
We have several other articles of which Hippocrates (or whoever wrote the Oath) would approve, as they each aim to improve our ‘ability and judgement’ in assessing and treating patients. Jackie Palace’s team suggest a practical approach to assessing patients with spinal cord syndromes ( see page 187 ), Satish Khadilkar and colleagues ( see page 201 ) provide a structure to help make sense of limb girdle dystrophies, David Lawrence’s team ( see page 211 ) allow us to benefit from their extensive experience of neurosyphilis in patients with HIV and Stefano Tamburin’s team ( see page 227 ) provide comprehensive practical advice on how to interpret neuropsychological testing. We have several informative cases, a letter from Zimbabwe, our Book Club report and of course Carphology.
There is little evidence that Hippocrates was a neurologist despite his undoubted perspicacity. However, we know he was certainly a physician and most definitely not a surgeon, as the Oath goes on: ‘I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.’ Perhaps our earliest referral guideline?
Competing interests None declared.
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