Primum non nocere

A.D. Freudenheim, The Editor

“First, do no harm” (Primum non nocere) is a foundation principle of both ancient and modern medicine, a reminder to doctors that they must always consider the benefits of any action they might take in direct relationship to its risks – and put the welfare of the patient first. Among other things, this simple dictum serves to backstop the use of any new remedy before it is deployed, lest more harm be done; a sick person may present a tempting testing ground a new treatment, but the risks of that treatment, relative to its value, must always be carefully considered.

Perhaps it is time for us to require our politicians to make a commitment to this same principle: to do no harm when legislating for our benefit, and to consider – as an integral component of lawmaking, rather than an after-the-fact, blue ribbon commission by-product – the risks and dangers of any new legal “remedy” relative to the expected benefit(s).

At first blush, this may sound like a recipe for endless debate and inaction – which is, in its way, the system we have in place currently. Social Security reform has not happened because our legislators cannot agree on any changes to the system that do not, in their view, make it better for one set of constituents at the expense of another group. Our tax code continues to be a complicated, cancerous mess, and the Alternative Minimum Tax metastasizes unabated, ensnaring more and more of the middle class while Congress turns a blind eye. And Congress has failed dramatically to act in relation to the war in Iraq, other than to serve as a check-writing machine for the initiatives of our ill-advised President Bush. This legislative inaction hardly meets the test of doing no harm, since we can see quite clearly the impact of the war on both our soldiers and our financial deficit.

Maybe in governance terms the principle under discussion should not be one of inaction, but of more measured action, the equivalent of taking two aspirin and checking back with the doctor in the morning. (Few of our national governance episodes require a trip to the emergency room; for those that do, the immediate course of action tends to be quite clear.) So, in the case of Social Security, an obvious, aspirin-like step might be to raise the national age of retirement, from 65 to 70; there is little to debate in the fact that our citizens live longer and are therefore capable of working longer, and there are copious foreign examples (such as Germany) to show the negative effects of a younger retirement age on government-funded social welfare systems. This could hurt some people – e.g., those for whom 65 is one year away, and who have already begun to plan their retirement – but the impact could be mitigated by establishing a progressive scale for implementing an age increase over time. Of course, changing the retirement age would not address all of the Social Security system’s problems, but it would be a start, the rational beginning of a longer-term process, a treatment that remains consistent with the underlying, already-established mechanics of Social Security.

That point is key: legislating in a manner that is consistent with the accepted mechanics of the system in place. Everyone believes that the Social Security system is there to serve as a retirement fund (that they’re wrong is, unfortunately, rather beside the point), so changes should be made in a way that sustains that goal while strengthening the system itself. Likewise, our tax code is (more or less) progressive, which means it is designed to alleviate the impact on the less wealthy parts of the population and to demand more money from those who make more. Therefore, a fix to the Alternative Minimum Tax should be uncontroversial – even if it means lost government revenue – because raising the income threshold affected by this piece of the law would be consistent with the essential, accepted progressive aspects of our tax law (and with the reasoning behind the Alternative Minimum Tax in the first place).

Another important piece of this discussion concerns the involvement of citizens, beyond voting. We the people should, as in medicine, become more actively engaged in our own legislative health. Just as with medicine, where we hire physicians to help heal us – but where we must also take part in the process ourselves – so should we remember that our elected representatives are not hired solely to act on their own. Democratic principles must share with medicine a common understanding that the responsibilities of the hired help do not remove or negate the responsibilities either of the patient or the citizen. The recent, absurd Republican proposal for a $100 gas rebate for Americans is an example of citizen engagement: the voluminous (negative) response to this idea helped kill it. Likewise, protests across the country about changes to our immigration policies will probably reveal the value of citizen participation in the process of governance just as the civil rights protests of the 1960s helped eliminate racist laws.

In governance as in medicine, a variation on Newtonian physics holds true: every action causes a reaction. The question is whether the reaction is worse than the initial situation. It may be that a medical dictum such as Primum non nocere is inappropriate for governance, where the fundamentals of lawmaking are much more like the business of sausage-making than of health care, and where the patient rarely cooperates. The insurmountable difficulty is that most politicians believe in something few doctors accept: their ability to create a Utopian state, the governmental version of eternal life. Within the medical world, only the lunatic fringe spends its time on achieving human immortality. Sadly, in politics the rhetoric is always keyed to the idea that one person’s policies will cure everyone’s ills.