The Sneaky Violence of Nonmaleficence

A few months ago, I was chatting with a friend about her experience of medical school and her sentiments as she transitioned into residency. She told me about the well-known mantra in the medical field: "It's not if you kill your first patient, it's when."

I usually have to re-read that sentence to allow it to sink in. It's a somber statement about how the reality of practicing medicine is in contradiction with the oldest ethical tenants of the field: First do no harm.

[image description: an image of the symbol of the medical profession: two snakes wrapped up a staff with two wings extended at the top. The background is yellow and there is an image of green grass at the bottom. "FIRST DO NO HARM" is typed on the bottom. Image found on Google Images]

[image description: an image of the symbol of the medical profession: two snakes wrapped up a staff with two wings extended at the top. The background is yellow and there is an image of green grass at the bottom. "FIRST DO NO HARM" is typed on the bottom. Image found on Google Images]

Even while the phrase "first do no harm" is not verbatim in the Hippocratic Oath, the morality of this statement is deeply ingrained in the motivations and philosophies of people in helping professions and healing professions around the world. It is also deeply internalized by people of all religious and spiritual backgrounds. One version of it, Nonmaleficence, is outlined in the American Counseling Association ethics:

These professional values provide a conceptual basis for the ethical principles enumerated below. These principles are the foundation for ethical behavior and decision making. The fundamental principles of professional ethical behavior are

  • autonomy, or fostering the right to control the direction of one’s life;

  • nonmaleficence, or avoiding actions that cause harm;

  • beneficence, or working for the good of the individual and society by promoting mental health and well-being;

  • justice, or treating individuals equitably and fostering fairness and equality;

  • fidelity, or honoring commitments and keeping promises, including ful lling one’s responsibilities of trust in

    professional relationships; and

  • veracity, or dealing truthfully with individuals with whom counselors come into professional contact. 

The concept of "first do no harm", the internalized morale of nonmaleficence (aka non malevolence), and the nonchalance of "It's not if you kill your first patient, it's when" have been swimming in the back of my mind as I have watched the media, the nation, and the world erupt over recent events. Events from Brock Turner's rape trial, to election campaigns and candidates, to Nyle DiMarco and the Alexander Graham Bell Foundation's critique of him (they did have a follow-up response), to the Pulse Orlando massacre, to the dozens of other less publicized (related and unrelated) stories of injustice, murder, and discrimination

I have been watching as people question how these atrocities could happen, as people pour out support, as people condemn each other over the events, and as people criticize each other for their political beliefs and their responses to relevant events. As blame and judgement cycle and spiral back and forth, I've become curious about a pattern I have noticed.

No one seems to believe they are causing harm.

In fact, most people seem to think they are helping. Helping to dispel myths. Helping to eradicate ignorance. Helping to rid the Earth of people who are seen as Other and less-than. Helping our children. Helping protect our country. Helping themselves to wealth or pleasure. Helping...

Practice two things in your dealings with disease: either help or do not harm the patient.
— Thomas Inman

After all, how many of you wake up in the morning and think to yourself, "Today I will intentionally and unintentionally cause harm to others."?

[image description: a graphic of a sign post with four different signs. Each sign is an arrow, pointing in a different direction. At the top is a green arrow inscribed with "HIS FAULT". Next is a yellow arrow inscribed with "HER FAULT". Next is an orange arrow inscribed with "THEIR FAULT". The last arrow, at the bottom, is red and states "NOT ME". Image found on Google Images.]

[image description: a graphic of a sign post with four different signs. Each sign is an arrow, pointing in a different direction. At the top is a green arrow inscribed with "HIS FAULT". Next is a yellow arrow inscribed with "HER FAULT". Next is an orange arrow inscribed with "THEIR FAULT". The last arrow, at the bottom, is red and states "NOT ME". Image found on Google Images.]

Even when confronted with the pain we have caused, we seem to have internalized our moral nonmaleficence to the point that it does not compute. We think, "No. It couldn't possibly be my fault. If harm was caused, it must be someone else's fault or someone else's problem." We may even think, "That person needs thicker skin. They're taking this too personally. Quit playing the victim!" 

I know what you're thinking. OTHER people blame. OTHER people cause harm. OTHER people blame. Not me.

Maybe you practice honesty and accountability in your life. Maybe you donate to good causes. Maybe you engage in restorative justice practices. Maybe you volunteer your time. Maybe you're a therapist or a doctor or a teacher or a police officer, or a policy-maker with a heart for justice. Maybe you diligently practice your religion. What does all of this have to do with you?

I'm curious, too. Has our morality of nonmalevolence immunized us from accountability? Has it become a sneaky shield of protection, blocking out information that will highlight our fallibility and vulnerability? Do our moral standards imply that if we are good, we cannot cause harm? 

How prevalent is it that we each cause harm, anyway?

Anecdote #1

A recent episode (#716 Voice of Reason) on the Snap Judgement podcast shared the story of a new, bright-eyed lawyer (Christina Swarns) doing her best in 1994 to "help" a chronically homeless man who would dine and ditch in order to get arrested. He developed this routine in order to have a place to sleep--jail. Like many people who have drive to help the less fortunate, this case tugged at her heart. In her efforts to publicize his dilemma and raise support, he experienced humiliation by other incarcerated people for wanting to be in jail. The only place he had developed for safety, was no longer safe. Ultimately, he ended up not accepting any of the support that had been obtained for him, and was never heard from again.

anecdote #2

A recent episode (Update: Alleged cult leader plays shell game with US foreign aid) on the Reveal podcast shared the story of how billions of dollars from the US government, donated clothing sales, and employees' paychecks are being siphoned off by Planet Aid into untraceable foreign bank accounts, rather than being allocated to projects. This organization appears to be exploiting the generosity of others, claiming to offer humanitarian services, and the money is all but disappearing. And because it is documented that money is allocated for these programs (that never take place), it is difficult for these communities to get additional support elsewhere. Unfortunately, many well-intentioned NGOs and Non-Profits offer services that are never utilized. Schools are built and the buildings are abandoned. Donated money is allocated to donors' intentions rather than what is needed at a grassroots level (i.e. Haiti). When you donate money, how do you know where it is actually going? Do you track where your tax money goes?

anecdote #3

In the novel, Shantaram, and the sequel, The Mountain Shadow, by Gregory David Roberts, the main character, Shantaram (aka Lin) befriends a mouse while in prison. He feeds him. He extends generosity. He trains him to the point that they have a safe relationship. When he is moved to another cell, he informs the next person that the mouse in that cell is well-trained. The inmate subsequently tortures and kills the mouse. This haunts Shantaram, and he questions whether his generosity was the predicating factor that made the mouse more vulnerable to harm. If he had not taught the mouse he was trustworthy, the mouse would not have altered its self-protective behaviors. It would not have had the audacity to approach the next inmate. It would not have died cruelly.

Sometimes we have the best intentions, but we’re focusing on the wrong thing. Are you willing to consider the possibility that, just maybe, you have focused on the wrong thing?
— J. Parrish Lewis, www.munkymind.com
[image description: cartoon image of a person standing in front of a mirror, angrily pointing at the mirror. The person is wearing green pants, a blue shirt, and glasses. They appear to be blaming and yelling at their own reflection. Image found on The Barefoot Spirit.]

[image description: cartoon image of a person standing in front of a mirror, angrily pointing at the mirror. The person is wearing green pants, a blue shirt, and glasses. They appear to be blaming and yelling at their own reflection. Image found on The Barefoot Spirit.]

Perhaps we all are causing harm every day. Even the most ethical, most honorable, most logical person lapses. This pattern of unintentional hypocrisy is deeply embedded in our colonial history. During the Crusades, Crusaders believed they were manifesting the Kingdom of God while killing non-believers. During westward expansion and Manifest Destiny, homesteaders believed they had a right to the land that was usurped from Native tribes. During slavery, Protestants believed that because they were Christian, stealing, killing, raping, and forcing labor upon slaves couldn't possibly be a bad thing. Our morals and internalized positive self-image (or desperation for a positive self-image) appears to have the capacity to blind us from the reality that we cause harm.

 

We all partake in the game of judgement, passing on the toxic burdens of shame and blame to the next person. 

In the practice of supporting optimal social, emotional, and psychological well-being, we must be able to differentiate between guilt and shame. Unfortunately, we are exceptionally good at deflecting guilt (and responsibility) by engaging in shaming practices. We've learned from Brené Brown's work, shame deteriorates our psyche, our relationships, and our communities. Judgement and blaming are useful tools for deflecting shame and vulnerability. They are less useful for creating positive change and creating healthy, safe communities. 

Ethically, what does this mean? As a counselor, bound to the ethics listed above, I believe this means letting go of these standards as a measure of myself and my work. I believe it means that I stop assuming that I am being helpful when I think I am, and stop assuming that my good intentions preclude me from causing harm. It means I spend less energy tracking for evidence of my help, and more energy tracking and acknowledging where I missed the mark. It means I am prepared to appropriately apologize, to admit when I am wrong or when I don't know, and to make amends. 

Why? Because it is possible to learn that a) having inherent value as a human, and b) inevitably causing harm, are not mutually exclusive. Because healthy relationships are less about never causing harm (as the Hippocratic Oath and Counseling Ethics may imply), and more about repairing a relationship after hardship.

What would happen if we let go of the introject that we must only be good and must never cause harm? What if we came to terms with our own pain, our own malevolence? What if every time we wanted to criticize, condemn, or judge someone, we looked inward and could acknowledge "In some way, I do that, too."? What would happen if we all took a deep breath--a slow inhale that filled our bellies and an slow exhale of release, and could also extend gentleness, love, and compassion for ourselves? What if we engaged in the artful mastery of appropriate apologies?

And what if you're already doing these things? Take a moment and check...are you judging the people who aren't?


One of my mentors, Carla Sherrell, frequently reminds me and others that oppression is "sneaky." Carla's work, words, wisdom, and her own mentors, teachers, and ancestors therefore created a foundation for the thoughts expressed in this blog.

My clinical supervisor, Duey Freeman, has been influential in my understanding of how repair is essential to the development of healthy relationships. His work at the Gestalt Equine Institute of the Rockies (GEIR) and the Gestalt Institute of the Rockies (GIR) has also created a foundation for the thoughts expressed in this blog. The GIR summer intensive (August 2016) will look at some of these topics in A Call To Action: Exploring the Depth of Racism, Privilege, Power, and Diversity.