The Latin phrase primum non nocere – in English ‘first do no harm’ - is a principal
of medical ethics, sometimes called ‘the principal of non-maleficence’. Healthcare
students are taught its fundamental importance during their initial training.
Primum
non nocere is thrown into sharp focus by the
behaviour of the English surgeon, Ian Paterson, who was convicted last week of seventeen
counts of the wounding-with-intent of nine women and one man. He had subjected
them to breast surgery which was wholly unnecessary. There is now talk of
hundreds of other unknown victims of this man.
Primum
non nocere is a principal that also applies to all
child protection professionals, whether they be medically qualified or
otherwise. But there have been some notorious
occasions on which it has not been followed. In 1991 children were taken into
care and adults arrested in response to what turned out to be false allegations
of ‘ritual’ or ‘satanic’ sexual abuse on the Orkney island of South Ronaldsay. After five weeks, during which the parents had
no contact with their children, the claims were dismissed by a judge as
"completely unfounded".
In 1987 children living in Cleveland, in
the North East of England were removed from their homes by social services having
been diagnosed, by two paediatricians at a Middlesbrough hospital, as having
been sexually abused. The children were
said to show signs of ‘reflex anal dilation’.
So many children were taken into care that there were insufficient
foster places for them and some had to be housed in a hospital ward. The
validity of the test used to diagnose the children was disputed by other
doctors and subsequently an enquiry led by the distinguished judge, Dame
Elizabeth Butler-Sloss, concluded that most of the diagnoses were incorrect. As
a result, 94 of the 121 children were returned to their homes with no further
action.
In 1999, paediatrician Professor Sir Roy
Meadow gave expert evidence in the trial of Mrs. Sally Clark, a solicitor
accused of murdering her two infant sons, in which he stated that the odds
against two cot deaths occurring naturally in the same family were greater than
70 million to 1. Meadow had erroneously assumed that the two events were
statistically independent, which they are not. In reality the occurrence of a previous
cot death points to the existence of conditions (environmental, genetic etc.) that
make the occurrence of a second more,
not less, likely. Sally Clark was wrongfully convicted and spent several years
in prison before her conviction was quashed in 2003. She died in 2007 having
never recovered from the trauma of the deaths of two children, being unjustly
convicted of their murder and being separated from her third baby as a
consequence of her imprisonment.
There is a common theme connecting these
events with the case of the discredited surgeon Ian Paterson. It concerns lack
of challenge. For reasons which are
not yet clear, Paterson was allowed to continue operating for years even though
serious concerns had been expressed about his competence to do so. In a similar
way, once the allegations of ‘ritual’ abuse in Orkney were taken seriously, uncritical
net-widening ran amok and more and more children were sucked in to what proved
to be a moral panic. In Middlesbrough, the apparent scientific basis of the
diagnosis made it hard to question the mistaken opinion of the paediatricians involved.
In the case of Sally Clark, nobody in the court seems to have been able to
challenge an expert witness who had made a basic statistical mistake.
Challenge is one of those words which one minute sounds positive and the next
threatening. If I am challenging something or someone, then that is heroic and
good. But if someone is challenging me, then that is aggressive and unfair. So,
we need to make sure that we get the culture of challenge right.
If we are carrying out tasks which are safety critical – ones in which people
might suffer or even die if things go wrong – then challenge is not something which
is an unwelcome or painful inconvenience to be avoided at all costs. Rather it
is a welcome opportunity to get things right. Everybody, including the most
senior manager, who works in a safety critical context needs to be taught not
just to expect challenge, but to welcome it. And everybody, including the most
junior employee, needs to be taught how to initiate challenge of even the most
powerful and distinguished colleagues.
Failing to get challenge right is not just
unfortunate. It is downright dangerous. Unchallenged practice is unsafe
practice. We all need to realise that, if we are to avoid doing unnecessary harm.
