Primum non nocere and the S.A.F.E. Principle


Primum non nocere (Latin for "first, do no harm")

Choosing appropriate treatments for patients with any medical condition must always be guided by one of medicine's most basic principles: primum non nocere (Latin for "first, do no harm"). As health care providers, we must always consider the potential harm that a treatment can cause. Even the Hippocratic oath that many physicians recite at graduation emphasizes the promise to "abstain from doing harm."

My "S.A.F.E." Principle: A Personal view on the Modern Latin Phrase

As a hair loss physician, I'm frequently reminded of the importance of "primum non nocere" when treating any of the dozens and dozens of common and rare hair loss conditions. Primum non nocere closely mirrors a principle that I've shared with medical interns, residents and medical students for many years, namely treating patients in a manner that is "S.A.F.E". Each of the four letters S, A, F, E in this four letter acronym reminds me of factors to consider when recommending treatment to patient - in order to specifically avoid causing harm. My S.A.F.E. Principle applies to any treatment in medicine, but I've adapted it here for my practice in hair loss.

S: Safety

The first letter S stands for "Safety". Fundamentally, our patients count on us to bring them treatments have a good safety profile with side effects that are minimal. This is particularly important with treating hair loss, where our patients our often healthy and treatments have the potential to make them unhealthy. I can tell you first hand that the risks patients are willing to take to grow more hair is incredibly varied. For some patients with hair loss, any side effects are unacceptable. These patients often proclaim "after all, doctor, it's only hair." For others, hair is central to their self-identity and many risks are accepted. It seems unbelievable to an outsider when I share with them results from studies that have shown that men are willing to give up years of life for better hair. Helping patients better understand not only the side effects of a given medication or treatment but also how commonly they occur is important in order for them to be fully informed. Initiating treatments with many potential side effects has the potential to harm the patient and is clearly not in keeping with "primum non nocere."

A: Affordability

The second letter "A" in my S.A.F.E. Principle stands for affordability. Helping patients find affordable, safe and effective treatments is the responsibility of the physician. What is the cost of the given treatment and is it affordable? What are the alternatives and the cost of alternatives? Are there one time costs or ongoing costs? Is the treatment covered by insurance? I can think of many hair loss conditions where I can achieve the same result with a $ 100.00 treatment as I can with a $ 20,000 treatment. What is the best option? Fortunately, I don't have to answer that as society dictates what the correct answer is. Unfortunately, it is often forgotten what the correct answer is. Clearly, starting a treatment that is not affordable to the patient can create considerable harm and is not in keeping with "primum non nocere."

F: Feasibility

The third letter "F" stands for feasibility. For any treatment we need to consider how feasible or "likely" is it for the patient to ultimately adhere to the recommended treatment. Some treatments administered by the patient "at home" and are too time consuming, too messy or too inconvenient for them. There treatments may sound okay to the patient sitting across from me at the office, but once the patient gets home it quickly becomes clear this just is not feasible. Similarly, some treatments require frequent office visits which also create challenges. Clearly, starting a treatment that is not feasible to the patient can create harm by wasting time or creating other difficulties in the patient's life and is clearly not in keeping with "primum non nocere."

E: Effectiveness

The final letter "E" in the four letter acronym stands for effectiveness. Not all treatments for hair loss have the same effectiveness! Some are very effective, some are mildly beneficial and others don't help at all or have the potential to worsen hair loss. Using a treatment that is highly advertised but highly ineffective takes money from the patient, delays treatment for the patient and may even allow the hair loss to progress. At present, there are very few regulations or laws to protect patents and sadly another Latin phrase often comes into effect for patents with hair loss: caveat emptor (Latin, buyer beware). The use of ineffective treatments is also not in keeping with "primum non nocere."


Treatments must be safe, affordable, feasible and effective. The four letter "S.A.F.E." acronym reminds me of these important considerations in order to practice in a manner reflecting the principles of "primum non nocere."
Article by
Vancouver Dermatologist