If There's No Benefit, Why Tolerate Any Risk?

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We have all grown accustomed to the scare of the week.

Each week we learn about another hazard that is lurking in our environment. We learn of something we are not doing that we must do -- or else.

We must eat fish, but not all fish. Last year if you fed your child butter you were negligent; this year if you feed your child margarine you are negligent. Tomatoes are health foods, or not.

We, the healthy, are taught that life is a minefield. We, the healthy, seem to have an insatiable appetite for scares of this sort. We leap to our own defense regardless of the reliability of the scare, the validity of the remedy or the expense.

With increasing fervor, the ill amongst us are learning a corollary lesson. The vaunted American health care system can be hazardous to your health.

First we learned that hospitals were dangerous places; if evil infections don't get you, errors by the staff might. But you don't need to be hospitalized to be at risk from modern medicine. Every week we have learned that another device or another pill was a Trojan horse, waiting to unleash some horror down the road.

Today I want to consider the question that should precede an assessment of hazard. In order to weigh a hazard, one must have a handle on the benefit.

The more the benefit, the more we might countenance some hazard. Likewise, if there were no important benefits then we would tolerate absolutely no risk.

Several common medical interventions have recently come under the gun and even succumbed to the identification of a measured, important, and putatively likely hazard that has been bellowed by the media -- often perking up the ears of the plaintiff's bar.

There are important lessons regarding the assessment of benefit in these examples:

Drugs to Treat Adult Onset, Type 2 Diabetes

Avandia is one of a newer class of drugs designed to lower the blood sugar of adults whose blood sugar is higher than is said to be good for them.

As we age, our own insulin is less effective in helping our blood sugar enter our cells to provide an energy source. Some of us have this tendency earlier than others, particularly if we have a big gut-to-butt ratio and/or we're poor.

This higher blood sugar and its fellow-travelers (higher blood pressure, higher cholesterol, and lesser wealth) are associated with earlier death, but only if any or all are particularly severe.

For over 50 years medicine has recruited the pharmaceutical industry to smite each of these "risk factors" a mighty blow in order to spare us grief. Avandia is another attempt to tackle persistently elevated blood sugar.

It works. It lowers the blood sugar. Furthermore, the earlier generations of drugs designed to do this also lower the blood sugar. They work too.

However, no one feels better for a lower blood sugar. Some feel worse or get fatter depending on the drug. And no one feels worse for a high blood sugar, except for the rare patient with adult onset type 2 diabetes who can mobilize an extremely high blood sugar.

It's like "high" blood pressure.

So Avandia does nothing for the quality of your life. Does it do something else -- save your life, or postpone the horrid complications some patients can get with adult onset type 2 diabetes and its fellow travelers?

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