Consider the Natural History

What do we know of the natural history of disease? We are committed in the United States to doing something. We get paid for doing things. We get praise for doing things. We get a net increase in malpractice protection for doing something. We get credit for all recoveries when we do something, whether the patient got well because of or in spite of our intervention. As a consequence, we become less aware of the course that a disease may take if left alone.

In the population at large, nearly every new symptom, if ignored, will abate without lasting harm. When we get ourselves exercised about “access to care” in the United States, a feature of “distributive justice,” we seem to forget this natural history of commonplace symptoms. In a Medicaid system, created to reduce access barriers, the patients may come into the medical system without regard to the severity, significance, or treatability of their symptoms. The lethal is admixed with copious quantities of the trivial. Since every diagnostic pathway has an error rate, if we increase the proportion of the trivial, we can reach a point where the harm that comes to those who are treated as though their complaint is serious exceeds the benefit of treating those who do have a serious problem. The ethical problems of access are, therefore, not necessarily solved by removing all barriers.

Reasoning from empirical information, we can compare to the biblical ethical standard of good stewardship and achieve ethical advice about “access to care.” Knowing the natural history allows us to put “doing nothing,” or nothing curative, in among the choices for treatments for a patient to consider. Sometimes knowing the natural history or considering more widely what a “cause” is of a disease, allows us to put in a choice that doesn't look very “medical.”

A few years ago I treated a family that had two small boys. Both parents worked, the mother at a job that had health insurance, the father's job did not. The boys had repeated infections – diarrhea, ear aches, pharyngitis, coughs. The mother was grateful for the medical insurance, especially since one of the boys had some high expenses relating to complications from ENT surgery. Of course, the boys stayed in group day care while their parents worked. Finally, I summoned the courage to introduce the possibility – probability – that the boys were picking these things up in day care. The mother had long lamented that she would prefer to stay home with the boys, but was worried how she could manage such bills without health insurance. She quit her job. The infections subsided. Maybe coincidence. It is also possible that she was inadvertently keeping them in a situation that led to illness in order to have money to pay for the illnesses. Chasing your tail.

How is this ethics? If you have ever tried to suggest to some American parents, especially mothers, that they should consider staying home you have risked the very gates of Hell. You risk a clash of beliefs. Beliefs as to which is more important, the benefits from the second family income, or of having a parent at home. One of our major roles as physicians in medical ethics is to provide empirical information. The natural history of disease is one important piece. What is likely to happen if no treatment is provided? In various places in medicine the general answer differs, but in primary care the most likely answer is that the patient will recover rather promptly with no sequelae. Empirical information that bears on the points we are asked about is not really all that easy to come by. When it comes to our contribution in medical ethical decisions, however, it is our unique contribution: we need to know the natural history. We need to know treatment alternatives and how they compare. We need to know costs. We need to know risks of treatment. We need to know the prevalence of diseases. Knowing these things is not easy.


Excerpt from "Counseling Persons with Questions on Medical Ethics"