We have a tendency to substitute the mechanisms we have learned for outcome data. Pharmaceutical detail people major in mechanisms.
Pharmaceutical rep.: “This new medicine – Lipid-lo – scours atheromas at their base, substituting a slick, non-stick Teflon layer while the displaced lipids are carried by the ultra low density lipoproteins to the liver, where they are recycled along with aluminum cans into bone matrix that reduces osteoporosis.”
Doctor: “If my patients take Lipid-lo, is there evidence that their all-cause mortality or morbidity will fall?”
Pharmaceutical rep.: “This study in Stockholm last year, where they've used Lipid-lo for 1000 years, shows that middle-aged men had 22% fewer cardiac events than a control group that did not take the drug.”
Doctor: “I said all-cause. Did the Lipid-lo group have more hepatitis, or cataracts, or renal stones, or such?”
Pharmaceutical rep.: “I have another study here from Ohio in which the cardiac output during acute M.I.'s fell 33% less in the treated group than in the untreated group.”
Doctor: “Wonderful! But, did the treated group on the whole live better or live longer than the untreated group?”
Pharmaceutical rep: “It comes in convenient dose form shaped like a pretzel. See, you can break it in several points to get the right dose without having to switch to a new prescription.”
It's as if we were talking past each other. Mechanism is offered in place of evidence of outcome. Mechanisms are wonderful mnemonic devices, but things that stand to reason do not always stand to evidence.
What has this to do with making ethical decisions? When communicating with our patients, adding our unique input, we should as often as possible speak in terms of net outcome as based upon evidence. In medicine we are prone to focus on numerators.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
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