Anthony Daniels: Ibuprofen or aspirin? Don't expect your doctor to know

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The Independent Online

People naturally assume that any medicine they buy over the counter must be safe. In this context, safe means absolutely safe, beyond any possibility of doing harm.

Unfortunately, no such substance is known to man: as the old saying goes, "everything is a poison when taken in sufficient quantity". Moreover, everything (if you look hard enough) will be found to cause some harm even in lesser quantities.

The discovery that the consumption of ibuprofen, one of the most common over-the-counter painkillers, is associated with an increased risk of heart attack, has come as a very nasty surprise to many sufferers from arthritic and other pains who had previously assumed that it was safe, except perhaps for those few who had idiosyncratic reactions.

Now they don't know what to do: whether to suffer in silence, take some other drug (only to learn at a later date, perhaps, that it is similarly unsafe) or risk a heart attack for the sake of a little relief.

Of course, a statistical correlation is not proof of causation, but this is unlikely to be of much consolation to people who want to know whether they should continue to take the drug or not. A large association of sufferers from arthritis have asked that the medical profession should urgently provide firm guidance on the matter.

Personally, I think this is quite reasonable. After all, that is what doctors are for.

On the few occasions in my life when I have been seriously ill, I have wanted the doctor to decide what to do and then to do it, without any intellectual input from me (a doctor). The last thing I wanted was to hear a disquisition on the various possible courses of action the doctor could take, with all their possible disadvantages, and then to have to make up my mind as to which I thought was best, or least bad.

However, this attitude is rather against the temper of the times: it smacks of a return to paternalism. What we want is information, more and more of it, to help us decide what is best for us.

Orthopaedic surgeons tell me that they now see far fewer patients in their clinics, because they have to explain so much to each of them: the risks, the failure rates, the side effects, the possible benefits, and so forth, down to the nth degree. Not only are many patients kept waiting even longer, but those lucky enough to reach the surgeon are bemused by the range of choices open to them.

They thought they were going to the expert to be told what was right for them, and find themselves having to decide for themselves. The problem is that there are many questions in medicine that are without a definitive or indubitably correct answer. Is it worth running a small relative risk of a major side effect to obtain relief from a non-life-threatening condition? (The absolute risk, which is rarely included in health scare stories, is much more important, from the point of view of the individual, than the relative risk, because the doubling or tripling of a tiny risk means that the risk remains tiny and insignificant.)

Perfectly sensible people may give different answers to precisely the same question, according to their own scale of values. Unfortunately, people don't like living with this kind of uncertainty. For them, intellectual honesty has its limits as a virtue. They (or perhaps I should say we, because we are most of us the same in this respect) prefer living with a sense of certainty, at least about our illnesses, even if this certainty is not well-founded.

We want the doctor to act as if he were certain, even if he is not certain. And this desire is not completely without rational justification, because faith in the doctor has a healing quality. It is hard to put one's faith in a man who presents us with a series of insoluble dilemmas.

Not long ago, I had a patient with somewhat raised blood pressure. I conscientiously told him that there was a small statistical chance that treatment would do him a lot of good, but a large statistical chance that it would do him no good. Did he want treatment or not?

He looked at me as if I were mad. He hadn't come to the doctor for this, but to be told what to do. I don't think he had ever thought of medical treatment as a kind of game of roulette: for him, treatment either worked in every case or it didn't.

"I don't know," he said. "You're the doctor. Do what you think is best."

What he meant was, be a paternalist. To have refused his request would have been - well, paternalistic.

Anthony Daniels is a prison doctor

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