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A case in point…the tension between harms and goods:A 45 year old man, healthy, vigorous, a marathon runner, had done his knee in. Too much running. And he went to an orthopedist and arthroscopic surgery was recommended, which is a fairly minor procedure these days. The ratio of risks to benefits seemed acceptable. So, he had arthroscopic surgery, went home, and three days later an embolism traveled from his knee, lodged in his lung, and then traveled through his heart, through a sepal defect and finally lodged in his brain. He was brought into the hospital having had this massive stroke, hemiplegic, unable to move the one side of his body, unable to speak. Now there's a new drug which was developed initially for dissolving clots in the heart called TPA and they have found, at least in American studies, that if TPA is used within three hours on the onset of symptoms for a stroke caused by a clot, not by a bleed, then it can virtually reverse all symptoms of the stroke in the vast majority of patients. Again a favorable ratio of benefits to risks. However, in some small minority of patients, it actually produces a cerebral bleed, so you have a worse stroke. The European data suggests that if it's done within six hours of the onset of symptoms, it can have this effect. So here's an example of how the "facts" differ between groups of investigators. This guy came to the emergency room and more than three hours after the onset of the symptoms of the stroke, the clot, they gave him TPA and the worst outcome ensued. A "double whammy." He had a massive bleed that left him completely paralyzed, unable to speak, and in an intensive care unit. And it was at that point that his wife called me--and this is where the matter of values comes in--because she said that he made it very clear that he would not have wanted this kind of life, a life of profound disability, confined to a wheelchair, this kind of thing. She wanted the aggressive life sustaining treatments withdrawn. And acting on the basis of her statement of his values, what he valued, that's what happened. So here's this guy who had simple knee surgery and two weeks later was dead. A tragic example of the tension between harms and benefits, and of uncertainty in medicine. continued...
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