The end of clinical freedom

Abstract

Clinical freedom is dead, and no one need regret its passing. Clinical freedom was the right – some seemed to believe the divine right – of doctors to do whatever in their opinion was best for their patients. In the days when investigation was non-existent and treatment as harmless as it was ineffective the doctor’s opinion was all that there was, but now opinion is not good enough. If we do not have the resources to do all that is technically possible then medical care must be limited to what is of proved value, and the medical profession will have to set opinion aside. ‘‘The active management of myocardial infarction’’ makes a good example, though similar topics could doubtless be found in any medical specialty. In theory restoring the blood supply to heart muscle after occlusion of a coronary artery is a highly desirable aim, and there are several ways in which this might be achieved. In practice what we need to know is whether any of the possible treatments saves life or reduces morbidity. Just because one centre has performed coronary artery bypass operations on a small number of highly selected patients with acute infarction and has achieved the remarkably low hospital mortality of 3.8% does not mean that everyone else should attempt to do the same. Those who claim that such results are possible should conduct a randomised trial to compare early operation with conservative management, and until this has been done healthy scepticism is the appropriate attitude. The intracoronary administration of streptokinase undoubtedly lyses coronary artery thrombi, but the evidence is conflicting on whether this improves myocardial function, and there is no evidence at all that it prolongs life. Until good clinical trials have been published intracoronary streptokinase should remain only a research technique, for it is expensive and in inexperienced hands it may be dangerous. More important, with our present limited resources treating even a few patients in this way must prevent the routine investigation of other patients, from whom real benefit may be withheld – for example, those with valve disease who may need surgery or those with symptomatic coronary artery disease. One man’s provision is another man’s deprivation, and if extra facilities for cardiac investigation are to be provided so that many patients with suspected infarction can be studied acutely this will have to be at the expense of some other medical specialty such as geriatrics or orthopaedics. It may be that increasing cardiological rather than geriatric facilities is the right thing to do – but it cannot be justified without the appropriate clinical trials being carried out first. According to the recent leading article in the BMJ, we should ‘‘contemplate acute coronary angiography in some patients with suspected infarction,’’ but this is precisely the sort of clinical freedom that is no longer possible or permissible. What is needed is a large multicentre trial in which a randomly selected group of patients with suspected infarction is submitted to coronary angiography and the outcome compared with that of a control group managed in the traditional, conservative manner. Until this has been done – and until it has been shown convincingly that early angiography does substantially more good than harm – no resources should be allocated nationally or appropriated locally by creating developments for such treatment. The medical profession has always preferred to travel hopefully rather than to arrive, because arrival is often so disappointing. This habit leads to oscillating fashions, and fashion in treatment is something that we neither can nor should afford. The use of anticoagulants for the secondary prevention of myocardial infarction was largely abandoned in Britain, not because the evidence in their favour was poor (which indeed it was) but because the reduction in mortality of about 20% that anticoagulants seemed to confer was thought not to be worth the trouble. The anticoagulant fashion was followed by the antiarrhythmic fashion, but the routine use of prophylactic antiarrhythmic drugs after myocardial infarction has now mainly been given up in Britain after trials showing that these drugs do as much harm as good. Would it not have been preferable for the trials to have preceded the fashion and not vice versa? The problem, of course, is that doctors expect too much of their remedies. Although the value of prophylactic treatment of infarct survivors with a beta blocker has Hampton JR. The end of clinical freedom. Lancet 1983; 287 pp1237-8. Reprinted with permission. Published by Oxford University Press on behalf of the International Epidemiological Association