A few months back, we admitted a patient we’ll call Mr. Jones to the hospital for a severe gastrointestinal bleed. We had discharged him two weeks earlier after he had come in with a heart attack and made sure he was on aspirin to prevent future cardiac events. He dutifully took his aspirin and on the day of the readmission, had a massive bleed. He made it to the hospital barely alive and an endoscopy in the ICU showed an active bleeding gastric ulcer. For Mr. Jones, the gastrointestinal bleed, likely brought on by the aspirin, was an “unintended consequence” that almost killed him. Yet no one questioned whether we should have given him aspirin in the first place. I felt terrible about what had happened but found solace in knowing that while for some patients the risks of aspirin are worse than the benefits, for the general population of people like Mr. Jones, the benefits are clearly worth the side-effects.
We do risk-benefit analyses every day in clinical care, knowing that for some patients, the benefits will be outweighed by the harm. We try to be thoughtful about who might be hurt or not, but most of the time, we just can’t predict. So, when the benefits appear to outweigh the risks, we move forward and try to learn from cases like Mr. Jones.
While this kind of risk-benefit analysis is common in clinical practice, it’s unfortunately not how we discuss health policy interventions. No policy intervention is ever without risks, and it is rare that a new policy will have no side-effects at all. Yet, every time policymakers put in a new initiative, they sell it as a panacea. Critics, upon finding an unintended consequence, then declare the whole thing a failure.
An excellent example of this is health information technology, a topic that I have blogged about in the past. Proponents only talk about its benefits, allowing critics to highlight every shortcoming and failure. Thank goodness I don’t have to deal with proponents and critics like that every time I consider prescribing aspirin to my patients.