'When Treatment Doesn't Work as Intended'
CAERS SUBSTACK ARTICLE #15
‘WHEN TREATMENT DOESN’T WORK AS INTENDED’
CAERS SUBSTACK ARTICLE #15
Given the emotional and visceral challenges of working in the health care disciplines, I suspect that most people who enter into them are motivated primarily to help others beyond just wanting a ‘job’ or a ‘career’. And most of us in health care would like to think that we generally succeed in improving the health and lives of those we serve. In fact, the medical profession addresses this directly with the dictum ‘primum non nocere’—above all do no harm.
But how realistic is that dictum given the complexity of the human body and the limits of what medical science can know or do at any given time? Add to this the fact that any intervention we undertake involves a complex interaction between our treatment and a specific individual, and there are more than seven billion of us unique creatures on the planet. It has often struck me that any attempt to medically intervene to produce benefit is fraught with the risk that we could harm unintentionally.
And, unfortunately, no matter how hard we work, no matter how much we want to help, we do end up doing harm more often than we would like, or like to admit. We try to minimize this, of course, but as imperfect humans we cannot reduce this to zero. As is so often the case in a world we do not and cannot fully understand, we accept that prudent action is often superior to fearful paralysis, especially when someone is suffering.
This means that all medical interventions can and do produce unintended consequences. We use the term ‘side effects’ to describe such events. Interestingly, side effects need not necessarily be bad just because they are unintended; beauty is in the eye of the beholder, so to speak. A pill intended to lower blood pressure that incidentally promotes hair growth might be welcomed by those who are ‘follicle-challenged’! An antidepressant that causes delayed ejaculation might be just the right one to give a man with premature ejaculation.
However, when the side effect produced is bothersome or harmful to the person taking it, we refer to that side effect as being an ‘adverse event’. If it is mild and tolerable it may be worth enduring if the condition being treated is serious and the medical intervention is sufficiently effective in alleviating that condition. But the more serious the adverse event and the more trivial the condition being treated, the more likely people are to discontinue that therapy.
Some potential side effects of a therapy can be known ahead of time, but by no means all of them. And just as everyone is not equally helped by a given therapy, not everyone is equally harmed by a given therapy either. In truth, we often cannot predict who will have a side effect and who will not. Even more unsettling is the fact that we do not know which side effect any particular individual will suffer. Part of that relates to the troubling reality that we often do not fully understand why a treatment produces the side effects it does: why does one person get diarrhea, another gets headaches and yet another gets a rash?
People don’t always realize that biological systems are not just complicated, they are complex. A mechanical system, like a watch, can be complicated because it has many parts that interact in a very specific and integrated fashion. But the parts of the watch stay the same, they are static. Biological systems, however, are complex because not only do their parts interact with each other, but the parts themselves are always changing and in doing so they change one another, in a continuous and dynamic fashion. The dirty dishwater that travels through the PVC piping of my kitchen sink to the local water treatment plant is not changed by the piping, nor does it change the piping, because neither are alive. But our blood is full of living cells that are travelling though pipes like arteries and veins that are also composed of living cells, and all of these cells interact dynamically with one other in a far more profound way than dishwater and drain pipes ever can. That’s why we get blood clots that cause heart attacks and strokes, for example. It also explains why medical interventions have side effects, good and bad, and why they are difficult to understand and even more difficult to predict, let alone prevent.
Because the universe and the biological systems in it are highly complex, there are always risks when we try to manipulate them for our benefit. This reality need not paralyze us from engaging in medical interventions. But it should humble us enough that we proceed cautiously when trying to intervene with our therapies in order to help others. Have the authorities been sufficiently humble and cautious with all of the measures instituted during the pandemic? Were risk and harms acknowledged and explained in a transparent fashion? In a democratic society, these are important questions that demand serious answers.
J. Barry Engelhardt MD (retired) MHSc (bioethics)
CAERS Health Intake Facilitator
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