Guidelines
for doctors recommend prescribing cholesterol medication for patients who show
a ten percent (or even lower) chance of developing heart disease over the next
ten years by the most recent approved measure. When I first heard about this it
struck me as odd, even absurd: another case of a hammer seeing everything as a
nail. For doctors, all of us are only varying degrees of sick, and hence in
need of treatment, since we are never perfectly healthy, right? But how could
10 percent be something to worry about? Isn’t it intuitive that something is
probable only if it's >50 percent? And 10 percent is so far below that that
it seems downright improbable.
But then I thought about it in a different way: Suppose someone handed
you a revolver with ten chambers in the cylinder and a bullet in one of them.
Would you be willing to play Russian roulette?
Or suppose you were one of ten people in a room, one of whom was to be
chosen at random to be killed (or be given a stroke, the way experimenters
induce them in lab animals). Would you feel comfortable?
I think those ways of thinking about it make ten percent appear to be
far from negligible.
Another way to enhance the impression is to imagine a room with 100
people in it. To be told that 10 of them would soon die seems significant
indeed, doesn’t it?
Or
that of a crowd of 1000 people, 100 would be killed or severely injured. Begins
to sound a lot like what just happened in Las Vegas, eh? (speaking of odds,
aptly enough).
Part of what is going on here with these Gestalt shifts of risk is that
risk consists in not just probability but probability times magnitude of the
outcome. In this case the outcome is heart attack, stroke, or death. If we were
just talking about a ten percent chance of losing 5 cents, we would say the
risk is negligible. But if the risk is losing your life (or lifestyle), then
the same probability yields a much higher risk.
So my initial impression of risk was based on a fallacious conflating of
risk with just probability, discounting the magnitude of the outcome. In other
words, I was considering only a number, a statistic, in the abstract, and not
its concrete application, in this case, to heart disease.
Of course, none of this predicts in the individual case. Also, there must be countless variables not taken into consideration. Consider also that any medication taken to ameliorate the condition brings its own bevy of risks. Finally, the drugs are hardly likely to guarantee their intended results, and may in fact be efficacious in only a small percentage of cases. (Thank you, Mitchell Silver, for that last point ... who also adds a further point: The severity of the heart disease in question needs to be specified, since in theory it could cover a range from severe to negligible.)
This is why, in the end, treatment (if any) is what is commonly called a matter of judgment ... and also preferences. So presented with the facts as stated -- let's say, 10-percent of folks like you (in some but of course not all respects) will (untreated, I presume....?) likely develop heart disease of such-and-such range of severity in the next ten years, and Medication X has been shown to avert or at least ameliorate heart disease in n percent of such cases, but also poses such-and-such risk of so-and-so side effects -- should your doctor prescribe or should you take the med? I think there's no "should" about it. The only question is: What will you do once you have reflected on the relevant facts?
Of course, none of this predicts in the individual case. Also, there must be countless variables not taken into consideration. Consider also that any medication taken to ameliorate the condition brings its own bevy of risks. Finally, the drugs are hardly likely to guarantee their intended results, and may in fact be efficacious in only a small percentage of cases. (Thank you, Mitchell Silver, for that last point ... who also adds a further point: The severity of the heart disease in question needs to be specified, since in theory it could cover a range from severe to negligible.)
This is why, in the end, treatment (if any) is what is commonly called a matter of judgment ... and also preferences. So presented with the facts as stated -- let's say, 10-percent of folks like you (in some but of course not all respects) will (untreated, I presume....?) likely develop heart disease of such-and-such range of severity in the next ten years, and Medication X has been shown to avert or at least ameliorate heart disease in n percent of such cases, but also poses such-and-such risk of so-and-so side effects -- should your doctor prescribe or should you take the med? I think there's no "should" about it. The only question is: What will you do once you have reflected on the relevant facts?
Addendum 1
Here's
another way to think about the recommendation to take a statin if there is a
ten percent chance you will develop heart disease in the next ten years.
It is telling doctors to, in effect, shove pills down the throats of ninety
percent of people fitting the profile even though they don't need it, and even
though the pills will bring risks of their own, as well as various inconvenient
and unpleasant side effects for many who take it (and not to mention
that the pills will not be effective even for all of the ten percent who
will develop heart disease if they take nothing).
The pro-pill folk can reply that there are
many situations like this, for example, insurance, where the many subsidize the
few since all are at risk but only an unknown few will actually be struck (by
disease, fire, theft, accident, lawsuit, etc.). The anti-pill folk can reply
that the "premium" in the case of statins may be too high for the
individual (or even the society) to afford or be comfortable with (given its
risks, possible incommodiousness, or cost), not to mention that the “insurance
company” will “cover your loss” in only a percentage of the cases (since the
drug is not 100 percent effective). The pro-pill folk can reply that the
relatively high likelihood (ten percent for heart disease, as opposed to
something minuscule for, say, your house burning down) justifies the (possibly)
significant “premium.”
Addendum 2
A more expansive objection to taking a statin is that the drug
is an arbitrary intervention. Given that life itself is fraught with every kind
of risk, from choking on your food to being incinerated by an asteroid, and it
just so happens (no, not “just so happens”; somebody saw the potential for
financial profit in this) that people have found a way to ameliorate this particular
one (risk of heart disease), we are now expected to avail ourselves of statins.
But carried to the extreme, every aspect of our lives could become
circumscribed by preventative measures. Indeed, this is already the case -- hence
playgrounds with
umpteen safety features and ringed by barbed wire with armed guards surrounding
them. Thus, the quality of life suffers the more we orient to the avoidance of
risk, to the point of absurdity.
But the
pro-statin contingent has an answer to this too. The above argument smacks of
an archaic conservatism: “If man were meant to fly ….” Human beings have not
lived in their “natural” state since forever. Today we live, on average, longer
than ever. It is only natural, in an extended sense, therefore, that we may
rely on artificial supplements to maintain our “unnatural” lifespan and good
health. Granted, this can be taken to extremes; but so can anything. So here as
everywhere, “All things in moderation.” It seems reasonable not to smoke, to
wear a seatbelt, to make sure you get exercise regularly, to come inside if
there is lightning, to get a flu shot, and so forth. Similarly for taking
statins. It doesn’t mean you have to hide under the covers all the time (which would
surely bring its own risks!). Judge each case on its merits.
Addendum 3.
Your move.
