Tuesday, 11 November 2008

High Cholesterol : Fact or Fiction Pt 11

Cary G Dean.

A Question of Ethics

Is it ethical to impose a regime on people in the hope that heart disease will be reduced?

Surely prevention is better than cure, you may say.

But is it?

Such an attitude ignores the real possibility that such intervention may do more harm than good.

'Preventative' medicine as practised in the case of heart disease, takes two forms.

Firstly we are to change our lifestyles, and secondly we are screened by our doctors on an opportunity basis.

But this screening is not prevention of the disease, it is merely the early detection of it.

For such procedures to be of use a number of criteria are well established.

One important one is that the disease should be both common and serious, as screening for an uncommon disease will throw up many false results.

These will inevitably incur the cost of further testing, and cause unnecessary anxiety which itself is harmful.

The first problem with screening in CHD, is deciding what to test for.

As a predictor of coronary risk, total blood cholesterol turns out to be irrelevant, and merely testing for that is regarded by many experts as misguided.

Far more reliable, they claim, is measurement of HDL (the 'good' cholesterol).

However, in a test of the accuracy of checking for HDL at various laboratories, values differed by as much as 40% in 95% of the samples tested.

In another study, 16 instruments manufactured by nine companies were tested in 44 laboratories.

In this test, although the inaccuracies of the machines were lower at 3.6-4.4%, biases attributed to the methods used ranged from -6.8% to +25%.

The accuracy of desktop machines is even more suspect.

A third study to evaluate the ability of cholesterol screening to detect individuals with blood cholesterol abnormalities concluded that 41% of those with abnormal levels would not be detected using present guidelines.

Another criterion is that an effective treatment for the disease is available, as there is little point in early diagnosis or detection of a disease for which there is no effective remedy.

Some will say that we do know the cause of coronary heart disease; it is high cholesterol, or too much fat in our diets, or not enough exercise.

Or it could be something else.

In 1981, two hundred and forty six 'risk factors' for heart disease were listed.

That number is now well over three hundred.

These so called risk factors include having English as a mother tongue, having a diagonal crease in the left earlobe, not taking siestas, not eating mackerel, snoring and wearing tight underpants.

What a list of this size really tells us is that we have little idea what causes coronary heart disease.

And it is certain that if all the 300 plus do play a part, we have no chance of defeating the disease.

A director of the Health Education Programme of the American Medical Association denounced the lifestyle changes with their false promise of benefit as a quasi- religious crusade when in 1984 he wrote:

" Constant lifestyle self-scrutiny in search of risk factors, denial of pleasure, rejection of the old evil lifestyle and embracing a rigorous new one are followed by periodical affirmations of faith at revival meetings. . . the self-righteous intolerance of some wellness zealots borders on health fascism".

"Historically, humans have been at greatest risk while being improved in the best image of their possibilities as seen by somebody else."

Telling people who feel fit and well that they are not and, that if they do not make major changes to their lives, they could drop dead at any moment, not only worries them unnecessarily, it can have a profound effect on their attitudes to life.

The benefits of mass screening are doubtful and the risk of harm is high.

Such intervention, therefore, can only be justified ethically when either the patient has requested it or symptoms are such as to make it desirable.

If we go to our doctor with a complaint and he treats us with the best medical knowledge, he should not be held responsible for defects in that knowledge.

If, however, the doctor initiates treatment without being consulted by the patient, then he is in a very different situation.

Cochrane and Holland write that before advocating a course of action in such circumstances.

" He should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened."

If he does not, he may be held responsible for any harm done.

But in the case of heart disease, recognised medical standard tests and ethics have been thrown out the window.

The recommendations were forced on the public even before they had been tested, and now the perpetrators are afraid to admit that they could have been wrong.

But until they do, whole populations are suffering unnecessarily.

In the United States blood cholesterol level testing for all is routine and that nation is becoming a nation of 'cholesterophobics'.

More concerned with death than with life, many interviewed said that their lives were ruined as, if they had a treat, it was accompanied by feelings of guilt.

One of COMA's principles is that the measures should.

"Afford a reasonable prospect of improvement in life expectancy overall, and in the quality of life for the population as a whole."

Experience around the world, and particularly from the United States, makes it certain that neither of those principles will be met.

In Britain, general practitioners, practice nurses and health visitors are starting to use desk-top cholesterol testing machines, the majority of which have been loaned by drug companies.

A suggestion in the Lancet is that this is designed merely to enhance the drug companies' profits by increasing sales of cholesterol-lowering drugs, and questions their ethics.

There is also the question of the psychological harm that could be done to people in view of the experience of the inaccuracy of such machines.

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