BMJ  2004;329:E318 (11 September), doi:10.1136/bmj.329.7466.E318

BMJ USA: Editor's choice

Editor's choice

In harm's way

In 1859, Florence Nightingale echoed Hippocrates when she wrote that "the very first requirement in a hospital is that it should do the sick no harm." It is a laudable but probably unachievable goal. Perhaps the best we can aim for is a favorable balance between benefits and harms, but that assumes we can measure each of them. As we learn from a number of articles in this issue, balancing benefits and harms is often a complicated business.

In order to compare benefits and harms we must have evidence about both. Tom Dent and colleagues point out that in contrast to drugs, new interventional procedures—surgery, angioplasty, and the like—usually have had little assessment of their safety and efficacy (p 437). Even when studies have described adverse effects, as they have for drugs, Yoon Loke reminds us (p 441) that what we need is quantifiable information, not a list of 54 possible side effects. Loke also presents a helpful table of bedside scenarios in which an attempt should be made to explicitly assess a drug's benefits and harms.

One area of benefit-harm analysis that is necessary today is assessing the likelihood of drug interactions with the increasingly large number of herbal remedies being taken by Americans. Edward Mills and others systematically reviewed the literature on drug interactions with St John's wort (p 450). Although the methodology of some of the research studies was weak, they concluded that patients and doctors should be aware of the high likelihood that St John's wort will decrease the bioavailability of conventional drugs taken concurrently.

Benefits and harms are not just weighed at the clinical level, of course. They also need to be balanced when governmental and public health decisions are made. Oakley and Johnston (p 485) assert that sometimes good evidence is not enough to tip the balance, citing the continuing absence of folic acid food fortification in England despite its clearly documented effectiveness. In a commentary, Nicholas Wald (p 488) calls public health decisions like these "silent prevention" and criticizes those who oppose them in the name of freedom of choice. He says that it is the job of public health and government officials to make choices in the best interest of all after weighing the benefits and harms.

One problem for which the benefits and harms are well understood is tobacco use. The latest data from the now 50 year long study of British doctors' smoking and death rates (pp 443, 454) convincingly show that the risks of persistent smoking are, if anything, larger than previously thought—and the benefits of quitting are clear at any age.

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