Be bold and be sensibleBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7414.0-g (Published 04 September 2003) Cite this as: BMJ 2003;327:0-g
- Richard Smith, editor ()
“Fortune assists the bold,” wrote Virgil, thinking of the Trojan wars not of medicine. But there is room for boldness in medicine, and I see examples in this BMJ.
The Global Initiative on Chronic Obstructive Lung Disease—a pretentiously named outfit that must have slavered over its acronym GOLD and which is backed by the National Institutes of Health and the World Health Organization—warns against using opioids in managing patients with dyspnoea and chronic obstructive pulmonary disease (p 523). We all know that opioids are respiratory depressants and that such patients have almost no respiratory reserve. Yet some experienced doctors believe that morphine can help patients with refractory dyspnoea. A bold group from Australia has now conducted an adequately powered crossover trial of oral morphine against placebo in patients with refractory dyspnoea in whom the underlying aetiology is maximally treated (p 523). The morphine produced important improvements. The authors think that the results are generalisable to primary, respiratory, and palliative care settings but warn that a bigger study is needed to evaluate safety.
Louis Lasagna, the man who “created clinical pharmacology,” was clearly bold. His obituary describes how 50 years ago he injected saline subcutaneously into surgical patients with steady, severe wound pain and found that roughly a third reported satisfactory relief of pain (p 565). It was essential, he argued, to consider the placebo response in clinical trials.
England's National Institute of Clinical Excellence (NICE) seems to be getting bolder, perhaps because its chairman, Mike Rawlins, is also getting bolder. For years he was chairman of the Committee on Safety of Medicines, but at a recent meeting he was dismissive of what he described as its traditional method of a lot of old boys sitting round a table and issuing instructions. It's too paternalistic. A better method might be to give people clear information and let them make up their own minds.
NICE has now decided that in vitro fertilisation works and should be available on the National Health Service (p 511). We didn't need NICE to tell us that in vitro fertilisation works, but the idea that it should be available to all subfertile couples is bold. Most such couples have had to go to the private sector to get treatment. The cost of treating all couples would be hundreds of millions of pounds each year, meaning that treatments for other patients would have to be denied.
Unfortunately it's not NICE's job to tell the NHS what should be ditched to free up the millions needed, but it does offer some guidance on treatments that shouldn't be used—strictly on the evidence. Thus it last week advised against the use of thiazolidinediones (glitazones) in patients with type 2 diabetes except in narrow circumstances (p 520). Diabetes UK immediately leapt in and condemned the advice as “rationing.” NICE should be bold enough never to fear “the r word” that politicians don't dare to speak.
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