Balancing benefits and harms in health care: Summary of webchatBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7463.458-b (Published 19 August 2004) Cite this as: BMJ 2004;329:458
A webchat on the benefits and harms issue took place on 8 July 2004.1 The editors of the theme issue began by raising several topics for discussion.
Should complementary and alternative medicine have featured as much as other aspects? Would their recognition improve evidence about their benefits and harms?
How will the European Trials Directive affect trials focusing on the safety of treatments?
Has anyone tried to report adverse effects in a developing country?
What is the role of consumers (patients) in determining an acceptable ratio of benefit to harm?
Should vulnerable populations in whom drugs are not licensed such as pregnant women, children, and elderly people be considered?
The topic that dominated the webchat for most of its duration and informed whatever other ideas were raised was, however, government intervention in health care, exemplified by fortification of bread with folic acid and perhaps also vitamin B12. Participants expressed surprise that something that had been proved to be beneficial in the United States and Canada had not been implemented internationally.
The press had not taken this topic up as much as might be expected, and several participants suspected that people generally found it difficult to make up their own minds, believing what their families or the media told them. Public health interventions would be difficult to implement as a trial first because of ethical considerations. Also, when something has already been proved to be beneficial, why should a trial be necessary? The absence of knowledge of possible long term consequences to the public must be communicated.
Comparisons were made with the much debated fluoridation of drinking water, which has been rejected so far, and the legal requirement to wear seatbelts in cars and crash helmets on motorcycles, which the public seems to have adopted, although wearing a seatbelt might lead to more dangerous driving from a false sense of greater security and confidence. Seatbelts may have become widely accepted because wearing them entails an element of choice that fortifying bread with folate does not. Folate comes as a pill and is regarded as a drug, which may prejudice people. The iodisation of salt has, however, been widely accepted internationally.
Communication is key
Fashions in policy making mean that the data that inform policy vary. Academic bias may influence recommendations for or against government intervention programmes. People might not object if they knew something is being done for a good reason (salt, for example). The fact that they may just not recognise a public health measure as good might point towards a communications problem.
Maybe people who are more educated and better informed sometimes have to make decisions on behalf of those who are less well educated and informed. But the public needs to be convinced that medical professionals will do what is best, and the medical profession must do what is right but remain in a clear advisory role.
Patients should perhaps be part of research as the overlap between research outcomes and outcomes of public interest may not be complete. Communication channels are also missing for feeding research findings into policy making. A directory of good journalists to whom doctors could confidently speak when they want to make something public might be a solution.
At the danger of repeating the same message over and over again, clear communication is important. Communication may also need to be education, rather than just information, to raise a well informed generation that participates in public debate.
Competing interests None declared.