Against reductionismBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3855 (Published 22 September 2009) Cite this as: BMJ 2009;339:b3855
All rapid responses
Susan Levenstein wrote, "Both positions in the head to head, "Does
Helicobacter pylori really cause duodenal ulcers", reflect a
pathophysiological reductionism that should long since have become
obsolete.[..]..Instead of simply assigning one "cause" at a time our
thinking will expand to encompass the more complex--and much more
interesting--interactions of multiple factors that come into play in the
development of most medical conditions".
This, I submit, is a primary cause for polypharmacy, drug related
morbidity and mortality, and rising vosts of care certainly in the US.
If, as I have proposed, an energy deficit is the cause of most if not all
morbidity and mortality then diagnosis and management depend firstly upon
identifying the degree and duration of this abnormality and then
identifying the causes be they, in the case of dudoenal ulceration, H
pylori, hypersecretion of acid, smoking, chronic gastroduodenal ischaemia,
or a chronic systemic energy deficit. Consider the implications in the
resuscitation from shock (1).
In this consensus paper we recommended additional goals, to
supplement the tradionaly goals AB and C: "D" for increasing the delivery
of oxygen to levels that meet the metabolic demand by all tissues in the
body, especially those tissues within the splanchnic circulation, and "E"
for ensuring extraction and utilization of oxygen by the tissues. Future
needs for goals that address reperfusion injury, translocation of
bacterial toxins, and their release of cytokines.
Whilst these additional goals need to be refined to address nutrient
needs, which appear to me to be far more important than oxygen needs, the
paper makes it very clear that reperfusion injury, translocation of
bacterial toxins, and the release of cytokines are all secondary and even
tertiary events. This potential for "market segmentation" provided by
these secondary and tertiary events is a businessman's dream. Conversely
the prospect that goals D and E might devalue these potential market
segments and, horror of all horrors, canabalize existing products is
his/her worst nightmare.
Of course "the more complex..interactions of multiple factors that
come into play in the development of most medical conditions" making
diagnosis and treatment "more interesting" but reductionism needs to be
complete if it is to avoid the creation of unnecessary and costly new
market segments and sustain the use of costly and profitable existing
1. FIDDIAN-GREEN, RICHARD G MD, FACS; HAGLUND, ULF MD, PHD;
GUTIERREZ, GUILLERMO MD; SHOEMAKER, WILLIAM C. MD, FCCM. Goals for the
resuscitation of shock. Crit Care Med 1993; 21:S25-S31
Patents issued in my name.
Competing interests: No competing interests