Treatment of mild hypertension: On whom does the burden of proof rest?
27 August 2012
I would like to thank Drs Floyd, Clark and Ferro for their comments, however, I must clarify something that may not have been evident in the article; it was not the "authors’ conclusion" that "the analysis should lead to dramatic changes in the way doctors treat mild hypertension," as Dr Floyd states, rather it was ONE author's conclusion - that of Dr Cundiff. Indeed, as a group, they simply called for further study.
While I applaud Dr Wright, as a senior author on the paper, for not insisting on a single unified interpretation of what to do about the data, I did question him about Dr Cundiff's interpretation and all Dr Wright would say is that the data suggest the need for more study.
I think this difference of opinion about what to do in the face of uncertainty raises a fundamental question about what one promotes in the absence of positive evidence of net benefit: Does one say, "Yes, let's do it anyway even though we lack firm evidence of net benefit," or do we say, "Wait up. Let's see what's proven that we can do (e.g., Mediterranean diet, exercise, weight loss, quit smoking) until something else is proven,"?
If you are to say "Take the drug because we believe it works - even in the face of suggestive evidence that it might not work" then we might as well promote homeopathy and remote prayer in my mind. We are beginning to understand that disease creep, the expansion of treatment groups to include low- and even very low-risk individuals - is too often far better for pharmaceutical sales than for the public health.
I thank Drs Wright, Cundiff, Floyd, Clark and Ferro for bringing this question to the fore; a question I’d really like to see the medical community address: In the face of uncertainty, on whom does the burden of proof rest?
Competing interests: author of BMJ news article
independent, 19 Ridge St., Kingston, NY 12401 USA
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