Folic acid supplementation and the complexities of blame

In 1999 we published a letter by Nicholas Wald and others that estimated that 45% of pregnant women had taken folic acid supplements “immediately before becoming pregnant” (doi:10.1136/bmj.319.7223.1499).1 A Medical Research Council study from 1991 had shown a “lower risk of pregnancy affected by neural tube defects” with periconceptional supplements. But the authors were concerned that the message wasn’t getting through. They argued for a population approach by fortifying flour with folic acid. Replies to Wald’s letter made it clear that the challenge was a global one. Indeed, Canada fortified flour in 1998. It took 23 years for the UK to follow suit in September 2021.

In December 2021 Philip Mitchell, a general practitioner, was found guilty of negligence for periconceptional advice he gave 20 years earlier. The case of “wrongful conception” was brought by Evie Toombes, a showjumper born with spina bifida, on behalf of her mother. Andrew Papanikitas and colleagues explore the many complex issues that arise from this ruling (doi:10.1136/bmj.o79),2 one that has been met with sympathy for both Toombes and Mitchell. It has raised fears among clinicians about retrospective action over past advice and that the level of clinical note keeping required by a judge is unrealistic in a time pressured service. It also raises the question of who is ultimately responsible.

Interventions tend to be more successful at a population level than at the individual level, which is exactly what Wald and colleagues were arguing in 1999. Had ministers followed their advice then, and not waited until 2021, how many births with neural tube defects might have been avoided? Are they negligent too, for not applying the evidence?

What’s clear is that health is complex, and evidence is easy to misjudge or interpret in different ways. Financial incentives can “nudge” people to make certain decisions, such as taking up breast cancer screening. But the evidence for the benefits of breast cancer screening is disputed, and money would be better spent on promoting informed choice on the balance of benefits and harms (doi:10.1136/bmj-2021-065726).3 Is overpromoting an intervention, for instance, a form of negligence?

What if you wrongly advise millions of people, on national television, about the efficacy of vaccines (https://www.sciencemediacentre.org/expert-reaction-to-a-doctor-challenging-the-health-secretary-sajid-javid-on-compulsory-vaccination-at-kings-college-hospital)?4 Or fail to stay up to date with the latest research on vaccines and myocarditis (doi:10.1136/bmj-2021-068665)?5 Perhaps you need an update on management of chronic anal fissures (doi:10.1136/bmj-2021-066834) and extreme preterm birth (doi:10.1136/bmj-2021-055924)?67 How about the company executives refusing scrutiny of their trial data while profiting by the billion (doi:10.1136/bmj.o102)?8 Or the editors, journalists, and politicians unwilling to cover the growing concern about China’s human rights abuses (doi:10.1136/bmj.o44)?9 What of Facebook’s responsibility in trying to censor legitimate concerns about the conduct of clinical trials (doi:10.1136/bmj.o95)?10

This is before we start asking about the people turning a blind eye to the crises in social care and the NHS (doi:10.1136/bmj.o107; doi:10.1136/bmj.o103; doi:10.1136/bmj.o125; doi:10.1136/bmj.o118; doi:10.1136/bmj.o99) and the impact of covid on other illnesses and death (doi:10.1136/bmj.o100).111213141516 In each and every one of these instances somebody is making decisions that could be suboptimal or placing people at risk; somebody may be found “responsible” in a court of law. That’s why, if the goal is better decisions, we need better evidence and better systems and processes to support individual decision making.