Intended for healthcare professionals

Rapid response to:


The idolatry of the surrogate

BMJ 2011; 343 doi: (Published 28 December 2011) Cite this as: BMJ 2011;343:d7995

Rapid Response:

Re: The idolatry of the surrogate

The existence of surrogates should not be judged as it is part of errare humanum est; we favour certainty and face value logic.

The beauty of the body lies in its complexity. Sheer physiology and pathogenesis training has made us aware of interconnected multidimensional arrangements for its continuous quest for homeostasis of PH, electrical charge, catabolic and anabolic processes, which get saturated or even oversaturated. Enzymes have a ceiling effect. There are numerous compensatory mechanisms to protect the homeostasis, i.e. in infection swelling is needed to temporary encapsulate and immobilise, the diseased body part. Edema can have an effect of diluting toxins. Sometimes, vascular overfilling is to safeguard sufficient perfusion. The body's homeostasis is also contextual, i.e. at high altitude polycythemia safeguards sufficient uptake of oxygen. Abnormal cholesterol levels are a reflection of long term dysfunctional metabolic dynamics or unhealthy eating habits and stress. In diabetes these levels can be an epithet of micro-lesions of the blood- vessels which might be irreversible. Stress has a negative effect on health. Medicine deals with above threshold pathology and is less astute on the more subtle abnormalities, illness precursors and non-medical interventions, which cure or aid in recovery at this stage.
In medicine, even with exquisite diagnostic methods, we tend to see the tip of the ice berg, i.e. the overt dysfunction, but not the underlying long term deficits and unsuccessful compensations. For all sort of reasons, i.e. biological factors, life threatening situations, risks of acute serious deterioration of illness or lack of or ownership of one’s health, symptomatic interventions are the most appropriate treatment. However, simply treating the tip of the iceberg can paradoxically remove natural internal compensatory safeguards, particularly when surrogates are at play. In other situations there can be other health repercussions, i.e. insufficient absorption of essential nutrients at long term use of antacids. For example Vitamin D deficiency can ensue, the consequent aberrant calcium metabolism can result in osteoporosis and atherosclerosis, which is further enhanced by reduced inflammatory protection of blood vessels.
In service of simplification of education and management a reductionist view is used which also influences research. This can result in a fast tracking of cause and effect interpretations1. Cognitive dissonance and invested interests, even in terms of time and money spend to master a theory can result in reluctance or even dismission of conflicting evidence. Group think does not easily allow for a dismantling of the emperor’s new clothes pseudo-evidence. All of these dilemmas are feeding ground for the idolation of surrogates. One of many simple examples is a POEM published in the BMJ, September 2004 2,3, abdominal liposuction did not reduce the metabolic concerns in patients with excessive abdominal fat and until today there is no convincing positive evidence . In research there is always an element of hidden confounders due to ‘unknown’ independent factors, which determine outcome. Outcomes which symbolise (an aspect of) health function, Number of receptors and receptor occupation can be deceitful in its true value for health. Compensatory mechanisms for receptor blocking or enhancement can induce a disconinuation syndrome of certain drugs, which can be misinterpreted as relapse. Outliers and unexpected results/outcome should be further examined or studied, even as a form of post hoc analysis.

We need to keep some degree of sKepticism of results based on monotheistic theories. For research transformational processes an open mind on possible surrogates is required and therefore an ability to embrace a certain degree of uncertainty, even if that involves some degree of ‘off the mark’ debates.
1. BMJ 2011;343:d7995
2. BMJ 2004;329:0.8
3. Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med 2004;350: 2549-57

Competing interests: No competing interests

26 January 2012
Ruth L. Brand Flu
Developmental Child Psychiatrist