What Is the Best Way to Treat Diabetes?
You might think, as the writer of the editorial evidently thinks, that the matter is now settled once and for all: surgery is best. But I noticed something implicit in the figures to which the authors did not fully draw attention. Patients who underwent surgery were twice as likely to have strokes as people who had angioplasty, and furthermore the strokes that they had were twice as likely to be incapacitating as those suffered by the angioplasty group. If my arithmetic serves me (which it may not), there were about 10 more patients in the surgery group with incapacitating strokes than in the angioplasty group. On the other hand, about 50 lives would have been saved by the surgery by comparison with angioplasty.
How does one compare the worth of five lives saved at the cost of one incapacitating stroke? To make an informed decision, a patient must know both the absolute and relative risks of good and bad outcomes of the procedure to which he is giving consent, and to make that decision at a time when he is probably not feeling at his best. Even the doctor advising him may not have all the evidence at his fingertips, or understand its meaning: such a thing has been known. Besides, according to the new medical ethics, the doctor is no longer an adviser, which is paternalist and therefore bad: he simply lays the scientific evidence before the patient in as neutral and objective a fashion as possible, and lets the patient decide. Perhaps diabetic patients with ischaemic heart disease will have to be given a copy of this paper. I wish them luck.
There is one more question to which the paper does not address itself, but is not without a certain importance. Many or most of the patients treated were approaching the age when their cognitive reserve had shrunk. Surgery is often associated with an irreversible decline in cognitive functioning, sometimes a very marked one. If, then, there were a difference in outcome between the procedures from the point of view of the patient’s cognitive capacity afterwards, it would be important for him to know it: that is, if Man is a rational animal and mere survival not his highest good.
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