Balancing benefits and harms in health care

Editor—The interesting selection of papers in the BMJ on balancing harms and benefits in clinical medicine and public health all seem to make a questionable assumption. While all speak of “balancing” harms and benefits, in the arguments presented the authors assume that a purely rational judgment can be made about whether or not the true harms outweigh the true benefits.

For instance, Dieppe et al point to a dearth of evidence which causes us to mis-estimate the true magnitudes.¹ Greenhalgh et al point to the variety of cognitive biases which “prevent” people from making rational judgments.² Oakley and Johnston, with Wald, can barely conceal their annoyance at the irrational public and the devious industrial interests that try to delude them.³

Yet in at least some cases differences in “balancing” come about because of differences between people about what is important to them, rather than differences in estimation of probabilities and errors of logic.⁴

Some utilitarians think that everything can be reduced to a rational calculus of pleasures or pains; most of the rest of us do not. Hard choices about withdrawing drugs or licensing genetically modified crops are not hard because we are ignorant, or irrational (although we often are). They are hard because they represent conflicts of value. Failing to take account of this is the classic mistake of bureaucratic attempts at social reform from above.

A whole issue on balancing harms and benefits, without thought of the ethical dimension? An opportunity missed.