Box 1.

Requests for suboptimal treatment

Case A: drugs to reduce transfusion need

Jim is a 38 year old man who is scheduled to have an elective major operation. Jim is anxious about his forthcoming surgery. In particular, he is worried about the possible need for a blood transfusion. He would prefer not to be transfused even if he has significant blood loss during surgery. Jim has read that recombinant Erythropoietin and supplemental iron would reduce his chance of needing a transfusion [23]. However, Jim’s haemoglobin level is normal, and national guidance states clearly that medical practitioners should not offer Erythropoietin to patients who are not anaemic [15].

Case B: smoking cessation

Julia is a 40 year old woman who has smoked heavily for 20 years. She strongly desires to give up smoking, and has made many previous unsuccessful attempts to do so. Julia has gone to her GP to request a drug to help her give up smoking. The GP offers her a prescription for Varenicline, a nicotine partial agonist that has been shown to be effective. However, Julia has heard about a naturally derived medicine (Cytisine). She strongly prefers natural remedies, and is worried about side effects from Varenicline. Current evidence summaries acknowledge that Cytisine may be more effective than Varenicline, however, because of a lack of large trials [24] there is some uncertainty and therefore it is not recommended.

Case C: double embryo transfer

Jane and Peter are academics in their late thirties. They have been trying to conceive unsuccessfully for several years. They are requesting IVF, and have specifically asked for two embryos to be implanted. National guidelines and local policy strongly encourage single embryo transfer for women of Jane’s age because of the increased risk of multiple birth with two embryo transfer, with consequent increased maternal and fetal complications [20]. However, Jane is not concerned about the risk of multiple birth. She was a twin herself. She would like to have several children, and is concerned that if she implants only a single embryo she will have to pay for further IVF cycles (they have limited financial resources), and will need to take a longer break from her career.