Are you sure – the importance of ‘‘reasonable doubts’’

One of my patients always finishes our

consultation by leaning forward and

asking me about my advice – ‘‘are you

sure?’’ I first responded by saying ‘‘No –

I’m making it up.’’ I have known him

and his wife for a long time and we can

banter and laugh at each other so we

have developed a repartee which we

play out at each consultation. The

problem of course is that I am not

always sure and it worries me. This

introduces the concept of ‘‘reasonable

doubts’’ and whether it is a burden or

strength.

Unfortunately too many people do

not appear to experience reasonable

doubts. A lot of the problem stems

from observational studies in medicine

where belief is an accepted mandate for

management without the proof of

properly constructed randomised trials.

Hormone replacement therapy as a

form of cardioprotection and vitamins

have been advocated as being beneficial

but sadly the painful proof, long in

coming, identified no advantages.1,2

Many were advised without reasonable

doubts and without a clear statement of

lack of harm – no one was sure but

many thought they were.

In contrast calcium antagonists were

promoted as being harmful.3 There was

no controlled evidence to support the

claims but belief overcame doubt and

the damage was comprehensive and

certainly driven by forces other than

patient care. It might be charitable to

excuse the sequence of events as a lack

of reasonable doubt but I fear there

were darker forces at work.4 I was

never sure of the data and its presenta-

tion and said so in this journal. We

now know our doubts were valid and

our position in contrast to the Lancets

was in the best interest of the patients.5

Journals have a duty to try to offer

honest balance and express their

opinion based on fact. Above all else

all editors should possess reasonable

doubts and promote the ‘‘are you

sure?’’ philosophy before adopting

extreme positions. The British Medical

Journal adopted a similar extreme and

unsupported position regarding female

sexual dysfunction.6

Atenolol was recently questioned in

the Lancet regarding its role in the

treatment of hypertension.7 There was

no balanced editorial link in contrast to

the totally unbalanced link to the calcium

antagonist ACTION trial which

perpetuated biased belief in the absence

of proof.8,9 Editorial failures like this

suggest an absence of reasonable doubt

at the highest level – where it is most

needed.

When we feel sure without proof we

must be certain the consequences of our

subsequent actions will not be harmful

especially if we are dealing with large

populations of people. This applies to

politics as much as medicine – the UK

government was sure there were weapons

of mass destruction in Iraq – if only they

had had reasonable doubts!

We live in interesting times, often

beyond the reach of satire. Watching

curves part or fail to do so in clinical

trials is the platform for being sure

about treatment providing the studies

are properly constructed and evaluated.

In the absence of solid data decision

making can only be determined by

belief but it must be a belief that is

not absolute and a belief that is shared

with colleagues and patients in a trans-

parent way. This may seem self evident

given that we all know we do not pos-

sess all the answers but for some having

doubts is a sign of weakness. In my

view admitting to doubts is a reflection

of the empathy we all should possess

with those about whom we are making

decisions. Having or expressing reason-

able doubts is a sign of medical (polit-

ical or way of life) maturity and

strength . . . . am I sure? Yes.

Graham Jackson

Editor

REFERENCES

1 Wenger NK. Menopausal Hormone

Therapy: Is there evidence for cardiac

protection? In: Shaw LJ, Redberg RF,

Eds. Coronary disease in women.

Totowa: Humana Press, 2004; 321–48.

2 Heart Protection Study Collaborative

Group. MRC/BHF Heart protection

study of cholesterol lowering with sim-

vastatin in 20536 high risk individuals;

a randomised placebo-controlled trial.

Lancet 2002; 360: 7–22.

3 Jackson G. Calcium antagonists: never

let the truth get in the way of a good

story. Br J Clin Pract 1006; 50: 291–3.

4 Jackson G. Calcium antagonists: a

scandal in need of an inquiry. Int J

Clin Pract 2003; 57: 455.

5 Jackson G. The value of VALUE: the

importance of lowering blood pressure

quickly. Int J Clin Pract 2004; 58:

901.

6 Moynihan R. The making of a disease:

female sexual dysfunction. BMJ 2003;

326: 45–47.

7 Carlberg B, Samuelsson O, Lindholm LH.

Atenolol in hypertension: is it a wise

choice? Lancet 2004; 364: 1684–89.

8 Poole-Wilson PA, Lubsen J, Kirwan B

et al. Effect of long-acting nifedipine on

mortality and cardiovascular morbidity

in patients with stable angina requiring

treatment (ACTION trial): randomised

controlled trial. Lancet 2004; 364:

849–57.

9 Psaty BM, Furberg CD. Contemplating

ACTION – long-acting nifedipine

in stable angina. Lancet 2004; 364:

817–8.

ª 2004 Blackwell Publishing Ltd Int J Clin Pract, December 2004, 58, 12, 1097

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