Category Archives: blood pressure

Do I really need those blood pressure pills?

Dalrymple explains that drugs used to reduce blood pressure

have to be taken regularly and often for the rest of a person’s life. Their purpose is to reduce the statistical risk of heart attack or stroke. They can have side-effects.

He points out that at least half of people prescribed antihypertensive drugs have stopped taking them by the end of the year.

Most people who take them will not benefit from them, though when someone does benefit—by not having the heart attack or stroke he would otherwise have had—it is a very great benefit indeed.

The question of whether it is worthwhile for someone to take antihypertensives

cannot be answered with a simple yes or no. It depends on the size of the risk and the values of the person taking them. Some people prefer to take their chances than take the pills; others take any number of pills all their lives for a minimal reduction of risk.

You’re the doctor. Be a paternalist

Screen Shot 2016-04-29 at 08.52.09Dalrymple writes that when he has been in need of treatment,

I have wanted the doctor to decide what to do and do it, without any intellectual input from me (a doctor). The last thing I wanted was to hear a disquisition on the various possible courses of action the doctor could take, with all their possible disadvantages, and then to have to make up my mind.

But, he says,

this attitude is rather against the temper of the times: it smacks of a return to paternalism. What we want is information, more and more of it, to help us decide what is best for us.

The problem is that

there are many questions in medicine that are without a definitive answer. Is it worth running a small relative risk of a major side-effect to obtain relief from a non-life-threatening condition?

Perfectly sensible people

may give different answers to the same question, according to their own scale of values.

Unfortunately,

people don’t like living with uncertainty. For them, intellectual honesty has its limits as a virtue. They (or perhaps I should say we, because we are most of us the same in this respect) prefer living with a sense of certainty, at least about our illnesses, even if this certainty is not well-founded. We want the doctor to act as if he were certain, even if he is not certain. And this desire is not completely without rational justification, because faith in the doctor has a healing quality. It is hard to put one’s faith in a man who presents us with a series of insoluble dilemmas.

A patient comes to Dalrymple with somewhat raised blood pressure.

I conscientiously told him that there was a small statistical chance that treatment would do him a lot of good, but a large statistical chance that it would do him no good. Did he want treatment or not? He looked at me as if I were mad. He hadn’t come to the doctor for this, but to be told what to do. He had never thought of medical treatment as a game of roulette: treatment either worked in every case or it didn’t. ‘I don’t know,’ he said. ‘You’re the doctor. Do what you think is best.’ What he meant was, be a paternalist.

My hand shakes; I want to interrupt, to shout

Zeven Hoofdzonden (detail), attr. Jheronimus Bosch, c. 1485 or after. Museo del Prado

Zeven Hoofdzonden (detail), attr. Jheronimus Bosch, c. 1485 or after. Museo del Prado

Dogmatism, writes Dalrymple,

is the reaction of those who want to know best but suspect that the metaphysical foundations of their supposed knowledge are shaky. Ambiguity disturbs them: how can there be rational criticism founded on argument and evidence, when at the same time there is no disputing taste? The solution to the tension is to stand behind a stockade of indubitable truth.

The search for certainty

is much more important than the search for truth. I know a man, an eminent writer, who has changed his opinion many times in his long life, often by 180°, but never admits to having done so. He has held every successive opinion with angry intransigence. Challenges by people of another opinion make him turn red with rage: they do not merely differ from him in opinion, they are attacking him personally. It is not true that bigotry is the exclusive province of the ignorant and stupid; there is the clever and well-informed variety, the more dangerous because the less easily recognised.

Dalrymple does not exclude himself.

When someone expresses an opinion that is very different from my own, I often feel a mounting tension, though the subject may be one that, if I am honest with myself, is of little importance or consequence to me. Certainly it cannot harm me that someone thinks differently from me about it; yet my heart begins to beat wildly, and I am sure that my blood pressure has risen. I feel an excitation, I tell myself to keep calm but I don’t succeed; my hand shakes; I want to interrupt, to shout. I am not defending truth, but my opinion. Generally I succeed in controlling myself, but occasionally I do not, especially when my interlocutor is young. I immediately feel ashamed of myself afterwards; I even feel ashamed that, at my age, I am still so little capable of detachment.