Monday, November 10, 2008

Dilemmas of testing and treatment

An editorial in a Pakistani newspaper offers this seemingly commonsensical ethical directive: do not give patients treatment until they have been correctly diagnosed (via testing procedures) to have the condition the treatment is meant for. Following this train of thought, a contrast is worked up between what the author calls 'speculation-based' and 'evidence-based' medicine. The former -- typically represented by 'quacks' -- can lead to all sorts of bad consequences, such as the potential harm caused when patients are given treatment for conditions they do not actually have.

In contexts of poverty, however, the connection between testing and treatment often gets complicated. Sometimes the access to treatment is better than the access to testing; sometimes it is the reverse. When diagnostics are scarce, sometimes all you have to go on are clinical symptoms and educated guesses. You don't have to be a 'quack' to find yourself in this position: just being a doctor in an under-resourced area of one of the world's poorer countries is enough. While this sort of guesswork can put patients at risk, doing nothing while waiting for reliable diagnostic tools to arrive is not risk-free either. Are doctors who make medical decisions about patients without testing them first to confirm their condition acting ethically? The World Health Organization has taken a pragmatic position on this issue, and for years it has recommended administering antiretroviral treatment for HIV/AIDS based on clinical criteria when no reliable diagnostic tools are available. As for testing without treatment, this -- a situation faced by many thousands in the developing world -- might be worse in some ways than treatment without testing: the latter at least involves the chance of receiving appropriate treatment.

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