False economy syndrome

[injuryupdate]

Dr J Sport Health March 2001

As a part-time clinical doctor, part-time researcher, I take every opportunity to promote medical research. It is sometimes difficult to convince the relevant authorities, which are usually more interested in treating existing cases of disease than prevention of potential cases. Most medical research does not come to earth-shattering conclusions, but the sum total of many studies can have more impact on health outcomes than even the best forms of treatment. With this in mind, I would generally applaud any controversy that leads to more medical research being conducted.

The recent media frenzy over Deep Venous Thrombosis has unfortunately confirmed the increasing public impotence of the medical profession compared to its legal counterpart. DVTs have been occurring for years and I swear that I learnt many years ago, as a medical student, that long-haul plane flights were a risk factor. When I was passed on this piece of information, and perhaps even now, the pronouncement was based on anecdote rather than well-conducted and controlled scientific research. DVTs are an uncommon (as opposed to rare) but serious illness that should already have ongoing funding for surveillance and risk factor studies. These studies will finally now be funded, but unfortunately, not because of a recommendation of the medical profession, but because a bunch of aggressive lawyers are suing and an old condition is suddenly a ?new? story.

The lawyers will this time lead us to the right outcome, but perhaps for the wrong reasons. The airlines have been culpable in not previously conducting health surveillance of their passengers during and after their flights and publishing the results in medical journals. The medical profession should be taking this opportunity to push other private companies to be funding scientific research into their products and services, preferably in collaboration with the usual government bodies to keep them honest. Should the ******s be obliged to fund research into problem gambling? You bet. Should manufacturers of 4-wheel drive vehicles be forced to research whether these cars are an increased danger to other (smaller) vehicles in city traffic? Yes again. Should gun clubs and manufacturers have a legal need to fund research into accidental shootings and youth suicides? Ditto. Should modelling agencies be funding research into anorexia? The list keeps growing. The minimum requirement for all of this research should be publication in the scientific literature, and perhaps there should be a government body created to make sure that public companies spend a percentage of their profits on scientific research into their products and services. Of course, companies are not going to want to voluntarily spend money to find out secondary harm that they may be creating, but the emphasis of the law should be that they have an obligation to do this. Ignoring this obligation should be a case of ?False economy syndrome?.

Unfortunately, most of the legal pressure on the airlines will be regarding the informed consent issue, one that is familiar to doctors. In my opinion, most informed consent issues are legal baloney, with cases upheld for the sole purposes of making the legal profession more profitable. If it turns out that the risk of DVT with associated major pulmonary embolus on a Sydney-London flight is 1 in 50000, what person is, on the ?balance of probabilities?, not going to take a flight when they learn of this risk? The answer is no one, discounting paranoids and people with phobias. The outcome of this legalistic rubbish is that airline tickets will have a small print waiver on the back that no one will bother reading. This is less harmless than the analogous situation that doctors find ourselves in where we legally have to needlessly worry patients with warnings about 1 in 50000 complications of drugs or surgery that are going to have no bearing on whether the patient chooses to take the drug or undergo the procedure.

With respect to prevention of such rare complications, if it turns out that taking an Aspirin tablet can lower your risk of DVT on a flight, then this should be a recommendation from the airlines. The key message is that the recommendation should be as a result of a randomised controlled study, which should be funded in preference to the printing and signing of legal waivers before you step on the plane. The problem with recommending the Aspirin tablet is that the airlines will need to get you to sign another waiver against the risk of fatal GI haemorrhage.

Warnings about rare complications that will just distress the average person are a waste of time and create undue panic. Scientific research into these rare complications is vital. In some ways, we can complain about the lawyers forcing us to waste time on consent forms with small print, but in today?s society, we must reluctantly thank them if their work leads towards more funding for important medical research. This may be the case with respect to DVT research in the future, because the lawyers and the media have pushed the issue that there is a connection between DVTs and long-haul flights. This is one effect of the adversarial legal system that appears to push the cause of medical research.

On the other hand, the legal system is also structured with an incentive to not undertake research in novel areas. With respect to the DVT legal cases, one of the defence arguments for the airlines will be that there is no scientific proof (e.g. a series of well-designed blinded studies) that there is an increased risk of DVT that the airlines could have taken measures to prevent. If you are talking about what is ethically correct, then the airlines should be studying this hypothesized association. If you are talking about what is tactically advisable in a legal sense (quite often the opposite to ethically correct) then there is an incentive to not want any evidence showing such an association, that is to not want to fund the study in the first place.

I am acutely aware of the moral versus legal issues with respect to injury surveillance in sport, an area in which I derive income, which may lead to some bias. Even taking my bias into account, most people would not disagree if I asserted that there is an ethical imperative for sporting bodies to undertake injury surveillance as a means towards understanding and eventually reducing injuries in their athletes. However, from a legal perspective, knowledge is potentially dangerous. For example, the AFL injury surveillance system is making some excellent progress in trying to understand whether certain types of playing surface lead to a higher risk of injuries. As this issue is being discussed, lawyers appear to be falling out of the sky trying to claim extraordinary compensation payments for their injured clients, citing a substandard playing surface as being the cause of the injury. It is a dubious right of certain players (and of course their legal team) to receive greater compensation for injury than their colleagues with similar injuries, given that a no-fault compensation system exists. That is, a player who tears his ACL and misses the season will get paid by his club even though he doesn?t serve them on the playing field. Dubious rights seem to be as good as genuine rights in the modern world. The legal system appears to be immune to accusations that it is set up with the primary aim to provide income to lawyers rather than justice to society. Society has written lawyers a blank cheque to provide justice and they are more concerned with cashing the cheque than anything else.

A very similar analogy applies to the situation with artificial turf in the USA. There are so many games of American football played on both artificial turf and natural grass, it seems incongruous that science has been unable to definitively assess the relative risk of injury. The only explanation is that the cost of actually answering the question is too great in a legal sense, in the country that is the world leader for bogus lawsuits. If it was conclusively known and conceded that artificial turf had a higher or lower rate for certain injuries, then there would be enough lawyers filing injury compensation claims to fill the Grand Canyon.

Scientific research has done a huge amount to improve the standard of living of the world?s citizens. Now that we are in the golden age of databases, the potential to answer even more questions has increased exponentially, and the novel field of sports medicine is poised to benefit. The legal system offers sports medicine a double-edged sword ? an imperative to the authorities to spend money to react to existing knowledge about injuries, but a fear of the legal cost of further knowledge.

(Sections of this article appeared in a column that John Orchard wrote for Australian Doctor magazine on February 4th).

[sweveSek73]

If letting enemies pillage your capital is your normal strategy, you need to change more than your economy...