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RESPONSE |
In The Magic Mountain (1), the narrator periodically interrupts the flow of the novel with encouragements to the reader that this immense book is one quarter, or one half, or almost all done. In like manner, take courage, gentle reader. After my 4000-word essay (2) and the 7200-odd words of commentary (3–10), the end is near.
I thank the authors of those commentaries, several of whom propose interesting physiologic pathways to explain the phenomena outlined in my essay. In this response, I will (somewhat narcissistically) concentrate on those commentators who rejected the conclusion stated in the final sentence of that essay.
I am fascinated by the studies of blood pressure in the very old. I find these results astounding—worth thinking and talking about, trying to make sense of it all. But some of the discussants seem unastounded, not even interested. They understand exactly what is going on with blood pressure in the very old. Not me. I am confused, and I worry just a tiny little bit about those who are not. I do not wish to participate in a debate. In a debate, all evidence against one's position is ignored, and evidence supporting the position is put forward in the best possible light. That is fundamentally boring. How much more interesting it is to consider complex issues seriously. That is what I attempted in my essay. Some of the respondents want to turn this into a "protreatment versus antitreatment" debate. I do not see the utility of adopting an attitude of certainty when the available evidence is so confusing.
Over the years, I have published a number of studies and commentaries on what might be termed extrascientific influences on medical practice. I cite those that still may be of interest (11–22). Two articles in particular are relevant to the issue at hand, and I would be happy to send somewhat yellowed reprints of these to interested readers. One, which I wrote with my wife, is "The Tomato Effect" (11), and the other is "Geriatric Ideology" (12). In "The Tomato Effect" (11), we discuss instances in the history of medicine when efficacious treatments were rejected, and harmful ones were accepted, because the former did not fit into the prevailing medical paradigm, while the latter did. In other words, theory trumps empirical observation (11,13–15). In "Geriatric Ideology" (12), I argue that much of what we say in geriatrics is more ideological than scientific. In other words, much of the content of modern geriatric medicine is value driven, rather than data driven. That does not mean that the content is wrong. However, it does mean that it is outside the realm of science (23). According to Popper, science is restricted to the process that produces postulates that are potentially falsifiable by experiment (24). One might ask whether any set of empirical data would cause some of the respondents to rethink their beliefs about hypertension in the very old.
Drs. Aronow (3) and Thomas (10) imply that I should have reported a 6% rather than 14% excess mortality associated with antihypertensive treatment in the meta-analysis (25). The authors of this meta-analysis reported 2 sets of results. One set included an unblinded open trial lacking a placebo control, and the other set was limited to the double-blind, placebo-controlled trials. I used the second set of data. Do Drs. Aronow and Thomas really want me to include results from an unblinded trial without a placebo group? Is that likely to get us closer to an understanding of this issue? Putting the meta-analysis aside, are not Drs. Aronow and Thomas at least interested in the fact that 3 of the 4 randomized controlled trials of antihypertensive treatment that included subjects over age 80 demonstrated a clear loss of efficacy in the over 80 population?
Dr. Newman (9) chides me for emphasizing all-cause mortality as an outcome rather than heart attack and stroke. Perhaps Dr. Newman is correct when she implies that morbidity should be valued higher than mortality. In other words, perhaps 80 year olds would rather be dead than alive and disabled. That would be an easy enough premise to test. But unless we accept that premise a priori, it is difficult to understand her statement that the benefits of treating hypertension for patients well into their late 80s are substantial and well documented.
Dr. Newman also worries that questioning the importance of elevated blood pressure in those older than 80 years might foster therapeutic nihilism. I doubt we have to worry that much about therapeutic nihilism. She should consider the issue from the perspective of Marx (26). What economic forces promote therapeutic nihilism? Certainly not the pharmaceutical industry, which funds much of the continuing medical education in this country. And not fee-for-service medicine, which is not exactly conducive to therapeutic nihilism (16). Besides which, is combating therapeutic nihilism a justification for treating octogenarians with high blood pressure?
I am puzzled by the commentary by Dr. Harris (6). She starts with a series of dismissive statements: (a) I am "haunting" the literature; (b) all this has been said before; and (c) besides which, it is all based on flawed studies. But she then goes on to repeat many of the same concepts that I mentioned as potential explanations for the phenomena reviewed in my essay. However, in her hands these are no longer "potential" explanations. They are presented as established facts. Indeed, they are so well established that citations are not required to buttress them. Everyone knows these things. In particular, everyone knows that chronological age is unimportant. What is important is physiologic, or biologic, aging. Here we come face to face with one of the founding tenets of geriatric ideology, and a tenet that confuses me.
In the first place, it is simply not true that chronologic age is unimportant. One simply cannot make age "go away" as a predictor of survival, no matter how many physiologic, functional, and medical variables one adds to the analyses (27).
But a more fundamental question is: Why is it important for us to pretend that chronologic age does not matter? This assertion that chronologic age does not matter is put forth as an ethical principle, what Foucault called an immanent rule, not really characterizing how we actually act, but characterizing the way we talk about how we act (28).
What is it about age that would elicit the sentiments expressed in the last sentence of Dr. Harris' commentary? What value, or set of values, underlie such an opinion? Presumably we would not be criticized for taking into consideration other potentially relevant factors, such as ejection fraction, or comorbid illness. The underlying value seems to be that older patients must be shielded from having their age considered in order to prevent their physicians from giving up on them (echoing the therapeutic nihilism concerns of Dr. Newman). Isn't this assumption a bit patronizing of older people, as well as demeaning of the clinicians who provide their medical care (29)?
Another value that seems to underline several of the commentaries is that messages to practicing clinicians must be kept simple. If we reopen the question of treating 85 year olds with hypertension, then the message will become muddled, leading clinicians to not treat 75 year olds with hypertension. In other words, regardless of whether ideas are right or wrong, they may be dangerous. In my experience, clinicians are actually quite a bit better at dealing with complexity than are those who seek to inform them. Scientists study groups (groups of people, groups of molecules, groups of electrons), and scientific rules are only valid to the extent to which the individuals in those groups are similar to each other (30,31). Clinicians, on the other hand, treat one person at a time, and thus must always be focused on individual preferences and differences. Clinicians and their patients are ill served by rules and guidelines that do not embrace that complexity.
In summary, most of us would agree that more data are required to increase our understanding of high blood pressure in the very old. Perhaps equal in importance to more data would be a vigorous elicitation and discussion of the values that color the interpretation of those data. I encourage readers to read the original studies relevant to blood pressure in the very old, and to decide for themselves whether it is more appropriate to embrace complexity, or flee into certainty, at this stage in our understanding of elevated blood pressure in the very old.
REFERENCES
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| Journals of Gerontology Series B: Psychological Sciences and Social Sciences | |
