Thanks, Kev
I only now realized that the use of term "rational" may have caused a confusion as it appears that it was misinterpreted...This is common decision-making jargon/vocabulary and in no way is intended to be used in deragatory sense...it does not imply that one choice is considered more "sane" that the other...In fact, there is huge debate in philosophy, psychology, and decision science literature related to definition of "rationality"...
In this sense, this debate is about definition or criteria for rational decision-making and from which approach the society can benefit most...While there is disagreement among philosphers, psychologists and decision scientists what consitutes "rational" decision-making, many authors hold the view that rationality represent those kind of states or processes that help us achieve our goals. So, if our goals can be achieved using formal, logical rules, then that would be consistent with rational approach. However, according to this view, if our goals are met by violating these rules, then such behavior is also rational. (To stimulate further debate on this really important issues, we recently posted a short piece on SMDM website "Health Care Reform & Criteria for Rational Decision-making" (http://www.smdm.org/newsletter/spring_2010/#a22)
So, if the goals is to prevent flu pandemics while no squandering the precious resources, which of the strategy (e.g., vaccine vs. vaccine) get us there? [In EBM paradigm, epistemic rationality (= existence of reliable evidence) is often (but admittedly, not always) used as necessary for what is known in the literature as "rationality of action" that in turn leads to fullfillment of our goals. It appears from this ad hoc and admittedly not well done survey that epistemic rationality is not required for rational action, which contradicts EBM approach (where high-quality evidence implies he "truth", or being closer to the "truth"- recommendations on such evidence are expected to be endorsed by the majority of people, which was not case here)].
ben
ps. by the way, I also recommended and personally got double vaccine (and also took a packet of tamiflu pills when I went to Cochrane meeting to Singapore last year ...just in case)
________________________________________
From: Evidence based health (EBH) [[log in to unmask]] On Behalf Of k.hopayian [[log in to unmask]]
Sent: Monday, June 14, 2010 4:28 AM
To: [log in to unmask]
Subject: Re: AW: What to do about flu? results of ,survey
Hello All,
I agree with Hilda's point, the design of the questionnaire does not
allow us to draw those conclusions. I participated and found the
phrasing of the questionnaire awkward because it did not state
explicitly state to WHOM vaccination should be recommended. I put
myself in the position at the beginning of the epidemic. The facts
about the illness were not quantifiable but we did know that there was
an associated mortality. Until further proof was available, the
correct conclusion for me as a GP advising patients was to recommend
the vaccine to high risk groups. I won't go into all the reasons but
mention one that has not been mentioned at all yet: the need to have
consistency in public health policy. As long as the vaccine did no
harm and probably did good, it should be promoted [I work as a general
practitioner responsible for vaccination of a defined, stable
geographical population]. I concluded differently for antivirals.
There as evidence of harm and evidence of little benefit.
You may disagree with my decision but please don't say it is not
rational ;-) I think the above is logical given the premisses from
which I started. The main conclusion I draw from the survey is that
the questionnaire was not designed adequately to meet the purpose of
the study or to allow any conclusions to be drawn (sorry, Ben), but is
has sparked an illuminating discussion and given us an insight into
how people arrive at decisions. I would love to hear more.
Kev (Kevork) Hopayian
On 13 Jun 2010, at 19:27, Bastian, Hilda wrote:
> Dear Ben
>
> Perhaps the assumptions could first be questioned, rather than
> jumping to assuming there is an issue about whether people's
> decision-making is rational? By what basis is the evidence for those
> medical treatments "lousier" than the evidence for hand-washing? And
> the hand-washing etc: who wants to (or really will) wash their hands
> a gazillion times a day and not hug, kiss or shake hands for months?
> Should the rationality of people who might not want to implement (or
> rely on) that difficult approach - which in other contexts would be
> called obsessive-compulsive behaviour - really be called into
> question?
>
> When any of us fail to convince other people to share our point of
> view, it does not mean that the other people are operating non-
> rationally. Although it is always possible of course that they - or
> we - are being irrational, it is not a necessary pre-condition for a
> difference of opinion. Interpreting evidence is a subjective,
> qualitative process, shaped by value judgments (and not only
> commercial interests, but values - including ideological biases).
> That people interpret this evidence differently seems to me to be
> completely normal. I can see no need to question the rationality or
> motives of everyone who does not agree with one particular point of
> view.
>
> The EBM-decision making paradigm - to me - accepts that people have
> different values and will interpret evidence differently - and then
> apply it in their lives and decisions differently - as Ted's story
> showed, also in the context of our health beliefs and other
> complexities. That this means that people come to different
> decisions and actions, does not challenge the paradigm at all. Nor
> does it seem to me that every time someone makes money out of
> something, tht it follows, ipso facto, that the people who agree
> with those interventions are somehow suspect.
>
> Regards
>
> Hilda
>
>
>
> -----Ursprüngliche Nachricht-----
> Von: Evidence based health (EBH) [mailto:[log in to unmask]
> ] Im Auftrag von Djulbegovic, Benjamin
> Gesendet: Sonntag, 13. Juni 2010 18:44
> An: [log in to unmask]
> Betreff: Re: What to do about flu? results of ,survey
>
> Sorry for keeping this thread alive, but it really deserves further
> discussion...(I was hoping that someone else will comment first, but
> let me take the first stab at it)...
> Think about for a moment what we have here:
>
> 1. Evidence is LOUSY at best
> 2. Conflict of interest (COI) is HUGE (as it has been discussed
> repeatedly here and troughout the literature there is strong
> empirical support to doubt the accuracy of research findings in the
> setting of COI. Indeed, in this case no one denies that declaration
> of pandemics by WHO and many other national agencies was a bonanza
> for pharmaceutical companies, which made an extraordinary profit by
> selling vaccines and drugs. So, when WHO made guidelines refusing to
> disclose the names of the panel and their ties with industry, any
> reasonable observer would doubt motives or even the correctness of
> recommendations...) 3. Cost to society (-ies) has been ENORMOUS
> (think about the opportunity costs and how many lives could have
> been saved if the money spent on stockpiling of vaccines and drugs
> was used for other pressing societal or health problems...)
>
> and yet,
>
> the majority of people (45%) (all highly knowledgable folks with
> intricate understanding of all issues discussed here) would pretty
> much endorse the guidelines made by WHO and other national agencies
> (such as CDC etc): most of us would recommend double vaccine to
> others as well to the members of their family, or take double
> vaccine themselves. Why is this so? What is going on here? I think
> this case represents a challenge to EBM decision-making paradigm,
> and truly deserves more discussion.
>
> In my opinion, this case indicates that human processes information
> both at intuituive (system 1) and deliberative level (system 2),
> something that Neal Maskrey has pointed out many times in the past.
> It feels that consequences (regret) of not getting vaccinated are
> much higher that potential consequences (regret) associated with
> unnecessary vaccination...
> Having said this, a respectable minority (25%) adheres to rational
> (system 2) decision-making paradigm- outside good medical practice
> such as hand washing etc they would not endorse using neither
> vaccine nor drug. I wonder, if one could choose, whom one would like
> to select as the guidelines panel member? Would society be better
> off if the experts use system 2 only, or allow human intuition to
> play a role as well?
>
> Sorry for a long message- but I hope it will stimulate some good
> discussion
>
> ben
>
> -----Original Message-----
> From: Djulbegovic, Benjamin
> Sent: Saturday, June 12, 2010 3:39 PM
> To: [log in to unmask]
> Subject: What to do about flu? results of ,survey
>
> Dear all,
> at half time of hopefully successful debut of the US soccer time at
> the World Cup (1:1 against England at the moment), I went ahead and
> compiled the results related to the flu management survey (prompted
> by the accusation of the WHO in the way they manage pandemics and
> developed guidelines for prevention and treatment of seasonal and
> H1N1 flu). Although a response rate was rather minimal, the results
> based on selected group of highly knowledgable folks reveal striking
> variation/uncertainty about the best advice one could offer to the
> public (see attached).
> Personally, this discussion has been one of the most interesting
> discussion we have had over years- there is still a lot to digest,
> but in the mean time it would be good to have some comments on the
> results of the survey
>
> Thanks'
>
> ben
>
>
>
> -----Original Message-----
> From: Evidence based health (EBH) [mailto:[log in to unmask]
> ] On Behalf Of Djulbegovic, Benjamin
> Sent: 09 June 2010 16:10
> To: [log in to unmask]
> Subject: Re: WHO and the pandemic flu "conspiracies" ..,survey
>
> Thanks everyone for this fascinating discussion. So, here we have
> all (typical) potpourri of the issues: conflict of interest, poor
> quality evidence, trade-offs between potentially good and bad
> outcomes, difference in the risk attitudes etc However, decisions
> have to be made HERE & NOW (or, rather in 3 months from now). This
> discussion group is made of probably most informed people that can
> debate this (or, any other )health issue.
>
> So, I'd like to ask the members of this group to make the following
> decisions/ recommendations in 2 situations( pertaining to identical
> indications discussed in this thread and the WHO documents):
>
> A) imagine that you serve on the WHO panel and is asked whether to
> recommend
>
>
> 1) seasonal flu vaccine
> 2) H1N1 vaccine
> 3) both seasonal and H1N1 vaccine
> 4) tamiflu for prevention
> 5) tamiflu for treatment
> 6) no drug/no vaccine (hand washing, gloves, alcohol)
>
>
> B) imagine that you personally or members of your family face the
> same decision as in A). What would you do?
> 1) get a flu vaccine
> 2) get H1N1 vaccine
> 3) get both
> 4) take tamiflu for prevention
> 5) take tamiflu for Rx
> 6) 6) no drug/no vaccine (hand washing, gloves, alcohol)
>
> It would be truly fascinating to see what will be this group'
> "vote" (all smart and attuned to the issues of evidence and decision-
> making) May I ask you to send me your responses to this ad hoc
> survey- I will then collate responses and share (aggregate) data
> with the group.
> Thanks
> Ben
>
> Ps this is not a research- if the results are meaningful, they can
> be send to the WHO or other agencies to help them deliberate how to
> improve the quality of their decision-making process.
>
> Ben Djulbegovic,MD
> Professor of Medicine
>
>
>
> On Jun 9, 2010, at 7:30 AM, "Dr. Carlos Cuello" <[log in to unmask]
> > wrote:
>
>
>
> I guess you already read the WHO response, but here it is
> anyway.
>
> <http://www.who.int/mediacentre/news/statements/2010/letter_bmj_20100608/en/index.html
> > http://www.who.int/mediacentre/news/statements/2010/letter_bmj_20100608/en/index.html
>
>
>
>
>
> On Wed, Jun 9, 2010 at 6:16 AM, Bastian, Hilda < <mailto:[log in to unmask]
> > [log in to unmask]> wrote:
>
>
> G'day, Tom!
>
> Better and more up-to-date information will make me
> very happy: whether or not more or less fridges get stocked is, I'm
> happy to say, not my issue - manipulating behaviour change rather
> than supporting individual informed choice is not (for me) justified
> here right now. I look forward to communicating whatever people/
> patients would want to know, as best we can judge what that is (and
> what our testing/evaluation shows). If that comes down "pro" or
> "contra" Tamiflu in individual situations is not for me to decide.
> We don't give recommendations: we try to inform neutrally (a very
> difficult thing to do!), and we consider and debate very heavily
> before we ever do otherwise (and that is rare as hen's teeth, and
> usually relates to immediate very serious danger, when neutrality
> could be reasonably expected or proven to be actively seriously
> harmful).
>
> Symptom-relieving is not what I meant: I mean days of
> sickness, days off work/school/daycare, and preventing healthy but
> exposed people in the household getting sick at all, as being
> outcomes of particular value. Adverse effects of course always
> important - again, that's a personal trade-off, isn't it? And if
> they are not so bad that you have to stay home from work, then there
> will be people willing to trade that off (and others of course who
> are unwilling).
>
> Unless you find something really dramatic, I do not
> imagine I would expect to use the word "toxic" to describe Tamiflu.
> Many people would picture something almost like what is happening to
> some of those poor birds in the Gulf of Mexico with the word
> "toxic". What I want to be able to tell people is: what percentage
> are going to have diarrhoea or flu-like symptoms or whatever, so
> they can see what trade-offs they might be making.
>
> I look forward to reading more data!
>
> Thanks!
>
> Hilda
>
>
>
> ________________________________
>
> Von: Tom Jefferson [mailto: <mailto:[log in to unmask]
> > [log in to unmask]]
> Gesendet: Mittwoch, 9. Juni 2010 12:07
> An: Bastian, Hilda
> Cc: <mailto:[log in to unmask]> [log in to unmask]
>
> Betreff: Re: WHO and the pandemic flu "conspiracies"
>
>
> Dear Hilda, the points you make are fair and
> reasonable. However let me explain that the Tamiflu story is far
> from over, it is in fact only gathering steam for another version of
> the review which we hope to be able finish in reasonable time using
> mainly unpublished data. So far we have found very substantial
> publication bias, multiple inconsistencies across different versions
> of the same dataset, discovered the presence of ghost authors in
> some of the original published trials and at least one instance of
> guest authorship of a key piece of evidence and none of the non-
> Roche "authors" had access to their own data.
>
> So far this does not apply to symptom relieveing
> properities of Tamiflu (nor of Relenza) but we have not really
> looked carefully (because of lack of resources). Ths is something we
> will do in new versions of the review. Before you go stocking any
> more fridges please remember that the drug is toxic and it has never
> been tested against other symptom relievers. This is something that
> should be done as a matter of urgency.
>
> Best wishes,
>
> Tom.
>
>
>
>
> On 9 June 2010 09:17, Bastian, Hilda < <mailto:[log in to unmask]
> > [log in to unmask]> wrote:
>
>
> G'day!
>
> Leaving totally aside the issue of the
> influence of industry and concerns about process intransparency and
> undisclosed data, I think it's also important to remember that it is
> not only reduced mortality rate and so on that matters: patients
> care about other outcomes too. If you provide the results of Tom
> Jefferson and his colleagues' review of Tamiflu to patients,
> neutrally (that is, neither exaggerating them nor dismissing them
> because of your own value judgments), then many many people will
> think it is in some circumstances worthwhile. While many people will
> just want their GP to make a decision for them, many patients would
> like to think that they are being given unbiased information from
> their GPs too. But many people would - if they saw the evidence as
> it is, and without any industry influence - decide that Tamiflu in
> the back of the fridge was a good idea. If the only outcome was
> mortality reduction, say, then we could probably all agree. But this
> is not the only outcome: days off work can be very important to
> people too (especially depending on the timing). Just following
> without thinking is of course not the greatest. But there is also a
> lot of room for thinking, and then coming to a different conclusion.
> And somehow, it seems to me that far too often, the outcomes that
> patients care about just get dismissed in debates like this, and
> people's behaviour is slated when it is in fact totally reasonable.
> Just because the public behaves in a way that is inconsistent with
> the value judgments of experts, does not necessarily make them wrong
> - or even unthinking.
>
> Just to declare perhaps - I have never had
> any Tamiflu in my fridge: could absolutely imagine it, though, if I
> had kids in the house, some people were sick (and I was certain it
> was flu), and I absolutely was desperate for some reason in my life
> at that point not to get the flu. The small effect might not be,
> according to many people's judgments, important in terms of costs,
> or public health benefits: but that does not mean that every GP who
> prescribes Tamiflu has left their brains in neutral. Here an excerpt
> from the abstract of Tom's review in the BMJ <http://www.bmj.com/cgi/content/abstract/339/dec07_2/b5106?maxtoshow=&hits=10&RESULTFORMAT=1&author1=jefferson&title=neuraminidase&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&fdate=1/1/1981&resourcetype=HWCIT
> > :
>
> "The drugs are effective postexposure against
> laboratory confirmed influenza, but this is a small component of
> influenza-like illness, so for this outcome neuraminidase inhibitors
> are not effective."
> Many people might agree with this - for
> whatever reason. But just as certainly, many people in a household
> with people with laboratory-confirmed influenza who saw this review
> might disagree. They and the doctors who write their prescriptions
> are not necessarily unthinking - they may just have looked at the
> evidence that was available to them, and come to a different - and
> fully legitimate - conclusion. More than one conclusion from the
> same data can be fully legitimate - it can just depend on the values
> and perspectives. And the perspective of doctors is often not that
> of patients - nor does it mean that this means that doctors should
> always persuade patients to change their minds. When doctors and
> patients disagree, the doctors are not necessarily right! And either
> way - it's not their bodies/families, is it?
>
> We cannot make our decisions on information
> we do not have: and we are always making decisions with imperfect
> information. For something that cost the community so much money, we
> should have had better information. That's one thing we can all
> agree on! But there will often be a difference with what makes
> economic sense, and what individual people and patients value and
> choose - those choices should be understood and respected. (Of
> course, if the community decides not to pay, that has to be
> understood too - that is not the point I am trying to make here.) I
> just don't think that everyone who prescribed Tamiflu or who got
> some to put in the back of their fridge, should be judged harshly or
> dismissed.
>
> Regards
>
> Hilda Bastian
>
> Ressortleiterin Gesundheitsinformation / Head
> of Health Information Department
>
>
> ------------------------------------------------------------------------------------
>
> Tel: +49 (0)221/ 35685-401
>
> Fax: +49 (0)221/ 35685-81
>
> E-mail: <mailto:[log in to unmask]> [log in to unmask]
>
>
> ------------------------------------------------------------------------------------
>
> Institut fuer Qualitaet und
> Wirtschaftlichkeit im Gesundheitswesen/
>
> Institute for Quality and Efficiency in
> Health Care (IQWiG)
>
> Dillenburger Strasse 27
>
> 51105 Köln
>
> Germany
>
>
> -------------------------------------------------------------------------------------
>
> Institutsleitung / Director: Prof. Dr. Peter
> T. Sawicki
>
>
> -------------------------------------------------------------------------------------
>
> Internet: www.iqwig.de <http://www.iqwig.de/>
>
> Patienteninformation: <http://www.gesundheitsinformation.de/
> > www.gesundheitsinformation.de / <http://
> www.informedhealthonline.org> www.informedhealthonline.org
>
>
>
>
>
>
> -----Ursprüngliche Nachricht-----
> Von: Evidence based health (EBH) [ <mailto:[log in to unmask]
> > mailto:[log in to unmask]] Im Auftrag von OWEN
> DEMPSEY
> Gesendet: Mittwoch, 9. Juni 2010 01:56
> An: <mailto:[log in to unmask]
> > [log in to unmask]
> Betreff: Re: WHO and the pandemic flu
> "conspiracies"
>
>
>
>
> Hi Paul,
>
> Whilst I am also interested in the
> investigation into the potential collusion between WHO and the drug
> industry, which I have no doubt will eventually fizzle out, I am, as
> a GP interested in a phenomenon you could call 'zoning out' by GPs.
> This is where GPs switch off whatever critical faculty they may ever
> have had, and unthinkingly, do what they are told: to enact policy.
>
> I am thinking of the guidelines about swine
> flu vaccines and prescribing Tamiflu. A very easy and quick search,
> in 2009 by me, revealed that Tamiflu is of uncertain benefit (there
> may be equipoise on this point for some) as demonstrated by Carl
> Henegan's rapid response to the BMJ, reporting his journal clubs
> conclusions on the issue.
>
> For the 'interested' there is plenty of
> disturbing evidence suggesting that Tamiflu could cause more harm
> than do good. Yes, it is sad, that the government via the CMO
> decided to go for a "better to be safe than be sorry" policy, sorry
> of course meaning sorry that you might be blamed for causing harm,
> rather than sorry that you caused more harm than good, (knowing that
> even if we inadvertently do more harm than good then this, luckily,
> could never be proved anyway).
>
> It is even sadder that GPs and the RCGP just
> went along with it. I could, as a GP accept a situation, whereby a
> 'policy of healthcare'
> might save lives even though it put large
> numbers at risk of small harm. I do this all the time by supporting
> childhood immunisations to increase herd immunity. But I draw the
> line at completely unproven treatment strategies aimed at
> populations, targetting the young and the pregnant, for whom benefit
> is completely unproven. Where were you, the RCGP, when primary
> health care needed you?? Where were you, you completely trained to
> be unquestionng GP?? What does this say about medical education?
> Ethics for the birds? Numeracy highly valued - as long as you arrive
> at the right answer? Where was the global movement for evidence
> based medicine? Nowhere.
>
> Owen
> Owen Dempsey, GP.
>
>
>> Date published: 04/06/2010 16:12
>>
>>
>>
>> This joint investigation by the BMJ and the Bureau of Investigative
>> Journalism has found that the World Health Organisation's (WHO) key
>> decisions during the H1N1 influenza pandemic may not have been free
>> from commercial influence. The investigation questions the lack of
>> transparency involved and found that scientists advising the WHO on
>> pandemic flu planning did paid work for pharmaceutical companies
>> who stood to gain from the guidance the scientists were developing.
>> The WHO did not publicly disclose these conflicts of interest and
>> has dismissed inquiries into its handling of the A/H1N1 pandemic as
>> "conspiracy theories."
>>
>>
>>
>> The authors ask:
>>
>> * Was it appropriate for WHO to take advice from experts who had
>> declarable financial and research ties with pharmaceutical
>> companies producing antivirals and influenza vaccines?
>> * Why was key WHO guidance authored by an influenza expert who had
>> received payment for other work from Roche, manufacturers of
>> oseltamivir, and GlaxoSmithKline, manufacturers of zanamivir?
>> * Why does the composition of the emergency committee from which
>> Chan (Director General of the WHO) sought guidance remain a secret
>> known only to those within the WHO?
>>
>>
>>
>> They discuss the issues in details and write, "The number of
>> victims of H1N1 fell far short of even the more conservative
>> predictions by the WHO. It could, of course, have been far worse.
>> Planning for the worst while hoping for the best remains a sensible
>> approach. But our investigation has revealed damaging issues. If
>> these are not addressed, H1N1 may yet claim its biggest victim -
>> the credibility of the WHO and the trust in the global public
>> health system."
>>
>>
>>
>> In a related editorial, the BMJ Editor in Chief calls on the WHO to
>> publish its own report on the issue "without delay or defensive
>> comment, [and] make public the membership and conflicts of interest
>> of its emergency committee." She suggests that the WHO must act now
>> to restore its credibility, and Europe should legislate. The
>> editorialist notes, "Countries like France and the United Kingdom
>> who have stockpiled drugs and vaccines are now busy unpicking
>> vaccine contracts, selling unused vaccine to other countries, and
>> sitting on huge piles of unused oseltamivir. Meanwhile drug
>> companies have banked vast profits - $7bn (Ł4.8bn) to $10bn from
>> vaccines alone according to investment bank JP Morgan. Given the
>> scale of public cost and private profit, it would seem important to
>> know that WHO's key decisions were free from commercial influence".
>>
>>
>>
>> The editorial also calls on the WHO to develop and commit to
>> stricter rules of engagement with industry that keep commercial
>> influence away from its decision making.
>>
>>
>> Extract
>> Editorial
>> BBC News story
>>
>>
>> Ash
>> Dr Ash Paul
>> Medical Director
>> NHS Bedfordshire
>> 21 Kimbolton Road
>> Bedford
>> MK40 2AW
>> Tel no: 01234897224
>> Email: <mailto:[log in to unmask]> [log in to unmask]
>>
>>
>
>
>
>
>
>
>
>
>
> --
> Dr Tom Jefferson
> Scientific Editor PLoS ONE
> Reviewer, Cochrane Acute Respiratory Infections Group
> tel 0039 3292025051
>
>
>
>
>
>
> --
> Carlos A. Cuello-García, MD
> Director, Centre for Evidence-Based Practice-Tecnologico de
> Monterrey
> Cochrane-ITESM coordinator. Professor of Paediatrics and
> Clinical Research
> Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er.
> piso,Monterrey NL, México. CP64710
> Phone. +52(81)88882154 & 2141. Fax: +52(81)88882148
> <http://www.cmbe.net> www.cmbe.net
> <http://twitter.com/CharlieNeck> http://twitter.com/CharlieNeck
>
> The content of this data transmission must not be considered
> an offer, proposal, understanding or agreement unless it is
> confirmed in a document signed by a legal representative of ITESM.
> The content of this data transmission is confidential and is
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