‘Do no harm’: an intuitive decision tool to assess the need for gastrointestinal endoscopy

 

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Introduction

A fundamental principle of medical ethics states: “Above all, do no harm” [1]. Such maxim serves as a reminder to physicians that they need to be aware of the potential harms of their medical interventions. Because almost all medical interventions are associated with some downsides and costs, however, it is impractical to observe such maxim literally and without also balancing the benefit or effectiveness of an intervention with its cost.

Cost-effectiveness analyses have been used to develop guidelines of when to perform an endoscopy [2] [3] [4] [5]. Cost-effectiveness is generally calculated from a societal perspective to account for all personal and collective monetary costs that arise from an endoscopic procedure. The effectiveness of the procedure is measured in life-years saved through endoscopy, which may also become adjusted to their quality as quality adjusted life-years (QALYs). Cost-effectiveness analyses have proven helpful in forming national policies or professional guidelines, but are impractical as instruments for dealing with individual patients. It would be difficult to account at the bedside for all the potential costs of endoscopy and its probable impact on life expectancy. Guidelines by professional societies, such as the American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy, provide general rules for managing common medical conditions. They cannot cover all intricacies encountered in the daily routine of managing individual patients. Apart from a societal perspective of cost-effectiveness analyses and the general principles outlined in guidelines, a physician would also be interested in addressing the patient’s individual risks, needs, expectations, fears, or consider his/her own estimates of the downsides, limitations, costs, and benefits of the planned procedure.

The aim of this editorial is to present an intuitive decision tool that would be applicable in clinical practice without involving complex mathematical analysis. As a bedside tool, it would focus on the individual patient’s and endoscopist’s perspective rather than on abstract concepts detached from clinical practice, such economic costs or QALYs. The outcome of the analysis would be expressed as threshold probabilities of when to perform gastrointestinal endoscopy.

^* Drs. Sonnenberg and Pohl: These authors contributed equally.

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