Personal View: Risk—the game of life
Authors: Des Spence
Journal: BMJ (2005)

It was 1976, and I was 9 years old. My teeth were chattering so hard I thought that one of them would surely come loose. On the boat to the mainland the swirling wind whipped my hair into my eyes. My sopping wet Afghan coat stank like a goat, and my beads rattled as I shivered in convulsions. Why on earth had my mother moved to Orkney, and why did my father live 700 miles away in London? This was the first of many trips that I would make over the next 10 years. I wasn't alone; also travelling were my three brothers, aged 7, 10, and (our leader) 12.

The train trip was incredibly dull. Caithness looked like a nuclear test site, Inverness was a metaphor for dreariness, and our beef paste sandwiches smelled of fish. It wasn't until the oil workers got on the train to go home to Glasgow that things brightened up. They took pity on us: four English hippy kids whose only entertainment was kicking one another or learning German phrases from commando comics. They fed us chocolate biscuits and taught us to play cards. On later trips they would offer us cigarettes and cans of lager with pictures on of polyester clad women with names like Agnes and Frances. We arrived in Glasgow late at night and then walked through the city centre to the other station to board the overnight train. Stinking of Embassy Regal but elated, we rolled into Euston at 7 am to be greeted by my dad. Where's the relevance in all this self indulgent, tear jerking pap, I hear you ask.


Risk avoidance has become the mantra of health care


Consider: would four small children be allowed to travel by themselves for 24 hours, out of contact and with virtually no money, in today's society? In my generation this wasn't uncommon, and the children of earlier generations lived independently from an early age. Do we now live in a more dangerous era? What are the real risks we face?

As health professionals we deal with risk whenever we have contact with patients. Treatments and lifestyle changes are informed by a “personalised” risk assessment. This pursuit of risk avoidance has become the mantra of health care and is now a political manifesto pledge. Indeed, the new GP contract is a distillation of risk management, neatly reinforced by rigorous cost-benefit analysis. This can only be good medicine and common sense. Who could think otherwise?

Knowledge of risk, however, is poorly understood—and is only just surpassed by our knowledge of the absolute benefit of the interventions we initiate. The profession is aiding and abetting in a disproportionate fear of all risks that is inducing major social change. This has meant, for many, an end to pleasures such as butter, salt, fried food, red meat, peanuts, and pork pies. The rest of us no longer have the pleasure of sunbathing, drinking more than five units of alcohol at one sitting, or loud music. Experts also insist that children must never be scolded or ignored. Sex is viewed with suspicion for the ever present risk of infections, erectile dysfunction, cancer, and pregnancy.

“Health” is in so many ways a state of mind, and our sanity is under threat by all these intrusive paranoid delusions of risk. This culture of risk aversion should be viewed as an extension of the prevailing “me” culture, which has replaced community spirit with its materialistic melancholy. The obsession with risk has also eroded our sense of wellbeing; and how long can childhood hold out against the pressure to test and treat? Unfortunately the middle classes, who so depend on the opinions of “experts,” will fare the worst. The inverse care effect will cause to be wrought upon them a plague of polypharmacy and a blandness of lifestyle. You need only look around you and you will see friends and colleagues haunted by “what if” questions. Risk, however, is fundamental to life, and without it we would have no love or happiness. A population without a balanced attitude to risk leads to extremes, with tremulous individuals cowering away from sausages while others seek out risk and self destruction through drugs.

I suspect that it's having been a hippy kid and my train journeys that make me question the prevailing medical dogma concerning risk. Will I personally ever have my blood pressure or cholesterol concentration checked by my doctor? I don't know. Test and treat may have some limited value. On a personal level, however, the small absolute benefits of endless treatments, limitations of lifestyle, and prolonged waits to see robotic experts may not be worth it. I will continue to eat butter, occasionally drink more than the recommended upper weekly limit, and may take a cigarette when my university friends produce a packet. Society and medicine are losing perspective about the uncontrollable, the unknowable, the unbearable, and the unpronounceable.