Doctors, alcohol, and the heart
Doctors have struggled for several years now over whether to tell their patients about the potential cardiac benefits of alcohol. Over 60 clinical studies have suggested that light to moderate alcohol consumption (the equivalent of one 1 ½ oz. of alcohol per day) can increase HDL cholesterol levels (the “good” cholesterol,) and can reduce the incidence of myocardial infarction (heart attack).However, excessive alcohol consumption reliably causes a number of severe and often fatal medical problems, not to mention the destructive social pathologies associated with alcoholism itself.
For all these reasons, a special advisory panel of the American Heart Association issued a formal statement, published in January, 2001 in the journal Circulation, urging doctors not to recommend alcohol to their patients as a means of reducing the risk of heart disease. This makes perfect sense. If doctors were seen to be encouraging alcohol, that would not only be politically incorrect, but might also lead to a significant increase in alcohol-related medical and social problems. Still, the apparent cardiac benefits of alcohol creates something of a dilemma for doctors.
In the January 9, 2003 issue of the New England Journal of Medicine, researchers report a new study that makes the dilemma more difficult. In this study, over 38,000 healthy males were followed for 12 years. The researchers found that men who consumed alcohol at least three to four days per week had a significantly reduced risk of myocardial infarction. This risk reduction was present even if small amounts of alcohol were consumed (the equivalent of a half glass of wine), as long as the frequency of consumption was 3 - 4 days per week. Drinking larger amounts of alcohol did not improve the risk reduction, and the type of alcohol consumed (i.e., wine, beer, whiskey) did not make any difference.
This is a very large, carefully conducted study with very impressive results, and it adds much credence to the great number of prior studies suggesting similar results.
Can doctors still withhold information about the possible benefits of alcohol?
Many will argue that this study doesn’t really change anything at all. We have all been lead astray by epidemiological studies before. And alcohol, even if effective, is still a dangerous substance. To society at large, alcohol is clearly a major health hazard, and the line between drinking "just enough" alcohol and "too much" alcohol is hard to define - and is probably different for everybody.So until it is demonstrated that encouraging drinking saves more lives than it costs (a dubious proposition at best) from a societal standpoint doctors should keep quiet. For an organization like the American Heart Association, one that aims to improve overall public health, such arguments are both reasonable and compelling.
But for doctors, the needs of society are generally (and appropriately) superceded by the needs of the individual patient. Indeed, to do otherwise is to violate the doctor-patient compact. It is the doctor’s duty – according to tradition, to medical ethics, and to the law – to act in the best interests of their individual patients. This is true even when those interests are contrary to the interests of society at large. Thus, if a particular patient needs a referral to a cardiologist but the HMO (society’s surrogate) discourages such referrals because of cost, the doctor is nonetheless obligated – morally and legally – to make the referral.
In the case of alcohol as a cardiac preventative, it is clearly in society’s best interest for the medical profession to avoid a wholesale recommendation that everyone consume a drink a day. To embrace such a recommendation might well cause net harm to society.
However, doctors commonly see individual patients who remain at high risk for myocardial infarctions, despite taking all standard measures to increase those levels and reduce that risk. To withhold from such an individual the scientific information about the potential cardiac benefits of alcohol would be unethical, immoral and illegal. Taking this argument a step further, one might argue that even if other, more routine, risk reduction measures are available, it still might be in the patient’s own best interests to be fully apprised of all their options.
As usual, it will be difficult to articulate a policy on the use of alcohol for cardiac prevention that meets both the needs of society and the needs of all individuals that comprise society. But the policy that is in wide use now – to simply avoid discussing the issue with patients – has just become a bit less tenable.
