A reasonable risk
=================

* Lara Hazelton

It was my ten o'clock patient who told me that the world had suddenly become more dangerous.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/169/10/1058/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/169/10/1058/F1)

Figure. Photo by: Fred Sebastian

Like many physicians, I was at work when I heard the news that a plane had crashed into the World Trade Center in New York on Sept. 11. 2001. As the day passed, information came to me with each appointment. Some patients cancelled. Others showed up late, afraid to take the subway. They came bringing updates as the second plane hit and the towers fell. I struggled to respond to their personal concerns in the context of what was happening, just as doctors in clinics, hospitals and offices across Canada wrote prescriptions, delivered babies and kept on tending the sick while the news rumbled in the background. 

In the weeks that followed, I saw patients who thought the world was ending and others who were sure it wouldn't — *Would it?* At the height of the anthrax scare, one man with obsessive–compulsive disorder became convinced he had been exposed. 

“Do you think I should get tested?” he asked, peering at me intensely.

It was a question that I was getting used to hearing from patients. “For anthrax? What do you think?”

He shrugged his thin, sloping shoulders. “You're going to say no. But I can't stop thinking about it. What if I've already been exposed? They say on television that your only hope is to be treated right away. What if I didn't get tested when I should have, and now it's too late?”

I had already told him several times that I thought he should stop watching the endless loop of television news. The controlled hysteria of self-important news announcers was toxic enough even for those without an anxiety disorder. Reading between the lines that scrolled across the bottom of the television screen, you could make out the angry assertion to which physicians are so often called to respond: *Everything has got to be okay. Something must be done to fix this, and fast.*

I was tempted to tell my patient that there was no way he could have anthrax. But to say this would have been futile, and would merely have fed his compulsion to seek reassurance. I considered pointing out that he had driven to his appointment — certainly more of a danger than anthrax from a statistical point of view — but I knew he was struggling with driving and I didn't want to discourage him. I tried another approach. 

“Let's think about this. What do you think, really, is the likelihood that you have been exposed to anthrax?”

“I'm not sure. I find it hard to know what a reasonable risk is anymore.” “Try.”

“A thousand to one, perhaps?”

“A thousand to one. Come on. Think about it. It's much lower than that. Maybe a billion to one. Less, even.”

He smiled strangely. “It's not zero, though, is it? For me, it doesn't matter how low it is. It's all the same as long as I know there is still a danger.”

He wanted me to tell him, of course, that there was no danger. He wanted me to say it in a way he could believe. I could feel him shift the weight of his anxiety to me. *Protect me, Dr. Hazelton. Isn't that what doctors are supposed to do?* 

I felt like saying, No, the risk is not zero. Go get tested if you want, if you think it will make you feel better. 

I imagined him going again and again for testing, bleeding himself dry in the search for peace of mind.

Like patients with cancer in remission, we wait and wonder. We want somebody to tell us that the threat is gone, the risk is zero: we are protected, everything is safe now, no need to be afraid.

It seems we live in unsafe times. This, despite the fact that we are living longer and more cautiously than ever before. One could paraphrase Dickens, and call this the safest of times and the most dangerous of times, a time of seatbelts and the unsteady SUVs they strap us into, of choreographed motions of flight attendants and planes that disappear off radar in a momentary blip. Now that God has been officially abandoned, we have become pilgrims in search of Big Safety, the benevolent deity of electric irons that turn themselves off when left in a horizontal position.

If it takes greater control to achieve such safety, we are willing to pay the price, more or less. Sure, we may shake our heads at increased security measures at the US border, or wonder at the wisdom of Bill C-36. But we submit, because we want to believe that more control equals more certainty equals more safety. I was amazed to read that 40% of Canadians think we should allow American soldiers to operate on Canadian soil in the event of a terrorist attack. Despite our protestations of love for freedom, what we really mean is that we love *our own* freedom (which we don't really believe we will need to sacrifice) and we hate the freedom of the dangerous other.

Perhaps I shouldn't be surprised at what we would trade so quickly. The whole issue of freedom and safety is one I have struggled with ever since starting my psychiatry residency 10 years ago. *Suffers from a psychiatric illness and is a danger to himself and others:* classic criteria for certification. The burden of finding the balance between freedom and safety in a particular case falls to the individual clinician; society as a whole has not thought the implications through, and thinks it is easy to sort the good sane from the bad crazy, just as it is easy to distinguish between terrorist and tourist by the stamp on a passport. Things are only getting worse as we move from a duty to warn intended victims of people with psychiatric illness to a duty to protect the universal, undefined victim that could be anyone or no one. This, despite a lack of convincing evidence that we can actually provide protection except in the most circumscribed of situations.

Many psychiatrists are becoming concerned about the way the responsibility for public safety is shifting from the judicial system to the medical system. It would indeed be convenient if we could accurately identify those people who pose a serious risk; unlike the police, doctors are not limited to locking up people who have acutally done something dangerous. A colleague once told me about a telephone call she received during residency training. It was from a police officer who wanted her to delay indefinitely the discharge of a patient. The patient had been admitted for depression and was ready to leave hospital, but the police wanted him kept in because they suspected he was a pedophile. Couldn't she keep him in? For a while? Even better, for ever?

In the Nov. 11, 2002, issue of *Macleans*, Jonathon Gatehouse wrote, “The power of terrorism is that it taps into some of the most basic types of fear — fear of death, fear of the unknown, and fear of the irrational.” Acts of terrorism are “the perfect synthesis of malevolence and randomness. They can't be justified or explained, and therefore fill us with dread.” 

Early in their training, physicians become acquainted with the enemy. Illness, like terrorism, is a synthesis of malevolence and randomness. It is better predicted in retrospect, and it doesn't play fair. You can eat right, exercise, never use cigarettes — and you may still have a heart attack. Aunt Martha might live for six months with her cancer, or she might die tonight. You never know when the attacker will strike.

But doctors are supposed to be able to predict and control. They gaze through the crystal balls of examinations, ever-more-sophisticated diagnostic tools and evidence-based medicine. Before they could do much to cure, a large part of the duty of physicians was to diagnose and prognosticate. Even if the news was bad, it was better to know what was going to happen. 

But now prediction and protection have become so entwined that it is difficult to separate them out. What benefit is a diagnosis without a matched treatment? We have come to think of the response to our interventions as an inherent quality of the condition itself, as if in the absence of our treatments the disease would not be fully defined. We separate the tumour with a good prognosis from the deadly one as if they were two distinct entities rather than artificial categories set apart by the level of our skills.

If we really have so much power to control illness, then a bad outcome cannot be the result of a random happening. It must be a breakdown in the matrix of measurements, medications and technologies in which we have caged the beast. This belief is reflected in the language we adopt. There are no “accidents” anymore, only “injuries.” The push is on to identify and prevent medical “errors” in the hope of removing that wild card from the deck. Maybe if we can do that, admission to hospital will be a little less risky. *Keep us safe. Protect us, doctor.*

What doctors should perhaps tell the world is that we cannot control for every variable. Most of the time, a prognosis is based on a loose association of statistics, previous experience and intuition, with a large fudge factor built in to allow for chance. In the end, what will happen is beyond our control. This is a fact we don't want to face any more than our patients do. As physicians, most of us have been extraordinarily successful in ordering our lives. We like to believe that in discipline lies safety and salvation. But the success we have had has made us only more anxious, and more convinced that we can't cope in the face of what lies outside our control. What if the world is random? What if people who don't smoke get lung cancer? What if a building tumbles from the sky? What then?

“So. It has been a long time since your last appointment.”

“Yes, it has.”

“I hope you are doing well?”

It strikes me that he hunches his shoulders a bit less. That his hair is shorter and more neatly cut. He shakes hands with me without hesitation, and without the subtle movement to wipe off the residue of my touch on the leg of his slightly wrinkled suit.

I would like to ask, Do you still think you have anthrax? I don't imagine he does. His fears may have found a new focus, perhaps when news reports moved on from the anthrax scare. I would like to hope that he has started to hear what I have been trying to tell him. Life is full of unreasonable risks, and we can't avoid them forever. The good news is that terror is not the only possible response to the unpredictability of existence. There are other avenues open if you don't need certainty to be satisfied. You might learn to be happy with one of the alternatives to safety: freedom, perhaps, or even peace.

**Lara Hazelton** Psychiatrist Halifax, NS

## Footnotes

*   *This article is the winner of* CMAJ's* 2002–03 Essay Prize.*