“My name is Khan, I am not a terrorist”. Was a famous dialogue from a 2010 movie. It has a very clear political message. All (most to be precise) terrorists are Muslims, but all Muslims are not terrorists. Looking at all Muslims with suspect; treating every Muslim as if they are terrorists is ethically, legally, politically wrong and that is very clear.
But the field of medicine does that, I mean a logically equivalent blunder, and nobody says it is wrong there!! I want to point this out only as a logical problem, with no political intentions. Just as some Muslims happen to be terrorists, some of the type 2 diabetics develop heart, kidney, brain related complications; certainly not all. But we still treat diabetics as if all of them are bound to develop these and insist on treating them. This is similar to what China is believed to be doing with Uighur Muslims. The china act came under heavy criticism a few years ago. (I don’t claim to know the reality and wonder why they have suddenly stopped talking about it now!). Are the two logically different? If one is unethical how is the other one ethical?
Perhaps diabetic medicine wants to treat everyone to be on the safer side and that should be good. Not treating them would perhaps be inviting trouble for them. So not treating them should be unethical isn’t it? This is far from reality. Putting together data from dozens of clinical trials and carefully analyzing it shows that glucose lowering treatment of diabetes as being practiced hardly prevents any of the complications (https://www.qeios.com/read/IH7KEP , https://doi.org/10.1002/14651858.CD015849.pub2 ). A number of trials claim so but a look at their raw data is sufficient to know that they have really tortured the data to come at the pre-determined conclusion. In many large scale trials, the treated group had significantly higher mortality than the controls. Many trials did not find any difference at all. If we cherry pick only the most “successful” trials, we find only 1 or a few percent absolute difference in the incidence of complications. There are many clear inferences from this. Even without any treatment, only a small percentage of diabetics develop complications over a span of decades. Treatment at the most makes a marginal difference. So how is this different from the “My name is Khan” (MNIK) phenomenon? There too only a small proportion of the community turn terrorists and huge investment in anti-terrorist squads is unable to prevent it entirely.
Treatment might be justified by saying that, “but we don’t know who is going to get complications. So it is good to treat everyone.” Then how is it different from suspecting every Muslim to be a terrorist? There also you do not have any a priori knowledge.
Moreover, it is not true that we cannot predict who will get complications. Data clearly show that in all classes of HbA1c, those who are physically fit are unlikely to develop complications (https://pmc.ncbi.nlm.nih.gov/articles/PMC6908414/ ). Physical fitness prevents many types of complications independent of weight loss or glucose control. The odds ratios for mortality across HbA1c categories varies between 1.1 to 2 in different studies whereas the odds ratios across fitness categories can even exceed 10 (https://pubmed.ncbi.nlm.nih.gov/40569873/ ). So physical fitness is much more important than glucose control. This means that even among the different glucose classes it is possible to judge who are more likely to develop complications and who are not. Then why treat everyone with high blood sugar?
But what is wrong in treating everyone? The answer depends upon the cost benefits of the treatment. The new generation drugs, mainly GLP-1RA drugs really cost a fortune. Apart from that there are psychological costs. An impression is created in the public in such a way that being irregular in taking medicine gives a guilt complex quite unnecessarily. But even more important and less well known is that under certain contexts the drugs are dangerous. In particular stringent sugar control in some trials resulted in greater mortality than control (https://pubmed.ncbi.nlm.nih.gov/18539917/ ; https://www.nejm.org/doi/full/10.1056/NEJMoa0810625 ; https://pubpeer.com/publications/417DE03905005C28E226F823C2AF63 ). Why do we still insist that everyone needs to be treated?
The answer is very clear to me. The difference between why we don’t treat every Muslim as terrorist is that so many of them are intricate part of the social economic machine. They are at responsible positions, often doing good jobs and not easily replaceable. Wherever communities are intricately linked and networked in daily functions and economics, it is beneficial for the society and for the state not to isolate any community for any reason. Perhaps Israel thinks they can do without the Palestinian community and so its behaviour is different. Ultimately what is beneficial to a state or a society in a given context at a given time decides what it politically considers ethical. Similarly in medicine the benefit matters. Treating everyone with ineffective drugs for the lifetime is beneficial for the pharma companies, so it is recommended and considered ethical. Ultimately cost benefit calculations matter. Everyone cares about selfish benefits, but sometime it is possible to fool others and that is the main use of ethics as commonly practiced. Both doctors and patients are fooled into believing that not treating a diabetic is unethical. This does not mean that selflessness or truly ethical behaviour does not or cannot exist. It does, but always in a minority. More commonly the rules of ethics are decided by the benefit of someone who is successful in fooling others to a large extent. As long as people including the practicing physicians are fools, the MNIK phenomenon will continue to exist in medicine.
My science, My way 