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Risk Taking: Can We Strike a Balance?


Many leaders and deep thinkers have written about the importance of risk in relation to creativity, enlightenment, and progress. In the words of the ancient Greek historian Herodotus, for example, "Great deeds are usually wrought at great risks." More than 2,000 years later, psychologist and philosopher William James wrote, "It is only by risking our persons from one hour to another that we live at all." Many others have encouraged us to take chances, and, in general, we admire risk takers—entrepreneurs, explorers, athletes.

But risking finances, career, or other facets of security is different than gambling with the irreplaceable—our health. We usually avoid choices that result in illness, injury, or death; we place great value in well-controlled clinical trials that identify population-based risk.

Finding the proper balance between risk taking and risk avoidance is complex. As physicians, we make such decisions for ourselves, and we often need to help patients decide when the avoidance of a risk is more burdensome than the risk itself. In office care, this might mean weighing side effects of a drug vs the drug's therapeutic effects. In sports medicine, we encourage healthy lifestyles, yet at the same time we provide medical coverage for events with predictable rates of injury. When we critically evaluate this dichotomy, can we honestly say we are representing the best interests of our athlete-patients? Perhaps our attendance at such events even legitimizes the activity.

Obviously, some sports are more dangerous than others. Without debating details here, what about boxing? Car racing (see News Briefs, page 11)? What about standing on the side of a ski hill watching young racers hurtle at 70 mph into trees and fences, knowing that the serious injury rate approaches 50%? What about watching football players whose intent is to hit other players as hard as they can? We don't need sophisticated epidemiologic studies to determine the most effective way to reduce injury!

This logic goes only so far, however. Applied too strictly, our efforts to promote safety engender another risk: that of producing beige drones with push-button adherence to rules and guidelines that extend existence but rob us of our joie de vivre.

So—what is "acceptable" risk? And what role does medicine play in the care of risk takers?

I think it's useful to draw an analogy with other subpopulations physicians are called on to treat. Whether the subset is street people or the affluent, young or old, gay or straight, smokers or nonsmokers, each patient has risk factors typical of his or her group—risks taken to variable and debatable extents by choice. Athletes are one such group. While aware of the complexities, the physician's charge is to provide the best possible care for every patient without judging the ethical underpinnings of the patient's situation or choices.

Care of the athlete-patient should also align with time-honored, accepted medical standards, free from the inherent conflict of interest engendered by the needs of the sport or team. Physicians should be selected on the basis of their desire and ability to provide top-quality healthcare to athletes and for no other reason. In providing this care, we need not endorse the level of risk that some sports entail. But to avoid ethical conflict and the appearance of conflict, we need to be careful: When the sport rather than the best interests of the athlete starts calling the shots, the physician must do what is right. This might even require leaving the venue and making public the fact that only lip service is being paid to the quality of care.

After all, risks are needed to effect change. In the words of George Bernard Shaw, "Reasonable people adapt themselves to the world. Unreasonable people attempt to adapt the world to themselves. All progress, therefore, depends on unreasonable people."

Gordon O. Matheson, MD, PhD