Broken Hearts: The Tangled History of Cardiac Care

Preface

Preface When I had cancer a few years ago, I was lucky in many ways. I faced no difficult decisions. As soon as the radiologist confirmed the existence of the fist-sized tumor I had first felt near my stomach, the course was clear. The tumor had to be removed. A kind surgeon quickly obliged, and I was tumor-free in ten days. When genetic analysis revealed that the tumor was not susceptible to any chemotherapy, I was spared another decision: there was no reason to try an expensive pharmacological treatment of uncertain value. Instead, I watch and wait and hope. If the cancer comes back, my surgeon has promised to try to remove it once again. Something about all this appealed to the historian in me. Mine was cancer therapy as it existed in the 1890s: find a tumor, cut it out, and hope for the best. That way of therapeutic thinking has an elegant logic and simplicity. Few areas of medicine today retain such clarity of purpose and action. I now face much more complicated decisions as an otherwise healthy 42-year-old than I did as a cancer patient. Fear of heart disease creates most of the trouble. Should I start taking a baby aspirin to prevent a heart attack? If not now, at what age? What about a statin to reduce the risk that one of my atherosclerotic plaques will rupture? I do not actually know that I have any, but as an American male, I almost certainly do. I could go to a local imaging center and purchase a CT angiogram of my coronary arteries, but this might open a can of worms. Am I ready to commit myself to a life of multiple prophylactic medications to preserve my cardiac health? And what if I ever did feel a twinge of angina? Then the dilemmas really become difficult. The decisions that all people now face, from the vitamins, supplements, and medications we take to preserve our health, to the drama of surgery and intensive care, reflect fundamental changes in medical knowledge and practice over the past half century. The capacity and complexity of medicine have been transformed. Yet the many blessings have brought their own share of curses. Patients and doctors in the early twenty-first century face exceedingly x Preface difficult treatment decisions. Will a treatment work? In what ways? How well? Is it safe? How does it compare to other options? What other factors, whether cost or quality of life, ought to be considered? Uncertainty dogs the effort to answer each of these. This book offers a historical perspective on the complexity of medical decision making. It uses the history of coronary artery bypass surgery and coronary angioplasty to expose vexing ambiguities that persist at the core of the medical enterprise, in particular the challenge of producing definitive knowledge about the efficacy and safety of medical treatments. This is a story about medical discovery, but one focused on the decision dilemmas created by the emergence of these two new treatments. An appreciation of their complexity, as seen through history, can help patients and doctors make more careful and deliberate decisions. New discoveries in the future may leave patients with easier and better choices. But it is unlikely that decision making will ever be just a question of medical knowledge and practice. Instead, medical decisions always involve priorities, values, and preferences. This history, as a result, can offer valuable lessons to historians, doctors, patients, and policy makers. ...