[HSF] Aprotinin

[Rwmfglycar at aol.com]

Hal,
I have been following the Aprotinin arguments with interest and steadfastly  
trying not to get involved. 
I will make only  6 points.
1)We all know that when a service is paid for that fact influences the  
decision to perform the service. For some malpractice lawyers and  some  
interventionalists it does so completely disproportionately. 
2) Some "consultants" are paid flacks. Most plaintiff expert witnesses  fall 
into this category. However, large and ethical companies (and they do  exist) 
know that they get far more from a consultant who gives them his honest  
expert opinion however much they don't like what they hear. So, the  opinions of 
people paid by another body are not automatically  disqualified  if they happen 
to serve the interests of the payer of the  consultant's fee. I trust Ben's  
vanity as a scientist more than I fear the  evil influence of aspirin money.
3) From your personal experience Hal, after a couple of bad cases of ATN,  
you developed a significant fear of using Aprotinin.
David Harris and others have used Aprotinin freely and are sure they have  
not seen ATN and do not fear using it.
4) I know both you and David as good surgeons practising your craft  honestly 
and well. Neither you nor David can make a definitive statement  about  
Aprotinin and ATN. I believe you know that I am a great supporter of  individual 
and personal  experience in medical decision making. I also  firmly maintain 
that  when we rely on personal experience we must  ALWAYS be aware of the 
limitations of our biasses, even as we use them to  guide our decision making.
5) We all know how deeply flawed the evidence is for many definitive  
statements that come out of the literature or in the form of guidelines, but we  must 
always be on the watch for the piece of evidence that finally provides  a new 
truth, a new paradigm, to follow. (Mangano's paper is not  that).
6) We also all know that the risk of personal damage or danger is, by  the 
ethics of our profession, not supposed to be a factor when we make decisions  
for the good of our patients.    (Doctors who fled the plague  were stoned by 
the populace when they returned). I believe that making decisions  for patients 
should not be influenced by what the crooks are up to and what they  might do 
to us. I can honestly say that that is what I did in 2 score years and  ten of 
surgery. But I said "I believe"; that is not the same as saying "you  should 
believe!"
I suspect this may not help,
Bob