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J Med Ethics. 2007 April; 33(4): 246.
PMCID: PMC2652777

Risk in public health and clinical work

I read with interest the article by Grill and Hansson1 on epistemic paternalism in public health. It focuses on the important issue of the patient's right to know and receive information about uncertain threats to public health. However, health and environmental scientists, professional risk managers and the general public strongly disagree about the seriousness of many risks.2 Moreover, risk is an intricate concept to give information about.

There are framing effects,3 and some framing effects are related to the dimension of time.4 Risk for a certain outcome to occur varies over time, and time for outcome could be assumed to vary with different health risks such as chemicals, transportation, food safety, medical advice and prescription drug use.5 Variables such as risk and time are generally perceived differently by the individual and society,6 with a longer time horizon for public health than that for the individual, with a difference in perceived risk over time.

In this article, both a patient's right and uncertain threats to public health are discussed. Risks in public health are mostly discussed in relation to groups of people, whereas information is given to individual patients. We cannot draw conclusions about individuals on the basis of group data, as the information about risk will be very risky.

Another issue is how risk is related to clinical inferences for individual patients. A reasoning error could be made when using risk in clinical inference, as diagnosticians attempt to link observed effects to prior causes.7 In contrast with this retrospective explanation, using risk in statistical prediction entails forward reasoning because it is concerned with forecasting future outcomes, given the observed information.

Risk is encompassed in public health and in many stages of clinical work with which the patient is associated. How to choose tests, how to interpret them, how to reach a diagnosis based on tests and clinical examinations, and what treatment should be chosen based on the diagnosis—all these make the outcome uncertain, and the discussion initiated of uncertainties and communicating risk improves health outcomes both from the perspective of the patient and the doctor in public health as well as in clinical work.


Competing interests: None.


1. Grill K, Hansson S O. Epistemic paternalism in public health. J Med Ethics 2005. 31648–653.653 [PMC free article] [PubMed]
2. Renn O. Perception of risks. Toxicol Lett 2004. 149405–413.413 [PubMed]
3. Buchanan L, O'Connell A. A brief history of decision making. Harv Bus Rev 2006. 8432–41.41 [PubMed]
4. Ortendahl M, Fries J F. Framing health messages based on anomalies in time preference. Med Sci Monit 2005. 11253–256.256 [PubMed]
5. Jardine C, Hrudey S, Shortreed J. et al Risk management frameworks for human health and environemental risks. J Toxicol Environ Health B Crit Rev 2003. 6569–720.720 [PubMed]
6. Ortendahl M, Fries J F. Individual and societal time aspects in health–a low tension improves health outcomes. J Clin Epidemiol. 2006. In press [PubMed]
7. Kempainen R R, Migeon M B, Wolf FM: understanding our mistakes: a primer on errors in clinical reasoning Med Teach. 2003;25:177–181. [PubMed]

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