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BAD LUCK IS THE MOST IMPORTANT CAUSE OF ALMOST ALL DISEASE

By Ståle Fredriksen
MD and Research Fellow at The University of Oslo

LIFE IS NOT FAIR and health is not better. People who are ill are often accused of causing their own illness – this is unreasonable. Ill people have most often had bad luck.

THERE IS NOTHING MYSTERIOUS or magic in all of this. Illness that occurs because of bad luck occurs through ordinary cause-effect mechanisms. The cause can be infections, cell changes, artery blockage or accidents. The problem is that we do not control these cause relations. Bad luck stands in contrast to control, and we have less control over our health than we think. Hence no magic. There is nothing that someone has in them that makes them extra vulnerable to bad luck. Bad luck is all that is not under control.

Ill people are often accused of causing their own disease. This is especially the case with lifestyle diseases. In the wisdom of the aftermath everybody knows that it was the fatty foods they ate, salt, smoking, overweight or inactivity that was the direct cause of the neighbour’s heart attack. The neighbour can only thank himself for his misery. He cannot even blame it on coincidence, but it has to bear all the responsibility himself.

This attitude is both unreasonable and false. It leads to unnecessary suffering and a harder society. As if it is not enough that those who are ill have to carry the burden of being ill; they also in addition have to bear the responsibility for causing the illness. This division of responsibility is built on the wrong impression that everyone gets the health they deserve, and that everyone deserves the health they get. In one sentence: This attitude builds on the belief that good luck and bad luck do not play any role in medicine. This is false. Bad luck is the most important cause of nearly all illness.

THERE ARE THREE BASIC CAUSES of bad luck in medicine. The first group of causes is causes we cannot influence. The other group of causes is causes we know nothing about. The third group of causes is causes that are chaotic. Based on this I will specify three types of bad luck. The first is constitutional bad luck. This is bad luck with genes, immune system, or other inherited factors that we cannot influence.

The second type of bad luck is situational bad luck. This is bad luck because of epidemics, accidents and other events that we end up in.

The third kind of bad luck is consequence-bad luck. This occurs when the consequences of our acts are determined by not-controllable influences. Cot death is a good example of it. We know that a small minority of children that sleep on their stomachs will die from cot death, but nobody can know on beforehand which one will die. Cot death, in other words, is to a high degree a question of good and bad luck.

It is not possible in practice to distinguish between these three types of bad luck. They are often mixed with one another. But the division makes it possible to see the difference between some basic types of bad luck.

All the types have one thing in common: It blurs the relationship between the act and the consequence. Simply put: When good and bad luck are in question, we do not necessarily get what we deserve. This goes for the good and the bad. But in medicine it is the «badness» that is of interest. For example, it is the case that only one out of ten smokers gets lung cancer. Didn’t this single one then have bad luck?

Here one should be aware of the fact that the relationship between smoking and lung cancer is one of the strongest cause-effect relations that we have. The cause-effect connection between overweight and heart attack or stress and high blood pressure is for example much weaker. In general, this is typical of biological cause-effect connections. They are rarely absolute. Most often they demonstrate themselves as tendencies at best; they are demonstrated only when one counts many cases.

THIS IS WHAT ONE TAKES ADVANTAGE of when one calculates risks in medicine. One counts many cases and finds a relative number. The decisive strength of these calculations lies in the fact that they can identify not-absolute cause-effect relations. They can identify the causes that only sometimes – under unknown conditions – have importance. Examples of such cause-effect relations are precisely the connections between smoking and lung cancer and connections between sleeping on the stomach and dying of cot death. These cause-effect relations are real, but not absolute. Therefore it is legitimate to advice people to stop smoking and to ask parents to lay their babies to sleep on their backs.

There are, however, some clear limitations when it comes to the validity of such calculations, limitations that rarely get the necessary attention. The first limitation is that for each patient it is not the «many counted cases» that matter. It is myself – or the neighbour – that matters.

The second limitation is that the risk model assumes that life is just. This limitation is more important for two reasons. Firstly it is not easily noticed. Secondly, it has large moral consequences. Risk calculations are based on games: ordinary games like throwing of dice or lottery. This is why it is usual to describe the medical decisions as a game where one knows probabilities, stakes and results, and where the only thing left is to evaluate these factors up against each other.

LET US SAY that you are 65 years old and have a moderately increased cholesterol level. The question is whether you are willing to pay the price (a tablet every day and mild side effects) to move from a lottery where you can draw from a box that contains 80 white and 20 black balls, to a lottery where you draw from a box that contains 90 white balls and 10 black balls. The black balls represent a heart attack in the course of ten years.

Let us say that you choose not to start treatment and that after six years you get a small heart attack. My assumption is that many – probably you included – would say that you have nothing to complain about. You took a calculated risk – and lost. If anything, you have yourself to blame.

This division of guilt is very important. It is not only based on the assumption that medical decisions can be interpreted as a game; it is also based on the assumption that the life is a just game. Only when you loose a just game do you loose the right to complain. If you loose (what turns out to be) an unjust game, you have every right to complain about life’s injustice.

It is justice that legitimizes the inference from insecurity to responsibility; it is exactly this injustice that bad luck sabotages. The small heart attack can be blamed on a genetic disposition, an infection in the blood veins, a thrombosis that got loose, or that you did not start the treatment; or, most likely, all these factors in combination with a long number of known and unknown factors.

THE POINT is that we only control a small section of these factors. Therefore we do not get the health we deserve, and we do not deserve the health we get. Health is first and foremost a question of good and bad luck, at least within the frame given by the society one lives in. (But at bottom, this is the biggest coincidence of all, nothing is more important to your health than if you are born in welfare Norway or in the middle of an African hunger catastrophe).

We deserve neither our health nor our illnesses. Both are determined by factors beyond our control. This is why it is unreasonable to blame those who are ill for their illness. It is more than enough that they have to suffer their disease. There is no need to increase their misery by demanding that they carry the responsibility for having caused their own illness. Such a distribution of responsibility is unreasonable, both morally and in relation to what has actually happened. Life is unjust, and health is also. The most important is to show compassion. Not in the least since you yourself could find use for the compassion of others before you know it.

ISSN 1504-5307