The BRAN Principle

Anytime one needs to make a medical decision nope, scratch that, most any decision, I believe it is important to consider all the sides of the issue. Unfortunately I find that very often people read one article or hear one story or one recommendation from someone they trust and then they just go with it without asking any more questions. I have a humanist perspective in that I don't think that anybody out there is deliberately trying to spread medical misinformation, but since there is so much conflicting information then it seems pretty obvious that the issues are more complicated than any one party is willing to admit. Thus my belief in studying it out for myself and then utilizing the BRAN principle.

In my childbirth class we were introduced to the "BRAN principle" which is to consider each potential course of action in light of the Benefits, Risks, Alternatives, and what would happen if we did Nothing (for the present). For example, while laboring with Bear I stalled out for several hours. I was having regular contractions, but was not dilating because the baby had floated up and there was no pressure on my cervix. The doctor said he could break my water, but if I didn't want that then I should go home because I wasn't progressing. He knew I was wary of interventions, so he gave me the choice. Well, the benefits of breaking my water were that the baby's head would re-engage and labor would almost certainly get moving. The risks were that without the water cushion labor was likely to get much more intense (which might affect my hopes for an unmedicated labor), and if labor did not progress as anticipated then broken water means an increased risk of infection, and thus a timeline for delivery (which could lead to needing pitocin or theoretically even a c-section). The alternative was to go home and try to rest and/or get things moving with the water sack intact. If we did nothing for the time being, well, that would mean going home. I knew that labor had to get more intense before the baby could come, and that because of the regular (if ineffective) contractions I wasn't going to be able to sleep anyway, so we opted to break my water. Was it interfereing with nature? Sure. Was it a good choice? I definitely think so. But most importantly, it was an informed choice.

Here in Alaska the public health department conducts regular screenings for Tuberculosis. It's an ugly disease, and one that has apparently held on here more strongly than in the rest of the country. I have never hesitated a moment in giving my permission for my children to be screened. If a screening comes back positive, that indicates that the person has been exposed to TB, so then they do another screen (a chest x-ray) to look for signs of actual infection (past or current). If the person has signs of infection, they put them on a medication. So far so good--I'm entirely comfortable with all of that. However, if the person does not have any signs of infection, the health department still wants to put them on 9 months of medication as a preventative/suppressive measure, in spite of the fact that the original screening has a certain rate of false positives (only some doctors will recommend re-screening before medicating). The downside of the suppressive medication is that it carries a risk of giving the person Hepatitis (aka liver failure). So they also prescribe vitamin B in an effort to prevent that possibility, and most doctors will do a blood test a month into the regimen to ensure that the liver is, in fact, not failing.
So wait, if the screening (which is safe, but may or may not give a false positive) comes back positive, then they will do an x-ray (which is more or less safe), and then regardless of the outcome of that x-ray they will prescribe a medication which is clearly only sortof safe?! Whoa, stop the train here, I think I needed to get off a couple of stops ago. Yes, I understand the desire to keep TB in check--I'm not arguing that point--but for someone with a clear x-ray, doesn't it make sense to require a second screening just to make sure before starting someone on a 9-month regimen of a medication that might kill them?!

Most medical actions (be they medications, procedures, or vaccinations) have some fairly clear intended benefits. Some have varying efficacy rates, so actual results may vary a bit, but the intended benefits are obvious. In many cases, the risks are not hard to determine either--some are decidedly larger than others, but pretty much any kind of action has some degree of risk. I think that most people are at least somewhat aware of these two sides of a choice. The parts that seem often overlooked are the alternatives (opting-out of the choice altogether, doing something else) and the always available option of doing nothing--at least for now.

Is that so very odd?



As my readers may have noticed, I have not shared my thoughts on swine flu nor the vaccination for it, nor do I intend to do so. I genuinely believe that it's best for each person to do their own study and make their own choice. However, the BRAN principle came to mind for me recently during a discussion on facebook, so I thought I would share it as something that is one of my guides in making these kinds of decisions.