Fourth

"What's the other side of the opportunistic cost you meant?" I went on.

"We have to consider the resource of conducting a trial. If drug companies put their effort on a few gigantic trials to prove the marginal benefit of some products, there would inevitably be less emphasis on areas that also need attention."

"And, as you used to call it, there is humanistic opportunistic cost as well," I began to see the point of my friend, "The number of suitable patient is often a limiting factor. If most of the eligible subjects participate in one mega-trial, there would not be enough patient for another potentially more important study."

"Quite right," my friend said, "And, from the society point of view, if more money is spent for drugs with marginal benefit, there would be less for other important function - education, social welfare, and so forth."

I found it difficult to find an appropriate reply.

And my friend continued, "The inevitable result is, therefore, by offering that marginal benefit to your patient at hand, you run the risk of jeopardizing the benefit of someone whom you may never meet. We call it a damage to the fourth party - the first three parties being the doctor, the patient, and the drug company."

I considered what he said for a while, "Your argument sounds familiar. Where does it come from?"

"You're right on that. Have you read the latest issue of Conversations with Charles in Clinical Medicine?" L smiled.

"Yes, right, that little article by Coemgenus. It used to appear on the last page of that official journal of the Royal College of Physicians of London." I said, and, after a moment of silence, I added, "Too bad Coemgenous is now retired and that fictitious Charles died on Mont Blanc."

"Very sad. Another Licht goes off." With that final remark, I found L walked away and gradually disappeared in the darkness.

Alas, unlike Charles, I am sure I shall see my cynical friend again in the future.

PS. Interested visitors should also read Clinical Medicine 2010; 10: 645-646.