Evidence & Judgment Why Science Alone Does Not Finish the Clinical Decision

A Familiar Dilemma * CLINICAL SCENARIO * A 72-year-old man is brought to the outpatient clinic with progressive breathlessness over three weeks. He has a history of ischaemic heart disease, stage 3 chronic kidney disease, and type 2 diabetes. His current medications include three antihypertensives, a statin, antiplatelet therapy, and insulin. Echocardiography reveals reduced ejection fraction. Evidence-based guidelines clearly recommend initiating an ACE inhibitor and a beta-blocker. The evidence for these agents in heart failure is unambiguous — drawn from landmark randomised trials involving tens of thousands of patients. But the patient’s creatinine is already elevated. He lives alone, is reluctant to add more medications, and asks whether he might manage with lifestyle changes alone. His daughter, present at the consultation, is worried about pill burden and side effects. The guideline says one thing. The patient sitting before you says another. At this moment, evidence alone canno