Dr. Alderman [1] is to be commended for shining a light on the "prevention paradox" [2] as applied to blood pressure management, thereby increasing awareness that prevention of disease is more complicated than it appears. Preventive interventions—proven in randomized controlled trials to reduce adverse outcomes—may have their largest effect on populations while conceivably harming single patients, particularly those whose absolute risks for the outcome studied are small and for whom intervention burdens are considerable. Risk-reducing interventions are most effective in individual patients when applied to patients at high risk for developing disease and those who already have disease, whether asymptomatic or symptomatic. Aiming intervention strategies to such patients to maximize the risk-to-benefit ratio to a single patient is clearly a less effective strategy for control of many diseases but is required by physicians taking the Hippocratic Oath to care for individual patients. Dr. Alderman nicely describes this general principle as it applies to blood pressure control and the reduction of cardiovascular end points.

Another aspect of this issue that he did not emphasize is the patient's perception of risk. Patients who are averse to risk might adopt any strategy, including those with troublesome burdens, to reduce their absolute risk, even if it is small.

At the other end of the spectrum, patients who are more likely to benefit personally from the proposed intervention may refuse it. They may be sensitive to intervention burdens such as labeling effects, side-effects, expense, loss of pleasure, and other poorly defined quality-of-life effects of our well-meaning attempts to reduce the burden of disease in populations. This is particularly true in patients who are risk takers.

Physicians can easily influence patients through framing effects when describing treatment options, and I would have enjoyed reading how Dr. Alderman presents information on blood pressure reduction to patients with a minimum of powerful framing effects and how he elicits and employs patient utilities to guide his individual patients toward optimal clinical decisions.