title: Medical Machiavellianism: the tradeoff between benefit and harm with targeted chemotherapy.
abstract: Machiavellianism is a word synonymous with the phrase "the end justifies the means", and in this article we have coined the term Medical Machiavellianism to describe the 'cruel-to-be-kind' administration of toxic chemotherapeutic agents in apparent violation of the precept first do no harm, while acknowledging the 'dirty hands' dilemma of having to decide between and choose the lesser of two evils in the setting of advanced cancer--i.e. to treat or not to treat. The perception that 'targeted' therapies are relatively non-toxic and therefore respect the Hippocratic First Commandment by virtue of their narrow selectivity is belied by their often inherent promiscuity, addressing multiple targets either inadvertently or deliberately, which may result in multiple side effects. The remarkable success of immunotherapy may have taken the bloom off the 'targeted agent' rose, however due to a lack of other approved treatment alternatives the toxicity of these agents may be overlooked or, at least, undervalued, especially given that the official measure of treatment success in oncology is overall survival (OS), not quality-of-life improvements. By analogy with the MACH-IV personality survey (1970), [1] which measures high and low Machiavellian orientation, we have defined in this article a rudimentary MACH scale for selected targeted chemotherapies, based on the means-to-ends ratio of toxicity and benefit. It is our hope that this comparison between targeted agents will itself function as a means to an end--to help oncologists strike the right balance between efficacy, toxicity and quality of life in the management of their patients.
authors.affiliation: EpicentRx, Inc., Mountain View, CA, USA.
authors.forename: Bryan
authors.initials: B
authors.lastname: Oronsky
authors.affiliation: Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Corey
authors.initials: C
authors.lastname: Carter
authors.affiliation: EpicentRx, Inc., Mountain View, CA, USA.
authors.forename: Anna
authors.initials: A
authors.lastname: Scicinska
authors.affiliation: InterWest Partners, Menlo Park, CA, USA.
authors.forename: Arnold
authors.initials: A
authors.lastname: Oronsky
authors.affiliation: CFLS LLC, San Jose, CA, USA.
authors.forename: Neil
authors.initials: N
authors.lastname: Oronsky
authors.affiliation: EpicentRx, Inc., Mountain View, CA, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Lybeck
authors.affiliation: EpicentRx, Inc., Mountain View, CA, USA.
authors.forename: Jan
authors.initials: J
authors.lastname: Scicinski
mesh_terms: D000970:Antineoplastic Agents / Q000627:therapeutic use* / Q000633:toxicity*; D006801:Humans; D058990:Molecular Targeted Therapy / Q000009:adverse effects*; D009369:Neoplasms / Q000188:drug therapy* / Q000401:mortality; D011788:Quality of Life
chemical_list: D000970:Antineoplastic Agents
keywords: adverse events; cancer; medical machiavellianism; risk to benefit
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