Postgraduate Medicine

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Contributory cause: Unnecessary and insufficient

Richard Riegelman

To cite this article: Richard Riegelman (1979) Contributory cause: Unnecessary and insufficient,
Postgraduate Medicine, 66:2, 177-179, DOI: 10.1080/00325481.1979.11715231

To link to this article: https://doi.org/10.1080/00325481.1979.11715231

Published online: 07 Jul 2016.

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 INTERPRETING MEDICAL STUDIES
A Series

Contributory cause: Unnecessary and insutficient

Can cigarettes cause cancer? Can cholesterol cause coronary artery disease? Can chemicals cause congenital
defects? The clinician is constantly confronted with controversies over cause and effect. To criticaUy evaluate a med-
ical study, the reader must understand the clinical concept of cause.

Richard Riegelman, MD, MPH
Whé. does clinical cause and effect
mean" The clinical concept of cause
is an , npirical definition known as
contributory cause. 1 It requires ful-
fillment of the following criteria. ( 1)
The attribute referred to as the
cause has been shown to precede the
effect. (2) Altering only the cause
has been shown to alter the effect.
Applying the criteria for
contributory cause
lt may seem simple to establish that
a cause precedes an effect, but as
the following hypothetical examples
show, investigators can be fooled.
A retrospective study of drugs
taken within the week preceding
myocardial infarction is conducted
in an attempt to identify the precipi-
tating causes of the disease. In this
study, 500 patients with myocardial
infarction are compared with 500
patients hospitalized for elective
surgery. The investigators find thal
the patients with myocardial
infarction are ten times as likely as
the contrais to have taken aspirin or
antacids during the week preceding
admission. They conclude that tak-
ing aspirin or antacids is associated
with subsequent myocardial infarc-
tion.
The investigators believed they
had established the first condition
for demonstrating causation, ie, that
the cause preceded the effect. But
had they? If subjects had angina
prior to infarction, they might have
misinterpreted the cause of the pain
and tried to alleviate it by self-
medication with aspirin or antacids.
That is, the medication might have
been taken to treat the disease and
Fourth in a series of five articles on
interpreting medical etudies
its use might not have truly pre-
ceded the disease. This study failed
to establish a prior, or antecedent,
cause because it did not distinguish
whether the disease led the subjects
to take the medication or whether
taking the medication precipitated
the disease. This example illustrates
the difficulty in separating cause
and effect frequently encountered
with retrospective studies.
Prospective studies have an ad-
vantage in that the possible cause is
established before the effect is expe-
rienced. The following example il-
lustrates, however, that even with
prospective studies there may be dif-
ficulty in determining whether the
"cause" preceded the "effect."
A group of 1,000 persans who
have stopped cigarette smoking
within the past year and 1,000 cur-
rent cigarette smokers matched for
total pack years of smoking are
fol/owed for one year to determine
the frequency of development of
lung cancer. This disease develops
in 5% of those who stopped smok-
ing cigarettes, compared with 0.1%
of the contrais. The investigators
conc/ude that they have demon-
strated thal stopping cigarette
smoking is a prior attribute associ-
ated with the deve/opment of lung
cancer. Therefore, they advise cur-
rent smokers to continue smoking.
In this study, stopping cigarette
smoking appeared to occur prior to
the development of Jung cancer. But
what if the smokers stopped smok-
ing because of symptoms produced
by Jung cancer? If this were true,
then Jung cancer would have
brought about stopping smoking
and not vice versa. Thus, one must
be careful in accepting that the hy-
pothesized cause preceded the
effect.
continued

VOL 66/NO 2/AUGUST 1979/POSTGAADUATE MEDICINE 177


Establishing that
cause preceded affect is
particularly difficult
in retrospective studies.
--.
J!f
----
cc!.:G-:>
-
lo:_~_:__, ------~-- ~
Illustration: Niculae Asciu
The criteria for contributory
cause also require demonstration
that altering the cause alters the
effect. The following example illus-
trates how this criterion can be
fulfilled.
Studies show that town X, which
takes ils drinking water from a
nearby lake, has five times as high
an incidence of ulcerative colitis as
similar, neighboring town Y, which
uses weil water. After town X
switches to weil water, its incidence
of ulcerative colitis falls to the
178
MEDICAL STUDIES CONTINUED
......... __...__..... _:::;
----
--
same leve/ as town Ys. The investi-
gators are disappointed when re-
viewers of their study conc/ude that
even though the study was weil
done, the criteria for contributory
cause were not fu/fi/led. The re-
viewers argue that how or why lake
water causes ulcerative colitis was
not explained.
If they performed the study prop-
erly, these investigators have ful-
filled the criteria for contributory
cause. Drinking lake water was
shown to precede the development
VOL 66/NO 2/AUGUST 1979/POSTGRADUATE MEDICINE
of ulcerative colitis, and altering the
water supply altered the effect. The
concept of contributory cause does
not require, as the reviewers con-
tended, demonstration of the imme-
diate or intermediate mechanism of
the effect.
Historically, there are numerous
examples in which lives were saved
by altering the contributory cause
without understanding the immedi-
ate mechanism of disease. Cholera
was controlled through hygiene be-
fore its bacterial etiology was under-
stood, malaria was controlled by
swamp clearance before its trans-
mission by mosquito was appreci-
ated, and scurvy was prevented with
citrus fruits before Limeys ever
beard of vitamin C .
PitfaUs in applying strict rules
of logic
The clinical concept of cause known
as contributory cause is an empirical
definition which differs from the
strict rules of causation required in
formai logic. Formai logic requires
two conditions in addition to the two
required for establishing contribu-
tory cause. 2 (1) The cause must be a
necessary element in bringing about
the effect. If the cause is absent, so
will be the effect. For example: If
smoking does not occur, lung cancer
will not occur. This is known as nec-
Richard Riegelman
Dr Riegelman is assistant professor and di-
rector of research, department of health care
sciences, George Washington University
Medical Center, Washington, DC.
If the clinical concept of cause requirecl that the
cause be necessary and sutficient, identification of
any clinical factors as causes of disease would be
practically impossible.
essary cause. (2) The cause must be
a sufficient element to bring about
the effect. If the cause is present, so
will be the effect. For example: If
cigarette smoking occurs, so will
Jung cancer. This is known as
sufficient cause.
If the clinical concept of cause re-
quired demonstration of necessary
and sufficient cause, identification
of any clinical factors as causes of
disease would be practically impos-
sible. The following hypothetical ex-
amples illustrate what can occur
when investigators adopt rigorous
standards of logic in determining
causation.
ln a study of the risk factors for
coronary artery disease, investiga-
tors identify from a population of
10,000 patients who have had myo-
cardial infarction 100 individuals
who experienced infarction despite
normal blood pressure, normal cho-
lesterol leve/, regular exercise, no
smoking, type B personality, and no
family history of coronary artery
disease. The investigators conclude
that they have demonstrated that
hypertension, high cholesterol leve/,
/ack of exercise, smoking, type A
personality, and positive family his-
tory are not causes of coronary ar-
lery disease, since not every patient
who has had myocardial infarction
possesses one of these risk factors.
Let us assume that ali of these
factors have been shown to fulfill the
criteria for contributory causes of
coronary artery disease. The investi-
gators in this study used as their
concept of cause the necessary cause
VOL 66/NO 2/AUGUST 1979/POSTGRADUATE MEDICINE
of formai logic. Contributory cause
does not require that ali those who
are free of the cause be free of the
effect. The failure of known causes
to predict ali of the cases of dis-
ease points up the limitations of cur-
rent knowledge of the contributory
causes of coronary artery disease. lt
does not, however, negate those fac-
tors for which there is evidence of
contributory cause, since a known
contributory cause may not be pres-
ent in each and every case.
A similar argument relating to
the concept of sufficient cause is
made in the following hypothetical
example.
ln a study of a military epidemie
of a new strain of meningococcal
infection, /0,000 otherwise healthy
men are identified as having throat
infections with the organism. Half
these men are randomly assigned to
a treatment group, and half are as-
signed to a placebo group. Meningi-
tis did not develop in any of the
treated patients during the next 12
months, but did occur in 5% of the
placebo group. The investigators
conclude that a cause-and-effect re-
lationship has not been established,
since meningitis developed in on/y a
small percentage of the untreated
patients.
These investigators have adopted
the criterion of sufficient cause from
formallogic, which requires that the
mere presence of the "cause" always
be associated with the "effect."
Even in infectious disease, a contrib-
utory cause may not always lead to
the effect. The investigators in this
study have established that the new
organism was a prior attribute and
that eliminating the "cause" elimi-
nated the "effect." This is an ade-
quate proof to establish the new or-
ganism as a contributory clinical
cause even if the criterion of suffi-
cient cause is not fulfilled.
Summary
Contributory cause is a clinicaUy
useful concept of causation. It re-
quires demonstration that (1) the pre-
sumed cause precedes the effect and
(2) altering the cause alters the
effect. It does not require that aU
those who possess the contributory
cause experience the effect. It does
not require that aU those who are
free of the contributory cause be free
of the effect. In other words, a clin-
icat cause may be neither neces$llry
or sufficient but it must be contribu-
tory.
Next: The fallacy of free extrapolation.
Address reprint requests to Richard Riegel-
man, MD, Department of Health Care Sci-
ences, George Washington University Med-
ical Center, 1229 25th St NW, Washington,
DC 20037.
References
1. Lilienfeld AM: Foundations of Epidemiol-
ogy. New York, Oxford University Press,
1976, p 250
2. Murphy EA: The Logic of Medicine.
Baltimore, Johns Hopkins University Press,
1976, p 180
179