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And we do not recognise, as readily, the decisions that were not even mooted, as we do those that were discussed even though not acted upon I know what my doctor did last time I had an appointment with him I recall a decision about cholesterol levels But I do not know what, if any, other decisions he made, let alone could have made, during that appointment I would have to undertake extensive research, or consult another doctor, in order to begin to have an idea about what other decisions were taken, or should have been taken It will be objected that this involves giving risk-taking too wide a meaning It could become dif cult to discover any incident or occasion that could not be properly analysed in terms of risk First, the focus is on decision-making rather than risk.

Presenting Chief Complaint: Burning & Rawness Lichen planus (LP) Burning pain, rawness, postcoital bleeding. Red, well-demarcated lesions in vulva, vagina, and gingiva. On keratinized skin, at-toped papules with lacy white dome; lesion-speci c punctuate allodynia. Normal vagina. Irregular heart s line with glossy moist well-dermacated red inner labial fold. Greater mechanical than punctate allodynia. Lichenoid pattern: band-like lymphocytic in ltrate in the upper dermis with basal cell damage, cell death, or vacuolar alteration. Biopsy helpful; histology similar to lichen sclerosis.

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offspring per female. Results showed that the CEA-based LOAEC was mostly more sensitive than either population parameter although the response was toxicant speci c. There was a signi cant linear relationship between CEA and the population level effects, demonstrating a linking of energy-based suborganism effect criteria with effects emerging at higher levels of organisation. At the time of writing no study comparable to this has been performed with sh. However, temporary and short-term reductions in energy reserves (metabolic disorders) have been recorded in sh during and following episodic exposures to sublethal contaminants (Sancho et al., 1998). In particular, heavy metals have been shown to exert a wide range of effects on sh metabolism (Soengas et al., 1996). Some marine sh species subjected to rapid decreases in water temperature enter a hypometabolic state to resist the challenge (Sayer & Davenport, 1996). Whether this physiologically-driven behaviour would also be protective against contaminant exposure has not been tested. Muscle energy metabolism can sustain prolonged effects following shock contaminant exposure, with, in some cases, full recovery to pre-exposure levels never being attained (De Boeck et al., 1997). Clearly more studies are needed to examine the effects of xenobiotics on SfG, AEC and CEA. These measures can be useful although their use must be related to the sh s natural history. Work also needs to be undertaken to clarify some of the inconsistencies highlighted in the literature to date. The bene t of each of the methods is that a reduction in SfG or AEC can be correlated to the body burden of xenobiotic or induction of detoxi cation system, and in the case of CEA has been linked to population level responses. Cellular energetics and energy budgets, therefore, offer an important link between these and higher order effects.

Second, the key point, it is submitted, is the potential that this extended analysis gives for preventive and proper professional practice It is not or, only exceptionally, rarely a simple question of should the patient be given the medication Medication is proposed, for example, to combat symptoms of schizophrenia But the medication might cause side effects A risk judgement that that medication is not appropriate, at that time, for that patient, does not, however correct and properly reached a decision, justify inaction evermore thereafter The patient still has distressing symptoms An alternative decision, likely to involve a risk, should be considered, until an active risk can be taken Even then, usually, that is not the end of it Most likely another risk decision should be considered from the new state of affairs achieved by the last risk Yes, risk-taking involves individual decisions.

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