In the midst of the recent tsunami of financial catastrophes the question of "moral hazard" has been raised to describe how the banks, which have made very wrong investment decisions, have been insulated from their harmful consequences by government bailouts and rescue packages.

Not allowing banks to fail as a consequence of their own idiotic mistakes insulates them from the negative feedback that might better correct their behavior in the future.

So how does the moral hazard of rescuing bad banks apply to HRT? Just this: that the separation between action and consequences, particularly if the consequences are delayed for years and occur somewhat randomly, and the "rescue" from consequences are the hallmarks of moral hazard, and they apply to medicine as well as banking.

There is no longer any argument among scientists about whether HRT is associated with an increased risk of cancer: it is. If HRT contains only estrogen, then there is an increased risk for uterine cancer. If HRT contains progesterone, then there is an increased risk for breast cancer.

Furthermore, all types of HRT are associated with an increased risk for stroke and blood clots. This is not a matter of how the hormones are made (from natural or synthetic products) but rather what they do. And what they do to the post-menopausal female is "unnatural" in the context of an otherwise naturally aging body.

We know that there is an increased risk of breast cancer in the group of women who use HRT, but we do not know exactly which of these women will get the cancer. It is important to understand that we only know the statistics for the group; we do not know precisely who will get the disease, and whether or not the hormones are responsible for it.

The moral and medical hazard associated with HRT is enlarged by the healthcare system "safety net" - the treatments that are available once one of the complications of HRT occurs. Today early treatment of breast cancer produces excellent survival statistics for most patients, but it is impossible to say exactly who will live and who will die of breast cancer because statistics apply to a group, not to an individual patient.

The recent discussion of HRT offered by Oprah Winfrey in her magazine and on her TV show presents both sides of the argument about HRT, but does little to settle the question. In the end women are advised to "talk to their doctor." As a woman, and as a breast cancer surgeon, I am afraid that millions of women will come away from Oprah's show with the impression that HRT may not be so risky after all. I disagree. HRT is risky; the problem is we cannot say exactly for whom it is risky. Do you want to take the risk that the bell tolls for you?

You say you cannot sleep at night. How much more sleep do you think you will lose if you are told you have breast cancer? How much sleep will you loose worrying about how to pay for all of your treatments? How much sleep do you think you will loose if you have to undergo surgery, and possibly loose your breast, as part of your treatment? How much sleep will you loose thinking that you might not have gotten breast cancer if you had not taken the hormones in the first place?

You say you have night sweats and hot flashes. How much more uncomfortable do you think you will be if you have to have chemotherapy for four to six months? How much worse are the side effects of chemotherapy compared to the symptoms of menopause?

You say you feel emotionally labile. How nerve-racking do you think it is to be worried about every twinge and pain and change in your body, dreading that your cancer has returned? How traumatic do you think it is to loose your hair just as you are recovering from surgery on your breast, the beacon of female sexuality? How chronically afraid do you think you might be wondering if you will live, while you watch so many other women die?

Menopausal symptoms do not last forever. Certainly they are challenging, but they can be managed with diet, exercise and emotional support. And bone loss can be managed with medications that have a lower risk profile compared with HRT. You will recover from menopause, and when you do you will no longer be subjected to the slings and arrows of outrageous hormones. No statistic can ever tell you if you will be the one to survive a breast cancer, or whether you will be the one to die. Think hard about the moral and medical hazards of HRT before you commit yourself to an uncertain future, one that you might regret.