Thinking about guidelines

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National Geographic Wild, Trafalgar Square in London, January 28, 2016.

On October 24, 2016, the CauseHealth crowd met with a small group of other philosophers, healthcare practitioners, and members of the guidelines community. We had a rousing discussion that lasted the whole day, with few pauses and enthusiastic participation from all in attendance. We talked about several issues with how guidelines are developed and implemented and how we thought philosophy could be relevant in solving those issues.

It is difficult to summarize the discussion in a few words—the topics were wide-ranging and participants shared complex ideas from multiple perspectives. I’m going to highlight here some of the themes that came up more than once, and to give an idea of where the group thought the discussion should go next.

Read more of Samantha’s review of the workshop
Read Rani on Real v. Ideal Guidelines
Read Elena on How Decisions are Made
Read Karin on the Ethics of Reduction
Read Stephen on the Notion of Guideline
Read Roger on the Challenges to Come
Read Fiona on Guidelines in Situ
Read Sarah on Truth, Simplicity and Personalization
Read Anna Luise on Challenging Multi-Morbidity
Read Stephen on Standards for Regulation
Read Samantha on Analogies and High-Stakes Inferences

It seems that there are two ways to think about the relationship between philosophy and healthcare guidelines. First, philosophy can be a tool for the ongoing work to improve guideline development and implementation. Philosophers have something to say about the kinds of reasoning required for assessing and systematizing available evidence, and the kinds of reasoning that physicians and institutions who put guidelines into practice require.

Members of our group raised questions about the reasoning involved. For instance, what kinds of evidence are needed for the development of useful guidelines? Elena spoke of the importance of the relationship between all levels of research, including basic science and the clinic, when creating and assessing evidence for guidelines. As Elizabeth commented, the problem of how to relate the parts to the whole is a pervasive difficulty when relating evidence to practice. A vigorous debate arose about how different kinds of evidence should be weighed: Rani argued for the importance of having a clear understanding of causal relationships, what we think they are and when we think they apply. Jeremy argued for the importance of frequency evidence when it comes to guidelines, but he agreed that clarity was important, especially if we want to prevent the misuse of such evidence.

Sarah raised the question of how we can determine when enough evidence has been provided to make a decision about whether a guideline applies—how many differences between the patient and the population can be allowed before the guideline ceases to be useful? Samantha talked about the importance of the analogies we use, and that how we decide when one patient is like another determines whether and when we think the same rule will apply to both cases.

Which brings us to a second purpose for philosophy: philosophy has tools for critique and analysis, useful for when it comes to understanding what guidelines are supposed to do and whether they accomplish these goals. Karin introduced the problem of reconciling phenomenological aspects of illness with biomedical categories used to decide which guidelines apply to which patients. Mary brought up a similar point in relation to mental health care, a context in which the categories used to choose a guideline are often not subtle enough to capture the way individual patients express mental health symptoms and clinician experiences on the front lines. Guidelines do not, and sometimes cannot, capture details of clinical care in a way that makes choosing the appropriate guideline for a particular situation easy.

The nature of guidelines and their purpose was a general theme in the discussion. Stephen wondered how we integrate the need for generalizable rules with the particulars of the clinical context, and we thought about how philosophical approaches to moral particularism and virtue ethics might help. Sieste pointed out that when inferences have to be made, in the development and even more importantly when physicians make decisions about the implementation of guidelines, different kinds of reasoning produce importantly different results. Fiona discussed her research into the role that community norms play when institutions and individual practitioners decide how guidelines should be put into practice. Roger pointed to the difficulties faced by clinicians who have to interpret guidelines: because clinicians are concerned with helping patients achieve their goals for healthy functioning, guidelines that are grouped by such goals may be better guides for clinicians than guidelines that sort patients by disease categories, for instance.

One important worry raised by multiple members of the group was how to reconcile the ideals and the reality of guidelines in healthcare. Beth drew us a picture of how guidelines are developed, through a long process that begins with raising a question and that seeks to integrate diverse perspectives and a variety of kinds of evidence. The goals of guidelines developers are to provide recommendations for care to help physicians, but not to produce rigid rules for care. But this differs from how guidelines are often used—as just those rigid rules, obedience to which seems to be necessary for clinicians worried about being seen as providing less than optimal care to their patients. Can we have guidelines that do not make recommendations, but only provide options, as Jeremy suggested? If we take the particularist route, what options are available to us, as Stephen inquired? And where is the fine line between enough information to be helpful and too much information?

As a final note, some other, deep and difficult philosophical questions came up a number of times during discussion as well: What do we mean when we say ‘true’ effect? How do we determine what the ‘best’ evidence is?

So, we covered a lot of ground last October—we will take the discussion forward and to the next level in a year’s time, when we have a conference to tackle issues relating to the philosophy behind healthcare guidelines in Oxford, October 3-4 2017. We have invited four keynote speakers to frame the conference who will bring diverse perspectives to the table: Nancy Cartwright, Trish Greenhalgh, Mike Kelly and Brian Broom. Watch for twitter announcements and our events page for further details as the program develops.

Comments from the CauseHealth crowd and other workshop attendees will follow in the coming days, and you are invited to share your perspective as well: what questions do you think our upcoming conference should address? Add a comment below and we will post it here, or email us at causehealth@nmbu.no

Attending the October 24 workshop were:

Rani Lill Anjum (CauseHealth, Philosophy)
Elena Rocca (CauseHealth, Pharmacology and Biology)
Karin Engebretson (CauseHealth, Public Health)
Stephen Mumford (CauseHealth, Philosophy)
Samantha Copeland (CauseHealth, Philosophy)
Mary Chambers (Mental Health Nursing)
Jeremy Howick (Philosophy, Nuffield)
Roger Kerry (CauseHealth, Physiotherapist)
Elizabeth Matovinovic (GRADE)
Fiona Moffatt (Physiotherapist, Social Sciences)
Beth Shaw (NICE, GIN)
Sietse Wieringa (GIN, GP, Interdisciplinary Research)
Sarah Wieten (Philosophy, CHESS)

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