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Can the Development of Practice Guidelines Safeguard Patient Values?

Published online by Cambridge University Press:  01 January 2021

Jodi Halpern
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Extract

In response to increasing use of practice guidelines in medicine, physicians have focused their attention on how these guidelines can restrict their medical practices. However, guidelines not only restrict physician discretion, but they also limit the treatment options available to patients. As a result, treatments which patients consider beneficial may not be recommended; for example, some hysterectomies for abnormal uterine bleeding, and cataract surgery in patients with dementia. When guidelines are used to determine which medical treatments a health care organization or insurer will cover, these recommendations become restrictions. Thus far, guidelines have been developed without adequate attention to the impact that their restrictive use has on diverse patient values.

Two significant tensions in current medical ethics relate to the inclusion of patient values in practice guidelines. First, a tension exists between the traditional paternalistic model of care, in which the physician judges unilaterally which treatments will benefit the patient, and the more recent autonomy model, in which the physician elicits the individual patient's health values to determine which treatments will be beneficial.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 23 , Issue 1 , Spring 1995 , pp. 75 - 81
Copyright
Copyright © American Society of Law, Medicine and Ethics 1995

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References

Bernstein, S.J. et al., Hysterectomy, A Literature Review and Ratings of Appropriateness (Santa Monica: RAND, 1992), p. 78.Google Scholar
Lee, P.P. et al., Cataract Surgery, A Literature Review and Ratings of Appropriateness and Cruciality (Santa Monica: RAND, 1993), p. 61.Google Scholar
Woolf, Steven, “Practice Guidelines: A New Reality in Medicine, III Impact on Patient Care,” Archives of Internal Medicine, 153 (1993): 2646–55.CrossRefGoogle Scholar
Uhlmann, R.F. Perlman, R.A. Kane, K.C., “Understanding of Elderly Patients’ Resuscitation Preferences by Physicians and Nurses,” Western Journal of Medicine, 150 (1989): 705–07; and Secklar, A.B. et al., “Substituted Judgment: How Accurate are Proxy Decisions?,” Annals of Internal Medicine, 115 (1991): 92-98.Google Scholar
Leape, L.L. et al., Coronary Artery Bypass Graft: A Literature Review and Ratings of Appropriateness and Necessity (Santa Monica: RAND, 1991).Google Scholar
John Rush, A. et al., Depression in Primary Care, Clinical Practice Guideline, Number 5 (Rockville: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, No. 93–0550, Apr. 1993).Google Scholar
Jacox, Ada Carr, Daniel Payne, Richard, co-chairs, Management of Cancer Pain, Clinical Practice Guideline, Number 9 (Rockville: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, No. 94-0592, Mar. 1994).Google Scholar
Lee, et al., supra note 2.Google Scholar
When panels rate the risks and benefits of treatment as “about equal,” the treatment is rated as “uncertain” or “equivocal” (id., p. vi).Google Scholar
Id., pp. 52–53.Google Scholar
Id., p. vi.Google Scholar
Jacox, et al., supra note 7.Google Scholar
Id., p. 24.Google Scholar
Id.Google Scholar
Id., p. 10.Google Scholar
Rush, et al., supra note 6.Google Scholar
“As with a medication trial, if psychotherapy alone is selected as the initial treatment, the practitioner is advised to monitor symptom response. If the psychotherapy is completely ineffective by 6 weeks or if it does not result in nearly a full symptomatic remission within 12 weeks, a switch to medication may well be appropriate since there is clear evidence of its specific efficacy” (id., p. 73). The guidelines describe a similar timetable for reassessing the use of combined psychotherapy and medication on page 93.Google Scholar
The guidelines do note that psychotherapy may help rectify “ongoing psychosocial difficulties that contribute to some depressive symptoms, such as pessimism, low self-esteem, or marital difficulties.” However, the next statement is that “the likelihood that adjunctive therapy is indicated may be better gauged once the depressive syndrome has largely resolved with medication, since medication alone improves psychosocial difficulties in many patients” (id., p. 89).Google Scholar
Id., p. 72.Google Scholar
An alternative approach to guidelines development, which includes patient preferences, has been suggested by Eddy. See Eddy, David, “Designing a Practice Policy: Standards, Guidelines and Options,” JAMA, 263 (1990): 3077–84.CrossRefGoogle Scholar
Bernstein, et al., supra note 1, pp. 72–72.Google Scholar
Redelmeier, D.A. Shafir, E., “Medical Decision Making in Situations that Offer Multiple Alternatives,” JAMA, 273 (1995): 302–05.CrossRefGoogle Scholar
Kaplan, S.H. Greenfield, S. Ware, J.E. Jr., “Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease,” Medical Care, 27 (1989): S110–S127.CrossRefGoogle Scholar
Haynes, R.B. Taylor, D.W. Sackett, D.L., eds., Compliance in Health Care (Baltimore: Johns Hopkins University Press, 1979).Google Scholar
Peters, William Rogers, Mark, “Variation in Approval by Insurance Companies of Coverage for Autologous Bone Marrow Transplantation for Breast Cancer,” N. Engl. J. Med., 330 (1994): 473–77.CrossRefGoogle Scholar