Reflection by Matthew Low on N=1
The CauseHealth meeting in January generated a lively and focussed debate surrounding a number of matters, all pertaining to the challenges of person-centred care. Among a number of questions that were raised and discussed included what types of evidence should inform decision-making for the individual person? How can we bridge the gap between evidence provided from population studies and their respective application to the individual? What was clear from the workshop was that population studies, especially randomised controlled trials (RCTs) are useful, but we should be cautious about exclusively relying on them to inform policies and individual decision-making.
Stephen Mumford and Rani Lill Anjum made a compelling argument against evidence-based policy. They argue that meta-analyses might show what known interventions benefit most people; however, policies are not necessarily clear on how to implement their findings and therefore a decision, through judgement, still has to be made about which intervention is best, given the evidence. The commitment to RCTs to create strict clinical guidelines was seen as building a form of rule utilitarianism, whereby one applies a rule that brings the most utility. In the case of evidence-based medicine, this would mean that an intervention would be recommended that would make most people better, leaving others with no benefit at all or even make some worse! Alternatively, a departure from adhering to such evidence-based policies may be in conflict with the circumstances of an individual case—this may cause a gap in one’s clinical reasoning. This tends towards act utilitarianism where the best act is always the one that produces the best outcome in a particular situation. This form of utilitarianism considers each case individually, rather than applying rules universally. Committing to act utilitarianism may bridge this gap. Ultimately, this would mean that the best intervention might be the one that produces the greatest outcome for a particular situation. This embraces the idea of evaluating all evidence, from population studies, clinical guidelines, one’s own clinical experience and that of the person including both parties values, thus creating a collaborative partnership, deciding the best treatment, at this particular time, in this particular context. To exercise this reasoning, Stephen and Rani lean towards moral particularism, where context and judgment are emphasised over following an absolute rule, thus epitomizing n=1, respecting individual variation and circumstances over the use of statistical analyses of population studies to inform decision making.
This is just one personal interpretation of the number of presentations given at the conference that produced such informative and interactive discussion by all involved. The conference certainly had a positive impact on me personally and I can recall one of the delegates commenting that it was one of the best conferences that they had attended, I agree. It created enthusiasm and inspiration that had previously dwindled in their clinical practice. I am certainly fortunate to be part of the project and agree wholeheartedly with Alex Broadbent, to quote:
“If the project continues to deliver events of this quality then it is in a good position to make a real contribution to both our medical and our philosophical knowledge.”