The Notion of Guideline

Stephen Mumford, Thinking about guidelines:

I was particularly interested in different models of decision making and the implicit assumptions we make about how this should work. In particular, the notion of a guideline seems up for grabs and I think it important that we do not inadvertently slip into one way of operating guidelines without philosophically scrutinising the idea. It would be easy, for instance, to interpret a guideline as a general rule, along the lines of ‘thou shalt not kill’. This sort of rule is interpreted as strict and exceptionless. The workshop confirmed that, irrespective of any intentions of those who write guidelines, there are pressures to follow them exactly. Failure to do so is often taken as a failure that leaves a clinician liable for any subsequent unfavourable outcome.

In moral philosophy, the idea that right and wrong can be defined by a system of rules has been challenged. If nothing else, it’s obvious that two rules could easily come into conflict and one of them has to be sacrificed. Telling the truth is good but not necessarily if a killer asks for the whereabouts of any intended victim. There could be circumstances in which it is right to lie. In response, Dancy proposed a theory of moral particularism, a view in which each situation has to be understood as complex and requiring its own moral assessment, which could well be unique and unrepeatable. I would favour coupling this with a strongly dispositional version of virtue ethics. Telling the truth tends to be right but not necessarily so. Assessing the whole complex of circumstances might weigh in favour of lying.

Now I think the issue of how to understand and use a guideline clearly relates to this discussion. We could interpret a guideline in a dispositional way rather than as an absolute rule. A particular intervention may tend to relieve a particular symptom but in many contexts it need not be the right intervention to prescribe. If this is right, I think it would be to the benefit of all stakeholders – clinicians, guideline bodies, regulatory authorities, and patients – to understand dispositionalism and particularism. This could be a challenge when rule-based laws and codes of ethics are easy to grasp, but there is a potential benefit to be gained from pushing ahead for a conceptual change.