Causality, Complexity and Evidence in Health Sciences

Samantha Copeland, Thinking about guidelines:

I have been interested for a while in how we justify the move from a single case to conducting research on other patients as research participants. For instance, there have been cases where unexpected (positive) results suggest that a novel approach to treating difficult patients may be found: such as the case in Toronto, Canada where electronic stimulation of a patient’s brain had an effect on his memory that suggested a new method for treating Alzheimer’s might be available; or in Bergen, Norway, when a patient with chronic fatigue unexpectedly recovered from her symptoms while undergoing treatment for Hodgkin’s disease. When a decision is made to start research, researchers must justify why they think the observations made of this particular patient could be repeated in others.

I believe this justification process is most simply expressed as an analogy: one argues that this particular patient is like some other patients in the right ways, and so we can reason that the same effects can be caused by the same treatment approaches. Therefore, it is both correct and ethical for research to attempt to recreate the same results by doing the same things to research participants as was done in this one case with this one patient. Continue reading “Analogies and High-Stakes Inferences”

Stephen Tyreman, Thinking about guidelines:

Following on from the stimulating and highly relevant discussion about guidelines, I want to raise the point that there is a political dimension to the guidelines question that can’t be ignored if the CauseHealth project is to have practical relevance.  I recognise that the previous discussion was around clinical guidelines such as those produced by NICE, but these cannot be divorced from the broader issue of guidelines as they concern professional regulation. Continue reading “Standards for Regulation”

Anna Luise Kirkengen, Thinking about guidelines:

I would like to depart from the most common situation in General Practice, namely: encounters with patients who are categorised as presenting multi-morbidity. This is how it is expressed in the medical language. I would try to change this formulation to something like: a GP’s encounter with a person suffering from what medicine conceptualises as a “number of different diseases”, either simultaneously or sequentially, in the same patient. The concept of “different” diseases does not apply when states of bad health are not strictly separable in terms of etiology, pathogenesis, treatment, and prognosis. Then the question is: on which level does medicine differentiate ethology or pathogenesis? If “two” diseases have a pathological characteristic in common, let us say inflammation, are these “two” diseases still “different” — and due to which criteria? Continue reading “Challenging Multi-Morbidity”

Sarah Wieten, Thinking about guidelines:

I was glad to participate in the CauseHealth conference planning meeting October 24th 2016 in London. In the aftermath of the meeting, I was happy to share these brief notes with Sam.

I noticed that the group as a whole seemed very interested in discussing the nature of truth. I was somewhat surprised by this because it can be very abstract work. This is the sort of topic which might be very strictly in the purview of philosophers, and I worry none of us there were the right people to deliver on that topic. If that is what will help the general project of producing better and more useful guidelines, and is a component that others expect we (as philosophers) will be able to talk about, perhaps we should be sure to invite some philosophers that do in fact study that to the conference. Continue reading “Truth, simplicity, and personalization”

Fiona Moffatt, Thinking about guidelines:

My research interest lies predominantly in the notion of knowledge translation, exploring the complex, non-linear relationship between what is ‘known’ and what is subsequently ‘done’. I understand evidence based guidelines and evidence based policy as key rhetorical devices (or technologies) bridging the liminal space between empirical knowledge and clinical practice. My methodological perspective is however, strongly influenced by the sociological discipline of STS, whereby all technologies are contingent, i.e. rejecting technological determinism. Continue reading “Guidelines in situ”

Roger Kerry, Thinking about guidelines:

My take home thoughts:

What is the real world, clinical role of guidelines? (provoked by Jeremy Howick’s suggestion that guidelines shouldn’t make recommendations, Sarah Weiten’s talk on values and mechanisms, and Sieste Wieringa’s talk on induction and reasoning)

Can a more holistic conceptualisation of causation really be integrated into guidelines which take population data as central to their development? (provoked by Stephen Mumford and Rani Anjum’s comments of the background philosophy of causation, as well as Karin Engebretsen and Elena Rocca’s talks on diagnosis and bench study data)

Can a guideline and evidence-based system truly move beyond hierarchies? (provoked by NICE’s Beth Shaw review of multiple evidence sources and their integration into guideline development. A beautiful talk, but I still think there is hierarchy at the core when push comes to shove. Show me I’m wrong!)

What is the future of implementation, governance, abuse-control strategies for guidelines? (provoked by Fiona Moffatt’s, Mary Chambers’, and Samantha Copeland’s highly informed musings on things from deep sociological concerns to PPI and the reality of the clinical shop-floor, and analogical thinking)

The planned conference for next year should turn out to be a hot-bed of challenge, controversy, and progress for all.

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. Continue reading “The Notion of Guideline”

Rani Lill Anjum, Thinking about guidelines:

I was really interested in the questions of how guidelines could include more leeway for the health professional. Rigid guidelines offering cost efficient solutions (e.g. 15 minutes per patient, or 30) emphasises the rule utilitarian approach and makes it difficult to use judgement and experience to give the best health service for the individual patient. If the patient represents at least as much of the causally relevant evidence (medical history, genetics, life situation, etc.) as population data, then how come the latter is given epistemic priority?

I thought that there were many good intentions behind the guidelines, but also a wide range of interests depending on who commissioned the guideline and what they want to use it for. This is why I thought the tension between real and ideal is important. New public management emphasises top down management, controlling, reporting, standardisation and efficiency. In the clinical setting, this approach might create chronic illness, if we simply treat or test the symptoms that the patient reports. Those who work on the importance of patient context and stories (Trish, Matt, Brian, Anna-Luise) have important knowledge to share, and show also that the most efficient treatment of such illness is to take more time with the patient to figure out what is actually wrong before offering an intervention or a test. Why could this not be in guidelines about chronic illness, MUS and comorbidity? Then we would also avoid reductionism and dualism of treatment.