Legal and political considerations of clinical practice guidelines

In the 4th century BC, Plato explored the difference between skills grounded in practical expertise and those based solely on following instructions or obeying rules. Using the clinician as his model, he set up a thought experiment: doctors would be stripped of their clinical freedom—“no longer allowed unchecked authority”—but would form themselves into councils to determine majority views about how to practise medicine in all situations.1

Plato's notion of codifying the majority decisions of panels (composed of clinical and non-clinical members) and publishing their work in order to influence (Plato says to dictate) “the ways in which the treatment of the sick is practised”1 prefigures many of the impulses which animate the clinical guidelines movement today.

In Plato's view, important hallmarks of expertise include flexible responsiveness and “improvisatory ability”—an approach to practice endangered, he believed, by use of guidelines.1 However effective health care by guideline turned out to be—and Plato was prepared to concede its potential—it remained in his view a debased form of practice, firstly because guidelines presuppose an average patient rather than the particular patient whom a doctor is endeavouring to treat, and secondly because the knowledge and analysis that go into the creation of guidelines are not rooted in the mental processes of clinicians, but in the minds of guideline developers distant from the consultation. Similar concerns trouble present day clinicians (box).