that will result in inconsistent and often conflicting judgments that, in turn, will induce confusion, hostility, and, ultimately, inequity.

SUMMARY

Management (if not resolution) of the tensions discussed in this chapter concerning ethics, costs, and information will depend on decisions about how health care is to be financed and delivered in the future. Developers of guidelines can illuminate debates over various individual and collective interests by presenting evidence, analysis, and expert judgment about the risks, benefits, costs, and patient preferences associated with alternative courses of care. Well-developed, evidence-based guidelines that are specific, logical, clearly explained, and accompanied by projections of health and cost outcomes (to the extent possible, given the dearth of this kind of information) can and will be incorporated in quality, cost, and liability management programs. Their incorporation, in turn, will provide powerful support for the consistent application of such guidelines in actual clinical practice.

Nonetheless, differences in philosophies, resources, attitudes toward risks, and other factors will ensure some inconsistency and dispute. Clinical experts and decision makers may argue among themselves about how to interpret weak or conflicting scientific data, how to estimate and weigh benefits, harms, and costs, and how to resolve questions of individual versus collective perspectives. Further, pure objectivity and perfect rationality may exist in the realm of theory but not in the world of real human endeavors. Decisions to use or not to use particular guidelines may consciously or unconsciously reflect economic considerations, inclinations toward "conservative" or "aggressive" styles of practice, and other factors. This is one reason that the committee places such emphasis on the attributes of good guidelines—they should reduce the opportunity for important but unacknowledged values or biases to affect the formulation or application of guidelines.

The committee judged that it is not now strategically or tactically prudent to impose on all developers of clinical practice guidelines the task of explicitly recommending what care is warranted on economic as well as clinical grounds. Nor should guideline developers be uniformly expected to declare what services constitute the minimum or required care for a clinical problem. As important and necessary as these judgments may be, developers of guidelines for clinical practice need not take on this responsibility.

A fundamental reason for this position is that users rather than developers of guidelines carry the actual responsibility for deciding how to



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