Allan Detsky's timely editorial1 invites us to take a broader look at the biases that shape the recommendations in clinical practice guidelines, beyond financial links with the pharmaceutical industry. We strongly support Detsky's suggestion that nonexperts be included in guideline development panels, but we suggest that the value of public involvement should be judged not only on the basis of its impact on bias, but also in terms of democratic legitimacy and concordance with society's and patients' values.
Crafting recommendations involves making value judgments about the relative importance of competing goals and interests: maximizing health benefits for individuals and the population, promoting an equitable and effective allocation of resources, and respecting patients' autonomy.2 The crucial challenge is to ensure not only that recommendations are informed by the best available evidence, but also that the process is seen as transparent and legitimate. The quality of recommendations should be judged on the basis of their concordance with both the available evidence and the values of patients and society.
Patients are experts in their illness experience, life context and preferences.3 Like other experts, they have interests and are vulnerable to manipulation by the pharmaceutical industry.4 However, patient participation in guidelines committees could enhance the role of patients in clinical decision-making.5 Despite claims that they promote patient autonomy, clinical practice guidelines are rarely designed as instruments that facilitate a patient's choice.
Even if involvement by members of the general public in guideline development does not eliminate bias, at least their participation might bring a greater degree of legitimacy and accountability to the development process. Their participation would be in line with patients' desire to play a greater role in clinical decision-making.
REFERENCES
- 1.Detsky AS. Sources of bias for authors of clinical practice guidelines [editorial]. CMAJ 2006;175(9):1033. [DOI] [PMC free article] [PubMed]
- 2.Cohen J. Are clinical practice guidelines impartial? Int J Technol Assess Health Care 2004;20(4):415-20. [DOI] [PubMed]
- 3.Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. London (UK): The Department; 2001.
- 4.Clinical practice guidelines and conflict of interest. CMAJ 2005;173(11):1297. [DOI] [PMC free article] [PubMed]
- 5.Crawford MJ, Rutter D, Manley C, et al. Systematic review of involving patients in the planning and development of health care. BMJ 2002;325(7375): 1263. [DOI] [PMC free article] [PubMed]