The Trouble with Guidelines for Healthcare

CDC and The Opium Wars: The Trouble with Guidelines

In this article Terri Lewis points out all the flaws in how the CDC guidelines were developed.

In developing guidelines, one considers all of the evidence and obtains input from the stakeholders who will be most affected by the guidelines. As a generally held principle, a guideline is neither a Standard of practice nor a regulation.

It carries no legal weight, it is nonbinding, and is unenforceable.

Guidelines cannot bind personal behavior. In healthcare, guidelines are intended to provide a consensus about the general direction for patient care after the patient is appropriately identified and selected into treatment.  

The Supreme court has ruled that agencies cannot use guidance development in the absence of existing rules as a substitute for rulemaking, and may not issue guidance beyond the scope of existing agency authority (GAO-15-834T, September 23).

The Office of Management and Budget (OMB) has established requirements for the issuance of guidance documents that are of any significance when it comes to public policy (GAO-14-704G).

Standard elements that must be included in significant guidance documents and directs agencies to

(1) develop written procedures for the approval of significant guidance,

(2) maintain a website to assist the public in locating significant guidance documents, and

(3) provide a means for the public to submit comments on significant guidance through their websites.

By definition, the practice of medicine falls under accepted ethical practices of ‘research’ which has clearly defined rules, and guidelines for practice contained within 45 CFR 46. Every patient, every problem, and every solution is unique, an “N of 1.”

Clinical judgment requires that each person be granted specific protections as clinicians sort out the patient’s presenting problems and the available resources that can be applied to a healthcare solution.

Each patient is an ‘experiment’ processed in less than controlled conditions of care. Results cannot be generalized beyond the individual to the population at large. Hypothesis testing requires that the clinician apply the rules of research to the experimental conditions of patient care. These rules have strong prohibitions against actions that might harm patients as a result of treatment. These patient protections include assurance of the right to self-select treatment (autonomy) and one’s treating providers, informed consent (veracity), education about risks and benefits (beneficence) and ethical practice (fidelity).

We don’t use treatment guidelines to recruit patients into treatment, nor do we use treatment guidelines to coerce patients into treatments not suited for their characteristics, needs or values.  Guidelines may not be used to reject a patient for treatment or to coerce them into accepting treatment.

The application of guidelines to patient selection before the needs of the patient are understood encourages a model whereby the patient is coerced into adherence and conformance to an untested protocol that potentially addresses the wrong theory of their problem.

Adherence and conformance to the wrong protocol may produce no positive outcome for the patient, and may well place the patient in an adversarial relationship with the treating provider as treatment outcomes fail to materialize. This leads to blaming the patient for treatment failure, an all too common outcome for chronically ill consumers.

Of concern are four distinct issues:

(1) In its current role, the government cannot direct the practice of medicine in the private sector, nor can it bind the selection of patients into research except under controlled experimental IRB-approved conditions.

(2) The dose established for medications is controlled through the manufacturers petition to FDA for approval based on clinical trials data – government does not have the authority granted under existing rules to supplant the rights of patients to agree or disagree to treatment protocols.

(3) The guidelines as written foster discrimination in the provision and practice of healthcare services across a class of disabled individuals solely by virtue of their healthcare attributes and needs (§1557 of the Affordable Care Act).

(4) The proposed guidelines as written are fraught with conflicts of interest, bias, and do not reflect the needs of the multiple populations who rely on and have successfully utilized a wide variety of opioid formulations and delivery systems to ameliorate chronic pain.

We are dealing with a continuum of consumer needs in this discussion from addiction to treatment for intractable lifelong palliative care.

There are many other social and biological factors that enter into this equation that are not addressed by the proposed guidelines as drafted – an omission of significant import.

let’s get back to the basics of ethical practice in the development of ethical guidelines conceived in collaboration with the input of the stakeholders who are most affected – persons who rely on opioids to address conditions of chronic and intractable pain.



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