incorporate a particular view of what defines a good outcome. If we can formulate
ageneral consensus over what constitutes a good outcome then this can provide an
adequate foundation for non-subjective agreement over outcomes. I would
respond to this argument b yraising two points: in the first place, it is ver yhard to
gain consensus over what constitutes a good outcome. Even basic imperatives like
preserving life can be contentious in certain situations. For instance, patients in
persistent vegetative states, if correctl ydiagnosed, will never recover from the
coma and it has been argued that simpl ypreserving their life is unwarranted.
Secondly, even if a consensus can be reached it is still important to recognise that
this is a particular view of a good outcome and it is possible that in different times
,or places) a different view of a good outcome could prevail.
11.12.2 How we employ the data in practice
To turn to the second argument: if we agree that clinical trials produce generally
accepted factual data about the interaction of particular drugs or therapies, how
can these facts establish which course of action should follow from them? The evidence itself will not automaticall ydictate patient care but will provide the fac- tual basis on which decisions can be made' [6]. No matter how good one's evidence is, it will not automaticall ydetermine which course of treatment should be recommended. The evidence of effectiveness ma yform the basis of a ver ygood reason for pursuing a particular course of action, but value judgements are needed to tell us whether weshouldtake that course of action. EBM claims that b yusing evidence that is of a higher qualit y, more scientific and more objective, it can make clinical decision making more objective. This is, to my mind, a confusion between two different things, the qualit yof evidence and the decision. While a decision that is made on the basis of good evidence will be of a higher quality, it will not be more objective in the sense that it is independent of value judgements or our perceptions and priorities. The evidence ma ybe more objective but the decision is not, as it necessaril yincorporates the values of those making the decision. This confusion leads to the belief that the evidence will indicate the course of action to be taken and that it is possible to locate thebest treatment for a condition. As Muir Gra ysa ys inEvidence Based Health Care: Decisions about groups of patients or populations are made b ycombining three
factors: 1. evidence; 2. values; 3. resources.' [7].
Acentral area where values shape how we should use the data and scientific
evidence is that of priorit ysetting. When bodies such as NICE decide on which
care-pathways or which drugs to recommend they have to balance two possible
competing claims: do we promote the interests of individual patients as paramount
and focus on the effectiveness of the treatment? Or should this individual ethic
make wa yfor concerns over the collective good, a population based ethic, and
focus on the cost effectiveness of the treatment? I think this is one of the ke yvalue
judgements that has to be made b yall health care s ystems and it is not a dilemma
that can be solved b yappealing to scientific evidence; it is a dilemma that can onl y
be solved b ydeciding what kind of values we wish to see drive health care.
Alan Maynard, Professor of Health Economics at York, argues that EBM focuses
on finding out which treatments are most effective and is therefore grounded in the
244 Nursing Law and Ethics