practice and formulate clinical guidelines that represent best practice. Since April
1994 all Trusts have had to show that the yhave started to develop clinical
guidelines. The NHS Executive stated that, `on the advice of the Clinical Outcomes
Group, [the yhave] begun to commend a selected number of high qualit yguide-
lines' [10]. The rationale behind guidelines is an attempt both to increase the
qualit yof care and to reduce the inequalities in access to health care. The regional
variations in service deliver yand health outcomes have been seen as a central
problem for the NHS. For example, the number of hip replacements in people over
65 years varies from 10 to 51 per 10 000 of the population. In Manchester the
death rate from coronar yheart disease in people aged under 65 years is nearl y
three times higher than in West Surre y[11].
There can be ethical dilemmas raised b yimplementing guidelines in practice.
Treatments which produce the desired effect can differ from person to person.
Even patients with identical manifestations of a particular disease could give
different weight to various outcomes depending on personal taste, social and
famil ysituations, life priorities and so on. When used to promote greater qualit yof
health care, guidelines can incorporate an assessment of qualit ythat is held to be
the same for all patients. This could come into conflict with an individual's par-
ticular conception of desirable benefit and their own personal qualit yassessment.
Man yauthors have drawn attention to the importance of recognising that good
outcomes must be seen as relative to the patient. Hopkins and Solomon [12]
illustrate this point with the example of the management of stroke patients. They
sa ythat the course of the treatment and the outcomes of rehabilitation cannot be
predetermined, because each person's disabilit yis unique. Hence the therapist has
to concentrate on the goals and needs of the particular patient. This illustrates that
effectiveness is usuall yseen as a relative concept, relative to the individual who
receives the treatment. This is an implicit recognition of the role that values pla yin
the definition of effectiveness.
However, supporters of clinical guidelines might argue against this view of the
treatment process. The ymight argue that there are enough similarities between
patients suffering from the same condition to see them as being members of the
same patient group ,in statistical language forming part of the same reference class
of patient). Therefore, all that needs to be established is which group the patient
belongs to and then the appropriate clinical guideline can be followed. Patrick
Suppes, for example, has argued that a decision regarding the individual patient
can be extrapolated from other cases: [13]
`Even though patients ma yvar yin man yrespects ,age, wealth, etc.), the direct
medical consequences and the direct financial cost of a given method of treat-
ment are the most important consequences, and these can be evaluated by
summing across the patients and ignoring more individual features.' ,p. 151)Suppes is right in one respect. It ma ybe possible to construct broad general-
isations about patients' preferences for certain medical consequences. However,
these would have to remain at a ver ybroad level as man yof the individual factors
affecting these consequences are ignored. For example, financial cost ma ynot be
an issue for someone ver ywealth y, whereas for others even the cost of a simple
246 Nursing Law and Ethics