Skip to main content
Log in

Guidelines for Appropriate Care: The Importance of Empirical Normative Analysis

  • Published:
Health Care Analysis Aims and scope Submit manuscript

Abstract

The Royal Dutch Medical Association recently completed a researchproject aimed at investigating how guidelines for `appropriatemedical care' should be construed. The project took as a startingpoint that explicit attention should be given to ethical andpolitical considerations in addition to data about costs andeffectiveness. In the project, two research groups set out todesign guidelines and cost-effectiveness analyses (CEAs) for twocircumscribed medical areas (angina pectoris and majordepression). Our third group was responsible for the normativeanalysis. We undertook an explorative, qualitative pilot study ofthe normative considerations that played a role in constructingthe guidelines and CEAs, and simultaneously interviewedspecialists about the normative considerations that guided theirdiagnostic and treatment decisions. Explicating normativeconsiderations, we argue, is important democratically: the issuesat stake should not be left to decision analysts and guidelinedevelopers to decide. Moreover, it is a necessary condition for asuccessful implementation of such tools: those who draw uponthese tools will only accept them when they can recognizethemselves in the considerations implied. Empirical normativeanalysis, we argue, is a crucial tool in developing guidelinesfor appropriate medical care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Anand, P. (1999) QALYs and the Integration of Claims in Health-Care Rationing. Health Care Analysis 7, 239-253.

    Google Scholar 

  • Anspach, R.R. (1993) Deciding Who Lives. Fateful Choices in the Intensive Care Nursery. Berkeley: University of California Press.

    Google Scholar 

  • Ashmore, M., Mulkay, M. and Pinch, T. (1989) Health and Efficiency: A Sociology of Health Economics. Milton Keynes: Open University Press.

    Google Scholar 

  • Atkinson, P. (1995) Medical Talk and Medical Work. London: Sage.

    Google Scholar 

  • Beck, U., Giddens, A. and Lash, S. (1994) Reflexive Modernization. Standford: Stanford University Press.

    Google Scholar 

  • Berg, M. (1992) The Construction of Medical Disposals. Medical Sociology and Medical Problem Solving in Clinical Practice. Sociology of Health and Illness 14, 151-180.

    Google Scholar 

  • Berg, M. (1997a) Problems and Promises of the Protocol. Social Science and Medicine 44, 1081-1088.

    Google Scholar 

  • Berg, M. (1997b) Rationalizing Medical Work. Decision Support Techniques and Medical Practices. Cambridge: MIT Press.

    Google Scholar 

  • Cicourel, A.V. (1986) The Reproduction of Objective Knowledge: Common Sense Reasoning in Medical Decision Making. In G. Böhme and N. Stehr (Eds.), The Knowledge Society (pp. 87-122). Dordrecht: Reidel.

    Google Scholar 

  • Clancy, C.M. and Kamerow, D.B. (1996) Evidence-Based Medicine Meets Cost-Effectiveness Analysis. Journal of the American Medical Association 276, 329-330.

    Google Scholar 

  • Cotton, P. (1992) 'Basic Benefits' have Many Variations, Tend to Become Political Issues. Journal of the American Medical Association 268, 2139-2141.

    Google Scholar 

  • de Bruijn, E., Klazinga, N.S. and Dillman, R.J.M. (1998) Passend kiezen in de gezond-heidszorg? Medisch Contact.

  • Deber, R.B. (1992) Translating Technology Assessment into Policy: Conceptual Issues and Tough Choices. International Journal of Technology Assessment in Health Care 8, 131-137.

    Google Scholar 

  • Dickenson, D.L. (1999) Can Medical Criteria Settle Priority-Setting Debates? The Need for Ethical Analysis. Health Care Analysis 7, 131-137.

    Google Scholar 

  • Drummond, M., Brandt, A., Luce, B. and Rovira, J. (1993) Standardizing Methodologies for Economic Evaluzation in Health Care. International Journal of Technology Assessment in Health Care 9, 26-36.

    Google Scholar 

  • Eddy, D.M. (1990) The Challenge. Journal of the American Medical Association 263, 287-290.

    Google Scholar 

  • Eddy, D.M. (1992) Applying Cost-Effectiveness Analysis. The Inside Story. Journal of the American Medical Association 268, 2575-2582.

    Google Scholar 

  • Eddy, D.M. (1993) Three Battles to Watch in the 1990s. Journal of the American Medical Association 270, 520-526.

    Google Scholar 

  • Elsinga, E. and Rutten, F.F.H. (1997) Economic Evaluation in Support of National Health Policy: The Case of The Netherlands. Social Science and Medicine 45, 605-620.

    Google Scholar 

  • Emery, D.D. and Schneiderman, L.J. (1989) Cost-Effectiveness Analysis in Health Care. Hastings Center Report 19, 8-13.

    Google Scholar 

  • Feinstein, A.R. (1994) Clinical Judgment Revisited: The Distraction of Quantitative Models. Annals of Internal Medicine 120, 799-805.

    Google Scholar 

  • Gifford, F. (1996) Outcomes Research and Practice Guidelines: Upstream Issues for Downstream Users. Hastings Center Report 26, 38-44.

    Google Scholar 

  • Granata, A.V. and Hillman, A.L. (1998) Competing Practice Guidelines: Using Cost-Effectiveness Analysis to Make Optimal Decisions. Annals of Internal Medicine 128, 56-63.

    Google Scholar 

  • Grimshaw, J., Freemantle, N., Wallace, S., Russell, I., Hurwitz, B., Watt, I., Long, A. and Sheldon, T. (1995) Developing and Implementing Clinical Practice Guidelines. Quality in Health Care 4, 55-64.

    Google Scholar 

  • Halpern, J. (1995) Can the Development of Practice Guidelines Safeguard Patient Values? Journal of Law and Ethics 23, 75-81.

    Google Scholar 

  • Heitman, E. (1999) Ethical Issues in Technology Assessment — Conceptual Categories and Procedural Considerations. International Journal of Technology Assessment in Health Care 14, 544-566.

    Google Scholar 

  • Holm, S. (1998) Goodbye to the Simple Solutions: The Second Phase of Priority Setting in Health Care. British Medical Journal 317, 1000-1002.

    Google Scholar 

  • Jennings, B. (1990) Ethics and Ethnography in Neonatal Intensive Care. In G. Weisz (Ed.), Social Science Perspectives on Medical Ethics (pp. 261-272). Dordrecht: Kluwer Academic Publishers.

    Google Scholar 

  • Kassirer, J.P. and Kopelman, R.I. (1990) Diagnosis and Decisions by Algorithms. Hospital Practice 25, 23-24, 27, 31.

    Google Scholar 

  • Klein, R. (1998) Puzzling Out Priorities. Why We Must Acknowledge that Rationing is a Political Process. British Medical Journal 317, 959-60.

    Google Scholar 

  • Kosecoff, J., Kanouse, D.E., Rogers, W.H., McCloskey, L., Winslow, C.M. and Brook, R.H. (1987) Effects of the National Institutes of Health Consensus Development Program on Physician Practice. Journal of the American Medical Association 258, 2708-2713.

    Google Scholar 

  • Mason, J., Eccles, M., Freemantle, N. and Drummond, M. (1999) A Framework for Incorporating Cost-Effectiveness in Evidence-Based Clinical Practice Guidelines. Health Policy 47, 37-52.

    Google Scholar 

  • Mol, A. and Elsman, B. (1996) Detecting Disease and Designing Treatment. Duplex and the Diagnosis of Diseased Leg Vessels. Sociology of Health and Illness 18, 609-631.

    Google Scholar 

  • Nord, E. (1999) Towards Cost-Value Analysis in Health Care? Health Care Analysis 7, 167-175.

    Google Scholar 

  • Perrow, C. (1984) Normal Accidents. Living with High Risk Technologies. New York: Basic Books.

    Google Scholar 

  • Redman, B.K. (1994) Clinical Practic Guidelines as Tools of Public Policy: Conflicts of Purpose, Issues of Autonomy and Justice. Journal of Clinical Ethics 5, 303-309. Riesenberg, D. (1989) Economics is Everybody's Business. Journal of the American Medical Association 262, 2897.

    Google Scholar 

  • Rigter, H., Willemse, G., Tiemeier, H., Lemmens, F., Smit, F. and Hutschemaekers, G. (2000) Establishing Appropriate Indications for Treatment of Mood Disorder in The Netherlands Using a Formal Group Judgment Method. Social Psychiatry and Psychiatric Epidemiology, in press.

  • Rothman, D.J. (1991) Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York: Basic Books.

    Google Scholar 

  • Sackett, D.L. and Rosenberg, W.M.C. (1995) The Need for Evidence-Based Medicine. Journal of the Royal Society of Medicine 88, 620-624.

    Google Scholar 

  • Sclove, R.E. (1995) Democracy and Technology. New York: Guilford Press.

    Google Scholar 

  • Starr, P. (1982) The Social Transformation of American Medicine. New York: Basic Books.

    Google Scholar 

  • Strauss, A., Fagerhaugh, S., Suczek, B. and Wieder, C. (1985) Social Organization of Medical Work. Chicago: University of Chicago Press.

    Google Scholar 

  • Tanenbaum, S.J. (1993) What Physicians Know. New England Journal of Medicine 329, 1268-1271.

    Google Scholar 

  • Tanenbaum, S.J. (1994) Knowing and Acting in Medical Practice: The Epistemological Politics of Outcomes Research. Journal of Health Politics, Policy and Law 19, 27-44.

    Google Scholar 

  • Timmermans, S., Bowker, G.C. and Star, S.L. (1998) The Architecture of Difference: Visibility, Controllability, and Comparability in Building a Nursing Intervention Classification. In M. Berg and A. Mol (Eds.), Differences in Medicine. Unraveling Practices, Techniques and Bodies (pp. 202-228). Durham: Duke University Press.

    Google Scholar 

  • van Hout, B., Goes, E.S., Grijseels, E.W.M. and Quarles van Ufford, M.A. (1999) Economic Evaluation in the Field of Cardiology: Theory and Practice. Progress in Cardiovascular Diseases 42, 167-173.

    Google Scholar 

  • Williams, A. (1992) Cost-Effectiveness Analysis: Is It Ethical? Journal of Medical Ethics 18, 7-11.

    Google Scholar 

  • Williams, A. (1996) Qalys and Ethics: A Health Economist's Perspective. Social Science and Medicine 43, 1795-1804.

    Google Scholar 

  • Williamson, C. (1992) Whose Standards? Consumer and Professional Standards in Health Care. Buckingham: Open University Press.

    Google Scholar 

  • Woolf, S., Grol, R., Hutchinson, A., Eccles, M. and Grimshaw, J. (1999) Potential Benefits, Limitations, and Harms of Clinical Guidelines. British Medical Journal 318, 527-530.

    Google Scholar 

  • Wynia, M.K. (1997) Economic Analyses, the Medical Commons, and Patients' Dilemmas: What is the Physician's Role? Journal of Investigative Medicine 45, 35-43.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Masja van den Burg.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Berg, M., ter Meulen, R. & van den Burg, M. Guidelines for Appropriate Care: The Importance of Empirical Normative Analysis. Health Care Analysis 9, 77–99 (2001). https://doi.org/10.1023/A:1011307112091

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1023/A:1011307112091

Navigation