Actually, NICE use GRADE and GRADE is garbage. There is no gold standard other than careful reasoning, when the chips are down. The difficulty is that dim people often find it hard to follow careful reasoning.
There are several interrelating areas here. The relationship between Medical Scientist/Doctor and patient is mediated by, ‘carefully reasoned’ medical ethics and Law as set out in various legal Statutes and Judgements. I will mention two areas here where ‘careful reasoning’ has set precedent and dictates the lawful and ethical behaviour required from Medical Scientists and Medical Practioners by UK society.
First the legal need for Medical Science and Medical Practice to gain the patients ‘informed consent’. Legal precedent judgements clearly set out that patients should be given full information on all medical explanations of their illness and the treatments available.The patient should also be given full information on the benefits and risks associated with each treatment/medical view and not be subjected to pressure to choose or undertake any particular treatment by the prescribing authority.
The law on informed Consent makes it quite clear that only the patient can decide whether they should undertake any (particular) treatment after having been given the full information required on all medical views and treatments available for their illness.
On the question of the attributes of an illness and its classification as primarily physical or primarily psychological this question has also been the subject of ‘carefully reasoned’ legal precedent and law.
My late wife after being ill since 1985 was diagnosed by her own Dr’s as suffering from PVFS/ME as a physical illness in 1990. Following this diagnosis she applied for and was refused Social Security sickness and disability benefits because the Department of Social Securities own Doctors diagnosed her with CFS of a psychological nature.
An appeal was made and was decided at the highest legal level by a Social Security Commissioner who recognised that the DSS Doctors who made a different psychological diagnosis had not in fact set out the reasons and evidence they relied upon to support their different diagnosis from the evidenced diagnosis provided by my late wife’s own Doctors. The SSC allowed her claim for this reason as this requirement for them to explain their different diagnosis was a legal requirement set out in Social Security law, which had been drawn up after ‘careful reasoning’ in Parliament and supported by ‘careful reasoning’ in judgements reached in individual cases like ours.
(For clarity I should also mention that the diagnosis of PVFS/ME as a physical illness was in fact posited/established many years before the unexplained and it appears medically unexplainable psychological diagnosis of CFS was applied to the same illness by a small group of Psychiatrists/Pschologists.)
It is noteworthy that in both these legal instances, ie not being able to explain the evidence relied upon to support their alternative ‘psychological’ diagnosis of PVFS/ME and the detrimental ramifications this has on their ability to fully inform patients in order to obtain their informed consent continues to confound their ability to practice ‘safe’ medical science or medical care with regard to PVFS/ME.
The practice (and our experience) of science and medicine is only as safe/good as the ‘careful reasoning’ underpinning it.
What is clear is that as ‘end users/patients’ of medical science and care we have the legal right to full information and choice of our medical care and we can make our own choices using ‘careful reasoning’ as our guide.
I leave it to you all to decide levels of ‘dimness’ as opposed to ‘wilful disregard’ of medical ethics and the law, both on the part of Individual Medical Scientist/practitioners and those responsible for allowing them to retain a licence to practice. The Regulatory governance in this area is, I think, another ‘can of worms’ which would benefit from much more ‘careful reasoning’ being applied.
