To the Editor: Dr Cabana and colleagues1 provide a helpful analysis of the failure of clinicians
to follow existing practice guidelines. However, they overlook the possibility
that such behavior may be deliberate, reflecting clinicians' disagreement
with the nonscientific value judgments of the guideline writers.
Clinical practice guidelines necessarily incorporate not only the beliefs
of the guideline authors about the medical facts, but also a set of evaluative
judgments about whether the anticipated outcomes are good or bad (and how
good or bad they are). These evaluations of outcomes reflect the value judgments
of the guideline authors. A practitioner or patient who evaluates the outcomes
differently may have a perfectly rational reason for refusing to follow the
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