Abstract
It started in fall when the results of this clinical trial became more and more clear. I counseled him, and since he decided to start treatment and became a participant in a study protocol, he has been exclusively in my care. If it was his wish to start treatment? Well, that’s a bit difficult to say: his wish. There are guidelines. As far as antiretroviral treatment is concerned, everything is changing incredibly fast. By the end of ’95 we really had a breakthrough where you now see for the first time that this combination of two medicines has finally, after such a long time, shown a real improvement in survival. According to the guidelines at that time, he had no clear indication for treatment, where you had to say: okay, the viral load is so high and the helper cells are so low that you have to do something. But we have actually become more and more aggressive lately, over the last year.
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“Distrust of science is still alarmingly prevalent, which conflicts with reasonable expectations. Is not the century now drawing to a close most of all remarkable for the technology that now fills our world and for the understanding of that world that has been won since, say, the discovery of the electron in 1897?”
(Maddox 1995: 435)
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Wieland defined medical experience as situated and personal, contrasting it to the abstract experience obtained in the experimental sciences: “The experimental sciences are concerned with supporting or rejecting general laws. The data of experience that contribute to this process are ideally simple, verifiable, and repeatable. In contrast, medical experience does not aim at general principles; it manifests itself in the physician’s ability to evaluate correctly difficult and problematic individual facts and events. It is such experience that enables the physician to frame appropriate basic statements. It correlates with a disposition that is closely bound to the person of the physician. It cannot be separated from the person and transmitted directly” ( 1993: 175–176 ).
Shortness might typically distinguish medical from anthropological writing. DiGiacomo for example recounted how the anthropologist William Dressler, working with epidemiologists, described the epidemiologists’ reaction to ethnography: “very nice, but so many words!” (1999: 449).
Among the central skills demanded from the new physician is a profound knowledge in statistics to interpret the probabilities and p-values symbolizing the scientific bases of his/her practice (Le Pen 1999).
The importance of these new instruments and techniques leads us back to an insight already gained for the production of scientific facts (chapter 2.3.): the development of specific complexes of instruments and the skills required to utilize them are among the preconditions to reshape knowledge (Rouse 1992).
The article is part of a series on the development, methods, and impact of practice guidelines (Woolf 1990; 1992; 1993).
They describe the purchasing of guidelines and protocols as follows: “This vision sees all interventions progressively being evaluated by randomized controlled trials and purchasers undertaking comprehensive assessment of need that will indicate which services should be purchased: locally adapted guidelines will be implemented by all providers; purchasers will buy not activities but guidelines or protocols” (McKee and Clarke 1995: 101.)
Eddy described the difference between standards and guidelines, which he united under the term “practice policies”, through their compulsoriness for the individual physician: “’Guidelines’ are intended to be flexible. They serve as reference point, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to serve individual needs. (…). ‘Standards’ in contrast, are intended to be inflexible. They define correct practice, and should be followed, not tailored” (1990b: 878, emphases in original). The definition of the two terms and their distinction through the degree of control left to the physician (none in the case of standards) indicates the relevance of these instruments in decreasing physician autonomy.
According to Woolf, the American Medical Association reasoned with patients’ well-being against expenditure targets by stating “that expenditure targets could force restrictions on medically necessary services and thereby ration care for elderly and disabled persons” (1990: 1812). In analogy to the current discussions around economic interventions through the state in Switzerland, as outlined below, it may be assumed that the American Medical Association was concerned not only about patients’ well-being, but also about its own members’ financial well-being.
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© 2002 Springer Science+Business Media Dordrecht
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Kopp, C. (2002). Evidence vs. Experience. In: The New Era of AIDS. International Library of Ethics, Law, and the New Medicine, vol 15. Springer, Dordrecht. https://doi.org/10.1007/978-94-015-9860-6_6
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