Making evidence based medicine work for individual patients

BMJ 2016; 353 doi: (Published 16 May 2016) Cite this as: BMJ 2016;353:i2452

Human rights and clinical guidelines

This type of analysis is most welcome and I agree with Stone’s rapid response, that ultimately the patient gets to make the final decision, and that those decisions take precedence over everything. It is not just the inclusion of patient's values and beliefs in shared decision making within the construct of evidence based medicine. So the term shared decision making is not correct when a human rights caveat is applied to clinical guidelines. This applies to avoiding medical interventions as well as requesting medical interventions because of perceived risks as seen in the Montgomery v Lanarkshire Supreme Court Ruling March [2015] in the UK (1). This shows respect for bodily integrity and fulfils the FREDA criteria for human rights in healthcare (fairness, respect, equality, dignity and autonomy). Speaking from a human rights in childbirth perspective, overarching analyses of the quality of evidence behind RCOG, ACOG, SOGC guidelines indicate that a minority of recommendations have high quality evidence behind them or vice versa majority of recommendations have lower quality evidence behind them (2-4). So where there is scientific uncertainty in the recommendation this needs to be highlighted to the patient, especially if it is thought that the patient would attach significance to it in light of the Montgomery v Lanarkshire case. If a clinician is truly patient centred rather than institution centred or guidelines centred this should present no problem, especially with good respectful rapport with the patient.


(1) United Kingdom Supreme Court. Montgomery v Lanarkshire Health Board. 2015. UKSC 11, United Kingdom.
(2) Ghui R, Bansal JK, McLaughlin C, Kotaska A, Lokugamage A. An evaluation of the guidelines of the Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol 2016; 36(5):658-662.
(3) Prusova K, Churcher L, Tyler A, Lokugamage AU. Royal College of Obstetricians and Gynaecologists guidelines: how evidence-based are they? J Obstet Gynaecol 2014; 34(8):706-711.
(4) Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL et al. Scientific evidence underlying the american college of obstetricians and gynecologists' practice bulletins. Obstet Gynecol 2011; 118(3):505-512.

Competing interests: On the Advisory Board of Human Rights in Childbirth (NGO) and on the Board of Directors of the International MotherBaby Childbirth Organisation (UN recognised NGO). Both are charities.

08 June 2016
Amali Lokugamage
Consultant Obstetrician and Gynaecologist
Whittington Health NHS Trust, University College London Medical School
Department of Obstetrics and Gynaecology, Whittington Hospital, London N19 5NF