Journal of evaluation in clinical practice
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The evidence based medicine movement has championed the need for objective and transparent methods of clinical guideline development. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was developed for that purpose. Central to this framework is criteria for assessing the quality of evidence from clinical studies and the impact that body of evidence should have on our confidence in the clinical effectiveness of a therapy under examination. ⋯ Finally, the GRADE method is unclear on how to integrate evidence grades with other important factors, such as patient preferences, and trade-offs between costs, benefits, and harms when proposing a clinical practice recommendation. Much of the GRADE method requires judgement on the part of the user, making it unclear as to how the framework reduces bias in recommendations or makes them more transparent-both goals of the programme. It is our view that the issues presented in this paper undermine GRADE's justificatory scheme, thereby limiting the usefulness of GRADE as a tool for developing clinical recommendations.
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Historical Article
Psychiatry's contribution to the public stereotype of schizophrenia: Historical considerations.
The public stereotype of schizophrenia is characterized by craziness, a split personality, unpredictable and dangerous behaviour, and by the idea of a chronic brain disease. It is responsible for delays in help-seeking, encourages social distance and discrimination, and furthers self-stigmatization. ⋯ In a strange conglomerate, the modern operational diagnostic criteria reflect all three approaches, by claiming to be Neo-Kraepelinean in terms of defining a categorical disease entity with a suggestion of chronicity, by keeping Bleuler's ambiguous term schizophrenia, and by relying heavily on Kurt Schneider's hallucinations and delusions. While interrater reliability may have improved with operational diagnostic criteria, the definition of schizophrenia is still arbitrary and has no empirical validity-but induces stigma.
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Comment
How to make a particular case for person-centred patient care: A commentary on Alexandra Parvan.
In recent years, a person-centred approach to patient care in cases of mental illness has been promoted as an alternative to a disease orientated approach. Alexandra Parvan's contribution to the person-centred approach serves to motivate an exploration of the approach's most apt metaphysical assumptions. I argue that a metaphysical thesis or assumption about both persons and their uniqueness is an essential element of being person-centred. I apply the assumption to issues such as the disorder/disease distinction and to the continuity of mental health and illness.
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Health technology assessment (HTA) is an evaluation of health technologies in terms of facts and evidence. However, the relationship between facts and values is still not clear in HTA. This is problematic in an era of "fake facts" and "truth production." Accordingly, the objective of this study is to clarify the relationship between facts and values in HTA. ⋯ We maintain that philosophy (in particular ethics) may have an important role in addressing the relationship between facts and values in HTA. Philosophy may help us to avoid fallacies of inferring values from facts; to disentangle the normative assumptions in the production or presentation of facts and to tease out implicit value judgements in HTA; to analyse evaluative argumentation relating to facts about technologies; to address conceptual issues of normative importance; and to promote reflection on HTA's own value system. In this we argue for a(n Aristotelian) middle way between the traditional positivist account of "evaluating facts" and the social-constructivist account of "facting values," which we call "factuation." We conclude that HTA is unique in bringing together facts and values and that being conscious and explicit about this "factuation" is key to making HTA valuable to both individual decision makers and society as a whole.
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Racial discrimination has been increasingly reported to have a causal link with morbidity and mortality of Black Americans, yet this issue is rarely addressed in a public health perspective. Racism affects health at different levels: institutional racism is a structural and legalized system that results in differential access to health services; cultural racism refers to the negative racial stereotypes, often reinforced by media, that results in poorer psychological and physiological wellbeing of the minorities. Lastly, interpersonal racism refers to the persistence of racial prejudice that seriously undermines the doctor-patient relationship. ⋯ This study represents an important milestone in the application of public health on racial injustices, yet racism must be tackled with a sustained, multilevel, and interdisciplinary approach. In conclusion, this paper addresses how public health interventions can empower Black minorities and bring forward long-term policies. Racism is a structural and long-standing system that can be eliminated only with the collective effort.