Salad Days

The Hastings Center Report has just concluded its thirty-ninth year of publishing, and the annual index at the back of this issue reflects the wide array of topics that the Center has dealt with over that span of time—from biotechnology to public health, and from moral theory to clinical medicine. My predecessor, Bette-Jane Crigger, sometimes referred to Report issues reflecting that array as "salads." The selection of articles and essays in this issue comprise one of those salads. At the same time, though, they reflect interests that I have underscored in both of the end-of-year editor's notes over the last couple of years—health policy and clinical decision-making.

A couple of the columns focus on health policy concerns, in various ways. The articles are about clinical decision-making. The lead article, discussed in more detail on the opposite page, is about ethicists' involvement in clinical decision-making and what must be done to ensure that their involvement is of consistently high quality. A second article is about the perception and management of risk in medical interventions involving pregnant women. There is a "tendency," note the authors, "to unreflectively judge any risk to the fetus, however small or theoretical, to trump considerations that may be of substantial importance to the woman herself." (This article also brings attention specifically to clinical decision-making issues involving women—which some readers have asked for more of.)

The essays in this issue combine the clinical decision-making and health policy interests: they are about health policy that could affect clinical decision-making. A set of five pieces collected and led off by our staff writer, Susan Gilbert, assesses the ins and outs of comparative effectiveness research—nationally coordinated research on whether medical treatments work as billed, how they compare, and what gives the best bang for the buck. That more evidence about medical effectiveness could be desirable seems beyond contest; Susan Gilbert discusses the social benefit and Pauline Chen the potential benefit for individual patients, and none of the authors in this set disputes that the evidence can be beneficial.

Where concern arises is over how the evidence is used and how it is collected. As several of the essays note, more evidence can never mean exhaustive evidence. Richard Payne argues that this means room must always be left for clinicians to exercise judgment; their decisions cannot be flatly dictated by the evidence. Coauthors Nancy Berlinger and Anne Lederman Flamm argue that more evidence cannot replace the patient's perspective, and so room must also be left for the patient in the decision-making. Coauthors Harald Schmidt and Julia Kreis point out that because lots of people have a lot at stake in how the evidence is used, the process for collecting it and deciding what use to make of it must reflect stakeholders' perspectives appropriately. In a nutshell, comparative effectiveness research represents a drive toward standardization, and the concerns with it are concerns about standardization—about how standardization squares with the complexity of cases and the plurality of perspectives people bring to them.

Five essays do not exhaust the topic. More are welcome.