Guidelines: problems aplenty


This critique is about the problems and adverse treatment consequences associated with medical treatment guidelines. It explicates the many ways in which they are misused, misleading, invalid, and a negative influence on clinical practice and health policy. The epistemological and methodological mistakes and mis-attributions associated with randomised controlled trials, and the resultant meta-analyses that are the major influence on guidelines, are discussed. The influences on the probity of the scientific process, and the biases that are an inevitable concomitant of the profit-driven pharmaceutical industries are enumerated, especially because doctors are naïve about fraud, and other adverse influences like advertising and gifts. The corrupted nature of the whole science publishing enterprise is a further powerful negative influence on the declining quality of the massively increased number of papers in journals which are often ‘pay-to-publish’ with lower standards of peer-review, or sometimes frankly incompetent, or faked, peer-review. The major publishing houses are now making profits exceeding those of large pharmaceutical houses. The net result of all these influences indicates that both RCT and M-A should be regarded with a great deal of caution and should not be considered, as they currently are, as an inherently superior form of evidence. Medical science and medical scientific publishing are in a state of crisis.


Doctors who aspire to keep up to date with medical science and practice have been cast adrift in a sea of mis-information epitomised by the now all-pervasive and all-influencing guidelines. They fuck you up, the bloody guidelines. They weren’t designed to, but they do. They’re filled with faults, then add egregious extras, just for you. A parody: my apologies to Philip Larkin Guidelines are the ‘final common pathway’ communicating data, that are generated by randomised controlled trials (RCTs), to practicing doctors. This commentary assembles the evidence that most RCTs, and therefore guidelines, are seriously flawed, and are often a negative influence on good clinical practice [1, 2]. First and foremost, this is because so many RCTs are based on corrupted data and corrupted methodology, which emanates from the systematic errors, manipulations, and distortions of clinical trial processes (mostly by ‘big pharma’): and distortions of the resulting ‘evidence’. As Orwell said, ‘
In a time of universal deceit, telling the truth is a revolutionary act
’. A great majority of all trials published are paid for by ‘big pharma’ [3], so that distorts the greater part of all published, and unpublished, medical science. The Lancet editor, Richard Horton, expressed this scathingly: ‘
much published drug-trial research is McScience
’; it is advertising, not science. He is among an increasing number of journal editors and prominent researchers who have commented in relation to this, along with other ex-editors of leading medical journals [4-10]. Horton has reviewed Kassirer’s (ex-NEJM editor) just-published book [11] and comments that ‘
The best editors get fired
’ [because making money and publishing good science are antithetical enterprises]. All these editors came to the realisation that they were being duped, manipulated, and blackmailed into publishing misleading science, through the prestigious publications they were in charge of. These publications had been turned into cash-cows and, [Horton] ‘
little more than information-laundering operations for industry
’, and [Smith] ‘extensions of the marketing-arm of pharmaceutical companies’ [7, 12].


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