Clinical guidelines may need ethical component
==============================================

* W. Göttens-Jansen
* E. van Leeuwen
* P.A.G.M. De Smet
* Jan K. Buitelaar

The AGREE collaboration has introduced a new research-based version of its instrument to assess the quality of clinical guidelines and the reporting of the underlying development process. 1,2 

This version maintains the same six quality-defining domains that underpinned the original AGREE approach: scope and purpose; stakeholder involvement; rigour of development; clarity of presentation; applicability; and editorial independence. By keeping these domains, the AGREE collaborators seem to imply that they do not consider an extension necessary.

Perhaps the guidelines (and tools) should explicitly help their users put the clinical guidance offered into practice in ethically competent ways. As acknowledged in the CanMEDS framework, 3 health care professionals need robust ethical competence to provide patient care. This is not only relevant in dramatic life-or-death situations, but also in the increasingly complex reality of everyday practice, where potential issues are usually less striking but far more common and often no less important. 4 

It is premature to propose adding an ethical component to the AGREE domains. Instead, we advocate research to explore how the codes of ethics for different professions can be supplemented with treatment-specific materials, how the process of developing such materials can be systematized in the spirit of AGREE, and how such materials can be used to increase ethically competent attitudes and behaviour in everyday patient care.

## Footnotes

*   **For the full letter, go to:** [www.cmaj.ca/cgi/eletters/182/10/1045#595795](http://www.cmaj.ca/cgi/eletters/182/10/1045#595795)

## REFERENCES

1.  1. Brouwers MC, Kho ME, Browman GP et al. Development of the AGREE II, part 1: performance, usefulness and areas for improvement. CMAJ 2010;182:1045–52.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTgyLzEwLzEwNDUiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTgyLzE0LzE1NDYuMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Brouwers MC, Kho ME, Browman GP et al. Development of the AGREE II, part 2: assessment of validity of items and tools to support application. CMAJ 2010;182:E472–8.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTgyLzEwL0U0NzIiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTgyLzE0LzE1NDYuMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  3. *CanMEDS 2005 framework*. Ottawa (ON): Royal College of Physicians and Surgeons of Canada. Available [http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf](http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf) (accessed 2010 Aug. 22).
    
    

4.  4. Carrese JA, Sugarman J. the inescapable relevance of bioethics for the practicing clinician. Chest 2006;1390:1864–72.