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June 8, 1994

Principles for Making Difficult Decisions in Difficult Times

JAMA. 1994;271(22):1792-1798. doi:10.1001/jama.1994.03510460086041

IN THE last article I described several issues or "battles" that will be particularly contentious in the coming decade.1 They relate to the evidence needed to justify use of a treatment, to the need to balance a treatment's benefits against its costs, and to the autonomy of physicians to answer these questions for themselves. (I will use the word "treatment" very broadly to encompass any type of health intervention.) One way or another, these issues will be resolved in the next few years. Setting aside for a moment the actual solutions that are developed, the process by which these issues are addressed will provide one of the most visible displays of how the medical profession manages itself and responds to an urgent social need.

The main battlefield on which these issues will be resolved will be debates over coverage and guidelines for individual treatments. These debates will occur in