Laws, Guidelines and professional choice

My wife runs a family business in the Lake District of England and regularly interviews people for a variety of jobs. Her business includes a visitor attraction centre, and she recently interviewed a very nice 42-year-old gentleman who wanted the job of handing out leaflets to local shops and hotels. All was going well and, as they got to the end of the interview, she asked him if he had any questions. He replied that he just wanted to clarify that the previous experience he had in canteens and workshops was actually gained while serving for 22 years in Durham prison for murder. It struck me that we do not meet people like this very often. As a rule we all seem to follow our national laws that state that we should not commit murder, robbery or fraud, and society seems to work quite well because of this. However, all this breaks down when we get into a motor vehicle. I am yet to meet someone who has not broken the speed limit in his or her car, and I count myself as one of those who blame the speed camera when I get a ticket. So what is it that makes one law beyond question and another acceptable to flout? In our own specialty, we have many guidelines produced by leaders in the field after meticulous systematic reviews that set the standards for our clinical practice. Who would question that prophylactic antibiotics are indicated for patients undergoing cardiac surgery or that aspirin should be given to all patients to improve vein graft patency (grade A evidence: American Heart Association 2004, [1])? In contrast, Nowell et al. [2] have provided us with comprehensive account of the evidence for and against warfarin therapy after an aortic bioprosthesis, together with current guideline recommendations. The dichotomies between the evidence, guidelines and current practice are striking in this paper. The ACCP [3] and the ESC [4] guidelines all recommend 3 months of warfarin, the ACC/AHA [5] disagrees, and surveys of current practice [6,7] show us that while 80% of us are aware of guidelines indicating warfarinisa-tion, over half of us do not anticoagulate after bioprostheses. So, what is the role of a guideline in the modern era if we do not follow their recommendations? I regard guidelines to be excellent resources for summarising the evidence on a large range of topics in a way …