When is it ethically defensible for a medical practitioner to deviate from clinical practice guidelines?
Open accessAbstract
In modern medical practice, clinical practice guidelines (CPGs) have supported physicians with the development of treatment plans through concise recommendations based on evidence from medical research. Yet, the growing demographics of older patients with complexities and comorbidities mean that there is a group of real-world patients which CPGs may not adequately cover. These guidelines, which are primarily based on randomised controlled trials (RCTs), often have restrictive inclusion criteria and hence exclude such patients in their studies, resulting in recommendations that may not be in the patient’s best interests. Hence, when treating such patients, physicians may be required to deviate from CPGs’ recommendation to ensure the best patient outcome. This puts doctors in a difficult ethical dilemma: whether to follow the CPGs, deviate and risk being complained of, or not treat and refer the patient for palliative care. This article explores the ethical principles and considerations involved when physicians choose to deviate from CPGs in the interest of individualised patient care. The guiding philosophy when using CPGs should be that CPGs can guide the development of treatment plans, but are not meant to direct, dictate or restrict doctors in clinical decision-making.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Regulatory bodies have limited mechanisms to enforce competency safeguards.
“Regulatory bodies have limited mechanisms to enforce competency safeguards 41 .”
From AI-induced never-skilling in medical education (2026) · cites this paper as [41]
Cites
Evidence based medicine: what it is and what it isn't
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996) · BMJ · doi:10.1136/bmj.312.7023.71 · Cited by 15,769 · see citing works
AGREE II: advancing guideline development, reporting and evaluation in health care
Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F., Feder, G., Fervers, B., Graham, I. D., Grimshaw, J., Hanna, S. E., et al. (2010) · Canadian Medical Association Journal · doi:10.1503/cmaj.090449 · Cited by 3,790 · see citing works
Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, A. F. (2002) · Annals of Internal Medicine · doi:10.7326/0003-4819-136-3-200202050-00012 · Cited by 1,624 · see citing works
Adapting clinical guidelines to take account of multimorbidity
Guthrie, B., Payne, K., Alderson, P., McMurdo, M. E. T., & Mercer, S. W. (2012) · BMJ · doi:10.1136/bmj.e6341 · Cited by 530 · see citing works
The changing prevalence of comorbidity across the age spectrum
Piccirillo, J. F., Vlahiotis, A., Barrett, L. B., Flood, K. L., Spitznagel, E. L., & Steyerberg, E. W. (2008) · Critical Reviews in Oncology/Hematology · doi:10.1016/j.critrevonc.2008.01.013 · Cited by 311 · see citing works
Montgomery and informed consent: where are we now?
Chan, S., Tulloch, E., Cooper, E. S., Smith, A., Wojcik, W., & Norman, J. E. (2017) · BMJ · doi:10.1136/bmj.j2224 · Cited by 305 · see citing works
Clinical Practice Guideline Development Manual, Third Edition
Rosenfeld, R. M., Shiffman, R. N., & Robertson, P. (2012) · Otolaryngology · doi:10.1177/0194599812467004 · Cited by 242 · see citing works
Yamamoto, K., Murayama, A., Ozaki, A., Saito, H., Sawano, T., & Tanimoto, T. E. (2020) · International Urogynecology Journal · doi:10.1007/s00192-020-04547-3 · Cited by 27 · see citing works
Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines
Ducis, K. A., Florman, J. E., & Rughani, A. I. (2016) · World Neurosurgery · doi:10.1016/j.wneu.2016.02.044 · Cited by 18 · see citing works
Specific recommendations to improve the design and conduct of clinical trials
Kupersmith, M. J., & Jetté, N. (2023) · Trials · doi:10.1186/s13063-023-07276-2 · Cited by 7 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
AI-induced never-skilling in medical education
Ke, Y., Jin, L., Ong, J. C. L., Thirunavukarasu, A. J., Car, J., Cheung, C. Y., Tham, Y. C., Ting, D. S. W., Ong, M. E. H., Compton, S., et al. (2026) · Nature Medicine · doi:10.1038/s41591-026-04438-y · Cited by 35 · see citing works
- Authors
- Lim, D. X. W., & Thamotharampillai, T.
- Affiliations
- National University of Singapore (SG)
- Duke-NUS Medical School (SG)
- Venue
- Annals of the Academy of Medicine Singapore
- Publisher
- Academy of Medicine, Singapore
- Published
- 2025-10-01
- Volume
- 54
- Issue
- 10
- Pages
- 664
- ISSN
- 0304-4602 (ISSN-L)
- 2972-4066
- OpenAlex
- W4414769711
- Cited by
- 1
- References
- 10
- Citations by year
- 2026: 1
- FWCI
- 0.92
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- Locations
- Annals of the Academy of Medicine Singapore (publishedVersion, cc-by-nc-sa)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Keywords
- guideline adherence, medical ethics, clinical decision-making, elderly patients, comorbidities, palliative care, ethical principles
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
