According to the Bible, during the journey of the Israelites from Egypt to the Promised Land, God summoned Moses to Mount Sinai (Horeb). The top of the mountain was covered with dense cloud for 6 days, but on the 7th day, Moses obeyed God's order to climb up through the clouds, and stayed there for 40 days and 40 nights. After he had talked to Moses about how his people should lead their lives, the Lord recorded his words on 2 stone tablets, written by the finger of God.1 Moses carried these 2 stone tablets down from the mountain and called them the Commandments of the Lord: he read them out to the Israelites and told them to learn them by heart. Since then, these commandments, or guidelines, have been the moral basis for thought in Western civilization, and their principles have been adopted for millennia as the fundamental model for human conduct, even by those who believe in other religions or in no religion at all. There have been other guidelines for governing human conduct, such as the Code of Ur-Nammu from the Sumerian period, which dates from around 2100 B.C.,2 and the Hammurabi code, dating from around 1750 B.C.3 − though neither of these codes was handed down by such a supreme authority as God. More importantly, these codes are very long – the Hammurabi code contains 282 laws – and look very much like our modern documents. The story of Moses is familiar to many of us, mainly because we, too, had to learn the Commandments by heart. Fortunately, it was not such an arduous task, as there were only 10 simple rules, short and easily remembered.

So what has Moses got to do with chronic obstructive pulmonary disease (COPD) and why are we talking about him in a scientific journal? Well, we believe that we can learn several things from the Commandments that could be useful for developing clinical practice guidelines. After having worked for many years on different aspects of COPD, it is gratifying to see the recognition that this disease has achieved in recent years, and how its impact on the health of patients all over the world is being alleviated. As a consequence, or as we would like to see it, as a direct result of this awareness, many national and international scientific societies have drawn up guidelines for orienting healthcare professionals in the care of their COPD patients. Yet, the authors of most of these documents, in their attempt to publish comprehensive, updated information, have produced large, complex instructions that are difficult to memorize and put into practice. There are several reasons why they are not more widely applied. Firstly, patients generally have more than 1 non-communicable chronic disease, making it necessary for physicians to simultaneously manage several different conditions, each of which has its own specific and independent guidelines. Secondly, healthcare professionals have limited time to devote to each patient, and moreover, are expected to meet administrative targets which leave them little time to reflect on their actions and compare them with guideline recommendations. Thirdly, clinical evidence changes over time, and scientific societies must update existing guidelines or issue new ones to include these changes. This makes it difficult to follow these recommendations due to the delay between the publication of the guidelines and their implementation in clinical practice. In the case of COPD, it is obvious from reports in the literature that even with the best intentions, the guidelines are often imperfectly followed.

So, what can we learn from the story of the 10 Commandments? Firstly, they are simple and direct. They have only one possible interpretation, and no exceptions are made for special circumstances. Alternative interpretations and exceptions to the rule are problems often encountered by experts sequestered in conclaves over long periods of time. In an attempt to provide “comprehensive” instruments that are applicable to any circumstance, the documents they produce are long and complex. Instead of guidelines, they are more like encyclopedias, and like encyclopedias, contain too much information to be memorized. Secondly, the story reminds us that the Commandments were not evidence-based, in fact they were not even based on expert consensus, since Moses went up the mountain alone and returned with the 2 tablets. Unfortunately, the current trend is that any recommendation included in the guidelines must be strictly evidence-based. However, in many real world situations, evidence is not available, nor is the considerable time and money needed to obtain it. Consequently, some recommendations generate confusion and are difficult to implement. In our opinion, when irrefutable evidence is lacking on certain aspects of clinical management, common sense and good practices should prevail. It is the old chestnut of recommending the use of a parachute, when its efficacy has not been proven in randomized trials. While avoiding these extremes, some recommendations in the field of COPD should be implemented without the need for large randomized trials. Indeed, there is no randomized trial supporting the benefit of smoking cessation, yet it is recommended in all guidelines. One of the responsibilities of a physician is to interpret their patients’ individual problems. Specific situations very often do not slot into any specific guideline recommendation. An analogy would be the case of a judge having to interpret the law and how to apply it in each particular trial. Judges often have to interpret how to apply the law, because the case in question does not exactly fit the letter of the law as written. Despite these impediments, judges and doctors in their daily practice employ not only their technical knowledge, but also their common sense, which is not always based on irrefutable evidence.

To return to the example of Moses, we have brought together the recommendations derived from scientific knowledge in the area of COPD, and, following the worthy example of a passage from the Old Testament that has served humanity for thousands of years, have set them down in 10 COPD commandments (see Table 1). This simple guideline constitutes an attractive, easy and practical approach to the management of COPD in all its variations, and will give physicians the freedom to provide the best possible care to their patients.