In 2015 I wrote a post about the causal interpretation of hazard ratios estimated in randomised trials, following a paper by Aalen and colleagues. One of the arguments made in that paper was that the hazard ratio does not have a valid interpretation as a causal effect in this setting, even when the proportional hazards assumption holds:

This makes it unclear what the hazard ratio computed for a randomized survival study really means. Note, that this has nothing to do with the fit of the Cox model. The model may fit perfectly in the marginal case with X as the only covariate, but the present problem remains.

With recent discussions on estimands in light of the estimand addendum to ICH E9, I have been thinking more on the argument/claim by Aalen *et al*.

Read moreCausal interpretation of the hazard ratio from RCTs when proportional hazards holds