Uncertainty

The relatively brief history of disorders of consciousness has seen two epistemic eras—the first was marked by certainty, both ethical and epistemic, about the vegetative state. The second era has been notable for its epistemic and ethical uncertainty. This chapter looks at the 21st century neuroscientific revolution in disorders of consciousness and its ongoing reverberations. Uncertainty about these disorders continues to increase. There are ontological and epistemic doubts about behavioral diagnosis, which looks for the contents of consciousness, or local states of consciousness, while trying to capture the global states of consciousness that are of most diagnostic and ethical interest. The scientific and medical uncertainty, and the high rate of misdiagnosis, complicate ethical decision-making for patients with these disorders.

The Anatomy of Uncertainty

Chapter 3 describes the anatomy of medical uncertainty, identifying key attributes that give it a three-dimensional conceptual shape, form, and structure. It characterizes uncertainty in terms of its (1) fundamental sources (root causes), (2) issues (substantive problems), and (3) loci (persons in whose minds uncertainty resides) and presents a conceptual framework that allows the variety of uncertainties in medicine to be classified and better understood. The chapter makes the case that in all of these ways, a three-dimensional conceptual framework can facilitate a more intentional, targeted, and rational approach to evaluating medical uncertainty. By providing a way of visualizing, ordering, and objectifying an otherwise invisible, disordered, subjective reality, the framework can ultimately enable clinicians and patients to better manage medical uncertainty.

Uncertainty in Medicine

This book offers a multidimensional, multidisciplinary perspective on the challenging problem of uncertainty in medicine. Adopting a textbook approach to the problem, it analyzes the nature, etiology, natural history, and management of medical uncertainty. It draws on insights from a wide range of fields—including clinical medicine as well as anthropology, behavioral economics, philosophy, psychology, and sociology—to develop a set of conceptual frameworks that provide a new way of thinking about medical uncertainty and approaching its management. It makes the case that uncertainty is an essential form of knowledge that should be maintained rather than eliminated, and that the goal of managing uncertainty is to promote uncertainty tolerance among clinicians and patients. The book identifies system-level strategies that can help make uncertainty tolerance a more central focus of medical care.

Introduction

Chapter 1 introduces the topic of medical uncertainty and discusses its importance in human life. It argues that medical uncertainty is a critically important but historically neglected experience of both clinicians and patients, and that the COVID-19 pandemic and other recent events have raised the need to better understand and manage this uncertainty. The chapter makes the case for the value of a conceptual framework in helping clinicians and patients to better understand, manage, and ultimately tolerate the uncertainties they experience and provides an overview of the book. A conceptual framework alone cannot change reality, the chapter argues, but it can help clinicians and patients to adapt to it.

The Natural History of Uncertainty

Chapter 4 describes the natural history of medical uncertainty—that is, the way that the phenomenon is manifest in people’s lives. It classifies people’s psychological responses to uncertainty within two main categories: primary (initial cognitive, emotional, and behavioral responses) and secondary (compensatory responses aimed at regulating primary responses). It presents a conceptual framework that classifies the variety of primary and secondary responses to uncertainty and discusses how the framework can help clinicians and patients evaluate and manage these responses. The ultimate goal of this framework is practical: to improve the management of uncertainty in medicine. The framework can promote this goal by enabling clinicians and patients to rise above their own regulatory responses to uncertainty and achieve greater tertiary control over them.

How Physicians Manage Medical Uncertainty: A Qualitative Study and Conceptual Taxonomy

Background Medical uncertainty is a pervasive and important problem, but the strategies physicians use to manage it have not been systematically described. Objectives To explore the uncertainty management strategies employed by physicians practicing in acute-care hospital settings and to organize these strategies within a conceptual taxonomy that can guide further efforts to understand and improve physicians’ tolerance of medical uncertainty. Design Qualitative study using individual in-depth interviews. Participants Convenience sample of 22 physicians and trainees (11 attending physicians, 7 residents [postgraduate years 1–3), 4 fourth-year medical students), working within 3 medical specialties (emergency medicine, internal medicine, internal medicine–pediatrics), at a single large US teaching hospital. Measurements Semistructured interviews explored participants’ strategies for managing medical uncertainty and temporal changes in their uncertainty tolerance. Inductive qualitative analysis of audio-recorded interview transcripts was conducted to identify and categorize key themes and to develop a coherent conceptual taxonomy of uncertainty management strategies. Results Participants identified various uncertainty management strategies that differed in their primary focus: 1) ignorance-focused, 2) uncertainty-focused, 3) response-focused, and 4) relationship-focused. Ignorance- and uncertainty-focused strategies were primarily curative (aimed at reducing uncertainty), while response- and relationship-focused strategies were primarily palliative (aimed at ameliorating aversive effects of uncertainty). Several participants described a temporal evolution in their tolerance of uncertainty, which coincided with the development of greater epistemic maturity, humility, flexibility, and openness. Conclusions Physicians and physician-trainees employ a variety of uncertainty management strategies focused on different goals, and their tolerance of uncertainty evolves with the development of several key capacities. More work is needed to understand and improve the management of medical uncertainty by physicians, and a conceptual taxonomy can provide a useful organizing framework for this work.