Between uncertainty and certainty

In this study, 10 hematologists and 10 lung oncologists were interviewed regarding the information they provide to patients in four situations of uncertainty: determining the treatment that is in the patient's best interest; recurrence or progression of the patient's disease; determining when to withdraw life-prolonging treatment; discussing death, addressing questions such as whether the patient will die from the disease, and when. The primary finding is that delivery of information to patients with low survival rates can be improved by more and better disclosure by physicians at an earlier stage. The crucial point for physicians is to ascertain the wishes of patients, to learn what to reveal about what patients should expect, short term and long term, as death approaches.     

The politics of certainty: Conceptions of science in an age of uncertainty

The prestige of science, derived from its claims to certainty, has adversely affected the humanities. There is, in fact, a "politics of certainty". Our ability to predict events in a limited sphere has been idealized, engendering dangerous illusions about our power to control nature and eliminate time. In addition, the perception and propagation of science as a bearer of certainty has served to legitimate harmful forms of social, sexual, and political power. Yet, as Ilya Prigogine has argued, renewed attention to the irreducible reality of time has brought us to "the end of certainty". As we enter the age of uncertainty, there is disagreement about how science should be understood and communicated. Some scientists cling to the ideal of certainty, while others emphasize the creative potential of spontaneity, novelty, and surprise.     

The social individual in clinical ethics

Except for several provocative final sentences, Sigrid Fry-Revere's "A Libertarian Critique of H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics" is not a libertarian so much as it is a philosophical critique. Engelhardt's work has been widely reviewed, and its arguments have been discussed in Fry-Revere's article and elsewhere. Although it would be impractical in this context to undertake the development of a full-scale, philosophical alternative to libertarianism in bioethics, some recent work in philosophy and clinical ethics bears strongly on the challenge that Engelhardt's work represents. In this commentary I will focus on the implications of a certain alternative philosophy -- and by comparison the limitations of Engelhardt's libertarianism -- for one important aspect of clinical ethics: our understanding of the nature of individuality, with special reference to the situation of the patient. I write as an admiring critic of Engelhardt's work, from which I have learned and drawn inspiration....     

Procedural justice effects on self-esteem under certainty versus uncertainty emotions

Building upon the idea that procedural justice effects are more pronounced when uncertainty is high, we proposed that recall of an uncertainty-eliciting emotion (fear) will render people more responsive to variations in procedural justice than will recall of a certainty-eliciting emotion (disgust). Results from Study 1, (n = 79 undergraduate students) confirmed that a fair procedure (voice condition) enhanced self-esteem relative to an unfair procedure (no voice condition) to a greater extent when people recalled fear than when they recalled disgust. Results from Study 2 (n = 147 undergraduate students) also showed that a fair, relative to an unfair, procedure enhanced self-esteem more strongly when recalling the emotion of fear rather than disgust, but only when these emotions were recalled from a self-immersed than a self-distanced perspective. These findings confirm that discrete emotions that orient people to interpret situations in uncertain versus certain ways are important antecedents of procedural justice effects.     

The Hippocratic Oath and clinical ethics

Its obvious shortcomings aside, this study by H. Steven Moffic, John Coverdale, and Timothy Bayer is disquieting. It comes as no surprise that residents have lapses of cognitive recall. Every medical teacher knows this very well. What is worrisome is that their amnesia concerns the oldest, most revered, and most influential moral statement in the history of the profession...Purely apart from its content, the oath continues to have power as the solemnification of a physician's entry into the profession. It signifies a willingness to submit to a way of life that demands some suppression of self-interest. If studying the oath more explicitly reenforces this solemnification or strengthens the physician's dedication to the welfare of the patient, the effort will be worthwhile.     

Phronesis in clinical ethics

This essay argues that while we have examined clinical ethics quite extensively in the literature, too little attention has been paid to the complex question of how clinical ethics is learned. Competing approaches to ethics pedagogy have relied on outmoded understandings of the way moral learning takes place in ethics. It is argued that the better approach, framed in the work of Aristotle, is the idea of phronesis, which depends on a long-term mentorship in clinical medicine for either medical students or clinical ethics students. Such an approach is articulated and defended.     

The degree of certainty in brain death: probability in clinical and Islamic legal discourse

The University of Michigan conference “Where Religion, Policy, and Bioethics Meet: An Interdisciplinary Conference on Islamic Bioethics and End-of-Life Care” in April 2011 addressed the issue of brain death as the prototype for a discourse that would reflect the emergence of Islamic bioethics as a formal field of study. In considering the issue of brain death, various Muslim legal experts have raised concerns over the lack of certainty in the scientific criteria as applied to the definition and diagnosis of brain death by the medical community. In contrast, the medical community at large has not required absolute certainty in its process, but has sought to eliminate doubt through cumulative diagnostic modalities and supportive scientific evidence. This has recently become a principal model, with increased interest in data analysis and evidence-based medicine with the intent to analyze and ultimately improve outcomes. Islamic law has also long employed a systematic methodology with the goal of eliminating doubt from rulings regarding the question of certainty. While ample criticism of the scientific criteria of brain death (Harvard criteria) by traditional legal sources now exists, an analysis of the legal process in assessing brain death, geared toward informing the clinician’s perspective on the issue, is lacking. In this article, we explore the role of certainty in the diagnostic modalities used to establish diagnoses of brain death in current medical practice. We further examine the Islamic jurisprudential approach vis-à-vis the concept of certainty (yaqīn). Finally, we contrast the two at times divergent philosophies and consider what each perspective may contribute to the global discourse on brain death, understanding that the interdependence that exists between the theological, juridical, ethical, and medical/scientific fields necessitates an open discussion and active collaboration between all parties. We hope that this article serves to continue the discourse that was successfully begun by this initial interdisciplinary endeavor at the University of Michigan.     

Casuistry and clinical ethics

For the last century, moral philosophy has stressed theory for the analysis of moral argument and concepts. In the last decade, interest in the ethical issues of health care has stimulated attention to cases and particular instances. This has revealed the gap between ethical theory and practice. This article reviews the history and method of casuistry which for many centuries provided an approach to practical ethics. Its strengths and weaknesses are noted and its potential for contemporary use explored.