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Registro detallado
Ttulo:
Uncertainty and the shaping of medical decisions.
Autores:
Beresford, E.B.
Fuente:
Hastings Center Report. Jul/Aug1991, Vol. 21 Issue 4, p6. 6p.
Tipo de documento:
Article
Descriptores:
*MEDICAL care
Resumen:
Asserts that, while uncertainty can never be eliminated from clinical practice, physicians can at least
come to terms with it. Identifies three sources of uncertainty affecting allocation of resources in a study
involving Canadian physicians; Research project set up in the Centre for Bioethics in the Clinical
Research Institute of Montreal to study the roles of Canadian physicians in allocating medical resources;
More.
Recuento total de palabras:
5739

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ISSN:
0093-0334
Nmero de acceso:
9110214431
Informacin del editor:
Traducir el texto completo:

Texto completo en HTML


UNCERTAINTY AND THE SHAPING OF MEDICAL DECISIONS
Contenido
1. Physicians as Resource Allocators
2. Sources of Uncertainty
3. Uncertainty and the Clinical Decision
4. Ethics and Uncertainty
5. Acknowledgements
6. References
While uncertainty can never be totally eliminated from clinical practice, physicians can at least come to terms
with it. In interviews with Canadian physicians in a variety of clinical settings, three sources of uncertainty
affecting the allocation of medical resources were identified. Technical ,uncertainty arises from inadequate
scientific data. Personal uncertainty arises from not knowing patients' wishes. Conceptual uncertainty arises
from the problem of applying abstract criteria to concrete situations.
Uncertainty shapes the decisions made by clinicians on a daily basis. It is endemic to clinical practice not
merely because there is too little information available to the physician or because the available information is
inadequately understood, but because of the very nature of the decisions that characterize the practice of
medicine. Clinical decisionmaking is affected by a variety of factors, including physicians' serf-interest, their
role as patient advocates, and their concern for the social good.(n1) I do not intend to locate uncertainty as one
factor among these, but rather want to suggest that it shapes the way these other factors are involved in the
process of decisionmaking, both by determining which are taken into account, and by affecting their
relationship to the ethical commitments of physicians. This in turn affects the physician's role in the social
institutions that medicine serves.
Uncertainty is clearly important for any adequate analysis of the ethical character of the decisions that doctors
make. Further, current attempts to control the costs of health care by targeting physician behavior make such
an analysis timely. The ethical significance of such cost containment measures can only be defined by paying
careful attention both to the actual practice of medical decisionmaking, and to the pressures brought to bear
upon clinical practice by cost containment practices.
Physicians as Resource Allocators
In 1988 a research project was set up in the Centre for Bioethics in the Clinical Research Institute of Montreal
to examine the roles of Canadian physicians in allocating medical resources and the new tensions introduced
into these roles by changes in the way medical care is financed and by the pressures on individual physicians to
reduce the costs of care. The project sought to examine how physicians themselves perceive and analyze the
dilemmas they face in the allocation of resources.
The project was divided into two parts. The first was a survey of the available literature, which confirmed our
suspicion that research on the allocation of resources by individual physicians has been minimal.(n2) Very few
articles focus on the role of individual clinicians, and those that do are largely theoretical and are written from
the U.S. perspective. This differs sufficiently from the Canadian context, with its different pattern of health

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care funding, as to preclude the insights being transferred without some qualification. Nonetheless, such
research should be of interest to those American readers who see the Canadian experience as providing useful
lessons for developing alternative structures of health care delivery in the U.S.(n3)
The second part of the project consisted of a series of twenty-five interviews with clinicians in a variety of
health care settings in Quebec and Ontario. The interviews were structured to give the physicians opportunity
to reflect on concrete cases from their practice and to express attitudes toward the pressures they face in
allocating the resources over which they have control. The interviews were not completely open ended, but
were not rigidly structured.
This part of the project was not intended to provide a statistically significant sample. Indeed, the attempt to
undertake such analysis would have been inimical to our intentions. In aggregating the behavior of groups of
people, statistical analysis can obscure precisely those aspects of physician-patient interactions that are
personal, individual, and unique. The greater power of generalization generated by statistical analysis is
therefore offer by a reduced ability to interpret the concrete interactions between persons in the relationships
in which decisions actually take place. Further, when considering the effects of changed policies on the
physician-patient relationship, "Because the physician is the object of change, the physician's behavior should
be the unit of measure, not aggregate behavior which might obscure effects on individual physicians."(n4) In
keeping with this concern I do not attempt to summarize material drawn from the interviews in the form of an
aggregate or a majority statement. Rather, since I wish to focus on those aspects of physician decisionmaking
that are concrete, contextual, even anecdotal in character, my approach is discursive and descriptive.
Sources of Uncertainty
The interviews identified a number of sources of uncertainty that may be classified as technical, personal, and
conceptual.
Technical. The most obvious technical source of uncertainty is the paucity of adequate data to predict the
effects of certain factors in the progress of a disease or the outcomes of certain interventions. Thus, a physician
working in "Preventive Leave"(n5) remarked that despite some excellent data bases provided by the National
Institutes of Occupational Health and Safety and others,
There is still a very grey area. In the issues of AIDS exposure [for example] ... should nurses who are pregnant
be working with patients who have AIDS? It's very difficult, the literature is not clear on that. We have the
same problem with hepatitis.
In a similar vein a neonatologist commented:
There are certainly some children who survive with significant morbidity about whom you feel most unhappy.
You feel unhappy bemuse there were not valid predictors of outcome you could have used at the beginning so
that you could have prevented this long gruelling process...
Such limitations of knowledge, and the problems they raise for practical decisionmaking, are commonplace in
any area of life. But, paradoxically, they are magnified greatly in an area where knowledge is expanding
rapidly, such as modem medicine. The exponential growth of medical knowledge makes it difficult for any
single practitioner to be sure that he or she possesses all the facts relevant to a given case. Further, each piece
of information, as part of a complex and multifactored web of data, becomes itself a source of more questions
that must be answered if we are to predict its significance for any particular situation or course of action. It is
hardly surprising, then, that one of the paradoxical results of the growth of medical technology is that the
medical indications for the use of many of the most expensive new technologies are not clearly defined.(n6)
This was repeatedly confirmed in our interviews and makes the use of these technologies--and attempts to
restrict their use--problematic. As Feinstein has observed,
A powerful technology of treatment has been created, but clinicians are not sure about the best ways to use it.
At every level of clinical practice today, from the delivery of a baby to the care of an octogenarian, the use and
evaluation of therapy is beset by controversy, dissension, and doubt.(n7)
Personal. By, personal sources of uncertainty, I mean those rooted in the physician-patient relationship. Two

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areas were particularly highlighted by the interviews. The first related to the problems faced by physicians who
had to treat patients who were incompetent or who, for a variety of reasons, were unable to make their wishes
known. Where the condition was readily correctable these situations did not appear to cause our interviewees
any major difficulties. But where the prognosis was less positive, the lack of knowledge of the patients' values
and concerns gave rise to some extremely difficult problems. Thus, a geriatrician recounted the case of an
individual admitted to his ward "who was really semicomatose, responding to pain only but not showing any
interaction with the staff." The next of kin were out of the country and could not be reached:
We had no indications of the patient's advance wishes at all. We had some very, very vague indication that the
person we were dealing with would not have wanted to prolong life... In that case we did recommend
implementing the D-feed for a limited time until the child got back.
However, as this physician also noted, many care providers find it emotionally much more difficult to remove a
D-feed than not to implement it in the first place. Such an action may therefore be seen as constituting a
predilection in favor of treating such patients.
The problem can be difficult even when it is possible to interact quite closely with the family. Several
physicians reported that they were not always certain whether families were acting in the patients' best
interests, or whether they were asking for rather more (or less) than the patients themselves would have.
The second personal source of uncertainty drawn from our interviews relates to the sense of attachment that
can grow between care providers and patients they see frequently or over an extended period. A senior
gynecologist reported always consulting with someone before doing a C-section because, "When you're
personally involved, it is harder to make a sensible decision than it' you're detached." This observation raises
the core question of whether the scientific ideal of the detached observer really translates readily into a
medical ideal of detached clinical judgment, or whether the inevitably human aspect of clinical practice must
necessarily qualify such detachment for it to result in sound clinical judgment. I shall return to Otis question.
Conceptual. The conceptual sources of uncertainty found in the interviews arise from two related difficulties:
the problem of incommensurability arid that of applying abstract criteria to concrete situations.
Incommensurability appears sharpest in the classic dilemma where two or more patients are directly competing
for a scarce medical resource. In the bioethics literature this problem is usually posed as most acute when the
two patients have identical medical needs. However, such situations rarely occur; as one senior physician put
it, "For us it hasn't been a choice between patient A or patient B. We've never had a situation that clear."(n8)
Much more common is the problem of balancing patients with quite different conditions who need access to
the same bed, personnel, or equipment. One diagnostic radiologist asked, for example,
Is an urgent case in the emergency room with a patient having seizures more important than a case out of the
surgical intensive care unit with a patient who has an abdominal abscess that is kind of shocky and needs a CF
scan? It's very hard to prioritize two different pathologies that are both serious.
The problem of applying general criteria to specific situations was also a source of uncertainty for the
physicians interviewed. One psychiatrist put the question succinctly: "How does one employ parameters
universally?" We found repeated examples of physicians uncertain about how to respond in particular
situations, unsure whether the situation fitted within the guidelines for a given investigation or mode of
treatment. This was particularly so when the criteria to be applied were felt to be inadequate or controversial.
Thus one psychiatrist noted that
without adequate ways of measuring, we may discover that what is really cost effective is not what seems to be
cost effective and easily measurable in terms of the drug response. The interactive response is much more
difficult to measure ... If something can't be measured to be effective then it almost doesn't exist.
The difficulty here is that the criteria for measuring the effectiveness of treatment are problematic in that they
obscure factors this clinician felt were appropriate to assessing treatment. However, even where the criteria
were uncontroversial their application was not straightforward. Illness rarely presents as a textbook case. Thus,
one neurologist observed that

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emergencies are frankly easier to deal with ... in general we cope with emergencies with no problem: then there
are the urgent cases and there are degrees of urgency that can be a little more difficult.
It turned out that admissions criteria only dealt in very general terms with degrees of urgency and routinely
failed to provide the sort of guidance that would distinguish degrees of urgency between cases. Indeed, one
diagnostic radiologist went further, suggesting that in principle such criteria would be of questionable
usefulness:
It would be almost impossible to have written criteria. Certainly life and death situations are handled
immediately. Unstable patients are handled immediately, but there's a whole range of severity from the most
severe, which is life threatening, to elective cases. I'm not aware of written guidelines and it would be almost
impossible to write guidelines.
Closely allied to this is the problem of what one interviewee described as "the limited if real applicability of
past experience to the present." Another physician remarked:
The trouble is that you can't tell when you take on a seventy-five-year-old man or woman with coronary-artery
disease, aortic aneurism, and a few other assorted conditions how they are going to do. Some of them do very
well and some of them just exist and after a few months or a year or so, they will have some major catastrophe
and die or be left even more crippled.
The issue here is not simply one of technical uncertainty. Rather, it is that uncertainty is an unavoidable
constituent of the particular and context-specific decisions physicians are required to make. Such decisions
require the exercise of judgment. It was on this ground that one interviewee objected to what he perceived as
increased interference from administrators:
I think there are problems having third bodies that are removed from the situation making a judgment. Most of
their judgments might be right, but I think that a lot of clinical judgment as to whether... a test is indicated
resides in your clinical skills in assessing the situation.
It is not merely that we don't know all the factors involved in a particular case, or that we could develop better
criteria and apply them more effectively if we did. Rather, the issue is one which Aristotle identified in his
discussion of phronesis:
Among statements about conduct, those that are universal are more general but the particular are more
true--for action is concerned with particulars, anti statements must harmonize with these.(n9)
Policies are, by their very nature as universal criteria, general and the guidance they offer to decisionmaking is
inevitably less than precise. I shall return to the question of the relationship of medical practice to phronesis.
At this point I want to draw attention to the range of sources of uncertainty that we have noted. These contrast
markedly with the three basic types of uncertainty identified by Renee Fox, which were all examples of what
we have identified as technological sources of uncertainty.(n10) This understanding of the origins of
uncertainty is a compelling rationale for pursuing medical science. Yet while not denying the obvious benefits
of medical science, we must also note that medical uncertainty is linked to the very nature of medical
rationality. Uncertainty will not be eliminated by any degree of technological advance; indeed, I have
suggested that it may be exacerbated by such advance. We must therefore examine how the presence of
uncertainty influences the way other factors are taken into account in clinical decisionmaking.
Uncertainty and the Clinical Decision
While the physicians we interviewed insisted that all their decisions, especially those affecting the allocation of
scarce medical resources, were made on the basis of clinical criteria regarding the best interests of the patient,
as the discussion continued several other factors influencing the course of testing and treatment chosen for
particular patients were identified. Most of these factors can be divided into three classes: those related to the
physicians' own needs and interests, those related to their role as the patient's agent, and those related to their
social role as members of the institutions in which they work and of society.(n11) I have elsewhere described at
length the range of factors that were identified from the interviews.(n12) My concern here is with the role of
uncertainty, and I shall discuss other factors only to the extent that they shed light on the effects of uncertainty
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on clinical decisionmaking.
Uncertainty most clearly affected the practice of the physicians we interviewed in the area of diagnostic
testing. The reasons for this seem to be linked to physicians' desires to provide as, surance to patients, to their
fear of litigation, or more generally to their pursuit of diagnostic certainty. Said one neurologist,
Sometimes, in order to reassure the patient, I will get a CT scan right then rather than trying out treatment and
then maybe later getting a scan if the treatment didn't work. It's difficult to say with 100 percent certainty that
you don't have anything serious.
And an internist remarked that with increased litigation there is certainly more pressure, if the headache
doesn't go away, to say "I'm sure there isn't anything there but we'll do a CT scan anyway."
Such pressures exacerbate the tendency, described at length by Kassirer, to overtest in the search for a degree
of diagnostic certainty that is both unnecessary and unobtainable.(n13) Criticizing this tendency, an orthopedic
surgeon stated:
I look at it in terms of how is it going to change my operation, whereas the patient is looking at it as how can I
have the most complete diagnosis. If you have a degenerative condition or deformity, having an absolutely
complete diagnosis with all the possible information is not necessarily going to help your treatment.
This constant pressure for more information increases enormously the amount of diagnostic testing done in
hospitals. It is not only expensive but often invasive and uncomfortable for the patient, and it may involve the
risk of long-term side effects. Yet such testing is often of questionable value. It would seem that in this case the
pursuit of the scientific ideal in medicine has overshot its legitimate bounds. Many physicians seem to confuse
epistemological certainty--the certainty required to make knowledge claims with confidence--with the practical
certainty needed for wise action. If this is so, we are confronted once again by a parallel between phronesis
and clinical judgment. We are also faced with the difficult question as to what the acceptable limits of
uncertainty are.
Uncertainty also affects clinical practice in the area of experimental procedures and their relationship to the
care of patients. On the one hand, physicians are socialized to be cautious, and in the face of media-stimulated
demand several ,of the physicians we interviewed expressed the view that one of their roles is to protect their
patients from technology that does not have a proven record of usefulness and safety. On the other hand,
technology has shaped the expectations of both physicians and patients. Not only is there a greater expectation
of a good outcome, but the way this outcome is perceived has also changed. The success of technology has led
to an increasing focus on the measurable, which has brought clear benefits. However, one of the psychiatrists
interviewed complained that this approach has real limitations in an area like his, where functional
improvement is not strictly quantifiable. This reliance on the technologically measurable may be one reason for
the lower investment in lowtech, labor-intensive disciplines such as psychiatry, geriatrics, and chronic care,
even in a health care system with socialized financing such as Canada's.
Uncertainty also has an effect on admission of patients to hospital facilities. One pediatrician reported that
there was a marked increase in the tendency of emergency room staff to admit a patient at the end of a shift It
seems that under time pressure, rather than make a quick decision and risk sending home a child who should
have been admitted, residents would say, "I'll admit this kid and let them sort it out on the floor." In another
case, a neonatologist at a highly specialized tertiary care center pointed out that they try to restrict admissions
to patients who would benefit from their specialized expertise, sending other patients to other neonatal units in
their region. However,
the difficulty for us here has been to determine, when you can't see the child and you're talking to a referring
physician or your own personnel who have gone to do the transport, what the child has, and to determine
whether the child should come here or go to one of the other neonatal units.
In such circumstances, previous interactions with the medical personnel trying to gain admission for the patient
obviously take on an increased importance.
Clearly, uncertainty shapes medical practice in a number of ways. The way other factors are weighed in a

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particular clinical decision depends on the degree of uncertainty involved in the situation. What significance
does the ubiquity of uncertainty have for the ethical analysis of clinical decisionmaking?
Ethics and Uncertainty
It can be said at the outset, I think, that any ethical analysis that does not take account of uncertainty will be
inadequate to the concrete realities of clinical practice. Yet despite Katz's plea,(n14) little systematic attention
has been given to the problem, and indeed one might be forgiven for concluding that a central concern of a
great deal of the bioethics literature is to banish uncertainty from even the most troublesome moral dilemmas
encountered in the practice of medicine. In giving this impression, bioethics not only collaborates in what I am
suggesting is a misplaced pursuit, but also sows the seeds for the inevitable disaffection experienced when
bioethics fails to provide generally accepted "answers" to the difficult problems that medicine poses.
What would acknowledging uncertainty involve? Two answers begin to emerge from the issues raised by the
interviews. First, bioethics must be willing to engage the subjective dimensions of the practice of medicine;
second, we require a renewed emphasis on the priority of the concrete and particular. These lead us to a
recognition of the phronetic character of medical decisions.
I referred earlier to the question of the role of the ideal observer, the model of the detached, neutral scientist.
However, doctors are not mere observers of clinical encounters, but participants, directly affected by what
they see and called to act. Cassell has argued that this subjective element is essential to the practice of
medicine, insisting that knowledge of medical science does not make a person a doctor.(n15) More definitive is
the exercise, of clinical judgment in which the generalities of medical science are brought into interaction with
the often ambiguous realities of the clinical presentation of a particular illness in the life of an individual
patient.
Yet judgments are by their nature not abstractions. They are made by individual physicians in specific contexts.
Further, if, as I have argued,judgments are frequently shaped by physician uncertainty, then failure to attend to
the subjectivity of clinical decisions will inevitably distort our account of what is happening in the clinical
encounter.
This rejection of the doctor as an ideal observer and the false objectification such an ideal involves leads to my
second claim: that clinical judgment is always context-specific. While medicine is scientific in that it is
dependent upon and applies the results of science, science and medicine are distinct activities. In contrast to
Feinstein,(n16) we are suggesting that the problem is not that clinical decisionmaking is an underdeveloped
science, but that it has been confused with science. Feinstein draws attention to a number of important
parallels between scientific experimentation and clinical practice, but he fails to note a crucial difference in the
explanatory project of the two activities. In science, the goal is ever higher degrees of generalization, the
generation of theories with greater and greater comprehensiveness and explanatory power. The scientist seeks
to obtain generalized knowledge by selected, and, if possible, controlled observation of specific cases to
explain the mechanisms underlying the particular observations. In medicine the goal is the application of such
general theories to the specific context of the patient's illness. The physician thus seeks to explain, predict, and,
if possible, change the course of the illness by attempting to apply generalized knowledge to the specific case
in hand.
This perspective on clinical decisionmaking views the judgments exercised in diagnosis as a form of
intepretation, as indeed implied in Sir William Osler's famous allusion to the patient as a text.(n17) Thus, a
number of scholars have drawn attention to the "clinical story," that "neglected but pervasive interstitial
medium for the transmission of clinical knowledge."(n18) Cassell also draws attention to the links between the
subjectivity of medical decisionmaking, its particularity, and the narrative basis of medical knowledge. So often
the cautionary advice warning against particular mistakes and identifying treacherous diagnostic terrain takes
the form of a story beginning "When I was an intern in... "Such anecdotal ways of knowing have generally
been deprecated in the theory of medicine. Yet Cassell reminds us that,
since individual experience is ineluctably anecdotal . . . and individual clinical judgments ineluctably contain
subjective elements . . . banishing the subjective and anecdotal from medicine necessarily demotes the
individuality of' the physician to the level of a contaminant.(n19)

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Obviously, an interpretive model of clinical decisionmaking such as this will not be able to define in advance
all the factors that will be decisive for a particular medical decision. It is for this reason that Feinstein's
clinimetrics is finally inadequate. I doubt that a "system for precise identification and classification," in which
the entire range of human factors involved in a clinical decision is reduced to a numerical scale, is possible. But
more importantly, even if such a scale could be devised for individual types of observation, for example, for
impact of treatment on family relationships, it seems unlikely that all such "soft observations" could be brought
onto the single numerical scale necessary for the clearly defined and repeatable judgments Feinstein seeks. To
assume that this is possible is to assume a variation on the claims that Nussbaum has described as metricity and
singleness.(n20) Metricity would mean that all the factors influencing a particular decision are reducible to the
pursuit of one value that varies only in quantity; and singleness, that the metric used to quantify this value is
the same in all clinical contexts. This appears to be yet another example of the technologically driven pursuit
of certainty, this time under the guise of "consistency," which again fails to take account of the fundamentally
incommensurable values at stake in the clinical context and the necessarily uncertain nature of clinical
decisions. For, as Eisenberg notes, "even with perfect information, physicians would not all make identical
decisions."(n21)
However, this need not preclude decisions being made, nor mean that medical decisions are arbitrary. There is
an alternative between quantitative judgment and sentiment, namely qualitative judgment. Indeed, it is
precisely the false dichotomy of technical reason and arbitrariness that drives the concern to banish the
subjective and anecdotal. Certainly exercising judgment involves risk, but it is not arbitrary. Rather, judgment
involves responding with reasons to the particularity of a given situation, and requires the ability to recognize
the salient features of a situation and thus identify it as a situation to which particular types of reasons are
appropriate. Such a practice requires not epistemological certainty, which secures the foundations of
knowledge in the face of skepticism, but practical certainty, whose mode and degree is appropriate to what can
be expected of the context and subject matter. Such certainty always leaves open the possibility of error, but is
sufficient to allow choice and action.
Finally, a number of parallels can be drawn between clinical decisionmaking as we have described it and
Aristotle's description of phronesis. Both are essentially practical and issue in action. Both involve the
application of universal criteria or general guidelines to concrete and specific situations. For both, the guidance
offered by such universal criteria is less than precise, and thus both involve us in the task of making decisions
and acting without the certainty that our actions are the best of all possible alternatives. This further
tmderscores my claim that uncertainty is endemic to decisionmaking.
According to Nussbaum, in the Nichomachean Ethics, Aristotle gives three basic reasons why general rules are
unable to give us the sort of precise guidance that would provide certainty in specific decisions.(n22) First, a
system of criteria set up in advance can encompass only what has been seen before. But the world of change
confronts us with ever-new situations in which we must determine the right course of action. Second, Aristotle
calls attention to the indefinable character of the practical, by which he seems to mean the necessity of fitting
appropriate choices to the complex array of features that must be taken ina) account. In this situation
predefined rules, like a manual of humor, do too little or too much too little because so much of what really
matters in a situation is concrete and particular; too much bemuse a rule would imply that it was itself
normative and so impinge on the flexibility of good practice. Finally, Aristore suggests that the concrete case
may contain some ultimately particular, nonrepeatable elements.
The important thing to note, however, is that this level of uncertainty need not compromise our ability to act
decisively in medicine any more than it does in ethics. The question is whether there is anything to be gained
from a conscious recognition by clinicians of the presence of uncertainty in their decisionmaking. I believe the
answer is yes. If the deeper level of communication that Katz has called for is to be realized, we need, as he
himself pointed out, physicians who are able to acknowledge uncertainty. Doctors will be able to do this better
if they recognize uncertainty to be not a technological failure caused by limitations in their knowledge or skill
in applying it, but rather a ubiquitous element of the inherently interpersonal, contextspecific, and judgmentdependent nature of the practice of medicine.
R. M. Hare invented two characters whom he calls the Archangel and the Prole.(n23) The Archangel can
achieve the critical perspective and detachment from which his dilemmas simplyvanish. The Prole cannot
achieve this perspective and sees his moral dilemmas as real and indissoluble. Nussbaum suggests that in
politics what we need is more Proles and fewer Archangels; after all, Archangels don't really know how to be
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human beings.(n24) I am suggesting that the same is true in medicine. Here even Archangels wood have to
face uncertainty, but only Proles could understand and act upon it.
Acknowledgements
The research for this paper was conducted as part of a research project in the Center for Bioethics in the
Clinical Research Institute of Montreal. Funding for the project was provided by the Social Sciences and
Humanities Research Council of Canada.
References
(n1.) John M. Eisenberg, Doctors' Decisions and the Cost of Medical Care (gain Arbor, Mich.: Health
Administration Press, 1986).
(n2.) Eisenberg, Doctors' Decisions, pp. 157ff. Our own survey of the literature only turned up a small number
of' articles directly concerned with the allocation decisions of individual physicians; almost all were analyses of
the U.S. context.
(n3.) John K. Iglehart, "Health Policy Report: Canada's Health Care system," NEJM 315 (1986): 202-8,
778-84, 1623-28. See also Arnold S. Relman, "The United States and Canada: Different Approaches to Health
Care," NEJM 315 (1986): 1608-10. From a Canadian perspective see Maurice L. Barer, Robert G. Evans, and
Roberta J. Labelle, "Fee Controls as Cost Control: Tales fi-om the Frozen North," The Milbank Quarterly 66,
no. 1 (1988): 1-64. Daniel Callahan, What Kind of Lip? The Limits of Medical Progress (New York: Simon and
Schuster, 1990), pp. 86-89, has contested the relevance of the Canadian situation, but I have suggested that he
has misidentified the ideological differences between Canada and the U.S. (see "What Kind of Limits: A
Canadian Response," Synapse 6, no. 1 [1990]: 2-3).
(n4.) Eisenberg, Doctors' Decisions, p. 161.
(n5.) "Preventive Leave" (Retrait Preventif) is a service of the Commission for Occupational Health and
Safety in the province of Quebec that provides for removing pregnant women from work environments that
may adversely affect the outcome of' their pregnancy. The work environment is assessed, and if it is deemed
hazardous the employer will be required either to move the employee to another less hazardous work situation
or to provide paid leave.
(n6.) Arnold S. Relman, "Cost Control, Doctors and Ethics," Issues in Science and Technology, 1 (1985): 105.
(n7.) Alvin R. Feinstein's clinimetrics is worked out in "An Additional Basic Science for Clinical Medicine,"
Annals of Internal Medicine 99, nos. 14 (1983):393-97, 544-50, 705-12, 847-48. The quotation is from issue
number 1, "The Constraining Fundamental Paradigms," p. 393.
(n8.) There was one instance mentioned in which a resident arrived on a ward where two patients suffered
cardiac arrests simultaneously. Most of the physicians downplayed this sort of one-on-one conflict as not being
terribly realistic.
(n9.) Nichomachean Ethics, 1107a: 29-32. In contrast with E. Haavi Morreim ("Cost Constraints as a
Malpractice Defense," Hastings Center Report 18, no. 1 [1988]: 5-10), Aristotle's point is not just that such
decisions are de facto impossible because of inadequate information, but that such a decision procedure is in
principle not possible because of the nature of practical decisions.
(n10.) Renee Fox, "Training for Uncertainty," in The Student Physician, ed. P. Merton, G. Reader and P.
Kendall (cambridge, Mass.: Harvard University Press, 1957), pp. 208-9.
(n11.) This classification follows Eisenberg, Doctors' Decisions, with minor modifications.
(n12.) Eric B. Beresford, "The Role of Individual Physicians in the Allocation of Scarce Medical Resources,"
paper presented to the annual general meeting of the Canadian Bioethics Society, 1989.
(n13.) Jerome P. Kassirer, "Our Stubborn Quest for Diagnostic Certainty: A Cause of Excessive Testing,"

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NEJM 320 (1989): 148-991.


(n14.) Jay Katz, The Silent World of Doctor and Patient (New York: Free Press, 1986), p. 165.
(n15.) Eric J. Cassell, "The Changing Concept of the Ideal Physician," Daedalus 115, no. 2 (1986): 194.
(n16.) Feinstein, "An Additional Basic Science," p. 393.
(n17.) William Osler, "On the Need of a Medical Reform in Our Methods of Teaching Medical Students,"
Medical News 82 (1904): 49-.53.
(n18.) Kathryn M. Hunter, "`There was this one guy . . .' The Uses of Anecdotes in Medicine," Perspectives in
Biology and Medicine 29, no. 4 (1986): 619.
(n19.) Cassell, "Changing Concept," p. 188.
(n20.) Martha Nussbaum, "The Discernment of Perception: An Aristotelian Conception of Private and Public
Rationality," Proceedings of the Boston Area Colloquium in Ancient Philosophy, ed.J.J. Cleary, vol. 1 (New
5brk: University Press of America, 1986), p. 154.
(n21.) Eisenberg, Doctors' Decesions, p. 65.
(n22.) Nussbaum, "The Discernment of Perception," pp. 175-78.
(n23.) R. M. Hare, Moral Thinking (Oxford: Oxford University Press, 1981).
(n24.) Nussbaum, "The Discernment of Perception," p. 169.
~~~~~~~~
by Eric B. Beresford
Eric B. Beresford is assistant professor, faculty of religious studies, McGill University, Montreal, Canada. This
manuscript received the 1990 Jeanette Lappe Memorial Prize.
Copyright of Hastings Center Report is the property of Wiley-Blackwell and its content may not be copied or
emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.
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