Department of Population Health Sciences, School of Life Course and Population Sciences, King's College London, London, UK.
J Eval Clin Pract. 2022 Oct;28(5):814-820. doi: 10.1111/jep.13675. Epub 2022 Mar 14.
Some have questioned the extent of medical intervention at the end of people's lives, arguing that we often intervene in the dying process in ways which are harmful, inappropriate, or undignified. In this paper, I argue that over-treatment of dying is a function of the way in which clinicians manage epistemic risk-the risk of being wrong. When making any scientific decision-whether making inferences from empirical data, or determining a plan for medical treatment-there is always a degree of uncertainty: in other words, there is always a possibility we make the wrong decision. As philosophers of science such as Justin Biddle have argued, there is no way to resolve epistemic risk without weighing up the consequences of being wrong. This requires us to draw upon other, non-epistemic considerations, like social and ideological values; as such, questions of epistemic risk cannot be answered solely with reference to epistemic considerations such as evidence. In this paper, I explore how epistemic risk arises in end-of-life care, highlighting how clinicians face epistemic risk when diagnosing patients as dying and when determining whether a particular treatment is futile. I argue that there is no clear cut-off between reversible and irreversible illness, nor between useful and futile treatment. Clinicians who diagnose a patient as dying thus risk failing to provide treatment which could be beneficial; conversely, clinicians who determine that a patient has a potentially reversible illness risk subjecting them to futile treatment that may be painful or distressing. Having outlined where and how epistemic risk arises in end-of-life care, I turn my attention to the values and norms which shape clinicians' management of epistemic risk. I highlight how societal attitudes towards death, the medicalisation of dying, and the practice of defensive medicine all contribute to clinicians erring on one side of epistemic caution, minimising the risk that they miss or fail to treat illness. By applying the concept of epistemic risk to end-of-life care, I offer a novel lens through which to view medical decision-making in dying patients.
有人质疑在生命末期进行医学干预的程度，认为我们经常以有害、不适当或不体面的方式干预死亡过程。在本文中，我认为过度治疗临终患者是临床医生管理认识风险（犯错的风险）的方式的一个功能。在做出任何科学决策时——无论是从经验数据中推断，还是确定医疗治疗计划——总是存在一定程度的不确定性：换句话说，我们总是有可能做出错误的决定。正如哲学家贾斯汀·比德尔（Justin Biddle）等所指出的，不权衡犯错的后果，就无法消除认识风险。这需要我们借鉴其他非认识因素，如社会和意识形态价值观；因此，认识风险问题不能仅参考证据等认识因素来回答。在本文中，我探讨了认识风险如何在临终关怀中产生，强调了临床医生在诊断患者死亡和确定特定治疗是否无效时面临认识风险。我认为，可逆性和不可逆性疾病之间，以及有用治疗和无效治疗之间没有明确的界限。因此，将患者诊断为死亡的临床医生有未能提供可能有益的治疗的风险；相反，将患者确定为患有潜在可逆转疾病的临床医生有让他们接受可能痛苦或不适的无效治疗的风险。在概述了认识风险在临终关怀中产生的地点和方式之后，我将注意力转向塑造临床医生管理认识风险的价值观和规范。我强调了社会对死亡的态度、死亡的医学化以及防御性医疗实践如何共同导致临床医生在认识谨慎的一方犯错，从而最大限度地降低他们错过或未能治疗疾病的风险。通过将认识风险的概念应用于临终关怀，我提供了一个新颖的视角来观察临终患者的医疗决策。
