Epistemic risk and nonepistemic values in end‐of‐life care

Abstract

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.

Philosophy and the clinic: Stigma, respect and shame

“…These contributions are followed by several highly original articles addressing the relationship between evidence and practice in medicine and healthcare, 27–29 demonstrating the application of specific, philosophically informed approaches to causal reasoning with reference to some very practical contemporary health controversies 30,31 . Continuing debates on pressing issues we have emphasized in more recent thematic editions, authors explain and analyse different conceptions of ‘patient‐centred care’ and ‘patient expertise’, 32,33 discussing the role of values in shaping our understanding of the mental and medical disorder, 34,35 and the relationship between epistemic risk and nonepistemic values in the end of life care 36 . The need to understand research, its implementation and interpretation in the broader social and political context is illustrated by a fascinating article on overdiagnosis 37 .…”

“… 30 , 31 Continuing debates on pressing issues we have emphasized in more recent thematic editions, authors explain and analyse different conceptions of ‘patient‐centred care’ and ‘patient expertise’, 32 , 33 discussing the role of values in shaping our understanding of the mental and medical disorder, 34 , 35 and the relationship between epistemic risk and nonepistemic values in the end of life care. 36 The need to understand research, its implementation and interpretation in the broader social and political context is illustrated by a fascinating article on overdiagnosis. 37 The edition includes stimulating and provocative discussions of shared meaning making and health literacy, 38 precision medicine and its effects on medical epistemology, 39 and the need to rethink our conception of ‘researcher bias’ in health research.…”