Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision‐making

Abstract

Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision‐making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision‐making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life‐sustaining treatment. Behavioural psychology research suggests there are two systems of thinking – fast and slow – that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health‐care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision‐making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.

Family‐centred care

“…When a pregnant woman is about to deliver an extremely preterm baby, we know that neonatologists differ in the way they counsel parents about the risks and benefits of resuscitation . Other examples in which the inherent biases of the ‘counsellor’ themselves are critical include the decision between palliative care and operative intervention for hypoplastic left heart syndrome and between palliative care and medical intervention for spinal muscular atrophy type 1.…”

Complex survival in extreme prematurity parents, their options and the need for a unified team approach

“…In addition, clinicians may need to reflect on their own intrinsic bias when informing and asking questions of parents regarding their choices. 17 The case of baby C illustrates the need to actively listen to parents and to ensure they understand their infant's condition and the long-term risks involved. Some parents may find later they cannot morally, emotionally or economically parent a child with a high risk of disability.…”

The Holobiont Blindspot: Relating Host-Microbiome Interactions to Cognitive Biases and the Concept of the “Umwelt”

“…Further investigations into these theoretical Holobiont Blindspots could change the way we understand and empathize with certain social behaviors. As System 1 thinking plays a role in systematic errors through reasoning (Kannengiesser and Gero, 2019;Preisz, 2019), studies aimed at ascertaining the potential effects (deleterious or otherwise) of a host's microbiome in this process could be extremely valuable. If part of our perception and intuition is influenced by "other" agents (i.e., microorganisms) considered to be constituents of the holobiont, could this change the way we view perception and intuition?…”