1. No category

Prognostication and Bioethics
Author(s): Nicholas A. Christakis
Source: Daedalus, Vol. 128, No. 4, Bioethics and Beyond (Fall, 1999), pp. 197-214
Published by: The MIT Press on behalf of American Academy of Arts & Sciences
Stable URL: http://www.jstor.org/stable/20027593
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A. Christakis
Nicholas
and Bioethics
Prognostication
scientific
Asocial
occur
social-science
tions
can
of the field of bioethics
critique
two levels. The first involves
the use of
on at least
underlying
theory
bioethics?for
are
how
ethical
are
decisions
sort
liefs?a
of
of
the assump
that ethics
example,
by arguing
in
relative.
The
second
culturally
social-science
methods
and findings
or
contingent
socially
the use of empirical
to show how bioethical
concerns
volves
some
to destabilize
shaped
"thick
out
play
in real
or
situations
and be
by real behaviors
of bioethical
decision
mak
description"
on the problem
and empirical
work
of
conceptual
on a multi-year
in medicine,
re
and drawing
prognostication
on this topic,
I intend
to do the latter
search project
of mine
numerous
here. My
research
involved
studies
complementary
that included
mail
cohort
surveys,
experiments,
psychological
content
of texts,
and participant
studies,
interviews,
analysis
ing.1 Using
observation?all
sicians
do
Patients
at understanding
directed
and
do
expect
prognosticate.2
to prognosticate
physicians
is simultaneously?yet
mistic.3
Consequently,
with
fraught
that embodies
how
and why
phy
not
impossibly?honest,
find
physicians
in a fashion
that
and opti
accurate,
in a situation
themselves
that
is, a situation
ambivalence,"
on
demands
the occupants
placed
"sociological
contradictory
a particular
social
role.4 This
social-structural
ambivalence
can
in turn result
in an intrapersonal,
ambiva
psychological
as a result
lence. Partly
of this ambivalence,
find
physicians
of
Nicholas
A.
departments
Christakis
of medicine
is associate
and
sociology
of medicine
professor
at the University
and
sociology
of Chicago.
in
197
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the
198
A. Christakis
Nicholas
about
the end of life, to be trou
prognostication,
particularly
to cope with
and
and
stressful,
they employ
bling
approaches
to
stress.
is
One
this
avoid
prognostication
simply
altogether;
but physicians
also adopt
other
atti
compensatory
behaviors,
even
comes
to
when
it
and
commitments
tudes,
ideological
prognostication.
The avoidance
of prognosis
ing. Despite
being a fundamental
is virtually
cal care, prognosis
in medicine
and
absent
is quite
thoroughgo
aspect of medi
important
from medical
education,
and patient
care.5 The
relative
texts, medical
research,
in modern
of prognosis
and
medical
practice
thought
cannot
be explained
of patient
need or
by an absence
certainly
are
however.
interest,
Indeed, when
sick, their interest
patients
to
in diagnosis
is often
in
and therapy
their interest
secondary
medical
absence
it turns
The avoidance
of prognosis
prognosis.6
by physicians,
nor
are
is
neither
accidental
for
there
out,
incidental,
powerful
norms
in the medical
the
both
against
profession
militating
and
communication
the
of
prognoses.
development
Physicians
are
to avoid
socialized
Remarkably,
physicians
prognostication.
tend to avoid
two
distinct
elements
is a
prognostication:
foreseeing
foretelling.
Foreseeing
course
estimate
the
about
future
inward,
cognitive
physician's
is the physician's
of a patient's
and foretelling
outward
illness,
to the patient.
are sev
communication
There
of that estimate
of
and
reasons
avoid
that physicians
prognostication,
including
of
the
and
the objective
difficulty
uncertainty
prognostication,
error
nature
in it, the consequential
of such error for
inherent
care and
the physician's
the depen
the patient's
reputation,
on social
to
dence
of prognosis
factors
that physicians
consider
eral
can evoke
emotions
the troublesome
prognosis
and physicians
alike. Finally,
avoid
prog
physicians
of a complementary
between
because
relationship
in both
the theoretical
and the practical
and prognosis
be
"soft,"
for patients
nostication
therapy
consideration
usually
and
given
to disease;
is nowadays,
prognosis
in medicine
Prognostication
whether
and how
also
raises
physicians'
questions
practice.
prognoses
about
Both
when
therapy
is avoided.7
is available,
as
it
raises
questions
quite
beyond
are developed
or communicated.
It
certain
of
ethical
and moral
aspects
the avoidance
of prognostication
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and
199
and Bioethics
Prognostication
have
important
implica
practices
a
of
wide
of bioethical
for
variety
theory
reality
to the challenge
of
decisions.
Pertinently,
physicians
respond
or
a
in
of
that
have
host
ways
religious
magical
prognostication
certain
and
the
not
overtones
generally
of
Here,
for bioethical decision
care.
I will
in medical
prognosis
plays
one aspect
detail
of physicians'
attitudes
in the self-fulfilling
their belief
namely,
proph
to illustrate
I hope
how social-science
research
the
role
in particular
toward
prognosis:
ecy. In so doing,
on medical
care
and
contexts.
in biom?dical
expected
some of the implications
Iwill examine
making
consider
and
attitudes
related
tions
inform
and
can,
should,
I will
And
bioethical
bioethical
argue
analysis.
in medicine
of the role of prognosis
standing
itself is a deeply
the notion
that prognostication
social
the physician's
under
in turn
supports
moral
aspect
of
role.
BELIEFS ABOUT THE SELF-FULFILLING
PHYSICIANS'
decisions
a clear
that
PROPHECY
Physicians do not merely find prognosis stressful and worthy of
neglect; they also find it dreadful. This dread primarily arises
two
from
physicians
predict
and
ethical
identified with
they
mortality,
impli
in
death
are strug
their role in forestalling or hastening death, and they
gling with
confront
unavoidably
death
patient's
have moral
is broadly
First, prognosis
care. When
medical
of which
both
sources,
cations.
and
is linked
prognosis
mysterious
and
physicians
believe
to the individual
both
relationship
in general.
death
To
that
the extent
is
with
death,
prognostication
necessarily
their
to
and,
dangerous,
that predictions
therefore,
can affect
dreaded.
Second,
outcomes
through
a kind of "self-fulfilling prophecy."8 The self-fulfilling prophecy
is a complex
physicians'
difference
phenomenon,
and
attitudes
between positive
fers
to
able
outcomes,
to unfavorable
fers
other
and, among
analysis
things,
in this area demonstrates
behaviors
favorable
predictions
and negative
predictions
self-fulfilling
cause
that
self-fulfilling
that cause
prophecy, which
a
re
favor
corresponding
prophecy,
of
re
which
unfa
corresponding
outcomes.
vorable
Beliefs about the self-fulfilling
broader
class
of
nonrational
prophecy
beliefs
that
are illustrative of a
are
evoked
by
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and
200
Nicholas
A. Christakis
of
supported
by the necessity
evokes
both magical
and
is not
This
prognostication?for
sentiments
religious
since both magic
and
unexpected,
prediction
in physicians.
are fun
religion
damental ways of coping with
the strain posed by the limits of
human
especially
The
and
ability
of
combination
in the
in particular?produces
and religious
ways
magical
high
face
of
death.
stakes, and high
in general?and
in prognostica
a situation
conducive
strongly
in medicine
interests
emotional
science,
of high uncertainty,
tion
of
thinking.9
Nevertheless,
to
physi
cians' belief in the self-fulfilling prophecy and their ideas about
are
it works
how
for bioethical
consequential
in a population
found
of
immune
from such seemingly
intriguing?and
are
decision
making?because
they
are ostensibly
who
are
and who
thinking
professionals
nonrational
committed
to, and trained
on
a
biom?dical
illness
and medi
for,
positivistic,
perspective
outcomes
cine. The
that preoccupy
transcendent
medical
care,
the malleability,
and meaningfulness
of these out
importance,
and
comes,
in medicine
the interrelationship
to provide
combine
between
and affect
technique
terrain
for the emergence
fertile
of such thinking.
self-fulfilling
uted to W.
real
tion
are not
current
affording
tems are unique.
in order
future
ways
that
of predictions
social
they are purposeful
tic.11 And
it is one
both metaphysical
effectiveness
and
greater
Prediction
behavior
future
People
to make
systems
rather
part
behavior
for
of the situation
and
on
the
attrib
as real, they are
a given
situa
also, more
outcomes.
In
but
subsequent
social
sys
the
about
predictions
come
to pass.
This
the predictions
is one of the main
about
the future
can
differ
from
reasons
in medicine
prognosis
and ethical
significance
on
prophecy,
ones?that
is,
physical
or stochas
deterministic
either
than
of prediction
gives
ethical
obligations.
is effective
about
self-fulfilling
act on their
of the main
as a consequence
outcomes
through
situations
Predictions
consequences."10
an integral
only
affect
an opportunity
effectiveness
his classic
essay
opens
a sociological
theorem
by citing
"If men define
prophecy
I. Thomas:
in their
important,
K. Merton
Robert
Sociologist
physicians
has
implications:
greater
clinical
the
power
two
It may
levels.
affect
present
its articulation,
and it may
affect
two
in
These
the change
behavior.
of
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Prognostication
effects
are
actors
that
in turn
by the conscious
these consequences.
enhanced
has
prediction
as a deliberate
fact use
201
and Bioethics
means
knowledge
to alter
among
in
may
People
the future.
In
predictions
can alter the future
it is the belief
that predictions
words,
as
the future), more
alter
how
beliefs
about
well
(as
predictions
that is essential
of the predictions
than the content
themselves,
other
to the effectiveness
sions
of what
If people
had impres
of prediction.
simply
or
accurate
future held
inaccurate)
(whether
the
but did not believe
that these
or
the present
as much
influence
influence
have
would
then prediction
future,
as it does. Moreover,
people
and act accordingly
prophecy
self-fulfilling
in fact,
of whether,
for example,
While,
gardless
works."
that
the
self-fulfilling
prophecy
in medicine
there is some
do
actually
predictions
should or could
not
the
in the
believe
impressions
contribute
to outcomes,
may
re
"really
evidence
the
key
point is that even if they did not, the majority of doctors believe
that
prophecy
attitudes,
believe
sicians
outcomes.12
identify three mechanisms
Physicians
filling
tients9
cause
can
predictions
The
works.
by which
and
behaviors,
that predictions
the self-ful
is to
first mechanism
affect
pa
For
phy
example,
or
anxious
patients
physiology.
can make
com
can influence
outcomes,
patients'
can
so
affect
and
and
outcomes,
modify
pliance
or cardiovascular
and so affect out
parameters
immunological
comes.
is to affect physicians'
attitudes
The
second mechanism
a prediction
For example,
and behavior.
of an unfavorable
treatment
with
a physician
to become
and so
neglectful,
a
was
outcome
that
unfavorable
Or,
predicted.
in the
ill patient
will
die can result
that a critically
can
outcome
cause
in the
result
prediction
withdrawal
The
so affect
and
depressed
of
third,
believe
life support
and most
and
provocative,
that the self-fulfilling
so cause
outcome.
the predicted
is that physicians
mechanism
prophecy
can work
through di
means:
a prediction
if it
is made,
and even
rect, quasi-magical
to
to the patient,
it can cause
is not revealed
something
happen
sort of way.13
in a word-made-flesh
be effec
That
that their predictions
believe
may
physicians
tive heightens
their
a prognosis
whether
prophecy
raises
the
sense
outcomes?
of responsibility
for patient
or not. The negative
self-fulfilling
that physicians
prospect
might,
frightening
is made
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202
A. Christakis
Nicholas
the
through
ever accurate
formulation
and
articulation
clinically
their patients. The belief in the negative
a powerful
unfavorable
consequently
places
and communicating
of
or probabilistically,
a prognosis,
how
or
even
harm,
kill,
self-fulfilling
on
constraint
both
The
predictions.
prophecy
formulating
self
positive
is only slightly less problematic. The belief in
fulfilling prophecy
the positive
raises
the unsettling
pros
self-fulfilling
prophecy
cause
to
that
be
whatever
fa
pect
physicians
might
expected
outcome
In
vorable
other
words,
they might
predict.
patients
once again hold physicians
might
Favorable
predictions?whether
elicited
by patients?considerably
responsible
volunteered
increase
for
the outcome.
or
by physicians
on physi
the onus
cians.
of prognosis
and the responsibility
for out
cause physicians
to believe
it engenders
that it is danger
ous to make
The danger
is compounded,
of prognosis
prognoses.
nature
of the possible
direct
however,
by the quasi-magical
The
effectiveness
comes
action
tions
them
of
the
The prospect
self-fulfilling
prophecy.
a
in
fulfill
themselves
might
quasi-magical
in that,
if they are
all the more
dangerous
non-logico-rational
and
understand
their
own."
that
a prognosis
then might
that
nism
are
that much
"take
to
harder
on a life of
by the prospect
a
to
in
behavior
patient's
might
changes
a
lead to
fulfillment
of the prediction?a
mecha
lead
sense?than
logical
they are threatened
by the
the prognosis
and
itself,
directly
obscurely,
to its own fulfillment.
the three mechanisms
Indeed,
that
of effectiveness
be ordered
that
effect
of the self-fulfilling
from
predictions
the patient's
least
have
prophecy
to most
on
dangerous
is less
patients
identified above
as
follows:
the
than
threatening
in turn is less
which
physicians,
effect
of predictions.
This
quasi-magical
a gradient
in which
the physician's
responsibility
predictions
than the
threatening
order
reflects
for
they
predic
makes
way
in a
effective
that makes
possibility
lead
the
then
Prognoses
might
are much
less threatened
Physicians
might
may
effect
way,
to control.
that
have
outcome
on
increases.
steadily
to affect patients
and
It is one
thing for
it is
thus outcomes;
prognoses
physicians'
to affect
another
for the prognoses
themselves
and
physicians
to
thus outcomes;
and it is quite another
still for the prognoses
outcomes
affect
the
themselves.
(and effect)
directly
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Prognostication
believe
The facts that physicians
203
and Bioethics
in the self-fulfilling
proph
is widespread,
and that the self-fulfilling
ecy,
are deeply
in
works
ways
multiple
consequential.
prophecy
act
will
and
that their predictions
with
the
fear
hope
Physicians
set of beliefs
outcomes.
This
affects
how physi
shape patient
this
that
cians
interact
belief
it can
consequently,
lems are analyzed
are
view
and how
they
patients
both how
affect
abstract
with
and
how
actual,
their
bioethical
relevant
ethically
work;
prob
decisions
made.
a prognosis
that articulating
believe
Physicians
to
This
control
behavior.
deliberate
way
patients'
be a
may
is indeed one
of the main ways
is believed to
that the self-fulfilling prophecy
to articulate
consciously
physicians
to
in
the
ben
for
achieve
prognoses
order,
example,
perceived
or better
out
of improved
eficial
effects
patient
compliance
often
and
work,
come. The
beliefs
action
modes
of
nicate
to patients.
for
not
The
communicating
the patient.
"protect"
tive has
ethics
about
also
come
choose
the self-fulfilling
affect
how
bad
news
the
and its
commu
physicians
offered
by physicians
to
to patients
is a desire
reason
classical
Over
prophecy
and what
last
few
decades,
under
this perspec
in the bio
criticism,
withering
especially
as being paternalistic
But the
and self-serving.
unfavorable
prognoses
may
against
articulating
or subconscious
the conscious
fear that the
from
have an effect via the self-fulfill
prognosis
might
literature,
prohibition
also
result
unfavorable
an unfavor
to articulating
the aversion
Indeed,
ing prophecy.
can be construed
as
within
earshot
of the patient
able prognosis
a form
or "negative
of "sympathetic
taboo"
This
magic."14
both
the withholding
of information
observation
helps
explain
from
patients
different
giving
family.
Although
of the
product
counter
patient's
not wish
bad news with
patients,
sharing
they also reflect
a
to avoid
to
in the
downward
trajectory
contributing
a self-fulfilling
illness through
do
Physicians
prophecy.
to be responsible
for patients'
deaths.
The
consider
given
patients
the widespread
of the physician
practice
to the patient
and to the patient's
information
are in part a
these communicative
behaviors
en
difficulties
and unpleasantness
physicians
when
a desire
ation
and
to the ethics
rarely,
to my
of communication
knowledge,
between
acknowledges
doctors
the
fact
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and
that
204
A. Christakis
Nicholas
fear
may
physicians
statements
their
that
cause
might
out
comes.
The belief in the self-fulfilling prophecy also strongly contrib
utes
to what
medical
be
may
called
the
as
Insofar
prognostication.15
can
favorable
cause
favorable
prognosis
if possible,
their
rather
an unfavorable
of
ways
positive
think
their
regarding
to say nothing,
patients
they choose
and
treatment;
than offer
that
outcomes,
they quite
to the optimistic
end of
predictions
their prognoses
try to "shade"
naturally
the continuum;
they favor demonstrably
with
about
and
their
ing
interacting
and
in
of optimism"
believe
physicians
"ritualization
More
prediction.
a favor
reservations
about
fewer
over,
they have
articulating
not only because
if appropriate,
this enhances
able prognosis,
effectiveness
and
relieves
the
of
their
feelings
professional
but also
patient's
anxiety,
serves
articulation
actually
because
believe
they
that
and
objectives
therapeutic
an
such
the
helps
patient.
generally, however, the belief in the self-fulfilling prophecy
Most
the norm
supports
Because
altogether.
tication
"dangerous,"
making
that physicians
the self-fulfilling
avoid
should
prognosticating
makes
prognos
prophecy
to lose by
often
have much
in the self
did not believe
physicians
If physicians
be much
they would
predictions.
more willing
to make
fulfilling
prophecy,
of prognostic
infor
The suppression
and state their predictions.
in clinical
interaction
the
mation
care, however,
impoverishes
since such infor
and doctors
between
and, especially
patients
is often
mation
such
to
critical
ethically
decisions.
can
nosis
itself
as we
Indeed,
be configured
SOME ILLUSTRATIONS
IN BIOETHICAL
see, the avoidance
as a moral
issue.
OF THE ROLE OF PROGNOSIS
and
with
practices
respect
in general
and the self-fulfilling
have
important
implications
and also
making
Prognostication
of prog
shall
tion
decision
compro
decisions,
DECISIONS
beliefs
Physicians'
tinged
(and the doctor) to make the best
the ability of the patient
mises
is in fact
the
for
for
a major
in particular
prophecy
ethical
the moral
to prognostica
analysis
standing
underpinning
of
of
clinical
doctors.
for many
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bio
205
and Bioethics
Prognostication
a fact that is typically
in the
decisions,
unappreciated
to
such
the practical)
consideration
theoretical
(and often
given
For example,
the
with
bioethical
about
decisions.
reasoning
as follows:
is
of life support
The patient
drawal
often proceeds
ethical
to die.
going
Life
is of no
support
further
Life
benefit.
may be harming the patient. Should we withdraw
This
often
type of reasoning
as: How
such questions
neglects
support
life support?
do
the patient is going to die? How do we know life
is
of no further benefit? Who is authorized to make
support
if they are wrong? What
if factors
these predictions? What
we know
outside
the patient's
contribute
predictions
of the situation?
ethics
case
influence
to the outcome
in patients
suicide
of physician-assisted
if the
What
the
"reality"
in the
debate
of the current
much
Analogously,
the predictions?
and change
are
who
irreme
diably terminally ill has focused on the ethical and legal aspects
in such behavior,
engagement
that doctors
taken for granted
of doctors'
generally
a patient will
and essential
when
predict
fundamental
ity,"
a
relatively
new
and has unfortunately
and able
are willing
to
die.16 Prognostication
the
is, indeed,
basis
for a determination
of "futil
doctrine
whereby
are
physicians
not
obligated to provide care that they deem futile to critically ill
patients.17 This doctrine is being increasingly invoked to justify
or withdrawal
the withholding
are being
who
withdraw
of
life
in rare
harmed
support
by it;
over family objections.
support
assertion
about
the intractability
of
life
damental
ease or about
the impotence
of
the course.
Both are prognostic
aspects?in
acknowledged.
and
termined
both
theory
Moreover,
by whom,
the doctor's
statements.
from
patients
to
invoked
a
is
fun
Futility
dis
the patient's
it is
cases,
to alter
treatment
Yet
the prognostic
and
practice?are
rarely
explicitly
is de
the key issues of how
futility
as well
as its inherently
self-fulfilling
are often
nature,
neglected.
a
core element
not only
is
in bioethical
deci
Prognostication
areas.
in numerous
sions at the end of life, but also
In
other
prophecy-like
organ
transplantation,
of allocation
component
a key (though
is the "greatest
are allocated
organs
from the transplant
for example,
decisions
the standard
rion,"
whereby
to gain the most
who
stands
the least chance
of rejecting
it
not
the only)
crite
benefit
according
and who
immunologically?which
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to
has
are
206
essentially
allocation
assessments.
prognostic
takes place
the
To
on
depending
extent
the
likely
essential
that
success
organ
of the
is an
element
of the
intervention,
prognosis
a
decision
allocation
organ
Indeed,
making.
typifies
of
informed
ethical
concern,
type
prognostically
namely
medical
ethical
broader
the
A. Christakis
Nicholas
allocation
scarce
of
products,
Another
blood
beds,
time.
is important,
of
analysis
prognosis
is in the ethical
be
ICU
resources?whether
or physician
area where
and
the use
is likely to
of genetic
so,
increasingly
tests. To date,
the ethical
of genetic
has gener
analysis
testing
on
focused
the
of
such
the prob
information,
ally
"ownership"
of such confidential
lems raised by revelation
information
(e.g.,
or the threats
to
for patients'
such testing
poses
insurability),
our
of collective
conception
nostic
of
aspects
risk
tests
these
and
raise
Yet the prog
community.
ethical
questions?
special
especially given the strong evocation
that
a test
sicians'
other
of one's
ardor
level,
nostic
genes
generates?which
for
communicating
the use of
however,
will
purposes
the current
of self-fulfilling
likely
bases
genetic
prophecy
temper
might
phy
an
On
information.
information
genetic
be more
for
palatable
for prog
physicians
is that
for prognosis.
The reason
to
information
will
be
the genetic
preor
appear
biologically
or social
to individual
dained,
fixed, unsusceptible
scientifically
than
clinical
will
there
and unmodifiable
influences,
by physicians.
Physicians
a
a
with
feel more
comfortable
fore probably
patient
telling
cancer
at
he
is
risk
for
with
that
increased
associated
gene
lung
even
cancer?than
that he will
they
develop
lung cancer?or
will
feel telling a patient who
cancer,
over,
prone
mental
sible
even
if the
may
The perception
physicians
to error.
cause
of
for both
Thus, many
nostication
the prognosis.
will
prognosis
events
will
the prediction
of the reasons
will
smokes that he will develop
are mathematically
identical.
feel that genetic
prognostication
likely
be
Nevertheless,
lung
More
risks
is less
is a so very funda
that genetics
to feel less respon
help physicians
made
and the outcome
observed.
that
act
to restrain
less prominent
the use of
when
prog
physician
underlie
genes
in
information
genetic
concerns
about
the role of
heighten
assume
concerns
that may
existential
readily
destiny,
overtones.
gious
individual
or
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reli
207
and Bioethics
Prognostication
to the basic ethical
of patient
autonomy,
concept
respect
as persons
should be respected
is the notion
that patients
which
to determine
and
their own care, the accuracy
and thus allowed
to
to
to
them
do
allow
the
of
information
given
patients
quality
are
so and the feasibility
such information
of developing
rarely
With
Much
examined.
on
depend
prognostic
decisions
arise
patients
are
they
the
of
possible
future. Advance
in which
complete
they
of
quality
ethical
Many
the
au
patient
to informed
Directives
"hypothetical
various
in the
specifically
often
is poor.
to respect
given
obligation
Advance
so-called
a sort
experience
might
ments
from
describe
physicians
decisions
time,
patients'
and
assessments,
from
ranging
involve
consent,
the
prognostic
information
that
tonomy,
of
in which
prognosis"
scenarios
that
patients
are docu
Directives
their wishes
express
with
respect to life support should they become both critically ill and
to speak
unable
for
themselves.18
elicit
the physician
preferences,
outcomes.
consent
Informed
the patient's
various
these
Ideally,
are
discussions
and guided by them.19 But in order to
initiated by physicians
must
first
predict
is the
expressed,
or research
to un
of patients
subjects
willingness
a medical
intervention
about which
have
they
adequate
possible
uncoerced
dergo
through a disclosure
information, predominantly
by physicians
consent
the informed
pro
During
consequences.20
interventions
the
characterizes
the
cess,
by
proposed
physician
outcomes
of possible
the inter
of both
descriptions
providing
of
vention
side effects
and the alternatives,
along with
possible
or researchers
consent
time doctors
obtain
each. Thus,
every
of
risks
and
a treatment
or to conduct
a patient
to administer
research,
are
to
extent
is
The
which
the doctor
using
prognosis.
they
a
to make
accurate
is therefore
and able
predictions
willing
in both advance
factor
directives
and informed
very important
from
and
consent,
it ought
to be an
important
factor
the ethical analysis of such decision making
behaviors
The
exhibit
physicians
of
bioethical
analysis
the specific social context
reality
whether
of
noses,
and
these
and
dilemmas
how
these
when
engaged
cannot
concerns
in which
emerge.21
physicians
factors would
both
in terms
of
and in terms of the
in such
decisions.
be separated
from
both the theory and the
Numerous
and
factors
influence
communicate
develop
need to be accounted
for
prog
in both
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208
Nicholas
and
making
outlined
various
the
analyzing
above. What
are
if doctors
ethical
decisions
systematically
from life-support
over-opti
technol
types
in their
mistic
ogy
with
A. Christakis
of
of benefit
predictions
in their discussions
overestimate
its utility
therefore
on
or
in their actions
behalf? What
patients
patients'
and
doctors
is not
to make
refuse
predictions?
if doctors'
biases
What
possible?
if accurate
What
if
prediction
in progno
or behaviors
it difficult for both them and their patients to make the
sis make
most
if predictions
ethical
decisions?
What
affect outcomes
and
so modify
even
as
it
the basis
for the ethical
is
decision,
being
cannot
be ignored when
made?
Surely the role of such questions
the right thing to do in clinical decisions
considering
dimensions.
ethical
notion
The
that
that have
have
strong
physicians
beliefs
(of one sort or an
to prognosis
into question
it comes
throws
the
can
to which
ethical
decisions
be
relevant
prognostically
or examined
such "social"
without
also considering
fac
and
preferences
when
other)
extent
made
indeed
nonrational
tors.
THE MORAL
DUTY OF PROGNOSTICATION
the role
Though
more
secularized
a prominent
mains
of the physician
has become
progressively
re
in American
death
itself?which
society,
re
ministrations?has
focus of physicians'
its mystical
and
is concerned
prognosis
cannot
avoid highlighting
tained
in modern
is only
medicine
of prediction
aspect
or
even
the
effective,
quasi-magical
by
dangerous,
it has.
believe
that physicians
This
healing.
augmented
properties
A view
of
casts
life that
mined
makes
the world
and
the events
amoral.
which
that
To the extent
properties.
religious
act
the
of
with
death,
prognostication
nature
of
nonsecular
the ineradicably
at
realized?the
least
some
future
as either
events
random
or predeter
uncontrollable,
experience
meaningless,
But in an indeterministic
world?one
elements
and
of
the
statements
future
about
can
in
be purposefully
it are
controllable,
to induce
emotions
its ability
and
on
out
in its (at times
effect
behaviors,
change
self-fulfilling)
of magic
and in its evocation
comes,
(and religion),
prognosis
in the role
resembles
and, as such, casts the physician
prophecy
meaningful,
and moral.
In
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of prophet.
reasons.22
I have
Elsewhere,
invoked
on
shed
209
and Bioethics
Prognostication
for three
analogies
of
the
aspects
neglected
they clarify an archetypical
these
First,
they
light
role of physicians.
Second,
prognostic
to medical
not
contexts?be
restricted
social
relation?one
a "prophet"
tween
And
the resem
and a "supplicant."
third,
blance between
of prognosis.
is morally,
of prophecy,
prognosis
or even socially,
Because
encoded.
a form
As
highlights
the moral
dimensions
ethical
and
and prophecy
prognosis
biologically
affect
both
not merely
can
prediction
and
it
and because
and physicians'
behaviors,
it
have
that
outcomes,
suggests
patients'
physicians
an important
when
they prognosticate.
Physi
responsibility
an obligation
to be aware
cians have
of the ways
prognosis
can
patients'
affect
to prognosti
and an obligation
their ethical
decisions
as possible.
as accurately
That
and empathetically
is, there
a
in
but
also
moral
is not only a moral
prognostication,
duty
the avoidance
that is
of prognosis
Thus,
duty to prognosticate.
informs
cate
care
in medical
prevalent
the
represents
shirking
not
only
a
of
but also of a moral responsibility by physicians, a
responsibility that pertains both to individual physicians and to
clinical
the profession
An
important
as a whole.
often
transcendent
source
involves
of
this
responsibility
concerns.
Death
is that prognosis
is a focus of ethi
attention
and moral
whenever
existential,
cal, religious,
remission
it occurs.
the
existence
however
and
Similarly,
are
examination.
the
also
moral
foci
of
Did
patient
suffering
to bring about
anything
led? What
dying person
death? What
death?23 The
fact
the
are
suffering? What
the implications
that physicians
often can influence
raises
still
of death.
This
is the meaning
in to modify
engage
nostication
influences
nected
the
life has
of an awareness
of
to the most
actions
the course
is linked with
these
the course
further
of
moral
of this influence, and how might
sorts
What
exercised?
of
do
of
meaning does the individual see in his or her
salience of these questions is heightened by the
the manner
What
sort of
and
thoughts
should
of
the
illness
and
questions.
it best be
or doctor
the patient
as prog
illness?
Insofar
suffering and death, and insofar as it
and
consequential
con
it is inextricably
actions,
sorts of moral
and meaningful
concerns.
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210
A. Christakis
Nicholas
to prognosticate
is further
supported
by
obligation
in the power
and knowledge
of
of an asymmetry
a
is sick, perhaps
with
The patient
and physician.
The moral
the
existence
the patient
and
has technical
and the doctor
terminal
illness,
knowledge
is seeking.
and emotional
The physical
that the patient
therapy
is
ill
of
such
and,
extraordinary
seriously
patients
vulnerability
of the physician,
suf
the professional
with
authority
coupled
the
entire
obligations.
As
fuses
patients
literally
patients
no
less
burden
able?by
claims
and
with
the
strongest
and of
this
of
result
possible
the trust
asymmetry,
over patients?and,
hold power
put in them, physicians
over
The
future.
their
fact that
and metaphorically,
on their doctors
creates
are so dependent
prognostic
obligations
ones. The
is better
encounter
clinical
a
it creates
than
of prediction
virtue
of expert
to authority?to
to enhance
the use
ity,
In order
and
diagnostic
more
falls
justly
lack
training,
it.24
bear
therapeutic
to the one who
of vulnerabil
in clinical
of prognosis
practice
(in the sense of both foreseeing and foretelling) and to meet
to prognosticate,
Patients
do not
certain
must
obstacles
be
the
over
clearly
and
information,
prognostic
always want
to
to
informa
will have
this. Prognostic
be sensitive
physicians
are generally
to patients.
need
tion can be harmful
Physicians
communi
in
and
inaccurate
the
prognoses
they develop
lessly
venues
in educational
cate.25 Information
prognosis
regarding
And
resist
minimal.
is
and materials
gen
physicians
currently
to
obstacles
These
information.
practical
erating
prognostic
duty
come.
not
subvert
the moral
for
opportunities
to improve both
future.
Inwardly,
improvement.
they
incorporate
routinely
as they
much
ment,
toms or test results.
track
of
the
track
of
the
sions.
this
should
prognostic
of
of
accuracy
respect,
strive
were
their
their
their
should
make
efforts
of the
and their foretelling
to more
thinking
incorporate
currently
In this vein, physicians
accuracy
If physicians
Physicians
their foreseeing
obligation
there are several
the level of the individual physician,
At
in
do
however,
prognostication,
to prognosticate.
prognoses,
formally
into their
the patient's
might
much
and more
manage
symp
mental
keep
as they
and
keep
deci
therapeutic
diagnostic
a process
to begin
of self-calibration
in prognosis
and
confidence
accuracy
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increase.
both
might
to avail
themselves
cause
also make
efforts
greater
Physicians
might
resources
of prognostic
be
that do exist
is increasingly
information
formulate
and
order.
evaluate
noses,
their communication
physicians
an effort
overcome
a very
so poorly.
and
exist,
have
Physicians
and they
tolerated.27
prognostic
to
attention
Greater
situations.26
do
In any case,
to foretell
the
to
physicians
extent
that
or
so
and
decisions,
these decisions.
of
quality
However
sympathetic
prognosis
not
be
it may
be
can make more
for
need
poor performance
no matter
how difficult
to prognosis
enhance
may
physicians
ethical
avoid
in
is also clearly
foretelling
time communicating
hard
prog
resources
to enhance
Yet good
aversion
their
error
who
on how
to
available
becoming
in many
clinical
information
future,
it. To
the
foresee
in prognosis,
numerous
ethical
211
and Bioethics
Prognostication
are
of
to
able
they
their propensity
the factual
enhance
for
basis
for
the
specifically
we might
be to individual
or who
or
make
advertent
physicians
inadvertent
we need not be so forgiving
in prognosis,
of the profes
an authority
on ways
to
sion as a whole.
As Alvan
Feinstein,
in 1983:
the science
of clinical
"The omis
enhance
care, noted
errors
sion
of prediction
from
has
the major
intellectual
the
impoverished
a modern
main
clinician's
make
The
science
goals of basic medical
content
of clinical work,
since
predictions."28
sional
level is particularly
deplorable
no
for
justification
interpersonal
education
tients, nor
From
might
in the care of patients
is to
at the profes
of prognosis
since at this level there is
challenge
avoidance
the
cannot
or
to
ethical
perspective,
individual
and
Research
harm pa
by any means
in textbooks
and journals.
we
whatever
allowance
regarding
prognosis
can coverage
of prognosis
a policy
accord
absence.
for
physicians
be none
their
of
avoidance
at the professional
level.
prognostication,
a
is
the
that
it is
moral
arguments
Despite
prognosis
duty,
also clear from the analysis
of physicians'
attitudes
and behav
to prognosis
iors with
that these attitudes
and behaviors
respect
there
should
are deeply
in the practice
embedded
concerns
the practical
and ethical
of medicine.
that
prognosis
Consequently,
raises cannot
It is
be addressed simply by the invocation of ethical principles.
not
possible
physician's
to
social
the
ignore
and moral
phenomenological
predicament
reality
in prognosis.
of
the
The
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212
A. Christakis
Nicholas
social
scientific
minates
the
the
role
of
complexity
ethical.
is not merely
that
of
study
rich
in medicine
of prognosis
this phenomenon,
illu
a complexity
ENDNOTES
noteworthy
examples of such work include: Ren?e R. Anspach, Deciding Who
Lives: Fateful Choices in the Intensive-Care Nursery (Berkeley: University of
California Press, 1993); Charles L. Bosk, "All God's Mistakes3': Genetic
in a P?diatrie Hospital
Counseling
(Chicago: University of Chicago Press,
1992); Ren?e C. Fox, Experiment Perilous (Boston: The Free Press, 1959);
Ren?e C. Fox and Judith P. Swazey, The Courage to Pail: A Social View of
Organ Transplants and Dialysis, 2d ed., rev. (Chicago: University of Chicago
Press, 1978); Jonathan B. Imber, Abortion and the Private Practice of Medi
cine (New Haven, Conn.: Yale University Press, 1986); and Robert Zussman,
Intensive Care: Medical Ethics and theMedical Profession (Chicago: Univer
sity of Chicago Press, 1992).
2Nicholas A. Christakis, Death Foretold: Prophecy and Prognosis
Care (Chicago: University of Chicago Press, 1999).
See
90ff.
3Ibid.,
also
S. Kutner
Jean
et al.,
"Information
Needs
inMedical
in Terminal
Ill
48 (1999): 1341-1352.
ness," Social Science and Medicine
inRobert K.
4Robert K. Merton and Elinor Barber, "Sociological Ambivalence,"
Merton, Sociological Ambivalence and Other Essays (New York: The Free
Press,
8.
1976),
5Christakis, Death
Foretold.
"Attitude
Iwashyna,
and
See also Nicholas
in a National
Sample of Internists,"
(1998): 2389-2395.
F. Degner
Breast
6See, for example,
Lesley
inWomen
Preferences
Regarding
Archives
et al.,
with
A. Christakis
Practice
Self-Reported
journal
Needs
of
J.
Prognostication
of Internal Medicine
"Information
Cancer,"
and Theodore
and
158
Decisional
the American
Medical
Association 277 (1997): 1485-1492; Christina G. Blanchard et al., "Infor
mation and Decision-Making
Preferences of Hospitalized Adult Cancer Pa
tients," Social Science and Medicine 27 (1988): 1139-1145.
"The Ellipsis
7Nicholas A. Christakis,
Thought," Social Science and Medicine
8Christakis, Death
Foretold,
in Modern
of Prognosis
44 (1997): 301-315.
135-162.
9As social theorist Talcott Parsons has argued: "The health situation
one
of
produce
magic.
ence
the
of
combination
a situation
But
precludes
the
fact
of
that
outright
Medical
and
emotional
is a classic
interests
strong
uncertainty
a prominent
strain
is very
and
frequently
the basic
cultural
tradition
of modern
medicine
magic,
which
is explicitly
non-scientific."
which
focus
of
is sci
See Talcott
Parsons, The Social System (New York: The Free Press, 1951), 469. This type
of magical thinking about prediction is in keeping with other forms of "seien
This content downloaded from 130.132.173.4 on Tue, 07 Apr 2015 20:13:59 UTC
All use subject to JSTOR Terms and Conditions
seen
tifie magic"
Health
in medicine.
See Ren?e
in Ren?e
Professionals,"
C.
C.
Fox,
Human
"The
Fox,
ed.,
213
and Bioethics
Prognostication
of
Condition
in Medical
Essays
Sociology:
Journeys into the Field (New Brunswick, N.J.: Transaction Books, 1988),
581, and Ren?e C. Fox, The Sociology of Medicine
(Englewood Cliffs, N.J.:
Prentice Hall, 1989), 198.
10RobertK. Merton, "The Self-Fulfilling Prophecy," inRobert K. Merton, Social
See
Theory and Social Structure (New York: The Free Press, 1968), 475-490.
K. Merton,
Robert
also
"The
Thomas
Theorem
and
the Matthew
Effect,"
For a broader consideration of the self
Social Forces 74 (1995): 379-422.
see
L.
Richard
"The Boundary of the Self-Fulfill
Henshel,
fulfilling prophecy,
ing Prophecy and the Dilemma of Social Prediction," The British Journal of
Sociology 33 (1982): 511-528.
1
Regarding
the
issue
of
of
the purposefulness
social
more
systems
one
12For example,
found
study
that,
one measure,
by
73
see
generally,
Karl Popper, The Open Universe: An Argument for Indeterminism
1982).
Routledge,
(London:
of physicians
percent
believed in positive and 61 percent in negative self-fulfilling prophecy. These
distributed among physicians. See
beliefs were relatively homogeneously
Christakis, Death Foretold, 225.
also
and
14Marcel
Foretold,
of prediction
simultaneously
A General
Mauss,
See
1972).
Norton,
144-150.
Death
13Christakis,
fectiveness
Theory
also
trans.
of Magic,
as
that
ef
the
mechanisms
Brain
Robert
"Words
J. Reiser,
Stanley
in the Clinical Dialogue,"
Evidence
I mean
"quasi-magical"
on rational,
explainable
mechanisms.
inexplicable
By
depends
partly
on nonrational,
York:
(New
Transmitting
Scalpels:
92 (1980):
Annals of Internal Medicine
837-842.
15This
term was
first
used
by Bronislaw
Science and Religion
Magic,
to medicine
applied
previously
A. Drickamer,
l?Margaret
See Bronislaw
Malinowski.
Malinowski,
(Boston: Beacon Press, 1948), 70. It has been
Parsons
by Talcott
A. Lee,
Melinda
and Linda
Fox.
Ren?e
and
in
Issues
"Practical
Ganzini,
126 (1997): 146
Suicide," Annals of Internal Medicine
Physician-Assisted
of Physicians
151; Melinda A. Lee et al., "Legalizing Assisted Suicide?Views
in Oregon," New England Journal of Medicine 334 (1996): 310-315.
S. Jecker
17Nancy
and
Lawrence
"Medical
J. Schneiderman,
to Treat," Cambridge Quarterly Healthcare
Not
Lawrence
J. Schneiderman
and Nancy
Rich,
and
Autonomy
"Prospective
The
Duty
in Practice,"
"Futility
Ar
153 (1993): 437-441.
chives of Internal Medicine
18Ben A.
S. Jecker,
Futility:
Ethics 2 (1993): 151-159;
Critical
Interests:
A Narrative
De
fense of theMoral Authority of Advance Directives," Cambridge Quarterly
of Healthcare Ethics 6 (1997): 138-147; Steven H. Miles, Robert Koepp, and
Eileen
P. Weber,
"Advance
view," Archives
Schneiderman
Treatments
et
al.,
Treatment
End-of-Life
of Internal Medicine
"Effects
and Costs," Annals
Planning:
A Research
156 (1996): 1062-1068;
of Offering
Advance
of Internal Medicine
Directives
Re
Lawrence J.
on Medical
117 (1992): 599-606.
This content downloaded from 130.132.173.4 on Tue, 07 Apr 2015 20:13:59 UTC
All use subject to JSTOR Terms and Conditions
214
A. Christakis
Nicholas
et al.,
19James A. Tulsky
Box:
the Black
"Opening
nicate about Advance Directives?"
How
Do
Commu
Physicians
Annals of Internal Medicine
129 (1998):
441-449.
20Ruth R. Faden and Tom L. Beauchamp, A History and Theory of Informed
Consent (New York: Oxford University Press, 1986).
"Ethics Are Local: Engaging
21See, for elaboration, Nicholas A. Christakis,
Cross-Cultural Variation in the Ethics for Clinical Research," Social Science
and Medicine 35 (1992): 1079-1091.
22Christakis, Death
Foretold,
179-199.
23SeeDaniel Callahan, The Troubled Dream of Life: In Search of a Peaceful Death
(New York: Simon and Schuster, 1993) and Arthur Kleinman, The Illness
Narratives: Suffering, Healing, and the Human Condition (New York: Basic
Books, 1988).
in power
is that
between
and physician
of the asymmetry
patient
to venal
is open
for self-serv
prognostication
by the physician
manipulation
on the part of the doctor
to avoid
this.
it requires
ing ends;
vigilance
24A corollary
25See,
for example,
A. Christakis
Nicholas
and
B. Lamont,
Elizabeth
"The
Extent
and Determinants of Error in Physicians' Prognoses inTerminally 111Patients:
A Prospective Cohort Study," British Medical Journal (in press); Elizabeth B.
Lamont
26For
A.
and Nicholas
Disclosure
to Terminally
illustrative
reviews,
Christakis,
111Cancer
see Nicholas
Preferences
"Physicians'
Patients,"
A.
Christakis
and
for Prognostic
manuscript.
unpublished
Greg
A.
Sachs,
"The
Role of Prognosis in Clinical Decision Making," Journal of General Internal
Medicine 11 (1996): 422-425; James F. Fries and George B. Ehrlich, Progno
sis: Contemporary
Outcomes
of Disease
(Bowie,
Md.:
Charles
Press,
1981);
Charles M. Wattts and William A. Knaus, "The Case for Using Objective
Scoring Systems to Predict Intensive Care Unit Outcome, Critical Care Clinics
10 (1994): 73-89; Michael Seneff andWilliam A. Knaus, "Predicting Patient
Outcome from Intensive Care: A Guide to APACHE, MPM, SAPS, PRISM,
and Other Prognostic Scoring Systems," Journal of Intensive Care Medicine 5
(1990): 33-52.
27See, for example, Robert Buckman, How to Break Bad News: A Guide for
Health Care Professionals
(Baltimore, Md.: Johns Hopkins University Press,
1992).
I:The
28Alvan R. Feinstein, "An Additional Basic Science for Clinical Medicine
Medicine
99
Internal
Fundamental
Annals
of
Paradigms,"
Constraining
(1983): 394.
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All use subject to JSTOR Terms and Conditions