Collaborative Decision Making, Uncertainty in

The Challenge of Uncertainty

Collaborative decision making is critically important in health care; however, it also poses several challenges, among the most difficult of which is the need to manage uncertainty. This need arises because the information exchanged by patients and clinicians is ultimately incomplete and imperfect, reflecting inevitable gaps in scientific knowledge and the constructed and dynamic nature of patient values and preferences. Collaborative decision making brings these limitations to light, producing uncertainty—the subjective awareness of ignorance—in the minds of patients and clinicians. Through this process patients and clinicians each gain a metacognitive awareness of what they do not know—that is, they move from ignorance to uncertainty.

Collaborative decision making, therefore, not only reduces ignorance but also produces new uncertainties that patients and clinicians need to manage. These uncertainties pertain to a variety of issues that are scientific, practical, and personal in nature. Scientific uncertainty is disease-centered and related to clinical evidence; it encompasses uncertainties about diagnosis, prognosis, causal explanations, and treatment recommendations. Practical uncertainty is health-system-centered and related to the structures and processes of care; it encompasses uncertainties about health care delivery and access. Personal uncertainty is patient-centered and related to psychosocial and existential concerns; it encompasses uncertainties about patients' values, goals, sense of meaning, and personal relationships.

Uncertainties pertaining to any or all of these issues are generated by the collaborative decision-making process, and their number and variety complicate their management. Furthermore, each type of uncertainty—scientific, practical, and personal—may arise from multiple sources: probability, ambiguity, and complexity. Probability refers to the fundamental indeterminacy or unpredictability of a phenomenon; ambiguity refers to the lack of reliability, credibility, or adequacy of information about the phenomenon; and complexity refers to features of the phenomenon that make it difficult to understand. Any or all of these sources may contribute to the uncertainties pertaining to the specific issues at hand. Consider just a few of the many uncertainties that confront a man contemplating radical prostatectomy for prostate cancer: his risk of cancer recurrence, the competence of his health care providers, his ability to adapt to treatment side effects, and the effects of treatment on his personal relationships and achievement of life goals. In theory, there are probabilities for all of these outcomes, and these probabilities are further associated with—and complicated by—varying degrees of ambiguity and complexity.

...