Conceptual, methodological, and ethical problems in communicating uncertainty in clinical evidence

Abstract

The communication of uncertainty in clinical evidence is an important endeavor that poses difficult conceptual, methodological, and ethical problems. Conceptual problems include logical paradoxes in the meaning of probability and "ambiguity"--second-order uncertainty arising from the lack of reliability, credibility, or adequacy of probability information. Methodological problems include questions about optimal methods for representing fundamental uncertainties and for communicating these uncertainties in clinical practice. Ethical problems include questions about whether communicating uncertainty enhances or diminishes patient autonomy and produces net benefits or harms. This article reviews the limited but growing literature on these problems and efforts to address them and identifies key areas of focus for future research. It is argued that the critical need moving forward is for greater conceptual clarity and consistent representational methods that make the meaning of various uncertainties understandable, and for clinical interventions to support patients in coping with uncertainty in decision making.

Figure 1

Sources of uncertainty in clinical evidence (Han, Klein, & Arora, 2011)

Figure 2

Software-based representations of randomness and ambiguity in probability estimates: National Cancer Institute (NCI) Colorectal Cancer Risk Assessment Tool (NCI, 2010) (A) Dynamic visual representation of randomness. Animation is used to randomly change the pattern of shaded icons every 2 seconds. (B) Representation of ambiguity. Textual and visual representations of a confidence interval; blurred borders of the interval are used to convey imprecision.

Figure 3

A rating scheme for associating qualitative estimates of confidence and likelihood (ambiguity and probability) (Risbey & Kandlikar, 2007)

Figure 4

Qualitative rating schemes for the quality of evidence and the strength of clinical practice guideline recommendations (A) United States Preventive Services Task Force (2008). (B) Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group (Balshem et al., 2011).