Problematic cases II: Probabilistic reasoning
multiple sclerosis, demyelination, dementia
DISEASE PROGRESSION, DISEASE, DEMYELINATING DISEASE, MULTIPLE SCLEROSIS, DEMYELINATION
The prototype-based reasoning that anesthesiologists used to make decisions about randomization in cases involving dementia contrasted with the probabilistic judgments they made in other scenarios. One situation in which interviewees consistently reasoned probabilistically was when caring for patients with multiple sclerosis, another contraindication they commonly highlighted in REGAIN cases. They worried that spinal anesthesia could cause a relapse in the condition. Below are two examples of interviewees describing patients they refused to randomize due to concerns over multiple sclerosis.[I]t’s been known for some time that the combination of anesthesia, both general and spinal, and surgery can actually trigger a relapse of [multiple sclerosis]. Now, the problem with that, it’s difficult to tease out how much the surgery versus the anesthesia contributes to that possibility. […] But we also know that a spinal anesthetic is more likely to cause that versus a general anesthetic. […] Now, the evidence is not so clear-cut. The problem is you could always find somebody that would fight her corner [in] court. […] I might not have lost the suit, but nobody wants to go to court, right? […] When she came to the OR, I thought long and hard about how to do this. So it wasn’t like, oh yeah, that’s it. It wasn’t black and white. For her, it was a gray area. (interviewee 4)So, she was allocated to the spinal anesthetic, but she had a history of multiple sclerosis. […] [B]ecause it’s essentially a demyelinating disease, there’s always the tendency not to undertake spinal anesthesia in case it can either cause the occurrence of the demyelination or cause progression of the disease. Although, the stress of the surgery may be associated with disease progression or reoccurrence. Itself, it might not be the spinal anesthetic […]. So there’s a tendency to avoid doing spinal anesthetics in people with multiple sclerosis. […] It could be the contributor, or it could confound it. (interviewee 22)Several features of these accounts are notable. First, the anesthesiologists attribute their various propositions about multiple sclerosis to the professional collective rather than to their individual experience (e.g., “we also know,” “there’s a tendency to avoid doing spinal”). Second, they at least imply that they are drawing on research data (e.g., “the evidence is not so clear-cut”), and they speak in the language of statistical relationships (e.g., “may be associated with disease progression,” “could be the contributor, or it could confound it”). Third, their hesitation in determining whether to randomize does not stem from trying to ascertain what type of patient they have encountered—these patients are simply accepted as having a multiple sclerosis diagnosis—but rather from the indeterminacy of how the body will react to spinal intrusion and thus whether a good or bad outcome will occur.