Medical Certainty Research Articles

Clostridium difficile Infections Can Hit Facilities in the Gut, Too

Clostridium difficile Infections Can Hit Facilities in the Gut, Too

Forensic Metrology: The New Honesty about the Uncertainty of Measurements in Scientific Analysis

In many cases, forensic scientists rely on measurements as a basis for their opinions. For instance, toxicologists measure the concentration of the toxic drug in human bodies to determine whether the level of toxin was high enough to have caused the person’s death. Accident reconstruction experts measure the length of skidmarks and yaw marks to determine the velocity of a vehicle. Measurements of blood alcohol concentration have long been critical in drunk driving prosecutions. Metrology is the science that studies measurement. Metrologists have long recognized that there is an unavoidable, inherent element of uncertainty in every measurement. Thus, if at trial the court permits the expert to testify to a single point value for the measurand, the trier of fact may erroneously conclude that the number is the exact value of the measurand. The presentation of a single point value can easily mislead the trier. It was understandable that in the past, the courts allowed the expert to present such testimony. The early view was that the expert had to vouch for his or her opinion as a scientific or medical certainty. Many courts demanded that the expert use the term “certainty” in the phrasing of his or her opinion. However, that view has fallen into disrepute. In Daubert, the Supreme Court recognized the limitations of the scientific enterprise. In one passage, Justice Blackmun wrote that “arguably, there are no certainties in science.” In investigational science, researchers typically rely on inductive reasoning. There are limits to inductive logic. It is true that if repeated experiments yield the same result, the outcomes can give the researcher a good deal of confidence in the hypothesis. However, another experimental test is always conceivable; and so long as that possibility remains, subsequent falsification of the hypothesis remains possible. Thus, the expert cannot regard the hypothesis as certainly or conclusively validated. This new understanding of the limits of the scientific process is impacting the judicial treatment of expert opinions. The initial step was to abandon the insistence that the expert vouch for his or her opinion as a certainty; the courts allowed the expert to testify in terms of probabilities and possibilities. However, the logic of the new understanding led farther. Post-Daubert, now a substantial number of courts forbid the expert from testifying to a “certainty” or “zero error rate.” This article points out that some courts are now taking an additional step. In several drunk driving cases in Washington, the courts have insisted that the prosecution expert provide the trier of fact with both a best estimate (e.g. a bias-adjusted mean) and a quantitative measure of the error or uncertainty of the estimate. The Washington cases have demanded that the expert compute a confidence interval for the estimate. However, as this article explains, in metrology there are other possibilities such as coverage intervals. This development is hopeful for two reasons. First, this development reduces the risk that the trier of fact will attach undue weight to a point value cited by an expert. The development may produce more accurate factfinding. Second and perhaps even more importantly, the development can promote a more honest, open relationship between law and science. Scientists have long known that there is an inherent element of uncertainty in measurement, and this judicial development permits them to be honest and frank in their courtroom testimony.

“Certainty” and expert mental health opinions in legal proceedings

This pilot study addresses the legal and scientific ramifications of the “certainty” expressed by mental health professionals when functioning as expert witnesses in criminal and civil proceedings. The sporadic attention paid to “certainty” in the professional literature has typically taken the form of general policy oriented analyses as opposed to empirical, data-driven investigations. In the current study, 25 doctoral and master's level mental health professionals were provided with 53 different statements. Some statements addressed “certainty” itself in the typical fashion (e.g., “Reasonable Degree of Scientific Certainty,” “Reasonable Degree of Medical Certainty,” and “Reasonable Degree of Psychological Certainty”). Other statements were confined to specifically legal standards of proof (e.g., “Beyond a Reasonable Doubt,” “Preponderance of the Evidence,” and “Clear and Convincing”). Additional statements included those that bore at least some direct forensic relevance (e.g., “Based upon All the Data at My Disposal,” “In My Medical Opinion,” and “In My Clinical Judgment”), as well as those of a non-forensic nature (e.g., “I Would Bet My Life Savings,” “On My Word of Honor,” and “I Am Personally Convinced”). Ratings were provided on one form as if the participant had uttered the statement, and on another form as if another expert witness had uttered the statement. Overall, participants did not tend to identify traditional legal terms as expressing the highest level of “certainty,” and respondents tended to ascribe more “certainty” to the same terms when uttered by themselves as opposed to when uttered by other expert witnesses. Those providing forensic testimony will do well to accommodate the court's traditional requirements while developing and preparing to justify their own notions of just what “certainty” denotes in this context.

The creation of non-disease: an assault on the diagnosis of child abuse

The triad of subdural hematoma, retinal hemorrhage and multiple fractures in a child has been extensively documented to strongly suggest non-accidental trauma. Based on confessional evidence, a medical workup excluding diseases that can present with some of these abnormalities, and almost 50 years of scientific medical supportive literature, the diagnosis of abuse is being made with increasing medical certainty [1–7]. The medical community and particularly child protection professionals take extraordinary care before making a diagnosis of intentional, non-accidental trauma and strongly consider alternative diagnoses. The foundations of medical diagnosis and treatment should be firmly rooted. While there will always remain instances in which the evidence is less than perfect and several diagnostic possibilities are acceptable, it is dishonest and fraudulent to advocate a diagnosis denied by reasonable medical certainty. In this ploy, the protagonist says “there is controversy” but as Oliver Wendell Holmes noted, “controversy equalizes fools and wise men—and the fools know it” [8]. This is what is occurring in the diagnosis of child abuse. A small group of individuals has, during depositions and court room testimony [9, 10], perverted cases by using incomplete statements of the facts and unproven hypotheses to obscure the straightforward historical and physical findings utilized to make the diagnosis of child abuse [11–18]. These individuals have utilized unethical methods to create controversy when there should be none. The role of the medical profession is to protect today’s child and future children. The question is not “who did it?” but rather “did the child suffer from non-accidental trauma?” A remarkably informative course titled “Imaging of Child Abuse: Fact, Fiction and Responsible Action” (4–5 February 2012) was sponsored by The Society for Pediatric Radiology and directed by Drs. Jeannette M. Perez-Rossello and Paul K. Kleinman [19]. Perhaps the most encouraging aspect of the weekend was the active participation of scientists, lawyers, and physicians of various clinical expertise. The course was preceded by a 1-day discussion between the speakers and other invited experts. The following day-anda-half seminar (Table 1, course outline) presented the scientifically accepted methodology for the diagnosis of nonaccidental trauma with emphasis on the pathophysiology of various injuries, and covered areas where new data have changed our understanding (e.g., subdural hematoma can occur from bleeding dural veins and not only bridging veins) [20–22]. The differential diagnosis of the various injuries was emphasized and appropriate workup of these childrenwas presented. There is no controversy that child abuse is real and deadly. In 2009, approximately 150,000 children were confirmed with physical abuse and 1,770 died [23]. As a T. L. Slovis (*) Department of Pediatric Imaging, Children’s Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd., Detroit, MI 48201, USA e-mail: tslovis@med.wayne.edu

Evaluating Causation for the Opposite Lower Limb

Abstract Causation analysis always should be based on current scientific evidence and the facts of a specific case rather than common opinions or beliefs, eg, the myth that “favoring” one lower extremity often results in injury or illness of the opposite lower limb. Temporal sequence does not prove causation, and in causation analysis one also must consider temporal disparity: Was an injury or exposure likely to cause the condition in question, or is there another, more probable, cause? To conclude that a given cause and effect are etiologically associated with a reasonable degree of medical probability or certainty (ie, more than 50% probability), all three of the following criteria must be met: the cause is medically probably; the effect is medially probably; and the cause and effect probably are etiologically related. That is, causation analysis must be based on an analytical approach and not patient history alone. The medical literature reveals no generally accepted studies that support a causal relationship based on an individual's “favoring” one extremity. Rather, evaluators must base conclusions on scientific evidence and facts of the case at hand rather than relying solely on patient history or false logic such as the post hoc propter hoc fallacy.

Scientific research as a service for our patients: utopia or necessity?

Clinical research has led to great progress in the care of patients. Scientific research principles have been applied to medical research, nevertheless the results of this human activity are somehow more discussed than in other fields of science. Evidence-based medicine (EBM) is a concept and a function used in human medicine since the 90s to apply research results to medical practice. This concept refers to the careful, transparent and wise use of current best evidence from research for the individual care of patients [1]. After an early enthusiastic welcome, the real value of EBM in clinical practice has been recently questioned. Pro. According to supporters, the aim of EBM is to provide new tools to assist clinicians, and new challenges to practitioners. Therefore, EBM represents a highly individualised, patient-centered approach to clinical decision making. Using EBM clinicians should be able to care at best their patients, looking for, and interpreting the quality of scientific evidence. Furthermore, clinicians should always take into account patients’ values and preferences in the decision-making process [2]. These supporters recognise that there is the need to integrate different types of evidence from a range of sources to improve decisions about individual patients, to include guidelines in personal clinical practice of the individual patient [1]. Supporters conclude that effective teaching of EBM to medical students is important for lifelong self-directed learning [3]. Nevertheless, there is evidence that at the undergraduate level, self-perceived does not correlate well with objectively assessed competence in EBM [4]. Con. The objection of EBM less enthusiastic supporters is that a wise physician should make individually tailored decisions on a background of scientific theory which might be seen as a source of medical certainty [5].

Jeffrey M. Jentzen, Death Investigation in America: Coroners, Medical Examiners and the Pursuit of Medical Certainty (Cambridge, MA: Harvard University Press, 2009), pp. 290, $49.95/£36.95/€45.00, hardback, ISBN: 978-0-674-03453-2.

Jeffrey M. Jentzen, Death Investigation in America: Coroners, Medical Examiners and the Pursuit of Medical Certainty (Cambridge, MA: Harvard University Press, 2009), pp. 290, $49.95/£36.95/€45.00, hardback, ISBN: 978-0-674-03453-2. - Volume 55 Issue 3

Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty

Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty

Death Investigation in America: Coroners, Medical Examiners, and the Pursuit of Medical Certainty

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue

Review of: Death Investigation in America. Coroners, Medical Examiners, and the Pursuit of Medical Certainty

Review of: <i>Death Investigation in America. Coroners, Medical Examiners, and the Pursuit of Medical Certainty</i>

Death investigation in America: coronors, medical examiners, and the pursuit of medical certainty

Death investigation in America: coronors, medical examiners, and the pursuit of medical certainty

Degenerative Disc Disease: The Myth of Work-Related “Cumulative Trauma”

Abstract The primary cause of degenerative disc disease (DDD) is nonoccupational factors such as genetics and aging, and attributing DDD to “cumulative trauma” at work is a myth that is not supported by current scientific evidence. Some authors have suggested that DDD is a misnomer because the condition is not a disease but rather an inevitable component of the aging process that occurs at variable rates in different persons. Causation analysis requires a link between a cause and an effect, and reference to “cumulative trauma” without identification of a specific accident is incomplete. Physicians appear sometimes to opine “to a reasonable degree of medical certainty” that certain work events caused or aggravated a condition solely on the basis of a temporal relationship. Further, DDD usually is not the cause of neck or back pain but rather is an incidental finding on x-rays or advanced imaging studies. A dominant view of disc degeneration has been that disc structures are damaged by occasional excessive forces and the cumulative effects of repeated loading—but modern science contradicts this view. The authors examine current publications regarding DDD (including four full abstracts from recent articles) and conclude that current scientific evidence does not support the premise that “cumulative trauma” results in or aggravates degenerative disc disease. “Repetitive strain injury” of the spine is a mythical medicolegal concept, not a clinical or pathologic reality.

The value of the ophthalmological independent medical examination: analysis of 344 cases

Aim:The aim of the study was to assess the value of the ophthalmological independent medical examination (IME) for detecting malingering, exaggerated or feigned symptoms, and incorrect causal relationship.Design:Retrospective observational cohort...

Paraganglioma of the hypoglossal nerve

After the incidental intraoperative discovery of a paraganglioma of cranial nerve XII, we searched our hospital database and literature for similar cases to determine whether evidence exists to support the existence of paraganglioma of the hypoglossal nerve. We describe a case of cranial nerve XII paraganglioma, recognized only during surgery, without any indicative preoperative sign or symptom nor diagnostic imaging studies. In light of published findings, only four cases described since 1966, and our experience, the report discusses diagnostic criteria that could aid in establishing a diagnosis of hypoglossal nerve paraganglioma based on a reasonable degree of medical certainty.

Reshaping the “Pillow Angel”: Plastic Bodies and the Rhetoric of Normal Surgical Solutions

This essay uses the controversial “Ashley Treatment” to argue that normative body rhetorics have become untethered from and more influential than traditional medical perspectives in determinations about surgical intervention. While disagreeing greatly over the ethics of the “Treatment,” both its supporters and critics construct rhetorics of a “healthy” body against which pre- and post-Treatment bodies can be evaluated. These rhetorics demonstrate how “health” and “illness” can be defined more through social ideology than medical certainty, resulting in fluid notions of what it means to have a “normal” body and how surgical techniques should be employed to achieve normality.

Academy for eating disorders position paper: Eating disorders are serious mental illnesses

It is the position of the Academy for Eating Disorders (AED) that anorexia nervosa and bulimia nervosa, along with their variants, are biologically based, serious mental illnesses (BBMI) that warrant the same level and breadth of health care coverage as conditions currently categorized in this way (e.g., schizophrenia, bipolar disorder, depression, obsessive-compulsive disorder). As set forth below, we advocate this position unequivocally based on an emerging science that affirms with a reasonable degree of medical and scientific certainty that eating disorders are significantly heritable; influenced by alterations of brain function; significantly impair cognitive function, judgment, and emotional stability; and restrict the life activities of persons afflicted with these illnesses. Accordingly, the denial or restriction of equitable and sufficient treatment necessary to avert serious health consequences and risk of death is untenable and should be vigorously protested. Commentary

Reasonable Medical Certainty: A Rose by Any other Name

The phrase “reasonable certainty” has become embedded in the legal world of expert testimony, the version used with physicians being “reasonable medical certainty,” and with psychologists usually “reasonable scientific certainty.” Such experts are required to sanctify their opinions in court in virtually every jurisdiction by uttering the magic words before their testimony will be admitted as expert. Unfortunately, the phrase has no consistent legal meaning, often no specified meaning at all. Courts differ as to its definition, if they define it at all. The author reviews case law and the legal and forensic clinical literature on the subject, and discusses options for expert witnesses forced to couch their opinions within the standard.

Pigmentation of Articular Surfaces of Bones as an Identification Factor

One of the classic problems of forensic pathology, the identification of a skeletal remains, involves techniques and expertise that span a number of disciplines. This forensic endeavor offers a more challenging and creative exercise because identification with medical and legal certainty often requires thinking beyond routine workups. Identification workups are creative in developing features that are unique as presented by an individual decedent. In this case report, a rare pathologic condition, ochronosis, has helped in the accurate identification of an individual from a systematic skeletal remains examination.

Computer-Aided Diagnoses of Chronic Head Pain: Explanation, Study Data, Implications, and Challenges

The differential diagnosis of diseases and disorders having head pain as a symptom is often a difficult challenge for health care professionals. The complexity of this problem, the need for computer aided diagnosis, and the assumptions upon which one diagnostic software program was developed are discussed. A database driven user-oriented Internet website was offered at no charge to headache sufferers, and this vehicle provided the data source for research. The software program compares consistent user surveys to 253 expert profiles compiled from searches of the best available material in the medical/dental literature. A database of 1288 consistent user surveys was studied and analyzed for this paper. Findings discussed are: 1. the large amount of users (63%) who do not match any expert profile to a reasonable degree of medical certainty; 2. the significance of the relatively large amount of headache sufferers (17%) whose diagnosis or diagnoses are solely within the realm of dentistry; and 3. the importance of differentiating between discriminating and substantiating diagnostic criteria. Many users do not fit existing algorithms for chronic head pain. Data generated by this computer-aided diagnostic software program challenge some current paradigms and concepts of diagnosis. The data generated question “correct to a reasonable degree of medical certainty,” challenge “a preponderance of the evidence” as scientific diagnostic standards, and also question whether rendering a working diagnosis is possible on each and every patient.

Willem de Blécourt and Cornelie Usborne (eds), Cultural approaches to the history of medicine: mediating medicine in early modern and modern Europe, Basingstoke, Palgrave Macmillan, 2004, pp. xxiii, 241, £50.00 (hardback 1-4039-1569-5).

Moving away from outmoded theories of “medical imperialism”, this collection seeks to reconstruct the “complex web of communications and re-configurations” in medical history. Addressing issues as diverse as heart dissection, masturbation, animal care, hermaphroditism and orthopaedics, in Europe between the 1600s and the present, it uses the concept and role of “mediation” to explore theories of sickness and healing. As identified by Roy Porter's foreword, the contributors seek to isolate the meanings of medical knowledge and expectations, rather than relying on filter-down or Foucauldian approaches to the development of modern medicine. Each of the essays claims to offer images of medical knowledge and practice that are more “rich”, “complex” or “comprehensive” than those currently in vogue. The eclectic range of subjects studied is promising, though its successes are mixed. Several contributors focus on “mediation” in terms of the construction and circulation of medical knowledge between texts and audiences, and between patients, practitioners and the wider community. Thus Louise Hill Curth draws parallels between human and animal medical theory and treatment to demonstrate the importance of “one medicine” in the humoral tradition. Micheline Louis-Courvoisier and Severine Pilloud, and Michael Stolberg use the extensive archival resources of the Genevan doctor Samuel Auguste Tissot. The former contributors focus on the formal and contextual composition of the letters and examine the social embeddedness of healing concepts. Michael Stolberg's account takes direct issue with the themes of “popularization” and “public understanding” that have become so central to medical history. Yet the stated aim of Stolberg's piece—to understand the impact of medical advice literature on the lay readership, rather than simply taking for granted that “dominant medical discourse will automatically be accepted”—is surely a standard objective of modern medical history research. A more promising approach to letters is suggested by Alfons Zarzoso's account of lay decisions over medical care and treatment in eighteenth-century Catalonia. That self-medication and advice from relatives and friends was commonplace during the period is well-known. Less extensively studied is the vocabulary of afflictions, and the accommodation of illness and disease within a specific socio-economic and political climate. In letters attributing disease to the localized impact of French Revolutionary disruption, rumour and fear became vocabularies for the transmission of disease theories. The remaining essays focus more explicitly on the problems of competing truth-claims and the limits of medical authority. Yarrah Bar-On draws on the memoirs of Louise Bourgeois to explore the functioning of medical knowledge as a form of “gossip”. Claims to (and the limits of ) medical certainty is also addressed by Palmira Fontes da Costa and Constance Malpas. Logie Barrow's story of nineteenth-century English vaccination shows how debates over medical authority did not take place in a vacuum, being embedded in (or mediated by?) wider political and social debates. This was no less so in earlier times, as illustrated by Catrien Santing's article on the heart in Counter-Reformation Italy. The remaining articles by Hera Cook and Toin Pieters on twentieth-century issues highlight the conflicts between individual desires for health- (or self-)improvement, and available medico-scientific resources. Each writer shows how the medical world responds with varying degrees of success to the needs and demands of the lay public. We are back to the theme of community participation in the world of the sick. In the modern age, however, that means taking account of, and using, a global media amidst the hum of rising public expectations about medical ability and advance. The revision of concepts like “mediation” is doubtless important to the expansion of meaning in medical history. It draws attention to what Zarzoso calls “medical pluralism”, and the historically-complex rituals of medical knowledge and practice. Yet the theoretical potential of “mediation” remains uncertain. Although the editors try to stabilize the term by focusing on the themes of transmission and reconciliation, its potential for generalization arguably disrupts influence and agency.