Cutter’s book explores the ethical implications of managing uncertainty in clinical decision-making during the COVID-19 pandemic and develops an ethics of clinical uncertainty that brings together insights from the clinical and biomedical ethical literatures.

“An Ethics of Clinical Uncertainty: Lessons from the COVID-19 Pandemic” was published by Routledge in 2024.

The book sets out to recognize the central role uncertainty plays in clinical decision-making and to acknowledge the different levels, kinds, and dimensions of clinical uncertainty. It also aims to aid clinicians and patients in managing clinical uncertainty and to recognize the ethical duty they have to manage clinical uncertainty.

To share more, Cutter answered seven questions about her book below.

1. If you were describing your book to someone outside of your field, what would you say?

“An Ethics of Clinical Uncertainty: Lessons from the COVID-19 Pandemic” explores the ethical implications of managing uncertainty in clinical decision-making during the COVID-19 pandemic. It develops an ethics of clinical uncertainty that brings together insights from the clinical and bioethical literatures. The project has five goals: it sets out (1) to recognize the central role uncertainty plays in clinical decision-making and (2) to map out intersectional levels, kinds, and dimensions of clinical uncertainty. It aims (3) to aid clinicians and patients in managing clinical uncertainty and (4) to recognize the ethical duties clinicians and patients have to manage clinical uncertainty in order to advance the welfare of those in clinical medicine, to respect their rights, to promote justice, and to care for one another in clinical relationships. In the end it offers (5) suggestions for managing moral distress and building moral resilience.

As we learned from our clinical actions during the pandemic, the ethical implications of not recognizing and managing clinical uncertainty in its expanded and intersectional expressions are notable. If we do not recognize and manage clinical uncertainty, we cannot develop evidence-based risk assessments and thereby promote the best interest of patients and clinicians and minimize their harm. We cannot develop proper informed consent processes and thereby respect the autonomy of patients and clinicians in their decision-making. We cannot distribute clinical resources fairly and thereby promote health equity and the fair opportunity to live a healthy life. We cannot tailor clinical tests and treatments to an individual patient and thereby care properly for patients and those who care for patients. In that such ethical duties interplay, we cannot promote each duty without attending to their intersections and interactions in terms of how they impact and are impacted by the identities and experiences of those in a clinical relationship.

If we do not manage clinical uncertainty, we cannot come to terms with the nature of clinical knowledge, clinical problems, and clinical evaluation and thereby fulfill prominent ethical duties in medicine. My hope is that we have learned some lessons about the need to manage clinical uncertainty from the COVID-19 pandemic as we go forward in health care from here on out.

2. How did you get the idea for your project?

In February 2020, I was drafting a book on managing uncertainty in decision-making in cancer medicine. As a biomedical ethicist and cancer survivor, I have written on breast cancer (Oxford, 2018) and wanted to continue my work on the challenges of managing uncertainty in the diagnosis, prognosis, and treatment of breast cancer. As any breast cancer patient or survivor knows, uncertainty marks the terrain of decisions that are made in a field that develops quickly and carries significant practical implications for patients and their families.

Despite my best-laid plans, in early 2020 when the COVID-19 pandemic hit the U.S., I found myself giving talks on managing clinical uncertainty during the COVID-19 pandemic. In my talks, we tried to come to terms with the uncertainties we all faced as the pandemic spread, our lives changed, and we made decisions under a great deal of uncertainty. Then, in spring 2022, I taught for the academic organization Semester at Sea and boarded a ship to teach undergraduate courses in biomedical ethics and the philosophy of death and dying.

While teaching on the ship over a four-month period in the Mediterranean and surrounding areas, the shipboard community experienced on a daily basis the challenges of managing uncertainty during the pandemic. Our travels to Italy, Greece, Cyprus, Croatia, Malta, Spain, Gibraltar, Portugal, France, Scotland, Denmark, Sweden, and Germany were preoccupied with different COVID-19 protocols and requirements for entry into different countries, self-assessments and testing for COVID-19, in-country isolation and quarantine practices, and a sundry of other land and sea protocols. Over 104 days, we experienced eight itinerary changes, five days in lockdown on the ship due to a significant rise of COVID-19 cases, and more than twenty COVID-19 tests during our travels, not including the ones we had before and after our time together on the ship. During my class field trips, we visited clinicians in Spain, France, and Scotland to discuss challenges they experienced during the pandemic. Managing clinical uncertainty emerged as a shared theme. Given these events, my research on clinical uncertainty in the context of cancer care morphed into research about managing clinical uncertainty during a pandemic. And so this project took shape.

3. Did your focus develop or change throughout the research and writing process? 

As mentioned, yes, my focus on the topic of managing clinical uncertainty changed and developed during the COVID-19 pandemic. As an applied ethicist who works with others on community boards and educational forums, I tend to look to current examples to illustrate some of the philosophical lessons I work on. The pandemic offered us so many examples of how we needed some lessons on managing uncertainty in the context of clinical medicine, and so I refocused my work to fit what was needed in my professional and educational work in clinical ethics.

4. Which idea do you write about that most excites, invigorates or inspires you?      

My work over 40 years tends to focus on the relations between what and how we know and what and how we value. In other words, what excites me most is the intersections among epistemology and ethics, in an applied format. This is what drew me to work in a department of philosophy, as opposed to another home for a philosopher of medicine and clinical ethicist.

5. Describe your writing space. Where do you do your best work? What time of day? Do you have any writing routines you are willing to share?           

My writing space has always been my kitchen or dining room table. There, I am able to lay out the books and articles, and pencils and paper, and create my projects. These days, I typically have a few laptops open with articles and clinical websites and go from there. I like to write in the morning and edit in the afternoons. When the children were young, I recall seeking advice from my dear friend and colleague Professor Ken Pellow from the UCCS Department of English about how to handle the typical distractions of parenting. I remember vividly what he shared with me: “Just write.” It sounds so simple, but the message is just sit down, stop the self-critique, and just put on “paper” the words that say what one wants to say. These days I draw from this advice as my grandchildren now run around (and under) the tables! I should also say that I realize that this type of academic life is only possible with the support of a department and institution that values academic research and creative works.

6. Is there a favorite quote or passage you want to showcase from the book?

Many of us have heard this famous quote, but now I get it: “Medicine is a science of uncertainty and an art of probability.” Physician William Osler (1849-1919) (Bean 1950, 125)

7. What new questions for future exploration have you discovered?

There are a number of topics that deserve further investigation by those interested in clinical uncertainty. These include:

1. the investigation of intersectional accounts of clinical uncertainty in the context of particular specialties in clinical medicine (e.g., pediatrics, oncology, genetics), select populations (e.g., in terms of age, race/ethnicity, sex/gender, economic status, political beliefs, spiritual beliefs), and individual differences (e.g., the focus of personalized medicine): A contextual treatment of clinical uncertainty will focus on particular clinical problems in order to appreciate the nuances of such particularities within specialized contexts and with regard to diverse identities of difference. Such will be in keeping with the theme of this inquiry that there is not one universal taxonomy of clinical uncertainty. There are lots of room for many, with diverse ethical implications in varying clinical practices. Clarifying such expressions will be theoretically and practically important in particular clinical specialties.

2. the development of educational programs for pre-health care undergraduates, health care graduates, post-graduates, clinical practitioners, and patients about clinical uncertainty: Clinicians and patients can benefit from learning about clinical uncertainty. Programs can be developed within the health care curriculum as well as in care facilities and be responsive to different populations of learners. Such programs can be lodged within philosophy of medicine sequences, complementing bioethical training that is typically available in clinical educational and training programs.

3. the investigation of social factors (e.g., workplace, education, media, politics) that frame clinical uncertainty, moral distress, and moral resilience: A sociology of medicine approach to clinical uncertainty can unveil the intersectional aspects of knowledge, nature, and values within social systems of thought and action. Such systems situate and define the components of clinical uncertainty and more work is needed in this area by clinical researchers.

4. the development of safe institutional policies and practices for educational forums, complaints, and whistle-blowing: Working under conditions of uncertainty can be unnerving and it will be critical to develop processes that create safe spaces for members of communities when they ask questions, raise concerns, or call for action.

5. the development of institutional coordination for sharing information between and among research groups and distributing medical resources in conditions of uncertainty: If anything, the pandemic has brought us face-to-face with the limits of institutions and their ability to coordinate the distribution of health care resources during a health care crisis marked with uncertainty. More work is needed on developing effective and efficient institutional practices during health care crises and beyond.

6. further reflections on what we have learned from our actions during the pandemic: When I sent off my manuscript to a notable press, an editor quickly got back to me to share that the press was concerned about “pandemic fatigue.” As one can imagine, I was in disbelief. How could we have gone through what we went through and witnessed so much need to rethink our actions, and not want to continue to reflect? Thus, I encourage the continuation of reflections on the pandemic. We still have much to learn about ourselves, our practices, and our institutions as we grapple with uncertainties during and after the pandemic.

UCCS celebrates faculty and staff who author and edit books each year. In recognition of their achievement, and as part of the UCCS Author Spotlight initiative, authors are invited to submit details on their published works.