Can we learn from hidden mistakes? Self-fulfilling prophecy and responsible neuroprognostic innovation

Abstract

A self-fulfilling prophecy (SFP) in neuroprognostication occurs when a patient in coma is predicted to have a poor outcome, and life-sustaining treatment is withdrawn on the basis of that prediction, thus directly bringing about a poor outcome (viz. death) for that patient. In contrast to the predominant emphasis in the bioethics literature, we look beyond the moral issues raised by the possibility that an erroneous prediction might lead to the death of a patient who otherwise would have lived. Instead, we focus on the problematic epistemic consequences of neuroprognostic SFPs in settings where research and practice intersect. When this sort of SFP occurs, the problem is that physicians and researchers are never in a position to notice whether their original prognosis was correct or incorrect, since the patient dies anyway. Thus, SFPs keep us from discerning false positives from true positives, inhibiting proper assessment of novel prognostic tests. This epistemic problem of SFPs thus impedes learning, but ethical obligations of patient care make it difficult to avoid SFPs. We then show how the impediment to catching false positive indicators of poor outcome distorts research on novel techniques for neuroprognostication, allowing biases to persist in prognostic tests. We finally highlight a particular risk that a precautionary bias towards early withdrawal of life-sustaining treatment may be amplified. We conclude with guidelines about how researchers can mitigate the epistemic problems of SFPs, to achieve more responsible innovation of neuroprognostication for patients in coma.

Time to Awakening and Self-Fulfilling Prophecies After Cardiac Arrest

“…Conventional models trained using observational datasets where WLST-N occurred learn to replicate past clinical decision-making. Factors that prompted clinicians or families to choose WLST-N are associated with poor outcome regardless of whether this relationship would hold in the absence of WLST-N (27). Insofar as this may inform future care, whether directly as decision support tools or simply by reinforcing clinicians’ prior beliefs, these spurious correlations will be perpetuated or even amplified over time (28).…”

Chasing Certainty After Cardiac Arrest: Can a Technological Innovation Solve a Moral Dilemma?

“…Moreover, machine learning is prone to exacerbating self-fulfilling prophecies 4 due to feedback loops. The problem of self-fulfilling prophecies in neuroprognostication requires in-depth analysis which we present elsewhere [11,48].…”

“…Self-fulfilling prophecies are recognized to be a general problem in intensive care[56] and in neuroprognostication specifically, especially for patients after cardiac arrest[57,58]. Discussing, in this article, the ethical and epistemic challenges they pose will take us too far afield but we dicuss these problems elsewhere[48].…”

Self-fulfilling Prophecy in Practical and Automated Prediction

“…Kopec (2011 Kopec ( , 1252 labels reflexive predictions that are transformative strongly reflexive predictions.44 Here we hope to draw an intuitive distinction, while sidestepping complexities in the relations among causation, explanation, and counterfactual dependence.45 In other work, we highlight the epistemic significance of operative SFPs and the danger of nonchalance about them. SeeMertens et al 2022. …”

“…The following sort of case has been discussed in biomedical ethics(Wilkinson 2009) and in debates about neuroprognostic research(Geocadin et al 2012, 979-980). See alsoMertens et al 2022. …”