Precise Yet Uncertain: Broadening Understandings of Uncertainty and Policy in the BPA Controversy

Calibrating variant curation by clinical context based on factors that influence patients' tolerance of uncertainty

PURPOSE

Shared decision making manages genomic uncertainty by integrating molecular and clinical uncertainties with patient values to craft a person-centered management plan. Laboratories seek genomic report consistency, agnostic to clinical context. Molecular reports often mask laboratory-managed uncertainties from clinical decision making. Better integration of these uncertainty management strategies requires a nuanced understanding of patients' perceptions and reactions to test uncertainties. We explored patients' tolerance to variant uncertainty in 3 parameters: (1) relative causal significance, (2) risk accuracy, and (3) classification validity.

METHOD

Deliberative forums were undertaken with 18 patients with predictive testing experience. Uncertainty deliberations were elicited for each parameter. A thematic framework was first developed, and then mapped to whether they justified tolerance to more or less parameter-specific uncertainty.

RESULTS

Six identified themes mapped to clinical and personal domains. These domains generated opposing forces when calibrating uncertainty. Personal themes justified tolerance of higher uncertainty and clinical themes lower uncertainty. Decision making in uncertainty focused on reducing management regret. Open communication increased tolerance of classification validity and risk accuracy uncertainty. Using these data, we have developed a nascent clinical algorithm integrating molecular uncertainty with clinical context through a targeted communication framework.

CONCLUSION

Maximizing test utility necessitates context-specific recalibration of uncertainty management and communication.

Confidence deficits and reducibility: Toward a coherent conceptualization of uncertainty level

Outside of the field of risk analysis, an important theoretical conversation on the slippery concept of uncertainty has unfolded over the last 40 years within the adjacent field of environmental risk. This literature has become increasingly standardized behind the tripartite distinction between uncertainty location, the nature of uncertainty, and uncertainty level, popularized by the "W&H framework." This article introduces risk theorists and practitioners to the conceptual literature on uncertainty with the goal of catalyzing further development and clarification of the uncertainty concept within the field of risk analysis. It presents two critiques of the W&H framework's dimension of uncertainty level-the dimension that attempts to define the characteristics separating greater uncertainties from lesser uncertainties. First, I argue the framework's conceptualization of uncertainty level lacks a clear and consistent epistemological position and fails to acknowledge or reconcile the tensions between Bayesian and frequentist perspectives present within the framework. This article reinterprets the dimension of uncertainty level from a Bayesian perspective, which understands uncertainty as a mental phenomenon arising from "confidence deficits" as opposed to the ill-defined notion of "knowledge deficits" present in the framework. And second, I elaborate the undertheorized concept of uncertainty "reducibility." These critiques inform a clarified conceptualization of uncertainty level that can be integrated with risk analysis concepts and usefully applied by modelers and decisionmakers engaged in model-based decision support.