The Precautionary Principle: Implications for Risk Management Strategies

The European Commission has published a Communication on the Precautionary Principle and a White Book on Governance. These provide us (as research civil servants of the Commission) an institutional framework for handling scientific information that is often incomplete, uncertain, and contested. But, although the Precautionary Principle is intuitively straightforward to understand, there is no agreed way of applying it to real decision-making. To meet this perceived need, researchers have proposed a vast number of taxonomies. These include ignorance auditing, type one-two-three errors, a combination of uncertainty and decision stakes through post-normal science and the plotting of ignorance of probabilities against ignorance of consequences. Any of these could be used to define a precautionary principle region inside a multidimensional space and to position an issue within that region. The rôle of anticipatory research is clearly critical but scientific input is only part of the picture. It is difficult to imagine an issue where the application of the Precautionary Principle would be non-contentious. From genetically-modified food to electro-smog, from climate change to hormone growth in meat, it is clear that: 1) risk and cost-benefit are only part of the picture; 2) there are ethical issues involved; 3) there is a plurality of interests and perspectives that are often in conflict; 4) there will be losers and winners whatever decision is made. Operationalisation of the Precautionary Principle must preserve transparency. Only in this way will the incommensurable costs and benefits associated with different stakeholders be registered. A typical decision will include the following sorts of considerations: 1) the commercial interests of companies and the communities that depend on them; 2) the worldviews of those who might want a greener, less consumerist society and/or who believe in the sanctity of human or animal life; 3) potential benefits such as enabling the world's poor to improve farming; 4) risks such as pollution, gene-flow, or the effects of climate change. In this paper we will discuss the use of a combination of methods on which we have worked and that we consider useful to frame the debate and facilitate the dialogue among stakeholders on where and how to apply the Precautionary Principle.     

Dimensions of the Precautionary Principle

This essay attempts to provide an analytical apparatus which may be used for finding an authoritative formulation¹ of the Precautionary Principle. Several formulations of the Precautionary Principle are examined. Four dimensions of the principle are identified: (1) the threat dimension, (2) the uncertainty dimension, (3) the action dimension, and (4) the command dimension. It is argued that the Precautionary Principle can be recast into the following if-clause, containing these four dimensions: “If there is (1) a threat, which is (2) uncertain, then (3) some kind of action (4) is mandatory.” The phrases expressing these dimensions may vary in (a) precision and (b) strength. It is shown that it is the dimension containing the weakest phrase that determines the strength of the entire principle. It is suggested that the four-dimensional if-clause be used as an analytical apparatus in negotiations of the Precautionary Principle.     

Methodologic Implications of the Precautionary Principle: Causal Criteria

Applying the Precautionary Principle to public health requires a re-evaluation of the methods of inference currently used to make claims about disease causation from epidemiologic and other forms of scientific evidence. In current thinking, a well-established, near-certain causal relationship implies highly consistent statistically significant results across many different studies, large relative risk estimates, extensive understanding of biological mechanisms and dose-response relationships, positive prevention trial results, a clear temporal relationship between cause and effect, and other conditions spelled out in terms of the widely-used causal criteria. The Precautionary Principle, however, states that preventive measures are to be taken when cause and effect relationships are not fully established scientifically. What evidentiary conditions, as reflected in the causal criteria, will be certain enough to warrant precautionary preventive action? This paper argues that minimum evidentiary requirements for causation need to be articulated if the Precautionary Principle is to be successfully incorporated into public health practice. Two precautionary changes to criteria-based methods of causal inference are examined: reducing the number of criteria and weakening the rules of inference accompanying the criteria. Such changes point in the direction of identifying minimum evidentiary conditions, but would be premature without better understanding how well current methods of causal inference work.     

Research Implications of Science-Informed,Value-Based Decision Making

In ‘Hard’ science, scientists correctly operate as the ‘guardians of certainty,’ using hypothesis testing formulations and value judgements about error rates and time discounting that make classical inferential methods appropriate. But these methods can neither generate most of the inputs needed by decision makers in their time frame, nor generate them in a form that allows them to be integrated into the decision in an analytically coherent and transparent way. The need for transparent accountability in public decision making under uncertainty and value conflict means the analytical coherence provided by the stochastic Bayesian decision analytic approach, drawing on the outputs of Bayesian science, is needed. If scientific researchers are to play the rôle they should be playing in informing value-based decision making, they need to see themselves also as ‘guardians of uncertainty,’ ensuring that the best possible current posterior distributions on relevant parameters are made available for decision making, irrespective of the state of the certainty-seeking research. The paper distinguishes the actors employing different technologies in terms of the focus of the technology (knowledge, values, choice); the ‘home base’ mode of their activity on the cognitive continuum of varying analysis-to-intuition ratios; and the underlying value judgements of the activity (especially error loss functions and time discount rates). Those who propose any principle of decision making other than the banal ‘Best Principle,’ including the ‘Precautionary Principle,’ are properly interpreted as advocates seeking to have their own value judgements and preferences regarding mode location apply. The task for accountable decision makers, and their supporting technologists, is to determine the best course of action under the universal conditions of uncertainty and value difference/conflict.     

A model‐based solution for observational errors in laboratory studies

Molecular techniques for detecting microorganisms, macroorganisms and infectious agents are susceptible to false‐negative and false‐positive errors. If left unaddressed, these observational errors may yield misleading inference concerning occurrence, prevalence, sensitivity, specificity and covariate relationships. Occupancy models are widely used to account for false‐negative errors and more recently have even been used to address false‐positive errors, too. Current modelling options assume false‐positive errors only occur in truly negative samples, an assumption that yields biased inference concerning detection because a positive sample could be classified as such not because the target agent was successfully detected, but rather due to a false‐positive test result. We present an extension to the occupancy modelling framework that allows false‐positive errors in both negative and positive samples, thereby providing unbiased inference concerning occurrence and detection, as well as reliable conclusions about the efficacy of sampling designs, handling protocols and diagnostic tests. We apply the model to simulated data, showing that it recovers known parameters and outperforms other approaches that are commonly used when confronted with observation errors. We then apply the model to an experimental data set on Batrachochytrium dendrobatidis, a pathogenic fungus that is implicated in the global decline or extinction of hundreds of amphibian species. The model‐based approach we present is not only useful for obtaining reliable inference when data are contaminated with observational errors, but also eliminates the need for establishing arbitrary thresholds or decision rules that have hidden and unintended consequences.     

Implementing the Precautionary Principle: Rigorous Science and Solid Ethics

The Precautionary Principle came out of European efforts to clean-up and protect marine ecosystems in the 1980s. Since then, several North American activities have elaborated on this approach in U.S. environmental programs. Unfortunately, US organizations and agencies have not developed strategies and guidelines for implementing the Precautionary Principle in either statutory or voluntary environmental programs. Recent interest in this approach from some members of the scientific, non-profit, and regulatory communities highlights the need to understand the history and conceptual basis of the Precautionary Principle. In this paper we address several of these issues. First, we summarize the pertinent US history of the Precautionary Principle. Next, we describe the scientific framework for the principle. Finally, we make the case that this provides unique opportunities for scientists to obtain meaning in their work by fulfilling what has been called the new Social Contract.     

Comparison of Bayesian-Utilitarian and Maximin Principle Approaches

The Precautionary Principle implies the adoption of a set of rules aimed at avoiding possible future harm associated with suspected, but not ascertained, risk factors. Several philosophical, economical and societal questions are implied by precaution-based public health decision making. The purpose of the present paper is to specify the scope of the principle examining the notion of uncertainty involved, and the implication of different approaches to the decision making process. The Bayesian-utilitarian approach and the approach based on the maximin principle will be considered, and the different meaning of prudence in the two settings will be discussed. In a Bayesian-utilitarian approach the small number of attributable cases will end up in a low average expected value, easily regarded as acceptable in a cost-benefit analysis. In a maximin approach, on the other hand, the issue will be to consider the high etiologic fraction of a rare disease in the highest category of exposure. In the light of the aforementioned cautions in interpretation, the core difference between the two approaches has to do with the choice between averaging knowledge or equitably distributing technological risks.     

Incorporating Science,Technology, Fairness,and Accountability in Environmental,Health, and Safety Decisions

The Precautionary Principle is in sharp political focus today because (1) the nature of scientific uncertainty is changing and (2) there is increasing pressure to base governmental action on more “rational” schemes, such as cost-benefit analysis and quantitative risk assessment, the former being an embodiment of ‘rational choice theory’ promoted by the Chicago school of law and economics. The Precautionary Principle has been criticized as being both too vague and too arbitrary to form a basis for rational decision making. The assumption underlying this criticism is that any scheme not based on cost-benefit analysis and risk assessment is both irrational and without secure foundation in either science or economics. This paper contests that view and makes explicit the rational tenets of the Precautionary Principle within an analytical framework as rigorous as uncertainties permit, and one that mirrors democratic values embodied in regulatory, compensatory, and common law. Unlike other formulations that reject risk assessment, this paper argues that risk assessment can be used within the formalism of tradeoff analysis—a more appropriate alternative to traditional cost-benefit analysis and one that satisfies the need for well-grounded public policy decision making. This paper will argue that the precautionary approach is the most appropriate basis for policy, even when large uncertainties do not exist, especially where the fairness of the distributions of costs and benefits of hazardous activities and products are a concern. Furthermore, it will offer an approach to making decisions within an analytic framework, based on equity and justice, to replace the economic paradigm of utilitarian cost-benefit analysis.     

Adjusting Scientific Practices to the Precautionary Principle

In most discussions of the Precautionary Principle, it is implicitly assumed that we are at a point near risk neutrality, so that the principle aims at moving away from risk neutrality in the direction of more risk-averse behavior. In this paper it is argued that actual decision-making in environmental issues is often on the opposite, risk taking, side of risk neutrality. A minimal version of the Precautionary Principle consists in moving from such a position in the direction of risk neutrality. Some methods for achieving this are discussed, such as less consensus-seeking scientific procedures, requirements that scientific committees identify less probable but serious scenarios, interpretative presumptions, and supplementary statistical measures for type II errors.     

Hospital profiling using Bayesian decision theory

For evaluating the quality of care provided by hospitals, special interest lies in the identification of performance outliers. The classification of healthcare providers as outliers or non-outliers is a decision under uncertainty, because the true quality is unknown and can only be inferred from an observed result of a quality indicator. We propose to embed the classification of healthcare providers into a Bayesian decision theoretical framework that enables the derivation of optimal decision rules with respect to the expected decision consequences. We propose paradigmatic utility functions for two typical purposes of hospital profiling: the external reporting of healthcare quality and the initiation of change in care delivery. We make use of funnel plots to illustrate and compare the resulting optimal decision rules and argue that sensitivity and specificity of the resulting decision rules should be analyzed. We then apply the proposed methodology to the area of hip replacement surgeries by analyzing data from 1,277 hospitals in Germany which performed over 180,000 such procedures in 2017. Our setting illustrates that the classification of outliers can be highly dependent upon the underlying utilities. We conclude that analyzing the classification of hospitals as a decision theoretic problem helps to derive transparent and justifiable decision rules. The methodology for classifying quality indicator results is implemented in an R package (iqtigbdt) and is available on GitHub.     

The Precautionary Principle in the Information Society

The Precautionary Principle aims to anticipate and minimize potentially serious or irreversible risks under conditions of uncertainty. Thus it preserves the potential for future developments. It has been incorporated into many international treaties and pieces of national legislation for environmental protection and sustainable development. However the Precautionary Principle has not yet been applied systematically to novel Information and Communication Technologies (ICTs) and their potential environmental, social, and health effects. In this article we argue that precaution is necessary in this field and show how the general principle of precaution can be put in concrete terms in the context of the information society. We advocate precautionary measures directed towards pervasive applications of ICT (Pervasive Computing) because of their inestimable potential impacts on society.     

The Precautionary Principle,Epidemiology and the Ethics of Delay

Ethics tells us: do good and do no harm and invokes the norms of justice, equity and respect for autonomy in protecting and promoting health and well-being. The Precautionary Principle, a contemporary re-definition of Bradford Hill's case for action, gives us a common sense rule for doing good by preventing harm to public health from delay: when in doubt about the presence of a hazard, there should be no doubt about its prevention or removal. It shifts the burden of proof from showing presence of risk to showing absence of risk, aims to do good by preventing harm, and subsumes the upstream strategies of the DPSEEA (Driving Forces Pressure Stress Exposure Effect Action) model and downstream strategies from molecular epidemiology for detection and prevention of risk. The Precautionary Principle has emerged because of the ethical import of delays in detection of risks to human health and the environment. Ethical principles, the Precautionary Principle, the DPSEEA model and molecular epidemiology all imply re-emphasizing epidemiology's classic rôle for early detection and prevention. Delays in recognizing risks from past exposures and acting on the findings (e.g., cigarette smoking and lung cancer, asbestos, organochlorines and endocrine disruption, radiofrequency, raised travel speeds) were examples of failures that were not only scientific, but ethical, since they resulted in preventable harm to exposed populations. These may delay results from, among other things, external and internal determinants of epidemiologic investigations of hazard and risk, including misuse of tests of statistical significance. Furthermore, applying the Precautionary Principle to ensure justice, equity, and respect for autonomy raises questions concerning the short-term costs of implementation to achieve long-term goals and the principles that guide compensation.     

Implications of the Precautionary Principle: Is it a Threat to Science?

Scientific research is of proven value to protecting public health and the environment from current and future problems. We explore the extent to which the Precautionary Principle is a threat to this rôle for science and technology. Not surprisingly for a relatively simple yet still incompletely defined concept, supporters of the Precautionary Principle come from different viewpoints, including a viewpoint that is at least uneasy with the rôle of science, and particularly its use in risk assessment. There are also aspects of the Precautionary Principle that inherently restrict obtaining and using science. The Hazardous Air Pollutant (HAP) provisions in the US Clean Air Act Amendments are an example of the Precautionary Principle, which both shifted the burden of proof so that the onus is now on showing a listed compound is harmless, and required maximum available control technology (MACT) instead of a primarily risk-based approach to pollution control. Since its passage in 1990 there has been a decrease in research funding for studies of HAPs. Other potential problems include that once MACT regulations are established, it may be difficult to develop new technological approaches that will further improve air pollution control; that by treating all regulated HAPs similarly, no distinction is made between those that provide a higher or lower risk; and that there is a perverse incentive to use less well studied agents that are not on the existing list. As acting on the Precautionary Principle inherently imposes significant costs for what is a potentially erroneous action, additional scientific study should be required to determine if the precautionary action was successful. If we are to maximize the value of the Precautionary Principle to public health and the environment, it is crucial that its impact not adversely affect the potent preventive rôle of science and technology.     

Performance of Thirteen Clinical Rules to Distinguish Bacterial and Presumed Viral Meningitis in Vietnamese Children

Background and Purpose

Successful outcomes from bacterial meningitis require rapid antibiotic treatment; however, unnecessary treatment of viral meningitis may lead to increased toxicities and expense. Thus, improved diagnostics are required to maximize treatment and minimize side effects and cost. Thirteen clinical decision rules have been reported to identify bacterial from viral meningitis. However, few rules have been tested and compared in a single study, while several rules are yet to be tested by independent researchers or in pediatric populations. Thus, simultaneous test and comparison of these rules are required to enable clinicians to select an optimal diagnostic rule for bacterial meningitis in settings and populations similar to ours.

Methods

A retrospective cross-sectional study was conducted at the Infectious Department of Pediatric Hospital Number 1, Ho Chi Minh City, Vietnam. The performance of the clinical rules was evaluated by area under a receiver operating characteristic curve (ROC-AUC) using the method of DeLong and McNemar test for specificity comparison.

Results

Our study included 129 patients, of whom 80 had bacterial meningitis and 49 had presumed viral meningitis. Spanos''s rule had the highest AUC at 0.938 but was not significantly greater than other rules. No rule provided 100% sensitivity with a specificity higher than 50%. Based on our calculation of theoretical sensitivity and specificity, we suggest that a perfect rule requires at least four independent variables that posses both sensitivity and specificity higher than 85–90%.

Conclusions

No clinical decision rules provided an acceptable specificity (>50%) with 100% sensitivity when applying our data set in children. More studies in Vietnam and developing countries are required to develop and/or validate clinical rules and more very good biomarkers are required to develop such a perfect rule.     

The influence of the proportion of carcinogens on the cost-effectiveness of short-term tests

The cost-effectiveness of using short-term genotoxicity tests to screen unknown chemicals for carcinogenicity depends upon the inherent reliability of the tests (sensitivity, or fraction of carcinogens giving positive results, and specificity, or fraction of non-carcinogens giving negative results) and also upon the proportion of carcinogens in the population of chemicals to be screened. Individual tests may be combined into batteries to improve reliability; however, this requires decision rules to declare the overall result positive or negative. A framework for developing such rules based upon minimizing costs of false-positives and false-negatives was presented in a seminal paper by Lave and Omenn (1986, Nature (London), 324, 29-34). We have extended their work, which is based on logit analysis, to consider, using Bayes' theorem, the influence of the proportion of carcinogens upon the decision rules for declaring a battery result positive or negative. If the proportion of carcinogens is high (20% or greater), then the most effective tests are those with high sensitivity, and if the proportion of carcinogens is low, then the most effective tests are those with high specificity.     

Multidisciplinary Research: Strategies for Assessing Chemical Mixtures to Reduce Risk of Exposure and Disease

The Precautionary Principle is founded on the use of comprehensive, coordinated research to protect human health in the face of uncertain risks. Research directed at key data gaps may significantly reduce the uncertainty underlying the complexities of assessing risk to mixtures. The National Institute of Environmental Health Sciences (NIEHS) has taken a leadership rôle in building the scientific infrastructure to address these uncertainties. The challenge is to incorporate the objectives as defined by the Precautionary Principle with the knowledge gained in understanding the multifactorial nature of gene-environment interactions. Through efforts such as the National Center for Toxicogenomics, the National Toxicology Program, and the Superfund Basic Research Program, NIEHS is translating research findings into public health prevention strategies using a 3-pronged approach: (1) identify/evaluate key deviations from additivity for mixtures; (2) develop/apply/link advanced technologies and bioinformatics to quantitative tools for an integrated science-based approach to chemical mixtures; (3) translate/disseminate these technologies into useable, practical means to reduce exposure and the risk of disease. Preventing adverse health effects from environmental exposures requires translation of research findings to affected communities and must include a high level of public involvement. Integrating these approaches are necessary to advance understanding of the health relevance of exposure to mixtures.     

血浆内皮素配合描记动态脑电图在儿童晕厥诊断中应用的临床意义

摘要 目的：探究血浆内皮素配合描记动态脑电图在儿童晕厥诊断中的应用意义。方法：选择2017年1月至2020年1月于我院接受治疗的83例存在晕厥风险儿童,采集其静脉血样进行血浆内皮素水平测定,并实施动态脑电图检测,而后以倾斜试验结果为金标准,分别分析单纯血浆内皮素、单纯动态脑电图以及血浆内皮素+动态脑电图对晕厥的诊断应用意义。结果：（1）83例入组儿童中阳性为68例,阴性为15例,血浆内皮素检测阳性51例,阴性32例,一致性为77.11 %,灵敏度为73.53 %,特异度为93.33 %,阳性预测值为98.04 %, 阴性预测值为43.75 %;（2）动态脑电图诊断一致性为78.31 %,灵敏度为80.88 %,特异度为66.67 %,阳性预测值为91.67 %,阴性预测值为43.48 %;（3）联合检测诊断一致性为93.98 %,灵敏度为94.12 %,特异度为93.33 %,阳性预测值为98.46 %,阴性预测值为77.78 %;（4）检测方式差异性比较发现,联合检测在一致性、灵敏度、阴性预测值方面明显优于血浆内皮素和动态脑电图检测,在特异度方面优于动态脑电图检测（P<0.05）。结论：血浆内皮素联合描记动态脑电图对儿童晕厥具有较好的诊断辅助价值,能够显著提高诊断的一致性、灵敏度和特异度。     

宫颈特殊染色法、液基薄层细胞学及人乳头瘤病毒检测对宫颈癌前病变的应用价值分析

目的:探讨宫颈特殊染色法(FRD)、液基薄层细胞学(TCT)及人乳头瘤病毒(HPV)检测对宫颈癌前病变筛查的应用价值。方法:选取2015年1月～2018年1月于我院行宫颈癌筛查的1794例妇女作为研究对象,所有研究对象均接受FRD、TCT、HPV检测,以经阴道镜取样活检结果为阳性标准,对比分析三种不同检测方法以及联合检测的诊断效能。结果:病理科活检检出阳性111例,检出率为6.19%;FDR检测检出阳性114例,检出率为6.35%,漏诊率为16.22%;TCT检测检出阳性115例,检出率为6.41%,漏诊率为19.82%;HPV检测检出阳性108例,检出率为6.02%,漏诊率为19.82%;FRD检测与TCT、HPV检测的检出率比较差异无统计学意义(P0.05)。FRD检测敏感度为83.78%,特异度为98.75%,阳性预测值为81.58%,阴性预测值为98.93%;TCT检测敏感度为80.18%,特异度为98.46%,阳性预测值为77.39%,阴性预测值为98.69%;HPV检测敏感度为80.18%,特异度为98.87%,阳性预测值为82.41%,阴性预测值为98.70%;FRD、TCT、HPV联合检测敏感度为93.69%,特异度为99.52%,阳性预测值为92.86%,阴性预测值为99.58%;FRD、TCT、HPV联合检测与FRD、TCT、HPV单独检测的敏感度、阳性预测值比较差异具有统计学意义(P0.05)。结论:FRD、TCT、HPV检测对宫颈癌前病变的诊断效能相当,而FRD、TCT、HPV联合检测的诊断效能优于各方法单独检测。     

Efficacy of Fungiflora Y staining for the diagnosis of oral erythematous candidiasis

doi: 10.1111/j.1741‐2358.2012.00668.x Efficacy of Fungiflora Y staining for the diagnosis of oral erythematous candidiasis Objective: The purpose of this study was to investigate the efficacy of Fungiflora Y staining (fluorescent stain) for the diagnosis of erythematous candidiasis. Subjects and methods: This study enrolled 48 patients who were diagnosed with erythematous candidiasis and who underwent fungal culture and microscopic examination of a smear specimen stained with CytoQuick (modification of the Giemsa stain) and Fungiflora Y. Fungiflora Y staining was observed using a portable fluorescent microscope (CyScope^®). The sensitivity, specificity and positive and negative predictive values were calculated using fungal culture as the gold standard test. Accuracy was calculated, and the difference between the CytoQuick and Fungiflora Y groups was examined using contingency tables and the chi‐square test. Results: The sensitivity and specificity of the CytoQuick stain was 0.51 and 0.91, respectively; the positive predictive value was 0.95, and the negative predictive value was 0.36. The sensitivity and specificity of the Fungiflora Y stain was 0.84 and 1.0, respectively; the positive predictive value was 1.00, and the negative predictive value was 0.65. The accuracy of Fungiflora Y (0.88) was superior to that of CytoQuick (0.60) (p = 0.0052). Conclusions: Microscopic examinations of smear specimens using a combination of Fungiflora Y staining and the CyScope^® portable fluorescent microscope was found to be useful for the diagnosis of oral erythematous candidiasis.