Advocacy, Bias, and the Herd Instinct in Medicine
by Gerald H. Ross, MD, CCFP

Author: Dr. Ross practices family medicine and is on the medical staff of the Environmental Health Center-Dallas. He is also Medical Director of the Nova Scotia Environmental Medicine Clinic in Halifax.

Source: This article was originally published in Apr. 1994 in the Canadian Family Physician, 40, 661-663.

Requests for reprints should be sent to: Dr Gerald H. Ross, Environmental Health Center-Dallas, 8345 Walnut Hill Lane, Suite 205, Dallas, TX 75231 USA.

A recent issue of Science contains a most unusual letter from Dr. Carl Sagan, a scientist and educator whose name and face are recognized throughout the western world. While directed primarily to readers of Science, his correspondence1 would also be of interest to physicians, because the topic applies to both the scientific and medical communities.

Sagan was astonished to learn that his scientific credibility had been called into question at a national meeting of the American Association for the Advancement of Science, where it was announced that he and others had been blacklisted because of advocacy. A writer for Science had apparently stated that Sagan had "left the realm of credibility" when he began writing and talking about the nuclear winter and the terrible human suffering that could follow nuclear warfare. The implication was that his advocating prevention of nuclear war had rendered him biased; this bias allegedly destroyed his scientific objectivity and, therefore, his credibility.

Sagan defended his position on this issue by writing the following:

Suppose you had found that the global consequences of nuclear war were much worse than had been generally understood . . . wouldn’t you be concerned? Would you think it your responsibility to keep quiet about this, because the results were not absolutely certain, or because the full-scale verification had not yet been obtained?

Or would you consider it your obligation to your children, and the children of everyone else, to speak up? Keeping quiet under such circumstances seems bizarre and reprehensible to me.1

As I reflected on parallel situations in medicine, the concepts of advocacy and bias stuck in my mind. So did the issue of whether bias and the loss of a physician’s objectivity is an automatic consequence of speaking out on certain issues.

For the past 3 years I have functioned as the Medical Director of the Nova Scotia Environmental Medicine Clinic in Halifax, a pioneering and courageous pilot project of the Department of Health and Fitness of that province.2,3 I have been quoted in the press and interviewed on Halifax radio and television about the plight of patients with environmentally triggered illness, such as the devastating consequences of sick building syndrome at Camp Hill Hospital in Halifax4 and the controversial issue of chemical sensitivity.5,6 Because of this, some physicians derisively dismissed my opinions as biased. I challenge open-minded readers to ponder this kind of reaction, because the more we think about it, the more we must realize that we are all biased. In fact, it is impossible not to be so.

We are biased by the perspectives and paradigms with which we were reared and educated and which we use daily. Surely, there is an innate and unavoidable bias contain din our social, political, and educational systems, certainly in our nation and historical perspectives. Like sponges, we soak up the knowledge, skills, and attitudes of those who have taught and influenced us: our parents, peers, and teachers.

For physicians, the same applies to medical education and the policies that arise therefrom. In spite of its many good qualities, the system that shapes medical training is often characterized by arrogance, which assumes that the knowledge being taught will imbue us not only with the truth, but the whole truth. Nevertheless, most new graduates quickly learn that their preparation for medical practice is neither adequate nor finished.

Moreover, during our training, we also receive a subliminal message that, if different philosophies or innovative treatments have not been taught to us in medical school, then they cannot be true. Lacking the medical school seal of approval, any such therapies must be devoid of scientific merit and value, or surely our professors and learned mentors would have told us.

New Ideas in Medicine
What factors and forces determine the acceptance of new ideas in medicine? In many ways, medical progress is made on the basis of the "herd instinct." The herd represents the bulk of current medical thought and opinion, which frequently contains an unspoken assumption of possessing truth.

The herd instinct clearly dictates that those who search for knowledge and improved medical treatment must never stray too far from the herd. Within the herd is the comfort of a large group of like-minded colleagues who offer support and encouragement. Woe unto independent thinkers who dare to wander from the safety of the herd (even with the best intentions) in search of improved treatment methods. They risk becoming the mavericks, the black-listed, and the quacks who stray too close to the fringe. In fact, mavericks who wander off the beaten track to search for knowledge sometimes greatly upset the unity of the herd.

Once having left the herd in opinion or practice, mavericks are initially ignored but eventually scorned and ostracized by the group, who might be completely unwilling to listen to new ideas, because they already possess truth. Such was the case of Dr. Ignaz Semmelweis. In 1848, he observed that the high death rate from puerperal fever could be reduced dramatically if physicians washed their hands before examining patients and delivering babies. His findings and publications were completely ignored. After a vicious attack on his professional integrity, he was ostracized. He died in 1865, after a mental breakdown. His observations and conclusions were correct, of course, but many women and children died needlessly because his colleagues were convinced they had the truth and that his observations had no scientific merit.

While the herd instinct in modern medicine has produced many benefits and pearls of wisdom, we must never assume that we as a profession possess the whole truth. In 1980, Drummond Rennie, the deputy editor of The New England Journal of Medicine at the time, held up a 1959 issue of the journal during an interview with the Toronto Globe and Mail.7 "This was the finest medical research of its time," he said, "and most of it has already been proved wrong. The best that can be said about today’s journal is that it’s publishing today’s lies, and we hope that the next year’s are a little bit better."7

Medical McCarthyism
As a consequence of the herd instinct in medicine, there arises another phenomenon that is very much akin to what happened to Carl Sagan. Some would call it medical McCarthyism, which occurs when a physician from within the herd is perceived as too closely aligned with opinions held outside the herd.

Such a person might also be labeled a maverick and then suffer the consequences of scorn, ostracism, and sometimes even legal action, depending on the nature of his or her opinion or practice. Should such a maverick express an opinion publicly, he or she risks being black-listed and labeled biased. Thereafter, his or her objectivity and scientific credibility is called into question in spite of previous academic or other credentials.

This very serious issue pervades medical politics, whether we choose to acknowledge it or not. In the final debate on advocacy and bias we must consider a simple question: who are we as physicians?

In our profession, do we not combine the art and science of medicine for comforting and healing the sick? Do we not act as friend and advisor, and do we not take our patients’ side against illness, trying our best to comfort and heal no matter what the cause of the problem? Are we not called upon occasionally to voice our medical opinions for the legal and public record? Consequently, from a sociologic and humanistic viewpoint, are we not advocates for our patients in the best sense of the word? We are, indeed, advocates, and so we should be.

However, does being such an advocate render physicians as biased, a contagion that induces the loss of intelligence, scientific objectivity, and credibility? Like Carl Sagan, are we physicians not morally compelled to express our opinions and findings, which might be based on years of experience and insight, however unpopular those opinions might be? Indeed, we are so compelled, and so we should be.

Our Obligations
In this context, is it ethically acceptable to censure those physicians whose public or private opinions and philosophies of treatment are different from ours, in the absence of demonstrable harm to patients? Have we not progressed enough in our collective maturity to eliminate the need for black- listing those who think differently than we do?

On one hand, our profession has both moral and legal obligations to strive to maintain high medical standards and to deal appropriately with those who would defraud or unduly endanger their patients. But we must also ensure that such vigilance does not lead to McCarthyism or attempt to suppress independent thought or innovation, a topic that has been addressed forthrightly by Horrobin8 and Carter.9

Collective benefit for our patients can and should be the result of a diversity of thought and opinion in medicine. Indeed, as a profession, we need those mavericks who do not think like everybody else, however uncomfortable they might make us feel. Perhaps among them is a modern Semmelweis who has insight or a valuable therapeutic approach that we have all overlooked.

Most great advances in human endeavor are made when pioneers put aside old paradigms, entertain new thoughts or approaches, and wander from the herd. Such is the nature of progress, especially for science.

Fortunately, however, medicine is much more than science. It is more than a rigid, analytical approach to our patients and their diagnoses. Practicing medicine is also an art in which we are morally obligated to use our knowledge, wisdom, and compassion to "cure sometimes, relieve frequently and comfort always." By so doing, each of us rightfully becomes an advocate for our patients.

********

References
1. Sagan, C. (1993). Speaking out [letter]. Science, 260, 1861.
2. Jones, D. (1992). Nova Scotia only province to provide clinic for "environmentally sensitive" patients. Can. Med. Assoc. J.,
    147(6), 931-3.
3. Ross, G.H. (1992). Environmental medicine [letter]. Can. Med. Assoc. J., 148(3), 368.
4. Jones, D. (1992) Sick hospital, sick doctor: Halifax hospital tries to cope with "environmental illness." Can.Med. Assoc. J.,
    146(1), 2054-61.
5. Ross, G.H. (1992, Oct. 8). Environmentally sensitive patients deserve better [editorial]. Halifax Chronicle-Herald, sec. C:
    C2: col 5-6.
6. Rogers, S. (1993, Apr.). Ill defined. Harrowsmith, 44-45.
7. Wolfe, M. (1993, Mar. 16). Today’s lesson comes from the medical Bible. Toronto Globe and Mail, Sec. A: A13.
8. Horrobin, D.F. (1990) The philosophical basis of peer review and the suppression of innovation. JAMA, 263(10), 438-41.
9. Carter, J.P. (1992). Racketeering in medicine--the suppression of alternatives. Norfolk, VA: Hampton Roads
    Publishing, 

 

To buy products for the chemically sensitive see http://www.aehf.com.
For more information on medical treatment see http://www.ehcd.com.
For more articles on the relationship of health and disease to environmental factors, see the list of available articles and other information available here.