Subversion as a Constructive Activity in Medicine

SUBVERSION AS A CONSTRUCTIVE ACTIVITY IN MEDICINE WILLIAM A. SILVERMAN* A report of positive results of a carefully researched proposal to relieve pain or to cure illness often bears the author's assurance that the hard-earned evidence can be depended on as the basis for widespread medical action. The warrant does not put off pesky doubters, who proceed to lay down a withering barrage of criticism. They are confident that the evidence is incomplete because it is impossible to devise criteria of completeness of clinical experience. Such skeptics run the risk of being labeled "nihilists" intent on subverting medicine's high purposes. But, I will argue, such irreverent troublemakers are indispensable. Infallible treatments are virtually nonexistent—critical examination (in pedantic detail) of all claims in medicine is the only way we have of determining the limits of applicability of innovations. Idols ofAuthority Authoritarianism has long been the enemy of the critical attitude in medicine. Ipse dixit (He says so) dominated the long Galenic age of dogmatic slumber, and down to the present day we are uneasy with the idea that there is no final sanction and authority for knowledge. Sociologist Robert K. Merton examined some of the contemporary effects of authoritarianism in the sciences [I]. He found evidence that psychosocial processes tend to still voices of doubt by reinforcing the influence of those who have achieved positions of prominence. Allocation of resources to scientists for their contributions, as an instance, appeared to effect the flow of ideas and findings through communicaThe author acknowledges with gratitude the generosity of The Rockefeller Foundation for making it possible for him to write this essay while a scholar in residence in the idyllic surroundings of its study center in the Villa Serbelloni, Lake Como, Italy. *Address: 90 La Cuesta Drive, Greenbrae, California 94904.® 1986 by The University of Chicago. AU rights reserved. 003 1 -5982/86/2903-0488$0 1 .00 Perspectives in Biology and Medicine, 29, 3, Part 1 ¦ Spring 1986 \ 385 m^^'fû NOT Uflí Nàti wmusw 4£-M&, ' ¦ f C^^r/oA m ??? cw*N , , *rr .' (VES)^-ArT/ 1 /WITHOU''" POl)ST trasoí Li^r,r^ßyrff/ '¦^ci^/rv^ ,t ¡s so/ T^ G î31r^v^ ß??t? Fig. 1.—ipse tfccií. (Drawing by Booth; © 1977 The New Yorker Magazine, Inc.) tion networks in their fields of knowledge. Interviews with Nobel laureates disclosed a common theme: eminent scientists received inflated credit for their contributions while relatively unknown workers were more likely to be denied recognition for comparable contributions. Merton called this the Matthew Effect, after the Gospel According to Saint Matthew: "For unto every one that hath shall be given, and he shall have abundance; but from him that hath not shall be taken away even that which he hath." When the Matthew Effect transforms fallible men and women into idols of authority, it serves to curb the advancement of knowledge by discouraging criticism. Alexander Solzhenitsyn observed, bitterly, that a highly honored Russian medical scientist went about the hospital wards with an entourage of followers, like some new Christ with his apostles [2]. The "god" lost the right to make mistakes or to be in doubt; he lost the right to be allowed to think things over. This penchant for deifying medical authority is not confined to totalitarian countries. The phenomenon is particularly obvious when highly publicized accounts of research results place heavy emphasis on the identities of investigators. In such personalization of evidence, who is speaking becomes more important than what is said. Preoccupation with Names and Results Formal communication of evidence is channeled through articles published in professionaljournals; the very important influence of skeptical review of such evidence by peers is missing in most other kinds of reportage . The judging process is weakened if referees are bedazzled by the contributions from well-known researchers in prestigious institutions. Psychologists Douglas P. Peters and Stephen J. Ceci examined the review procedure and found cause for uneasiness [3]. They took one published article from each of 10 leading researchjournals in their field, made a few cosmetic changes (author's name, title, and wording of the abstract were altered), and resubmitted the reports for consideration to the very journals that had previously...