Medicine and science must oppose intolerance and censorship

Science has always been — and should be — a battleground for contending views on what is true. Because of the close connection between knowledge and power, however, the risk is always present that those who command the dominant theories or ideologies will rely on their positions of influence to overcome those who oppose them. It is important that those who treasure tolerance and the value of open, unfettered discourse remain sensitive to these risks and — even when they personally disagree — to protect and foster the expression of contrary viewpoints.

When the nature of science and medicine is at stake, the importance of this task is especially pressing. We believe that the views promoted in a commissioned editorial in the Journal, by the Friends of Science in Medicine (FSM), exceed the boundaries of reasoned debate and risk compromising the values that FSM claims to support.1

In its own words, the key objective of FSM is “countering the growth of pseudoscience in medicine”, where true science is defined as a set of practices characterised by “an experimental, evidence-based approach”. The strategy of the group — which deliberately and forcefully relies on the unquestioned eminence of its members — is to apply pressure on governments and educational institutions to withdraw or prohibit funding for health practices referred to in a general sense as “complementary medicines”. The organisation models itself on similar groups in the United States and the United Kingdom and proudly refers to the success of these groups in having had funding removed from certain alternative medicine courses.2 It is clear that FSM aims to emulate this success in Australia through a campaign to influence public opinion and apply pressure on government and educational institutions.

We do not write to advocate complementary medicines. Indeed, two of us are physicians who practise exclusively in the field of Western medicine and are actively engaged in “conventional” laboratory and clinical research. Furthermore, we accept that there are serious and important issues to be considered regarding claims about, and risks posed by, many “complementary” health practices, and regarding the nature and status of evidence in medicine. As even the most vigorous supporters of complementary medicines accept, the field has been beset by excessive and fraudulent claims, which in many cases have misled — and, in some cases, posed direct risks to — vulnerable individuals.

We feel that the appropriate response to these problems is not to seek to suppress all approaches to health care which we cannot understand or with which we do not agree. Rather, it should be to establish a system of safeguards that minimise risk, while continuing to protect the rights of consumers to choose their own health care practices. Such safeguards should include legal, professional and conceptual criteria and target specific rogue practices while protecting and regulating others. We believe that any approach other than this would run the risk of threatening the core values and practices of science and medicine.

What are the core values and practices of science? FSM claims that what distinguishes the “scientific” nature of medicine is its reliance on evidence, and that all other approaches to health care are merely “pseudoscience”. We believe that this is wrong because it is at variance with the key insights of much of twentieth-century philosophy of science, which largely sought to understand the nature and meaning of science. There are many ways of defining what characterises science, but reliance on evidence is not one of them, because all systems of knowledge and belief make claims to interpretation of the evidence.3,4 Indeed, it is well known that, in Galileo’s day, Aristotelian physics commanded a much stronger empirical basis than did the esoteric theoretical idealisations of the Galilean system, not to mention Einstein’s theories of relativity in the years after they were proposed.5 Nor indeed is science merely a method, as it incorporates — and promotes — a wide array of methods and approaches.

What characterises the practices of science and medicine — as we understand and value them — is an openness to contrary perspectives and points of view, a belief in the merits of critical inquiry, a commitment to open and free dialogue to settle disputes and disagreements, and a renunciation of the use of polemic and force to suppress contrary viewpoints. We do not disagree with trenchant critiques of bodies of thought that cannot be substantiated by argument or data. What concerns us is a politicised process to apply pressure on governments and educational institutions to act in accordance with the views or convictions of one particular group.

In addition to this ethical point is a philosophical one. A key premise of many scientists and practitioners is that Western medicine is evidence-based whereas complementary medicine is not. There are several problems with this premise. First, as discussed above, is that it is mistaken to identify science with evidence. Second, the claim is based neither on evidence nor on a clear differentiation of the variety of forms of complementary medicines. While there may be little, if any, data to support more marginal, or fringe, forms of complementary medicines, there is an extensive evidence base relating to other complementary therapies, including Western herbal products, nutritional supplements, traditional Chinese medicine, and certain non-drug practices, such as meditation.6,7

The third problem is that the concept of evidence-based medicine, which was once so popular, is highly contested and debated within Western medicine itself.8 This is because the kind of evidence that is available to clinicians is never more than limited and partial, and that the clinical art always requires different kinds of inputs that set it apart from formal scientific deliberation. As has become widely recognised, clinical judgement draws together a range of skills and theoretical considerations. These include rigorous history-taking and examination, respectful dialogue with patients and relatives to determine the goals of treatment, and assessment of special biological, psychological or cultural conditions, risks, costs and other factors.9 Evidence from laboratory, epidemiological, clinical research and clinical trial studies cannot solely generate or determine the clinical decisions. These high-level data deal only with populations and probabilities and can, therefore, provide no more than hypotheses to be tested. It is the job of the clinician to convert these data into judgements relating to individual patients. This process of clinical decision making involves forms of judgement and kinds of knowledge that differ qualitatively from those which motivate and direct scientists.10 Medicine is a complex craft, and a large part of its richness and success depends on its ability to draw on a wide array of practices and forms of knowledge. Despite the undoubted wealth of information that laboratory and population studies provide, from the point of view of the clinician, a great deal of uncertainty remains, at the conceptual and methodological levels. We cannot afford to be overconfident about our own approaches or dismissive of those of others.

This does not mean that there is not a need for a vigorous and forceful debate about systems of medicine and individual practices, and it in no way detracts from the urgent need to protect vulnerable members of the community from those who seek to exploit them. Nor does this mean that we should not continuously re-examine the cultural role that universities play in society and their function is fostering critical learning, creativity and the pursuit of knowledge. These are important questions as they reflect ideas about the degree to which universities should promote or restrict access to different epistemologies and about where, and how, different disciplines and techniques should be taught and learnt. From whatever side one speaks, however, whether from the point of view of medicine or its interlocutors, the institutions of science and health care are too important to be subject to political campaigns seeking to enforce their own preferences regarding what they consider to be true science or how they believe clinical practice should be conducted.

It is important that those who seek to be friends of science do not inadvertently become its enemies. We call on the members of FSM to revise their tactics and instead support open, respectful dialogue in the great spirit and tradition of science itself.