Repeat after me: Enforcing medical and scientific standards is not “censorship”

I don’t mean to beat up on Dr. Michael Fitzpatrick. I really don’t. I realize I rather harshly criticized him yesterday for being so hostile to the concept of “denialism,” to the point where he characterized even the use of the term as a means of “suppressing” free speech. Normally, that criticism would have been enough. If Dr. Fitzpatrick answered, that would be all well and good; if he didn’t, I’d move on and forget about it. Unfortunately, I was made aware of another article he published at his usual gig at Spiked Online entitled Censorship is not the answer to health scares.

Damn if it wasn’t like waving a cape in front of a bull.

It really is depressing when someone whose work and activism against pseudoscience and quackery you usually admire a lot lets you down in such a spectacular fashion. In this case, Dr. Fitzpatrick is not only once again characterizing the British General Medical Council (GMC) action to strip Andrew Wakefield of his medical license, a decision that was announced on Monday, but he is also characterizing the sacking of Bruce Charlton, the editor of the distinctly cranky “journal” Medical Hypotheses similarly, as the enforcement of “doctrinal orthodoxy” against the “heresy” of “questioning science.” How I hate it when people mischaracterize science as religion as a way of defending cranks. I hate it even more when it’s someone who really, really should know better, someone like Dr. Fitzpatrick, who otherwise has done yeoman work in opposing pseudoscience. Unfortunately, here he seemingly willfully confuses threats to free speech with legitimate attempts to maintain scientific, medical, and professional standards. The two are quite different, albeit related issues.

Dr. Fitzpatrick is rather clever, though, in how he frames it. He starts by castigating an excellent editorial that appeared in the journal Vaccine by Dr. Gregory A. Poland, the Mary Lowell Leary Professor of Medicine, Infectious Diseases, Molecular Pharmacology and Experimental Therapeutics, Pediatric and Adolescent Medicine, Mayo Vaccine Research Group, and Ray Spier (D.Phil, FIChemE, FIBiol, FRSA) President of the International Society for Vaccines, Emeritus Professor of Science and Engineering Ethics, Former Professor of Microbiology at the University of Surrey, entitled Fear, misinformation, and innumerates: How the Wakefield paper, the press, and advocacy groups damaged the public health.

This is how Dr. Fitzpatrick characterizes the article:

How could this have happened?’ asks a splenetic editorial reflection on the MMR-autism controversy in the current issue of Vaccine, the leading scientific journal in the field of immunisation. The authors – Gregory Poland of the Mayo Clinic and Ray Spier from the University of Surrey – proceed to blame everybody but the scientific authorities for the scare that was launched in a notorious (and now withdrawn) Lancet paper by the former Royal Free gastroenterology researcher Andrew Wakefield who was finally struck off the medical register this week on charges of serious professional misconduct.

They blame Wakefield (citing the General Medical Council verdict that he was ‘dishonest, misleading and irresponsible’), public health authorities (who ‘stumbled in responding poorly and immediately to the issue’), and the public (for being ‘innumerate’ and ‘uncritical’). In the tone of exasperated schoolteachers scolding truculent adolescents, the authors also attribute ‘significant and disproportionate blame’ to autism advocacy organisations and recommend a period of penitence: ‘deep self-reflection would be appropriate’.

As I read this introduction, I couldn’t help but think: What’s wrong with the Vaccine article? Very little, from my perspective. In fact, I had planned on blogging about it, but the schedule just got too crowded and I let it pass. The editorial hits most of the right notes, but I will concede to Dr. Fitzpatrick the point that the article neglected to criticize one set of people who are deserving of criticism in l’affaire Wakefield. It’s true. Peer reviewers failed. Editors of The Lancet, in particular Richard Horton, failed. Even so, one must point out that peer review is particularly bad at catching outright fraud; so the fact that the peer reviewers failed is not in and of itself necessarily an indictment of the peer review system. However, where Dr. Fitzpatrick sees “exasperated schoolteachers scolding truculent adolescents,” I see two public health researchers expressing understandable exasperation at how the anti-vaccine movement, spurred by Andrew Wakefield, with the complicity of the credulous and sensationalistic British press, led to plummeting MMR vaccine uptake and the resurgence of measles in the U.K. In that, Poland and Spier are expressing nothing other than what I and many other supporters of science-based medicine have expressed. I guess that, to Dr. Fitzpatrick, outrage at pseudoscience and the promotion of an ideology that leads to disease and death is “scolding” and and being condescending. Either that, or it’s “censorship” or an urge to “stifle debate.”

To that, I respond, quite simply, bollocks. (I’m a bit of an Anglophile and love the lingo.)

Unfortunately, Dr. Fitzpatrick compounds his error by linking the General Medical Council (GMC) hearings that found Andrew Wakefield to have committed research misconduct in the ethics of how he conducted the study leading to the 1998 Lancet paper and ultimately led to the GMC stripping him of his medical license in the U.K. to the efforts of Elsevier to rein in a journal in its stable, Medical Hypotheses, that, under the leadership of its editor Bruce Charlton, had become a willing outlet for the publication of pseudoscience, HIV/AIDS denialism, anti-vaccine nonsense, and other woo:

The notion that organisational methods of censorship and repression are the appropriate response to influential currents of pseudoscience has unfortunately become widely established. This is well illustrated by the recent controversy surrounding the journal Medical Hypotheses – published, like Vaccine and the Lancet, by Elsevier. Under its founding editor David Horrobin, and his successor Bruce Charlton, Medical Hypotheses has rejected the procedures of peer review now standard among academic journals in favour of a policy of selection by the editor, according to what he considers interesting, provocative, entertaining. The result is an eclectic mixture of science and pseudoscience, sense and nonsense.

I suppose you could describe it that way, although the pseudoscience and nonsense seem more prominent. Moreover, an “eclectic mixture of science and pseudoscience, sense and nonsense” is not what I would consider a ringing endorsement of a journal that represents itself as being every bit as serious as a peer-reviewed scientific journal.

I’ve written about this situation before in detail. In brief, after Charlton went one woo too far, publishing an awe-inspiringly awful bit of HIV/AIDS denialism from Peter Duesberg in the pages of Medical Hypotheses (MH), an article so bad that Elsevier dissed Peter Duesberg and withdrew the article. Next, after an investigation, Elsevier issued an ultimatum to Charlton: Institute a system of real peer review rather than the system of “editorial review” that Charlton used to publish submitted papers in record time, or Elsevier would not renew his contract as editor. Clearly, what happened is that Charlton had gone too far with MH, and Elsevier was finally embarrassed enough by something published within its pages to be forced to act.

Another consequence of the Duesberg MH debacle was that a group of scientists got together to do something that should have been done a long time before, and that is to petition the Library of Medicine to delist MH from Medline, thus removing it from PubMed. In their letter, they cited their reasons, citing that the journal is not peer-reivewed; that the quality of articles in the journal has declined preciptously since 2003; that MH doesn’t publish original research, only editorials and letters to the editor; that MH has “developed a reputation for publishing trivial and occasionally offensive articles with no obvious relation to genuine medical research”; and, finally, that MH “has become a tool for the legitimization of at least one pseudoscientific movement with aims antithetical to the public health goals of the NIH and the NLM.” For this latter complaint, it was specifically HIV/AIDS denialism to which the authors were referring, but it could equally refer to anti-vaccine pseudoscience as well. After all, MH was where the Geiers published one of their most-cited papers (by the anti-vaccine movement, that is) that promoted chemical castration to treat “vaccine injury”-induced autism, as well a pseudoscientific tripe by Mark Blaxill blaming mercury in vaccines for autism.

Actually, the GMC striking off Andrew Wakefield and Elsevier reining in MH are related, but not because they represent some sort of fascistic “censorship” of iconoclasts. No one is preventing Andrew Wakefield from speaking out about his pseudoscience and anti-vaccine views to his heart’s content, for example. Just witness him speaking on Saturday at Autism One in Chicago. Witness Wakefield’s new book, Callous Disregard. Witness his being interviewed by Matt Lauer. Witness his speaking at an antivaccine rally just yesterday. To claim that Wakefield is being muzzled is, quite simply, nonsense. What has happened is that Wakefield has paid a professional price for his dishonesty, fraud, and abuse of human subjects research ethics. There may be a right to free speech, but there is no “right” to practice medicine. It is a privilege, and when that privilege is abused society has every obligation to its citizens to remove the offending physician from a position where he can continue to abuse the privilege of treating patients. Nor is there a “right” for pseudoscientists to publish their pseudoscience in the peer-reviewed medical literature or a “right” not to be shunned by the scientific community when they breach the standards of science and medicine so egregiously. Physicians who abuse their trust deserve to have their licenses revoked. In fact, at least in the U.S., it doesn’t happen anywhere near often enough to protect the public from bad practitioners or outright quacks. (Witness Dr. Rashid Buttar or Dr. Roy Kerry–or Dr. Wakefield himself, who got away with his misconduct for over six years after it was revealed by investigative journalist Brian Deer, a discovery that took the six years prior to unearth. Dr. Fitzpatrick seems to willfully conflate professional sanctions for misbehavior with “censorship” of “dissenting” scientific speech, which is utter rubbish.

Then he does exactly the same thing in his discussion of MH, but only more so:

Medical Hypotheses and its editorial policy were safe – indeed the journal has flourished under Charlton’s editorship – until he published an article by Peter Duesberg, the notorious retrovirologist who rejects the theory that HIV is the cause of AIDS. This brought Charlton into conflict with one of the most powerful scientific advocacy lobbies, the AIDS establishment, which ranks second only to the climate-change crusade when it comes to trying to suppress its critics, who are stigmatised as ‘denialists’ of doctrinal orthodoxy.

Oh, no. It’s the “science is religion” fallacy. I really, really hate that fallacy, because it’s so demonstrably, well, fallacious. Science is not a religion, and there is no “orthodoxy.” No one denies that humans have biases, and that the prevailing scientific theories of the day can sometimes ossify more than they should, making them more resistant to change than they should be in response to new evidence and data. But change they do in response to new evidence. It may be a very messy process and take longer than we’d like, but eventually evidence wins out. People who start disparagingly referring to science as “orthodoxy” or “dogma” are creeping towards crank territory.

Based on this fallacy, Dr. Fitzpatrick sees all sorts of dire conspiracies to “censor” Charlton. Oh, no! He insinuates, Charlton has offended the dreaded and mighty “AIDS establishment” and was therefore silenced like the heretic he was. To hear Dr. Fitzpatrick speak, it’s a good thing Charlton didn’t offend the global warming lobby. If you believe Fitzpatrick, you’d almost expect that Charlton would be buried under the foundation of the new Yankee Stadium if he had offended the apparently all-powerful anthropogenic global warming cabal!

The problem is that there is no “right” to be an editor of a scientific journal. Editors are hired and fired according to the company’s needs, and they are expected to uphold scientific standards. There are standards for editorial independence, but arguably Charlton abused those standards to the point where he was endangering the existence of MH itself. There is a lot of leeway, but arguably Charlton had gone beyond any reasonable accommodation. In fact, I am puzzled why Elsevier put up with him for so long and can only conclude that Elsevier didn’t much care about the quality of the science published in MH as long as the journal made money. Why do I say this? Simple. It’s because Charlton had published a constant stream of dubious science over the years, but it wasn’t until he had finally endangered MH’s status on PubMed and thus, arguably, the very existence of MH itself that Elsevier acted, despite numerous complaints over the years. The Duesberg paper was, quite simply, the last straw. Scientific journals that are not listed on PubMed are not nearly as widely cited or read, and fewer authors want to publish in such journals because they don’t show up in PubMed searches. When Charlton’s antics finally endangered the listing of MH on PubMed, they endangered the journal itself, as well as embarassing its publisher, which acted. This was not “censorship.” It was a long overdue attempt to impose a modicum of scientific rigor on a journal that had been sadly lacking them.

As I’ve said before, I don’t really have a problem with a magazine or journal that publishes speculative science, however irresponsible. There should be a role for such a journal, where scientists and physicians can let their minds wander and see what comes of it. That’s free speech. It may need to be countered, but I would never advocate censoring it. What I do have a problem with is when that journal’s editor thinks he has a right to be listed in MEDLINE, abuses that listing to publish irresponsible articles by HIV/AIDS denialists, and then cries persecution when his irresponsible publication policies lead to calls to delist his journal from MEDLINE. Worse, the only time Charlton appears to try to disabuse anyone of the notion that MH is a peer-reviewed journal is by occasionally showing up in the comments of a critical blog post (as he has before on this blog and others) to opine that, really, you shouldn’t take this stuff so seriously because it’s all highly speculative, and, oh, it’s “editorially reviewed” rather than peer-reviewed–which, he promises, is really, truly just as good.

I also have a problem with people like Dr. Fitzpatrick, who defend such editors and label attempts to enforce a modicum of scientific “rigor” as “censoring free speech.” While I agree (and have said many times) that the best response to hate speech or irresponsible speech is to refute it long and loud, that does not mean that there should not be sanctions for professional misconduct (which Andrew Wakefield richly deserved) or that scientific journals journals giving a platform to pseudoscience (which is what MH did on a routine basis) should not suffer some sort of professional and/or financial penalty, be it being delisted from Medline or losing readership. In advocating this, Dr. Fitzpatrick seems to be taking a position that is either so open-minded that his brains fell out or so enamored of the iconoclast or underdog that it has undermined all sense of scientific rigor. Want more evidence? Take a look at how Dr. Fitzpatrick closes his article:

The Vaccine sermon concludes with a declaration: ‘One and only one principle should characterise all actions and discussions in this regard [questions about vaccine safety and efficacy] – truthfulness and credibility via full transparency that evokes the trust of the public must be the one and only goal.’

Apart from the apparent innumeracy of this statement, it is contradicted in practice by the growing popularity among scientists of the principle of ‘the good lie’. This is the notion that it is justifiable to be ‘economical with the truth’ or to ‘spin the facts’ in the service of what engaged scientists deem to be a higher cause (saving the planet from global warming, stopping the spread of HIV/AIDS, deterring people from smoking, promoting ‘healthy lifestyles’, and now preventing childhood illnesses through immunisation). The pervasive cynicism of ‘the good lie’ is a bigger threat to trust, and ultimately to public health and welfare, than the pseudoscience of Andrew Wakefield.

Unfortunately, Dr. Fitzpatrick does not tell us poor, deluded and apparently repressive and fascistic scientists out to crush dissent and free speech under our jackboots exactly what the “good lie” was that Andrew Wakefield was “censored” to protect. Does Dr. Fitzpatrick believe that vaccines cause autism? No, he most definitely does not; he has said as much repeatedly. Does he believe that vaccines are safe and effective and that the anti-vaccine movement spawned by Andrew Wakefield and the British press is a threat to public health. I certainly hope he does and have no reason to believe that he does not. So where is the “good lie” for which Wakefield was apparently sacrificed? The same sorts of questions apply to MH. Where is the “good lie” being protected by Elsevier’s decision not to renew Bruce Charlton’s contract? Is it the “lie” perceived by HIV/AIDS deniers that HIV causes AIDS and protease inhibitor cocktails prolong lives? I certainly hope not, and have no reason to believe that Dr. Fitzpatrick doesn’t accept the science behind HIV and AIDS showing that HIV does cause AIDS and that the drug cocktails do work.

Dr. Fitzpatrick’s argument here is incoherent.

I do now detect one commonality to the sorts of scientific endeavors mentioned by Dr. Fitzpatrick as the sorts of science that to him scientists are all too eager to defend with “the good lie.” They are all scientific findings whose implications strongly suggest that public or governmental action is required to address a major problem: global climate change, deterring smoking, promoting healthy diets, and protecting children through vaccination. In an earlier review of Ben Goldacre’s Bad Science, Dr. Fitzpatrick wrote:

Yet other examples of pseudoscience that have, arguably, greater influence on the life and health of the nation remain curiously neglected in Goldacre’s account. For example, as recent contributions to spiked have argued, controversies over population, passive smoking, the HIV/Aids epidemic and the links between diet and health are characterised by the subordination of science to propaganda.

And:

These include a pessimistic outlook towards the prospects for nature and society, reflected in the popularity of apocalyptic and doomsday scenarios of all kinds, and notably in a willingness to embrace the likelihood of catastrophe from epidemic disease (whether in the form of AIDS, mad cow disease, SARS, bird flu or mere obesity). They also include a misanthropic outlook towards humanity, expressed in contemptuous attitudes towards the masses, notably towards people who vote for George W Bush or against the EU, those who smoke or are overweight. A third theme is a growing sympathy for authoritarian interventions to deal with social problems, whether the issue is AIDS, banning smoking, banning trans fats, or banning advertising for ‘junk food’.

He’s also written articles entitled The ‘McCarthyism’ of the anti-smoking lobby.

Oh, dear. I think I understand now. It’s those evil fascistic liberals wanting to impose their liberalism on brave libertarian iconoclasts like Dr. Fitzpatrick, who, even though he doesn’t smoke or believe vaccines cause autism, fully supports people’s right to smoke and pollute the air of people around him with their smoke and for physicians to engage in professional misconduct in order to promote their anti-vaccine agenda! Trying to curtail smoking is fascistic, as is enforcing professional standards, which, by the way is also “censorship.”

How sad.

In the cases of Andrew Wakefield and Bruce Charlton, it was more than just engaging in free speech that got them into trouble. In Wakefield’s case, he committed serious breaches in the professional ethics of the medical profession. As a result, the governmental body charged with regulating the professional conduct of physicians conducted an investigation and hearings and found that Wakefield had committed serious misconduct. That’s not “censorship.” That’s upholding the standards of the medical profession. In the case of Bruce Charlton, Elsevier arguably put up with him a long time. True, it was probably because MH made money under his editorship more than out of any concern for scientific accuracy, but eventually Charlton went too far to the point of violating the standards applied to journals indexed in PubMed. That led scientists to complain and Elsevier to try to tighten up the scientific standards.

As I’ve said before, scientists are human. Like any group, they sometimes engage in more tribalism than is good for them. Sometimes that tribalism even betrays science. A trait that is simultaneously both good and bad, scientists tend to have a very low level of tolerance for pseudoscience and anti-science. However, the difference between scientific discourse and just discourse is, of course, science. The same is true in medicine. Physicians and scientists have every right to free speech. They do not, however, have the “right” to expect that that free speech won’t have consequences in their profession.