Richard G. Petty, MD

Fatalism and Ethics

We are constantly inundated by reports of the consequences of bad decision-making, and that leads us to consider two issues: genetic determinism – the notion that our behavior is totally the result of our genes – and whether or not we have free will. This is a hugely important issue, not only for each of us personally, but also for our views about morality and the justice system. And what happens when everyone becomes convinced that they have no free will and that “they’re genes made them do it?”

We know from our own experience as well as empirical studies that changing a person’s sense of responsibility can change his or her behavior.

Interestingly, the link between fatalistic beliefs and unethical behavior seems never to been examined scientifically.

In two recent experiments published in the journal Psychological Science psychologists Kathleen Vohs of the University of Minnesota and Jonathan Schooler of the University of British Columbia decided to see if otherwise honest people would cheat and lie if their beliefs in free will were manipulated.

They gave college students a mathematics exam. The math problems appeared on a computer screen, and the subjects were told that a computer glitch would cause the answers to appear on the screen as well. They were told that to prevent the answers from appearing, the students had to hit the space bar as soon as the problems appeared.

This was a ruse: the researchers were observing to see if the participants surreptitiously used the answers instead of solving the problems honestly on their own. Before the test they used a well-established method to prime the subjects’ beliefs regarding free will. Some of the students were told that science has disproven the notion of free will and that the illusion of free will was an artifact of brain activity. The other group where told nothing about free will.

The results were clear: those with weaker convictions about their power to control their own destiny were more likely to cheat when given the opportunity compared with those whose beliefs about controlling their own lives were left untouched.

The researchers then went a step further to see if they could get people to cheat with unmistakable intention and effort. The experimenters set up a different deception. This time they had the subjects take a very difficult cognitive test. Then they were asked to solve a series of problems without supervision and to score themselves. They also “rewarded” themselves $1 for each correct answer. To collect the cash they had to walk across the room and help themselves to money in a manila envelope.

The psychologists had previously primed the participants to have their beliefs in free will bolstered or reduced by having them read statements supporting a deterministic view of human behavior.

This study shows that those with a stronger belief in their own free will were less likely to steal money than were those with a weakened belief.

The results of this study indicate a significant value in believing that free will exists. The work also raises some significant questions about personal beliefs and personal behavior.

“The flame of Christian ethics is still our highest guide.”
–Sir Winston Churchill (English Statesman, British Prime Minister, 1940-1945 and 1951-1955, and, in 1953, Winner of the Nobel Prize in Literature, 1874-1965)

“You’re born with intelligence, but not with ethics.”
–Masad Ayoob (American Firearms and Self-defense Instructor and the Director of the Lethal Force Institute in Concord, New Hampshire, 1948-)

“Fatalism, whose solving word in all crises of behavior is “All striving is vain,” will never reign supreme, for the impulse to take life strivingly is indestructible in the race. Moral creeds which speak to that impulse will be widely successful in spite of inconsistency, vagueness, and shadowy determination of expectancy. Man needs a rule for his will, and will invent one if one be not given him.”
–William James (American Psychologist and Philosopher, 1842-1910)

“To live lightheartedly but not recklessly; to be gay without being boisterous; to be courageous without being bold; to show trust and cheerful resignation without fatalism -this is the art of living.”
Jean de La Fontaine

“Custom has furnished the only basis which ethics have ever had.”
–Joseph Wood Krutch (American Naturalist, Writer and Critic, 1893-1970)

Fake News

There was a report in the British Medical Journal in April that got very little publicity, and even came in under my pretty sensitive radar.

The Center for Media and Democracy, a public interest group based in Madison, Wisconsin, that exposes "public relations spin and propaganda," issued a report that tracked the use of 36 video news releases (VNRs) aired by news outlets over the past 10 months. VNRs are designed to look like independently produced news but they are actually prepackaged promotions containing film footage created by corporate publicists or their public relations firms.

The media is always hungry for new material, but I was surprised to see that during the tracking period stations aired the pre-packaged VNR in its entirety more than one-third of the time. The other point of importance was that VNRs were not only widely used but their source was usually not disclosed. Another worrisome thing was that when it came to pharmaceuticals the safety data was usually shortened or even removed.

I have no problem at all with advertising and marketing. But it is surely misleading to dress up a company release as a news story.

To be fair, most television networks have rules and disclosure policies, but they are obviously sometimes (often?) being ignored.

I have been looking to see if there has been any change since this report came out in April, and I don’t see anything.

This strikes me as an important issues, so I shall continue to track it on your behalf.

Conflicts of Interest

Last week I made some comments about the claims made in the new book by Suzanne Somers.

As expected, I had a good many people who said, “About time somebody said something,” and a few others who just felt that her publisher should have arranged for more fact checking.

To the people who agreed with me, thank you.

To those who did not, I respect your various positions, and I think that we have to look at this problem in a bit more detail.

By “this problem,” it is not simply about whether Suzanne needs to have some facts checked. I think that there is a very real problem with someone who has no medical training giving medical advice.

The more so if that person or persons is unable to undertake a critical review of published research.

This is much the same as the monstrous comments made by Tom Cruise earlier this year. He abused his position to make comments that made no sense. I saw several people who were weeping and distressed by what he had said. Many were saying things along the lines of “These medicines have saved my life, how can he say something so terrible?”

This is similar to the recent problem with Kevin Trudeau, who has made a great deal of money out of peddling highly questionable advice. He can do so in the United States because of the First Amendment. Nobody would want to change a constitutional right, but I get very worried about people saying anything that they want about health, and if anyone gets harmed, they say that it’s not their fault.

Some don’t even seem to have the wit to understand that their recommendations may cause harm. Harm that can come not just from commission – taking something harmful or being given a harmful treatment – but also of omission: not getting a treatment with proven efficacy. Trudeau claims that he is fighting on behalf of the American public. In which case, why has he not contributed the entire proceeds from the sales of his books to an independent central fund to educate the public about health?

I certainly do not think that people with an MD, DO or ND have all the answers: none of us does. But when we are talking about people’s health, I think that we all have to be extremely careful about dishing out advice.

I am also very aware that there are millions of people – mainly, but not exclusively women – who have severe problems with hormonal imbalances, and that they have not always been well-served by the medical professions. Giving unsubstantiated advice to people who are suffering is so unfair.

A number of people who are known for their work in hormone replacement have published an open letter that they have written to Suzanne Somers’ publisher, Crown House, expressing their dismay over some of the claims in her book. The signatories include Christiane Northrup and Diana Schwarzbein. Neither of whom would be called pillars of the establishment.

The Endocrine Society has just published a position paper about bioidentical hormones that I would urge you to read if you want further clarification about the whole issue of hormone replacement.

The front cover of the magazine Life Extension gleefully proclaims “Suzanne Somers Versus the Medical Establishment.” Life Extension is a fine looking glossy publication that looks like a peer reviewed Journal. It seems, though, to be a medium for disseminating information about supplements. Some of the articles are really quite good, but there is always the subtext that they are written in order to promote products.

The Journal uses a familiar tactic in some of these magazines that are selling products. This tactic is that they are letting you in on A Secret. A secret that is being kept from you by those terrible doctors or, shock horror, pharmaceutical companies that are trying to keep you sick. I’ve worked with countless pharmaceutical companies, and I’m well known for speaking my mind. But I have to tell you that in every company that I’ve worked with on five continents, the vast majority of the people involved have had a genuine concern for human welfare. Yes, they have a business to run, but pretty much all the people that I’ve known in the industry have been in that particular industry because it meshes with their own life goals of helping humanity. And as I pointed out a moment ago, the open letter to the publishers was not penned by pharmaceutical company lackeys.

Is Suzanne Somers making money out of her claims? Well, of course she is. She is using her celebrity and her extravagant claims to sell books. I’m quite sure that far fewer people would be interested in reading her material ff she just stuck to the facts.

That in itself presents some important ethical issues. Clearly, if she stuck to the data and gave a clear account of the pros and cons of what she is suggesting, she’s not likely to sell so many books.

As a spin off, she is also getting large numbers of people to visit her website, where they may buy products that may not contain bioidentical hormones, but ARE touted as being “anti-aging.” In other words the products on sale make some of the same claims that are associated with the hormones. This is a well-known marketing tactic. She claims to have one million people in her database, though we have not been able to confirm those numbers.

People all over the Internet are trying to find out if she is receiving any payments for endorsing products. I know that because several have contacted me. Of course she can do any kind of business deals that she wants, but there are ever-evolving rules about conflict of interest. Some new rules have just been proposed in the medical literature, and it would be excellent if the same standards were applied in all publications, whether print, online, in infomercials, interviews or any other kinds of medium of communication.

An important article on conflict of interest and full disclosure has just been published in the American Journal of Psychiatry.

Most major scientific journals now require that authors fully disclose ALL sources of funding. There are also strong, and I believe welcome moves to ensure that when patients receive medications, that they are fully informed if the prescriber has any relationships with drug companies. I have seen some people suggest that there should be a complete separation of pharmaceutical industry and the medical professions. A moment’s thought shows that would not be an answer to anything. If we can do this in conventional medicine, why not in every area of healthcare?

(As I’ve said before, my own list of disclosures is available to anyone who wants them, and they get updated every time that I do any work for which I get compensated. And not just me, any members of our staff. We are determined to remain squeaky clean.)

So what to do about the people who make wild claims about health, without disclosing their conflicts of interest?

Since we’ve just been through an election we’ve all seen how the squeaky wheel gets the grease!

People who say things loudly and repeatedly and appear to be saying something novel, do get attention. There’s no question about it, and there’s a good reason: Our brains are hard wired to notice and respond to loud noises and novelty. But when we are dealing with outrageous medical claims, the soft whispers of good data will ultimately drown the foghorns of dogma and opinion, however loudly they are blasted from the rooftops.

Some of the claim makers retire behind the fig leaf of saying, “Well there isn’t any data but if there were any, it would prove what I’m saying.”

Believe it or not, I’ve had that said to me on several occasions by several different people.

All of whom managed to keep a straight face…

The Ethics of Complementary, Alternative and Integrated Medicine

In my recent item about ethics I mentioned that Paul Root Wolpe from the University of Pennsylvania is interested in the ethics of Complementary and Alternative Medicine (CAM), and, by extension, its offspring, Integrated Medicine. This caused some raised eyebrows, but it shouldn’t.

Using unorthodox therapies carries a number of ethical and moral responsibilities.

When I was still on faculty at the University of Pennsylvania, on one occasion I caused outrage amongst many friends using natural medicine, when I pointed out on a TV show that just because something’s natural doesn’t mean it’s safe. Think arsenic, deadly nightshade and hurricanes! But there is more to the ethics of CAM than just the safety of the treatments involved.

Just a few months ago I was asked to look at a study by someone claiming to debunk one of the tapping therapies. Neither the investigator nor the practitioners and patients inveigled into the “research,” understood the principles of informed consent. This is important: one of the many consequences of the Holocaust was a re-consideration of what to do with medical “data” collected by Nazi doctors in the most unprincipled ways imaginable. Should the data be kept, so that people would not have died in vain? Or should it be destroyed, because information from unethical experiments was tainted. After a great deal of heart searching, it was decided that any information obtained under those circumstances was likely to be junk. This is one of the reasons for the absolute insistence on informed consent. I shall say something else about consent in just a moment.

Let’s have a look at the ethical issues involved in CAM, because much of the criticism of the emerging models of healthcare has come from people genuinely concerned about patient welfare.

  1. If we do anything with or for an individual, there has to be informed consent. Informed consent includes full disclosure not just of the chances of efficacy, but also of the possible toxicity of a treatment and an agreement of what we hope to achieve. A therapist may want to balance your Qi and stop you getting sick in the future. You may just want to be rid of your headaches. When we ask about the chances of efficacy, we all run into the problem of positive bias. I was once planning some research with a very well known practitioner in the UK, who told me that he cured every single person he saw, whether they had cancer, schizophrenia, heart disease or anything else. I was astonished, and asked him for something to backup what he said. He flew into a rage! “How dare I question him?” he said.It soon turned out that although he probably was a genuine healer who got a lot of people better, he had no evidence at all. It was like a study in the medical arena in which the investigators decided that anyone who did not come back for treatment was cured! Not a common reaction if someone fails to turn up for an appointment!
  2. People often say to me that there can be no harm in giving someone a homeopathic remedy. And of course, from a purely physical and psychological perspective, that’s probably true. Though I once participated in an experiment in which I took the homeopathic remedy Pulsatilla, that is prepared from the Passion Flower. I had what is known as an exacerbation, and was unable to function for several hours. But we also need to think about some of the other things that can follow from using treatments that work at the level of the subtle systems. One of our biggest objections to people who believe that they can do acupuncture after a weekend course, is that acupuncture, homeopathy and the rest are powerful medicines. Putting a needle into the wrong part of a person’s anatomy may not just cause physical harm, but can do extraordinary things to a person’s subtle systems. A fact that is exploited in some martial arts. In the Jet Li movie Kiss of the Dragon, Jet uses acupuncture needles to do some extraordinary things. The filmmakers used little artistic license: with one exception I have personally seen all of the things demonstrated in the movie.
  3. I mentioned that informed consent includes full disclosure about the chances of efficacy and toxicity of a treatment and agreement on therapeutic goals. We can find ourselves in a real ethical dilemma when patients have unrealistic expectations for an untested remedy. Sometimes people don’t inform their patients realistically, and they rationalize it as either choosing not to remove hope or as providing support. But we have to be sure that we are not supporting potentially dangerous or harmful decisions. The problem is not necessarily the treatment itself. Using an untested treatment in place of something that we know can be effective can also lead us into difficult ethical waters. Regular readers will remember a sad case that I highlighted a few months ago.

I’m all for holistic therapy: the less invasive the better. I’ve spent the last 35 years helping develop new and better ways of integrating treatments.

But it’s really important to be realistic, to use what we know works and if we don’t know if a thing works, then to be totally honest with the individual, and keep meticulous records of why we want to use an untested remedy in combination with the conventional.

In the 1980s, the Research Council for Complementary Medicine began to train complementary practitioners in the basics of research, so that they could be better at obtaining informed consent and monitoring the effectiveness of treatments that they were using. We had some success, and it is high time that we helped practitioners in other parts of the world do the same thing.

Why Ethics Matter

I was thrilled and delighted to see an extremely important article by Paul Root Wolpe, one of my former collaborators at the University of Pennsylvania. What was so heartening was that the article appeared in the journal Cell, which is without question one of the very best biomedical journals in the world.

Paul is a bioethicist with very broad interests: He is a Professor in the Departments of Psychiatry, Medical Ethics, and Sociology, and senior fellow at the Center for Bioethics at the University of Pennsylvania. He is also Chief of bioethics at NASA. Paul also has a great interest in the ethics of complementary and alternative medicine. He has a remarkably keen mind that let’s him get to the bottom of even the most knotty problems.

I am going to quote a couple of lines from the paper, before summarizing Paul’s main points:

“Science is a powerful force for change in modern society. As the professionals at its helm, scientists have a unique responsibility to shepherd that change with thoughtful advocacy of their research and careful ethical scrutiny of their own behavior.”

He goes on to identify the eight top reasons scientists cite to avoid thinking about ethics and then offers substantive responses to invalidate these excuses. These are the eight reasons why many scientists don’t consider the ethical implications of what they are doing are:

"I’m not trained in ethics."
"My work has little to do with ethics."
"Ethics is arbitrary."
"Others will make the ethical decisions."
"Ethicists mostly say ‘no’ to new technologies."
"The public does not know what it wants."
"Knowledge is intrinsically good."
"If I don’t do it, someone else will."

The point that Paul makes in the article is that none of these points is actually true. In the same way that we cannot divorce your physical body from your mind and your emotions, science is intensely value-laden. We bring our beliefs and our prejudices to science, and we have to consider the practical consequences of what we are doing.

There have been some great blogs written in response to the article. One that particularly caught my eye was by Janet D. Stemwedel from San Jose State University. Well worth reading both the original article and Janet’s blog.

I have always thought it essential that those of us working in academia should remain fully engaged in the debate about the meaning of our work, and its moral and ethical implications. Many of us have been criticised for popularizing what we do, but I think that we have a responsibility to let the public know what we are doing, what we have discovered, and how it will impact them.

After all, they are paying the bills!

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Green Cheese Claims and Needless Dietary Chaos

The front cover item of today’s Newsweek Magazine concerns the confused and confusing state of dietary advice in America, and indeed around the world. So much of the advice on offer is based on political considerations and a fundamental misunderstanding about the way in which knowledge grows.

People outside the academic world are often astonished to discover that it is not a world of quiet painstaking investigation and careful intellectual deliberation, but is instead a hot bed of neo-Darwinian competitive frenzy. Every academic is under constant pressure to publish or perish. There are constant and intense demands to bring in grant money. This pressure can lead to huge problems. Data is often published before it is ready.

As regular readers of my columns know already, I have been vigorous in exposing scientific misconduct, but I am also concerned about raising false hopes or giving false guidance on the basis of single studies. Any study, however well designed and executed and however many subjects it contained, still needs to be confirmed and confirmed again. If somebody at NASA produced evidence that the moon was made of green cheese, I doubt that they would be believed. Not unless the observation could be confirmed by hundreds of independent investigators around the world.

Yet every day I see people who have fallen victim to green cheese claims. People who have been persuaded to part with millions of dollars to buy supplements to help them lose weight, on the basis of very limited data and sometimes wild extrapolations. Often they are just not needed. As an example, people are usually not told that ten minutes in the sun and a glass of low fat milk will give them all the calcium and vitamin D that they need for a day.

The Newsweek article does a great job of teasing apart many of the competing claims.

A year ago Mike Johanns, the Secretary of Agriculture, launched the new MyPyramid initiative to highlight the 2005 Government Guidelines for healthy eating, which for the first time emphasized the importance of individualizing any approach to diet and exercise. Although there were all the usual allegations that the guidelines were simply a confection designed for the health of American farmers rather than the health of the American population, I really cannot agree with those comments. The guidelines represent a considerable advance on the old food pyramid, but as I have pointed out in previous postings, the problem with weight management is not just what you leave out, but also what to include in any healthy eating plan. I really do suggest that if you haven’t already, you look back at some of the suggestions that I’ve made previously on this blog.

Let me also direct you to another resource: The Psychiatric Resource Forum’s article “Nutrition for Americans” will point you toward other good sources of information that we have carefully vetted for accuracy. Although this blog was created for healthcare professionals, it also contains a lot of information of value to readers of this blog.

Later this year, we plan to publish a short book on the precise approach to healthy eating that I have been using with great success for many years now.

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More on Scientific Misconduct

Today there have been reports from Reuters and the BBC that South Korean prosecutors have started questioning the disgraced scientist Hwang Woo-suk. The reason for their interest is that his fraudulent research was largely funded by public money. Thus he could be accused of misusing government funds.

The shock waves from this sordid scandal are still spreading.

A report  has just been published by a panel at the University of Pittsburgh that has cleared Gerald Schatten, director of its department of obstetrics, gynecology and reproductive sciences, of any scientific misconduct in his collaboration with Hwang Woo-suk. However, the University panel decided that although he was not involved in the falsification of data, he should have taken greater steps to ensure that the data were correct. The panel decided that Dr. Schatten was guilty not of research misconduct, but of “research misbehavior.”

Five years ago a former colleague of mine who has had a distinguished scientific career, became mired in scandal. Not because of something that he had done wrong, but because of something that he failed to do right, some ten years earlier. A young researcher in his department was cooking up research data, and even when the first suspicions were brought to his attention, for some reason he failed to check it out.

It is the responsibility of everyone involved in a research project to ensure that everything is correct. After that is the responsibility of reviewers to re-check everything. We owe that to patients, their families, and the public who pays for this research.

I just hope that one day Dr. Hwang will tell everyone why he felt that it was okay to betray the trust of millions of people around the world.

Addendum:  It is a little late, but I recently found a interesting podcast done on Feb 8, 2006 by the good people over at Scientific American that discusses the Stem Cell/Korean debacle.  I’m linking it here in case you want to have a listen. 

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The Ethical Brain

There is a nice blog, Brainethics, that discusses an interesting new book Hardwired Behavior by Laurence Tancredi. This really is an outstanding piece of work. The author is both a psychiatrist and a lawyer who argues that Society’s assumptions about free will and individual responsibility must be drastically revised in the light of scientific discoveries about the brain.

This is part of a large debate that is going on within psychiatry and psychology and within the legal profession. As an example, at what age should a young person be able to drive a car or be legally liable for their decisions? The driving question comes up because the brain and nervous system of a fifteen-year-old is still far from being fully mature, and may lead to poor coordination and decision-making. Can an eighteen-year-old be held liable for his behavior, at a time that his brain is not fully formed? Yet he is able to fight for his country. You will see that your answers to those questions are likely to be a mixture of political positions and personal experience. But there is also no doubt that the explosion of knowledge about the brain will be factored into some future legal decisions.

In Tancredi’s book, he applies knowledge derived from recent research to such traditional moral concerns as violence, sexual infidelity, lying, gluttony and sloth, and even financial fraud and gambling. For anybody working in the field, it is very clear that hormones, nutritional status, drugs, genetic abnormalities, injuries and traumatic experiences all have profound effects on the structure and functioning of the brain. Therefore they may all have an impact on our moral choices. Some experimental work implies that our actions are initiated by pre-conscious and unconscious processes in the brain before we are consciously aware of them. Does that mean that our sense of moral agency is a retrospective illusion? And what about free will?? Is that an illusion too?

I like this book, and also the recent book by Michael Gazzaniga, entitled The Ethical Brain. But I need to sound a note of caution: we are bewilderingly complex creatures, and there is powerful evidence for the existence of systems that can over-ride some of the neurological ones. So even after reading and studying hundreds of books and scientific papers and talking to hundreds of scientists around the world, I remain convinced that free will is not an illusion, and that there really is a genuine morality which is a great deal more than the firing of neurons in the brain.

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