Unhealthful News 121 - Adamance and conflict of interest (part 2)

Two days ago I started writing about a coincidental collection of essays that had crossed my screen over the last week, all touching on the themes in the title.  When I started, I thought that today I would bring it together with a unifying message, but nothing seemed to emerge.  I think the topic is just too big to pull together all the threads so easily.  So instead I will just add just one additional example its implications.

I had two interesting revelations while reading a really bad, naive analysis about the nature of COI.  An anti-acupuncture advocate was annoyed that an acupuncture practitioner/advocate/researcher criticized her for failing to disclose her COI in a journal commentary.  Her commentary briefly praised the new study it accompanied, which reported a lack of support for acupuncture in the existing literature.  It then went on to present an adamant broad attack on the claims that there is scientific support for acupuncture in general (she reposted the commentary here, with no paywall, if you are interested). 

Her best defense against the criticism of COI would have been:  "My commentary was so obviously anti-acupuncture that no reader could possibly accuse me of having a hidden agenda.  I wrote a general anti-acupuncture editorial that merely used the new study as a hook, so since I did not contribute any analysis about the study itself, there was no COI as there would have been if I purported to be neutrally assessing the quality of that work."  Picking up on the points I made two days ago, being an adamant supporter of a position – which this author clearly is – is not a COI so long as you are working from the clearly-communicated premise that that position is correct.  It is a COI if you are trying to offer an assessment of whether the position is correct or not.

But instead of making that argument, the commentator blogged that because she had no financial benefits or any material stake in anti-acupuncture, she did not have a disclosable COI under any circumstances.  This is a demarcating that is often offered, almost always without any analysis or support (or apparent brain involvement).  But she wrote pages purporting to support the claim but offered no convincing arguments.  She offers no compelling reason why an author who wants all readers to reach a particular conclusion because of passionate personal conviction differs importantly from one who wants them to reach that conclusion due to a financial or other material incentive.  In both cases, the reader deserves to know that the author has that goal, and it matters little why the author has this goal.  I found this to be informative simply because a good test of a position is whether its proponents can make a plausible case for it when the opponent's views are not even considered; this particular proponent certainly could not do so.

Her most substantive defense seemed to be that she was not anti-acupuncture, she was just pro-science, and her years of studying this particular topic had led her to a scientific conclusion that acupuncture was all bunk.  But someone who turns the corner and becomes an advocate rather than just a knowledgeable reader is at great risk of (a) having biases that she herself cannot fully recognize and compensate for and (b) being so focused on a goal that she fails to recognize that her actions have ethical importance and are no longer just some kind of cold pure science.  After all, when someone writes the following in her blog post about the journal commentary, it is pretty clear that she does have an interest:  "It gave me a soapbox in a major medical journal to say all the things I thought needed to be said about acupuncture."  Anyone who thinks there are things that "need to be said" on a topic has an adamance that is a disclosable interest. 

Does it matter that she has not made any money pursuing this work?  Well, imagine someone with her adamant views, and many years of advocacy, who you then learned also got travel expenses and a modest honorarium to give a talk at a medical conference.  Could that possibly change you opinion about the nature of her possible biases?  Obviously not.

But I found some important takeaway lessons and reminders nevertheless (so credit to the author for writing something provocative, which is perhaps even better than something that is correct but insipid).  First, it pointed out the enormous COI that is involved in opinions about the nature of COI.  Most of the time when someone tries to demarcate COI from lack-of-COI, they seem to draw the line so that they are on the latter side.  People who get grants to work on a topic claim that COI is an issue only if you are salaried.  People who have salaried jobs working on an issue with an NGO or advocacy arm of government claim that COI exists only if you have investment assets or involvement with corporations.  Those few people who work on an issue from a purely voluntary basis (like the author of the present example) claim that COI is all about monetary payments, and cannot exist merely because someone feels so strongly about an issue that they will donate their time to it.  But then, of course, even people who get paid to advocate on an issue will counter by figuring out a way to define COI so that it refers to anyone working on the opposite side of the issue, paid or not.

In other words, it is just like the dilemma of people working in highly politicized fields, where all the real experts have strong opinions about the controversial issue and so most end up as part of a political faction.  Most everyone who knows a lot about the travails of COI is expert because they are enmeshed in a world where it is a problem, and thus they have a worldly stake in how it is defined.  That is, they have a COI about defining COI.  There are only a handful of serious historian-of-science types who are experts as a result of their arms-length studies (who should not be confused with the countless armchair pundits who fancy themselves experts on the topic because they read a couple of books on ethics; my experience is that most of them are actually motivated by a personal stake, or are quite clueless about the issue, or both.)  When I have written studies about COI, I and my coauthors have disclosed my interests in how COI is defined; I do not recall ever seeing anyone else do that.  But the more I think about it, the bigger a problem it clearly is.

Even closer to home for me, the anti-acupuncture commentary was an excellent reminder of how an author with an adamant interest in a particular position cannot simply make blanket assertions.  Expert advocates often fall into the habit of writing for people who already know a lot of the background, and the habit of treating the many bad (in the opinion of the author) arguments on the other side as so groundless as to hardly be worth addressing.  The problem is that this does not work as communication for thinking readers who are not expert on the fight already.  As a reader, I read the anti-acupuncture essay as a series of definitive statements that, if true, would present a very strong case, and yet I found the argument to be absolutely unconvincing.  Why?  Because it felt analogous to reading about a single case study of a coincidence (e.g., someone who got acupuncture and had an amazing cancer remission) – you know such a coincidence exists somewhere, and that someone can spin it into an adamant essay.  So the fact that someone presented that essay tells you nothing – there was never any doubt that it could be done, or that someone could have presented something equally adamant (though perhaps with fewer allusions to studies) on the other side.  When the author adamantly presented one side of the argument, I was no more inclined to just take her word for it than I would have been had she disclosed that she was a paid advocate for her side of the issue.

So in the spirit of my Sunday sub-series on who to believe, I did not believe someone who wrote adamant assertions like she did, even though I suspect what she wrote is probably right.  So I, and the rest of you who are also advocates for some science-based cause, need to face that challenge – most claims of financial COI are just ad hominem attacks, but adamance can arouse doubt (even when it is inspired by ferocious support for good science).  Even though those who are very familiar with me know that I am probably the most effective critic of bad arguments made on my side of an issue (example), more so than the opponents of the position, why is what I write more convincing than the anti-acupuncture broadside?  Or is it?