Who’s there?

The past is prologue, isn’t it? Or at least it can help to explain how we now think about things -whether we accept the inevitability of uncertainty or flee from it like a pestilence. Of course, nothing can ever be completely certain: the sun may not rise tomorrow and yet we must act as if it will or accept that any plans or dreams we harbour are pointless. On the other hand, certainty itself is a spectrum…

I didn’t mean to bathe uncertainty in such an academic light, but it underlies an age-old schism of thought that I hadn’t appreciated until I happened upon an essay contrasting the views of no less personages than René Descartes, and Shakespeare. Written by Lorenzo Zucca, a professor of law at King’s College London, I felt at times I was attending a seminar on 17th century thought. https://psyche.co/ideas/much-ado-about-uncertainty-how-shakespeare-navigates-doubt   I suppose I was…

That Shakespeare lived in an age of uncertainty is well known; one of the biggest issues was religious conflict. Zucca sets the stage: ‘In the premodern world, religion provided absolute certainty: whatever we knew was implanted in our mind by God. We didn’t have to look any further. Once that system of beliefs started to collapse, Europe was left with a yawning gap. Religion no longer seemed capable to explain the world. René Descartes and Shakespeare, who were contemporaries, gave opposite answers to the sceptical challenge: Descartes believed that our quest for knowledge could be rebuilt and founded on indubitable certainties. Shakespeare, on the other hand, made uncertainty a leitmotiv of all his works, and harnessed its creative power.’

Take Hamlet, for example. ‘The whole play is marked by a deep doubt about how perception can mislead us… This sweeping type of uncertainty, let us call it philosophical doubt, has to do with the limits of human ability to know the world from a subjective viewpoint. How can we be certain that our beliefs are anchored in an indubitable perception? What if we are dreaming or hallucinating? Hamlet is a young philosopher who is incapable of making up his mind about anything.’

And then, of course, there’s Descartes’ Cogito ergo sum -the certainty that although he could be deceived about the truth of what he saw or thought, the fact that there was something that was thinking could not be denied. Certainty could, and did exist, even in the fog of uncertainty that cloaked much else.

But, can we even compare the visions of poetry with the logical assessment of philosophy? Is it merely pears piled on top of potatoes? Can we –should we- accept uncertainty?

Well, according to Zucca, ‘Shakespeare’s vision from uncertainty brings together the imagination of a poet, the judgment of a philosopher, and the creativity of a scientist. Being capable to stare into the abyss without being swiped away emotionally is a great attitude for whoever wishes to further our understanding of the world and the way we live in it.’ After all, ‘Moralising is another way of creating certainty out of chaos, and that would impinge on the view from uncertainty. It would require creating cardboard characters: villains with no redeeming features… Uncertainty makes freedom and creativity possible.’

Zucca asks us to imagine a life of absolute certainty –‘We would know our time and place of death, when we’d fall in love, and what our job would be. Who would be our friends and who the enemies.’ Would that be a life worth living? Maybe ‘Violence and conflicts arise from the confrontation of dogmatic, certainty-obsessed worldviews. The vision from uncertainty asks us to keep making sense of our life without imposing our values over one another.’

In a totally different Magisterium, I suppose, I am reminded of the days when I used to make up little stories to tell my daughter before she went to sleep at night. She loved the fairy-tales that I read from books, of course. She liked the idea that the words printed on the page magically contained the stories -as if pictures and ideas somehow hid inside them and my job was to unveil them for her.

Sometimes, though, she would fold her little arms over her chest and chide me for changing the words, or skipping over parts that she particularly enjoyed. But one time, when we were on a trip in my Volkswagen camper van and I’d forgotten our regular books, I decided to try something different.

“How good are you at imagining things in your head, Cath?”

She looked at me with the perceptivity of a three year old. “Did you lose the fairy book, daddy?” was her first reaction.

“Well, I forgot to bring it, I guess. But would you like to see if you can imagine a new story in your head?”

After looking around me to see if I was just hiding her bedtime book, she sighed theatrically and nodded her head -better a new story than no story was written all over her face.

So I made up a story about the adventures of a little girl, Dorothy, who lived in a bread-box and Catherine loved it so much that she asked me to tell it to her again the next night. But she questioned me before I began.

“Dorothy and I had a nice time last night, daddy. Does she do something different tonight?”

“Are sure you want her to, Cath?” Certainty had seemed her gospel with the fairy-tales. But maybe that was because it came with the assuredness of pre-printed words and pictures. There was an order to them that was hard to circumvent. Dorothy and the breadbox, though, was a different world -a world Catherine had begun to imagine and it was open. Uncertain.

She nodded her head, excitedly. “I can’t wait to watch something different in my mind tonight,” she said and settled as comfortably on my lap as the cramped little seats in the van allowed. And then she looked up at me with a wiser, older expression on her face. “It’s nice when there’s no picture on the page that tells me what to see,” she added, and waited with an expectant smile, eager for the night’s drama to unfold.

Scientific Fraud

Science –whose Latin etymology denotes knowledge- started off as a branch of philosophy and gradually morphed into its present form. Recently, however, it seems to be resting on a progressively unstable foundation with the general public. By its very nature, Science accumulates its knowledge by induction: observations elicit explanations which suggest experiments designed to test these. The results are always contingent –a classic example might be that of swans: if all we see are white swans, it might be reasonable to conclude that all swans are white –until, that is, we find a black swan. So knowledge is couched in probabilities –everything is potentially refutable and our statements about it must reflect how likely it is to be a continuing truth. This is fine unless we crave certainty.

In an increasingly uncertain world one can understand the appeal of religions, if for no other reason than the assurance that the mainstream variants project. But historically, even the supposedly eternal truths revealed by religions have been contingent upon success in battle, or survival in times of environmental or social disasters. Certainty is a horizon that shifts and recedes whenever it is approached. However close we may feel we are, it is, like the rainbow, forever out of reach.

Of course, many do not agree with this; many feel that certainty is attainable and harbour a lingering suspicion of any system that cannot provide it. Why should faith be piled onto something that accepts that it is open to being refuted -welcomes it, in fact?

There are enough confusing and seemingly contradictory studies published to challenge the Public’s trust in Science. At times, its credibility seems to be balancing on a knife’s edge; the slightest puff of scandal could well be enough to destabilize the already tenuous confidence. For some people, it is already gossamer thin.

It is with this in mind that my fears often migrate to the subject of fraud in science. For me, it is not only a question of how it could happen, but rather, why it would. I was intrigued by an article in an article in the Canadian Medical Association Journal from last year entitled: ‘Scientific misconduct or criminal offence?’  (http://www.cmaj.ca/content/187/17/1273.full) The article examines whether we should be treating scientific fraud as merely naughty ill-advised behaviour, incompetence, or criminally punishable conduct. The standard of proof needed to successfully achieve a legal conviction is apparently quite stringent and so, often in the interests of limited financial resources and depending upon the seriousness of the case, lesser sanctions are frequently used. In Canada there is a Secretariat on Responsible Conduct of Research. ‘The Secretariat is a government agency responsible for implementing the Tri-Agency Framework on Responsible Conduct of Research on behalf of Canada’s major federal government granting agencies… A researcher who breeches the framework may receive letters of education or admonishment. More serious cases could merit sanctions, including withdrawal of funding or even the ability to apply for funding.’ And each year, says Susan Zimmerman, the current executive director, ‘there are about 90 breeches of the framework, but very few, perhaps three or four, would be considered serious. Even fewer would constitute a criminal offence. And if one did, the Secretariat is already obligated to notify the authorities. Instead of trying to ferret out the rare egregious bad apple, the Secretariat, as stewards of public money, focuses on reducing unacceptable results. The agency considers that approach to be a more productive use of limited resources than trying to determine if a researcher made an honest mistake or acted in bad faith.’

All fine and good, I suppose, but I still wonder about the already suspicious Public Opinion about science in general. ‘In a 2014 BMJ article, Bhutta, who has a strong interest in research ethics, argued that scientific fraud can have huge consequences on public health and clinical practice, citing the damage to global vaccination coverage caused by the “fraudulent and discredited” research of Dr. Andrew Wakefield that linked vaccines to autism. There is little risk to committing research fraud, beyond damage to reputation, and the research community is doing an inadequate job of policing itself, according to Bhutta, who wrote that “additional deterrence through punitive measures such as criminal proceedings should be added to the repertoire of measures available.”’

If the results of a study were indeed woven out of whole cloth, the lack of legal consequences would feed the worst fears of an admittedly small segment of society which mistrusted western medicine’s perceived mantle of omniscience to start with. If it were fraudulent, they would wonder, then why wasn’t the doctor prosecuted? Was it because there was some uncomfortable truth to his findings that an embarrassed Medical establishment, which had been pushing the safety of vaccines for years, was trying to cover up? How many other studies are fraudulent that either haven’t come to light, or have been quietly hidden under the covers?

The point is not so much that infractions are few and often inconsequential, nor that the naysayers and critics are few in number, but that the the condemnations are loud and insistent. Without a visible and concerted effort to rebut their arguments, allay their suspicions, and demonstrate that there are consequences for deception, their doubts will only grow larger, and their trust in the scientific approach further diminish. Already we have seen the effects of an underlying mistrust in the uncertainties of science manifesting itself in the climate change deniers.

Add fraud to the inherent uncertainties embedded in the scientific method, and we can begin to worry about the punishment of Sisyphus condemned forever to roll a massive boulder up a hill then watch it roll back down again. Consequences must suit the action. Justice delayed is justice denied.

 

 

 

 

 

 

 

 

 

 

The Cancer We Think We Know…

In those early, once-upon-a-time days when I thought I knew everything and before humility had forced itself upon my stage, a haggard middle aged woman named Mary walked into my office a week early for her appointment. It was in the young days of my career and as it happened, a patient who was scheduled for that time had not shown up. So, I agreed to see her.

She had a wild look in her eyes, and they immediately pinned me to my side of the desk. Well-groomed despite her jeans and tattered grey sweatshirt she could have been mistaken for someone ten years her junior. But she had been referred by a family doctor that I, of decidedly conventional western medical training, had come to associate with fringe issues -homeopathy, hair analyses, colonic cleansing and the like- so I prepared myself for sifting through a ream of details I could not hope to understand.

“I don’t feel well, doctor,” she started, her voice as serious and worried as her face. “I’m 41 and for the last six months I’ve had a constant ache in my lower abdomen on the left side -my pelvis, actually. My periods are light, non-painful, and as regular as a calendar with no intermenstrual spotting; I have never had any pregnancies, operations or illnesses. I’m not on any medications, don’t smoke, and have no allergies. In fact, you’re the first specialist I’ve ever been referred to.” She managed a brief smile. “I had my family doctor order an ultrasound 4 or 5 months ago months and it showed a thin, normal appearing endometrial lining of the uterine cavity, but a 4 cm. complex cyst on the left ovary. A repeat ultrasound last month found it was still there, albeit somewhat smaller.” She hesitated briefly and then added: “I’ve had this kind of cyst before but usually without symptoms, and the cyst is always  gone by my next scan.” She looked at me for a moment and finally said, “So now I’m worried, of course.”

I have to admit I was a bit taken aback that she’d already answered most of the questions I had intended to ask, so I just sighed when she appeared to have finished her summary. “You seem to know your way around medical words…”

A smile appeared briefly on her lips, but one that couldn’t disguise her anxiety. “I have a PhD in pharmacology and am doing some research at the Cancer Agency so I guess I’ve picked up a few words…” She was sitting bolt upright in her seat, but the expression on her face said she wasn’t finished so I waited for her to speak. And anyway, I was running out of questions to ask.

“I’d like you to take everything out,” she said, suddenly leaning forward over the desk.

“Meaning..?”

“Meaning uterus, tubes, ovaries… everything!” She took a deep breath. “Look, I’m really afraid that all these cysts I’ve been getting on my ovaries are telling me something. There’s not a shred of cancer in the family, but I have this feeling about my ovaries that I can’t explain: I know  there’s cancer in one of them. Don’t ask me how I know it -I just do. And it’s only a matter of time before it becomes obvious in one of the ultrasounds… maybe too much time.

“I don’t want any kids; I’m not in a relationship; and I’m willing take hormones…” She blinked. “But I can’t take cancer.”

I’d been writing all this in her chart, but I put down my pen and looked at her. “Do you mind if I examine you and then we can talk about it?”

She agreed with a shrug of her shoulders. “Okay, but don’t tell me the recurrent cysts are just the result of anovulation…”

I had to smile at that one: it was precisely what I had intended to tell her. Anyway, I couldn’t feel the cyst and I told her so when we returned to the office after the examination. She seemed surprised.

“Are you sure? I mean I’m not questioning your findings, but why would it just disappear when it was still there last month? And a complex cyst as well,” she added, obviously aware of the possible ramifications implied by the term and searching my face for answers.

“Would you mind if I repeated the ultrasound?” I could see my findings had not reduced her concern in the slightest. “And maybe I’ll order some tumour markers, just in…”

“They’re usually not very helpful at my age.” The words seemed to escape her mouth before she could stop them, so she plastered an embarrassed smile over her lips. But she did agree to the repeat ultrasound.

*

I’m afraid I forgot about her until she returned a couple of weeks later, after the ultrasound.

“Well, it was normal,” I said as soon as she sat down. “But I suspect you already know that.”

She nodded. “I still want you to operate, though.”

I sighed, looked at the ultrasound report again and then at my notes in her chart. “But that left ovary is completely normal in appearance now -both of them are. The uterus looks normal… everything  looks normal.” I riffled through the few lab tests I’d managed to convince her to take. “Your periods are normal, so I admit that it makes non-ovulation as a cause for the cysts less likely, but the tumour markers are normal, the…” I glanced at her face. “No, I’m not putting too much reliance on them, but at least they’re reassuring as well.” I could see her fidgeting in her chair all the while staring at me. “Look, I can’t just take everything out in a woman your age without some good reason.”

She crossed her arms and a stern expression captured her face.

“So, how about we consider a couple of options?” I suggested, looking her in the eyes. She blinked, and I took that for an agreement. “The first is that we repeat the ultrasound in, say, six months and then…”

She shook her head firmly, and stared at me. “What’s the second option?”

“We get a second opinion -a female gynaecologist, maybe. If she agrees, then maybe she can do the…”

“I chose you, not another doctor,” she said slowly. “If the second doctor -the female– agrees, will you do the operation?”

I have to admit I felt a little flattered by that, and I suppose it’s why I agreed. But by the time she got a reluctant agreement from the other doctor and I was finally able to book the surgery, it was six or seven months later.

I went to see her on the ward the day after the surgery. “Everything went well, Mary. The uterus and tubes appeared normal, and the ovaries were both outstanding-looking citizens.” I don’t know why I said that; I suppose I was trying to make her realize that I was happy with what I’d seen.”

“When will we..?”

“Get the pathology report? It’s probably going to take about a week. But I’m not expecting any surprises, you know,” I said with a smile as I gently squeezed her hand.

But her eyes were wiser than my words. “Now that my ovaries are out, that bad feeling I used to have is gone; you got the cancer. I can tell…” Her voice faded as she closed her eyes and drifted into a narcotic-driven sleep.

*

I called her to come in to the office as soon as I got the report.

“It was cancer all along, wasn’t it?” she said in a soft, worried voice even before she sat down.

I nodded slowly and reached  across my desk for her hand. “But it was in the uterus, not the ovaries…”

Her face softened, and her shoulders relaxed; her response was a statement rather than a question: “That’s a better cancer to have, though, isn’t it?” Then she smiled and squeezed my hand this time.