Tag Archives: Science

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He’s mad that trusts in the tameness of a wolf

I am an obstetrician, and not a neuropsychiatrist, but I feel a definite uneasiness with the idea of messing with brains –especially from the inside. Talking at it, sure –maybe even tweaking it with medications- but it seems to me there is something… sacrosanct about its boundaries. Something akin to black-boxhood -or pregnant-wombhood, if you will– where we have a knowledge of its inputs and outputs, but the internal mechanisms still too complex and interdependent to be other than interrogated from without.

I suppose I have a fear of the unintended consequences that seem to dog science like afternoon shadows -a glut of caution born of reading about well-meaning enthusiasms in my own field. And yet, although I do not even pretend to such arcane knowledge as might tempt me to meddle with the innards of a clock let alone the complexities of a head, I do watch from afar, albeit through a glass darkly. And I am troubled.

My concern bubbled to the surface with a November 2017 article from Nature that I stumbled upon: https://www.nature.com/news/ai-controlled-brain-implants-for-mood-disorders-tested-in-people-1.23031 I recognize that the report is dated, and merely scratches the surface, but it hinted at things to come. The involvement of DARPA (the Defense Advanced Research Projects Agency of the U.S. military) did little to calm my fears, either –they had apparently ‘begun preliminary trials of ‘closed-loop’ brain implants that use algorithms to detect patterns associated with mood disorders. These devices can shock the brain back to a healthy state without input from a physician.’

‘The general approach —using a brain implant to deliver electric pulses that alter neural activity— is known as deep-brain stimulation. It is used to treat movement disorders such as Parkinson’s disease, but has been less successful when tested against mood disorders… The scientists behind the DARPA-funded projects say that their work might succeed where earlier attempts failed, because they have designed their brain implants specifically to treat mental illness — and to switch on only when needed.’

And how could the device know when to switch on and off? How could it even recognize the complex neural activity in mental illnesses? Well, apparently, an ‘electrical engineer Omid Sani of the University of Southern California in Los Angeles — who is working with Chang’s team [a neuroscientist at UCSF] — showed the first map of how mood is encoded in the brain over time. He and his colleagues worked with six people with epilepsy who had implanted electrodes, tracking their brain activity and moods in detail over the course of one to three weeks. By comparing the two types of information, the researchers could create an algorithm to ‘decode’ that person’s changing moods from their brain activity. Some broad patterns emerged, particularly in brain areas that have previously been associated with mood.’

Perhaps this might be the time to wonder if ‘broad patterns’ can adequately capture the complexities of any mood, let alone a dysphoric one. Another group, this time in Boston, is taking a slightly different approach: ‘Rather than detecting a particular mood or mental illness, they want to map the brain activity associated with behaviours that are present in multiple disorders — such as difficulties with concentration and empathy.’ If anything, that sounds even broader -more unlikely to specifically hit the neural bullseye. But, I know, I know –it’s early yet. The work is just beginning… And yet, if there ever was a methodology more susceptible to causing collateral damage, and unintended, unforeseeable consequences, or one that might fall more afoul of a hospital’s ethics committee, I can’t think of it.

For example, ‘One challenge with stimulating areas of the brain associated with mood … is the possibility of overcorrecting emotions to create extreme happiness that overwhelms all other feelings. Other ethical considerations arise from the fact that the algorithms used in closed-loop stimulation can tell the researchers about the person’s mood, beyond what may be visible from behaviour or facial expressions. While researchers won’t be able to read people’s minds, “we will have access to activity that encodes their feelings,” says  Alik Widge, a neuroengineer and psychiatrist at Harvard University in Cambridge, Massachusetts, and engineering director of the MGH [Massachusetts General Hospital] team.’ Great! I assume they’ve read Orwell, for some tips.

It’s one of the great conundrums of Science, though, isn’t it? When one stretches societal orthodoxy, and approaches the edge of the reigning ethical paradigm, how should one proceed? I don’t believe merely assuming that someone else, somewhere else, and sometime else will undoubtedly forge ahead with the same knowledge, is a sufficient reason to proceed. It seems to me that in the current climate of public scientific skepticism, it would be best to tread carefully. Science succeeds best when it is funded, fêted, and understood, not obscured by clouds of suspicion or plagued by doubt -not to mention mistrust. Just look at how genetically modified foods are regarded in many countries. Or vaccinations. Or climate change…

Of course, the rewards of successful and innovative procedures are great, but so is the damage if they fail. A promise broken is more noteworthy, more disconcerting, than a promise never made.

Time for a thought experiment. Suppose I’ve advertised myself as an expert in computer hardware and you come to me with particularly vexing problem that nobody else seemed to be able to fix. You tell me there is a semi-autobiographical novel about your life that you’d been writing in your spare time for years, stored somewhere inside your laptop that you can no longer access. Nothing was backed up elsewhere –you never thought it would be necessary- and now, of course, it’s too late for that. The computer won’t even work, and you’re desperate.

I have a cursory look at the model and the year, and assure you that I know enough about the mechanisms in the computer to get it working again.

So you come back in a couple of weeks to pick it up. “Were you able to fix it?” is the first thing you say when you come in the door.

I smile and nod my head slowly. Sagely. “It was tougher than I thought,” I say. “But I was finally able to get it running again.”

“Yes, but does it work? What about the contents? What about my novel…?”

I try to keep my expression neutral as befits an expert talking to someone who knows nothing about how complex the circuitry in a computer can be. “Well,” I explain, “It was really damaged, you know. I don’t know what you did to it… but a lot of it was beyond repair.”

“But…”

“But I managed to salvage quite a bit of the function. The word processor works now –you can continue writing your novel.”

You look at me with a puzzled expression. “I thought you said you could fix it -the area where my novel is…”

I smile and hand you back the computer. “I did fix it. You can write again -just like before.”

“All that information… all those stories… They’re gone?”

I nod pleasantly, the smile on my face broadening. “But without my work you wouldn’t have had them either, remember. I’ve given you the opportunity to write some more.”

“But… But I was stored in there,” you say, pointing at the laptop in front of you on the counter. “How do I know who I am now?”

“You’re the person who has been given the chance to start again.”

Sometimes that’s enough, I suppose…

 

 

 

 

 

 

 

 

 

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Noceboes? How Cute.

I have always been fascinated by neologisms –new words that substitute for more commonly used ones. They can be clever, rude, or just plain silly, but often their point is to get noticed –or perhaps draw attention to their inventors. There was a time –before social media, at least- when we used to applaud people like Shakespeare for turning nouns into verbs, or adjectives into more active participants. And it was a time when elders, if they forgot the word for which they were searching, would simply come up with a new one. Of course, they still do, but it is often  lost in the ebb and flow of media utterage (pardon the neologism). I have written about this before in another context, but the subject continues to intrigue me: https://musingsonretirementblog.com/2016/05/22/what-did-you-say/

This time, however, I was more interested in the clever contrast of nocebo with the word it was replacing, placebo, that was reported in an article in the CBC health news: http://www.cbc.ca/news/health/nocebo-effect-greater-expensive-drugs-1.4358664

I suspect we’re all acquainted with the placebo effect: the ability of a harmless, inactive substitute to have a beneficial effect if it is believed to be the treatment. Again, I have covered this in a previous essay: https://musingsonwomenshealth.com/2016/04/20/rethinking-placebos/

But there seems to be no end to our ability to fool ourselves, and the concept of ‘noceboes’ is yet another illustration. ‘The opposite of the placebo effect — perceived improvement when no active medicine is given — nocebo is the perception of negative side-effects from a benign “medication” in a blind trial.’

The article reports on a study published in the journal Science, which suggests that ‘Expensive medicines can seem to create worse side-effects than cheaper alternatives.’ This particular investigation ‘focused on the pain perceptions of patients who were treated with creams they believed had anti-itch properties but actually contained no active ingredients.’ And, as one could no doubt predict from the title of their publication, Nocebo effects can make you feel pain, ‘Though the scientists ensured the temperatures applied to the two creams were consistent, those who received the expensive cream rated their pain as nearly twice as intense as those who received the cheaper cream. The study suggested that patient expectations related to price can trigger brain responses resulting in higher perception of pain, said Alexandra Tinnermann, a co-author of the study and neuroscientist at University Medical Center Hamburg-Eppendorf.

‘Tinnermann’s team used a functional MRI scanner to identify areas along the spinal cord that were activated during participants’ experience of side-effects. They also pinpointed two brain regions that were more stimulated among participants who believed they received the expensive drug.’

The ethics of using placebos –tricks- is one thing, but what about those of choosing between several recognized and approved medications where the only difference is the price? On the surface, it might seem to be a saving for all concerned. If the data hold up in further studies, why prescribe new and probably higher cost medications, if they’re more likely to have side effects?

Unfortunately the very ethics that require medical practitioners to discuss the possible side effects of any medication, are also known to influence the experience. Knowledgeable patients report more side effects than those who, for whatever reasons, are blissfully unaware of what to expect. Perhaps it’s more a question of which of Pandora’s boxes the practitioner should open -a zero sum game, no matter.

I was sitting on a park bench in the shade of a tree one sunny summer day, trying to finish a book a friend had loaned to me. It wasn’t very interesting, despite her recommendations, and although I was determined to discover what she had liked about it, I found my mind looking for excuses to put it down. My ears soon found a distraction. Two little boys had abandoned their bikes on the  grass nearby and were engaging themselves in scaling the leafy tower of what I had assumed was my own special shade tree. Hidden by several bouquets of leaves fluttering gently in the afternoon breeze, I suppose they thought they were invisible in their private redoubt.

“Thought you were sick, Jay,” one of them said, as if he wondered if he was in danger of catching whatever Jay had.

“I’m on antibiotics, Jordan,” the other answered defensively.

They were silent for a few moments, although I could hear them grunting as they climbed ever higher.

“My mother doesn’t believe in them,” a voice, probably Jordan’s, said very firmly.

“Why?” was Jay’s surprised reply.

Jordan was silent for a moment, clearly trying to remember. “She says they can make you sick.” Even from my position far beneath them, I could almost feel Jordan’s italics.

“How?”

Another, grunt-filled silence as they switched branches. “She says they can make your skin go red…” He hesitated for a minute while he combed through his memory. “And give you… make you wanna throw up.”

Jay seemed to hesitate before answering. “Well, I’m not red or anything, but… uhmm, sometimes I do feel a little like throwing up, I guess. Anyway I have to go to the toilet a lot, so it’s hard to tell.”

“She says that’s what happens with them too, Jay. It’s why I just take vitamin pills.”

“My mother says those don’t usually work… People only think they do.” Jay felt a need to defend his antibiotics. “Mom says we imagine things sometimes…”

“Like what?” Jordan sounded sceptical. For a while, I could only hear the leaves rustling, so I wasn’t sure if they’d already climbed too high to hear.

“Like… Like that vitamins can keep us from getting sick.” I could hear one of them shifting somewhere above as a branch cracked. “And she says some people won’t take antibiotics because they’re afraid of, uhmm…” He hesitated, while he searched for the right word. “…the side-stuff.”

“You mean ‘side-defects’?” Jordan pronounced the words carefully, condescension fairly dripping from his words.

“Yeah. She says if they hear about the defects, they figure they’ll get them.”

“Well my mom says doctors have to tell people about them, though, Jay… It’s the law.” He added smugly.

Jay seemed to think about it for a second. “Then no wonder, eh?” he said, as if he finally understood.

“No wonder what?”

“No wonder people get ‘em,” Jay answered, triumphantly.

From the mouths of babes.

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Earthing Unearthed

Sometimes I feel disconnected. It’s almost as if I have been traveling on a highway all my life, largely unaware of the myriad roads that emanate from it. Unaware of the different coloured horizons that have been hiding out there all along. Or is skulking sometimes a better descriptor? Every so often I come across a concept so… bizarre, that I wonder how it even survived long enough to acquire a name. ‘Earthing’ caught my attention immediately.

I feel I have to explain that I don’t go looking for these things, but in the spirit of full disclosure I will confess to being a one-time member of the Skeptics Society –one time, I suppose, because the time constraints of a busy medical practice required that I relinquish at least some of my addenda. Now, retired and awash in compensatory time, I dabble once again.

‘Earthing’, for those of you as naïve as myself, is the act of walking barefoot –not just on the beach or over the soft grass of a lawn, however. It is to soak up earth’s energy fields previously denied to you –blocked, in effect- by your shoes. These energy fields apparently supply free electrons replete with many health benefits. Shoes, as disruptors, ‘[…] allegedly cause inflammation and autoimmune diseases, circadian rhythm disruptions, hormonal disorders, cortisol disorders, heart rate variability problems, arthritis, herpes, hepatitis, insomnia, chronic pain, exhaustion, stress, anxiety, premature aging […].’ http://www.skeptic.com/reading_room/bogus-claims-grounding-bare-feet-to-earth/ Uhmm…

How could I have journeyed so far along the trail of years and not heard this coming up behind me? Call me old fashioned, if you will –or just ‘old’, perhaps- but I would still feel more comfortable if there were credible, corroborative and objective evidence to substantiate assertions before I even decide to consider them -let alone examine them seriously… Anybody can claim things, but as Carl Sagan once declared: ‘extraordinary claims, require extraordinary evidence’.

Now I have to say that just because something seems counterintuitive, I don’t think it should be simply dismissed out of hand. Paradigms do shift, after all. But they still require critical analysis; it is not enough to suggest that, as in the case of homeopathy, for example, any attempt to verify it destroys the field in which it exists. Nor are statements like, ‘It may be that our connection with the earth carries information, helping align us with the greater network of intelligence of our planet.’ either provable, or refutable –the famous philosopher of Science, Karl Popper’s belief that what distinguishes science from pseudoscience is its potential for refutation. For example, to say that all swans are white, only holds until a black one is found. The assertion –if properly attested by observations- is scientific in that the demonstration of even one black swan is able to refute it.

But, academic considerations aside, there is something troubling about ‘Earthing’ and its ilk. That something like this arose at all is, I suppose, a function of the random accretion of isolated and misunderstood bits and pieces of our complex modern world that are only describable in metaphor –as in, say, electrons are the carriers of electricity. True, as far as it goes, I guess, but misleading if taken as literal. Maybe some shoes –all shoes?- may block electrons… But so what?

Just try and understand the electric fields on the earth and in the atmosphere. As an example, a description from (shudder) Wikiversity: ‘The Earth is negatively charged, carrying 500,000 Coulombs (C) of electric charge (500 kC), and is at 300,000 volts (V), 300 kV, relative to the positively charged ionosphere. There is a constant flow of electricity, at around 1350 amperes (A) [approximately 1100 A], and resistance of the Earth’s atmosphere is around 220 Ohms. This gives a power output of around 400 megawatts (MW), which is ultimately regenerated by the power of the Sun that affects the ionosphere, as well as the troposphere, causing thunderstorms. The electrical energy stored in the Earth’s atmosphere is around 150 gigajoules (GJ). The Earth-ionosphere system acts as a giant capacitor, of capacity 1.8 Farads. The Earth’s surface carries around -1 nC of electric charge per square meter’. Do you see why most of us non-experts are dependant on metaphor? And why explanations such as this about ‘constant flow of electricity’ unaccompanied by suitable annotations may lead to some unfortunate and perhaps misguided applications?

On the other hand, I think that trying to dissuade gullible adherents requires some tact. Attempts to ridicule them by referring to the authors of a book on the subject: Earthing. The most important health discovery ever? and saying ‘None of the book’s authors is a physicist— it shows.’ is just ad hominem. Or suggesting that scientific credentials are not available: ‘The studies were not published in mainstream journals. They involved small numbers of subjects and usually failed to use any controls.’ While true -and to those of us with any acquaintance with how science works, compellingly obvious- it likely fails to convince those who mistrust the scientific paradigm and its lack of certainty to start with. And it may antagonize them to the point of utter rejection of any meaningful dialogue. It becomes another us-and-them standoff.

So, what to do? Tolerate or proselytize? Divide and conquer? Provoke and legislate…?

Perhaps it’s my age, but I’ve seen many fads arise and then dissipate like waves on a beach, with any one of them having about as much individual significance. Think of alien abduction, recovered memory therapy, pet rocks… Each seems to have a brief super nova-like appearance, and is intriguing for a while, and then, when a new star is born, interest flags. Social media may extend the lifespan, perhaps, but novelty is usually trump for those attracted to the fringe belief realms. I’ve learned not to obsess on what I consider the irrational; I will attempt to educate, but not to the point of taking arms against a sea of trouble and by opposing, ending them –as Hamlet would have us decide. If they are not harmful, then they will, as certain as the tide, recede.

In the turmoil of this uncertain world I think we all try to find secure and novel refuge, and when the storm has passed, set out again. It’s what we do –Shakespeare again: ‘Wise men ne’er sit and wail their loss, but cheerily seek how to redress their harms.’

Earthing, with benign neglect, may itself be unearthed…

 

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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.

 

 

 

 

 

 

 

 

 

 

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The Science of Answering

I suppose in this suspicious age, everything is open to scrutiny. But some things are examined at one’s own risk risk -like turning over a familiar log in the garden only to find unexpected and sinister-looking creatures lurking quietly beneath. This is fine, of course, but it can be hard to know what to do with the results of such investigations without some attributions -either positive, or more likely, negative. And, depending on our experience, a vacillation between the two.

Science by encouraging unbridled curiosity has often not been neutral in this. With some trusted and unsuspecting products that have been on the market for years, subsequent studies have occasionally determined similarities of structure, or function, with other, more bothersome effects. Aluminum in cookware was one famous example. Aluminum was found in some plaques in the brains of patients with Alzheimer’s disease so of course products containing aluminum went into a precipitous decline from which they never really recovered despite subsequent studies that failed to substantiate the risk. Or think of the autism scare after a since-repudiated 2004 article suggested that thimerosol, a synthetic form of organic mercury which has been used for many years as an antimicrobial agent and preservative in many vaccines, was the cause of autism spectrum disorder.

Once these doubts have been cast, suspicion often lingers that is hard to eliminate. Conspiracy theoreticians emerge from the shadows to sew their seeds, flaunting the seemingly obvious and intuitive conclusion that there must have been something that made the scientists find what they did. The fact that science actually encourages refutation -that nothing is ever known for certain and that they’re rather happy with that- escapes those who would rather believe there is a cover-up.

And now, there is another study –one among many- that suggests that even low amounts of parabens –preservatives used in, among many other things, the cosmetic industry- might increase the risks of breast cancer! Researchers from the University of California, Berkley have published a study in Environmental Health Perspectives that seems to demonstrate this: Environ Health Perspect; DOI:10.1289/ehp.1409200

‘Existing chemical safety tests measure the effects of a chemical on human cells in isolation. However, as these tests fail to consider that compounds might interact with other signalling molecules, the tests are insufficient, explained the researchers.

Using the naturally occurring growth factor in breast cells, heregulin, the researchers stimulated the HER2 receptors in breast cancer cells and exposed the cells to parabens. The chemical caused the oestrogen receptors to activate genes, which led to the proliferation of the cells. Moreover, the effect was significant: parabens in the HER2-activated cells stimulated breast cancer cell growth at concentrations 100 times lower than in cells lacking heregulin.’

Is nothing safe? It’s difficult to know what to do with information like this. Surely there is a middle ground between merely shrugging our shoulders and accepting that the world is a dangerous place, and railing against Science for trapping us here. Do we sometimes just use our indecision as a reason to worry? Change seems to spawn unintended consequences no matter how hard we try to anticipate them. As an enthusiastic user of modernity I suppose I am closer to the shrug camp, but I recognize that there are different world-views out there and I dare not gainsay them. Especially if they are first time patients who are a little wary of me to start with.

Jona did not trust me; I could tell by her eyes as soon as I introduced myself in the waiting room. While her face said hello, her eyes threatened me with silence if I so much as stepped on the boundary. The hand that shook mine was aggressively firm and it was all I could do to keep from wincing. I hate that. I’ve always felt that the first contact should be a greeting, not a contest. A sign of mutual respect, not a dare. I don’t feel at all competitive at that stage, but from her expression, I could see she felt it was a form of sport. I was surprised she let me lead her into my office.

When I was finally allowed to sit and open up my computer, I saw that her referral to me was for dyspareunia –code word for pain with sex. She sat on the other side of my desk with everything on guard: face, posture, fists… Everything dared me to ask her why she was here. So I didn’t. I just let her talk –debrief, as it were. Her eyes –at least the ones that she had trained to pin doctors to their chairs- were hovering around my face, waiting for me to provide the excuse for an attack.

“I know that Maria has listed my problems in the letter she Emailed, doctor, but before you start on me, I just want you to know that I refuse to take, insert, or inject any medications.” She proceeded to cross her arms tightly across her chest, as if something was trying to escape from under her blouse. “Maria wanted to put me on estrogens, but as you know, they can cause strokes, heart attacks and cancer. Sex isn’t worth that risk.” She glowered at me, still holding off the eye-attack until I said something. “Then, she suggested the low-dose variety that you merely put in your vagina… Merely?? It’s hardly a little thing to put an uninvited foreign body in there, doctor! She thinks my vaginal skin is too thin and that’s why it hurts.” She thought about it for a moment. “And how would she know? She couldn’t even get a speculum in there, so how could she say that? I’m 48, not 68 for God’s sake. I’m still having periods and tampons have never hurt.” She sighed theatrically and continued. “I’ve tried lubricants and stuff, but if you look at what they contain and then Google the contents, it’s like playing Russian roulette with your vagina. Some of them even print disclaimers and suggest medical consultation before using them. They can cause allergies, skin irritation, infections… Some are even carcinogens when you look up the pharmacology. And then there’s that article saying that the parabols might even cause breast cancer…”

‘Parabens,” I corrected her and then closed my mouth, smiled sympathetically and waited for permission to say something more. Anything.

“Whatever. My husband doesn’t understand, either. All he wants is something quick before he goes to sleep. Of course, he thinks I’m making up the pain stuff…”

The short pause, and a brief journey of her eyes to a picture on the wall gave me an opportunity to ask her something: “Do you talk to your husband?” I said, and waited for the eyes.

“He won’t even talk to me when we’re eating dinner…” She said slowly and looked down at her lap, caught off guard by the question, I think.

“How long has it been since you were able to talk?”

Jona withdrew her eyes and they disappeared into her face along with her anger. Then she shrugged, and a few words spilled out. “It’s been so long, I can hardly remember when…” She suddenly stopped talking and stared at me. “But why did you ask about him, doctor? Do you think our…?” she said in a whisper. “My GP never even asked…” Her expression changed from one of defence to one of curiosity. “Why did you wonder if I talked to my husband?” she repeated.

“Are you a Shakespeare lover?”

Her face tightened for a moment in puzzled irritation, but then she laughed. “Double, double boil and bubble; Fire burn and cauldron bubble,” she said, obviously pleased with herself. “The witches, in Macbeth, I believe.”

I nodded, then grinned. “Well, let me quote from the play-within-a-play in Hamlet –Gertrude answering Hamlet’s ‘Madam, how like you this play?’… ‘The lady doth protest too much, methinks.’ she answers…”

A little smile –the first real smile she’d shown me- blossomed like a flower on her lips. “Maria said you were good, doctor… You’re smarter than you look,” she said with mischief in her eyes this time, and her body relaxed into the chair. “What do you suggest I do?”

I readied my fingers over the keyboard and chuckled warmly. “I suggest we start by making sure there is nothing you need to worry about.” I thought of another memorable phrase, this one uttered by Hamlet himself: ‘There is nothing either good or bad, but thinking makes it so.’ But I didn’t say anything; she’d had enough Shakespeare for now I realized.

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Critical Thinking and Bullying

A few weeks ago, a young woman came in to see me to have her first Pap smear. While I was taking a routine sexual history, she admitted she had recently been bullied online. I’m not even sure how the topic came up, but she didn’t seem very upset, so I asked her about it.

“The guy was a real dick,” she said. And when I asked her how she reacted, she merely shrugged. “Everything he said was false and all my friends should know that… So I ignored him.”

“And did he try it again?” I admired her reaction, but I have to admit I was curious.

She liberated a beautiful smile and shrugged mischievously. “Yeah, once… But then I guess he gave up.” She allowed her eyes to roll upwards comically. “My mother always told me to ignore stuff that wasn’t true.”

It got me thinking about why some people are able to withstand that kind of thing, while others succumb. I don’t pretend to know what motivates bullying, but I do suspect my patient was taught an effective remedy from an early age.

Critical thinking is a way of examining a statement or assertion in order to understand the background and motivating factors for its existence. Its credentials, in other words. It is a way of distancing oneself from the message and analysing everything that went into making it before either accepting or rejecting its content. Also, it is a way of avoiding confirmation bias –reading or assessing only those issues with which one already agrees, rather than sampling a variety of views and thinking of them as interesting, but as yet unproven assertions.

In important ways, this is what Science does: everything is open to checking and possible refutation. Nothing is spared re-examination. Carl Popper, the philosopher of science, suggested that an assertion, a theory, must be worded in such a way that it is testable, otherwise it can not be generalized -or as he would put it, it can only be considered scientifically valid if it is falsifiable- ie checkable. Anything else is merely an opinion -as, for example, the statement ‘Red is the most beautiful colour’. It is not testable, and therefore certainly neither provable nor undeniably valid. This is the first simple rule of thumb we can teach: we must help children to parse input.

Young children tend to question everything- it is how they learn. But in the very young –under, say, six or seven years of age- they often use magical thinking: cause and effect are not necessarily demonstrable either by reason, or even observation. Past that age, however, they begin to understand agency. Causal chains. It is a good time to introduce the concept of validity: was something really a result of an action, or was the action merely associated in time or location so as to seem to have influenced it? And although this is a good first start it is nonetheless one that is not necessarily intuitive. For example it would be tempting to assume that a boy running past a crying girl had done something to her -it might fit with a previous experience. But maybe he was running to catch a bus and it was a coincidence that the two were in the same area at the time she was crying… It requires more proof. More examination.

The habit of questioning things before accepting them can be taught. It can be made into a reflex before reacting. But it needs to be developed early, before the temptation to interpret hastily, or even reciprocate mindlessly, has become entrenched.

The basic elements of simple logic can be taught. For example with inductive reasoning, one attempts to generalize from observations. So if all the crows you have ever seen were black, then you might conclude that all crows are black… Until somebody sees a white crow that is… It is falsifiable, in other words. Most taunts are of that variety -and with practice, easily refuted.

Or even with deductive reasoning which works the other way -from the general to the particular: All men are mortal; Socrates is a man; therefore Socrates is mortal -the classical example. But it only works if the premise is valid (ie. that all men are mortal). And it may only be somebody’s opinion that it is valid…Once again, is it like that example of red being the most beautiful colour? We can all be taught to analyse things like this. We can all be taught to be wary of unsubstantiated statements. Rumours. Gossip. Taunts…

And the critical thinking approach can even apply to actions as well as assertions. A simple example: a young girl is hit by a snowball and another child, a boy, is standing nearby in a group of boys and staring at her. Was he to blame? Did he throw it? Maybe, but without further analysis, further investigation, there’s no proof. No reason to jump to a conclusion. Why did she think it was him? Is her reason based on anger, or is it justified..? This is the basis for the idea that a person is innocent until proven guilty… It is an important concept to inculcate in the growing mind. It is a way of distancing oneself from the action, no matter how provocative, and setting it aside until it has been analysed further. We all judge input, we all react to issues we encounter. And some things do require an immediate response. But it’s how we come to the judgement, how we analyse the data –how we react- that is critical.

You can see where this is leading I suspect: bullying. Bullying -whether on the playground or online, whether by deed or word- has the advantage of unfair leverage only if the process is unexamined. Only if the person being assailed is not used to subjecting taunts to the same questioning. Stepping back, if only momentarily, and processing the information. Checking it. Falsifying it. Refuting it -like my patient was able to do.

A difficult thing to do in the moment, for sure. But without any experience in dissecting assertions –deconstructing them, as PhD candidates are fond of saying- there are only reactive emotions. Victimization. Loss of self esteem that could and should withstand the storm. Self esteem, after all, is partly based on one’s ability to see oneself as in control.

As in mathematics and science, critical thinking is a valuable tool for assessing what we experience in the world. It helps us to parse what we read, what we’re told, what we think… It brings perspective to the unexpected, the hostile and the just plain annoying. It can and should be taught from grade school onwards, building on the simpler examples from year to year –class to class. Younger children may not understand the complexities of the Scientific Method, nor what Popper was on about, but with patience and persistence they will.

They deserve the chance…