I think the main thing I learned – very painfully – in 20 years as a health consumer advocate, is that zealots always, always end up hurting patients. Because whatever it is that they are against, is not the same as being for patients, and it will, inevitably, betray us.
I tweeted that thought in a conversation about recent events in the Cochrane Collaboration. Why have I been using words like zealotry and extremism, even though they are emotive? Let’s dig into this. It’s a central issue of our polarized times generally, and for much of science. And it’s definitely critical in health sciences, and for the Collaboration right now.
Political scientist, Joel Olson, published a terrific essay in 2007 called “The freshness of fanaticism: the abolitionist defense of zealotry”. This articulates the case for the kind of zealotry from people who want to bring about social change, in a noble cause. Olson showed the critical role it played in the movement to abolish slavery in the US, and wrote:
Zealotry is an activity practiced not so much by disturbed temperaments as by collectivities working to transform relations of power by creating an “us” in struggle against a “them,” and by pressuring those in between to choose sides. Accordingly, zealotry is political activity, driven by an ardent devotion to a cause, which seeks to draw clear lines along a friends/enemies dichotomy in order to mobilize friends and moderates in the service of that cause…
If the essence of zealotry as political activity is a vigor to draw lines between friends and enemies, then its antithesis is not reason but moderation, for moderation denies that us/them distinctions are the defining characteristic of politics…[Z]ealotry as a political strategy typically implies a three-corner fight among friends, enemies, and the moderate middle…
Resource mobilization scholarship finds that disruptive tactics and the extremist wing of social movements can add new energy to a movement and spur bargaining between elites and moderate elements of the movement. This suggests that zealotry may emerge when a movement is deadlocked with elites.
Movements of critics of industry have mobilized to attack, and/or fight for the soul of, the Cochrane Collaboration, as one of their heroes faces expulsion from the organization from which he derived so much authority (Peter Gøtzsche).
The final straw for the organization, the board said, was “repeated, seriously bad behaviour”, including to staff. But Gøtzsche put it down to various causes which he champions – one of which is opposing industry influence: [PDF here]
There is stronger and stronger resistance to say anything that could bother pharmaceutical industry interests…There has also been great resistance and stalling on the part of the central executive team to improving Cochrane’s conflict of interest policy. A year ago, I proposed that there should be no authors of Cochrane reviews to have financial conflicts of interests with companies related to the products considered in the reviews. This proposal was supported by other members of the Board, but the proposal has not progressed at all…
The collaborative aspect, social commitment, our independence from commercial interests and our mutual generosity are what people in Cochrane have always appreciated the most and have been our most cherished added-value…
As most people know, much of my work is not very favourable to the financial interests of the pharmaceutical industry. Because of this Cochrane has faced pressure, criticism and complaints. My expulsion is one of the results of these campaigns. What is at stake is the ability of producing credible and trustworthy medical evidence that our society values and needs.
Posts in parts of the movement for independence in drug evaluation and policy, like No Gracias and David Healy’s blog, suggest, I think, mutual importance of the relationship between at least part of the movement, and Gøtzsche/Cochrane – from whom they, too, have derived authority, and/or vested with high hopes.
Some are asking: how close to industry is too close for the Cochrane Collaboration? An important question. But there’s another that’s more relevant to the current situation: how close to industry-bashing and fear mongering about drugs and vaccines is too close? I think the resistance Gøtzsche experienced could be resistance to anti-industry bias and extremism, not support for pharmaceutical interests.
The problem that critics of industry influence seek to address is a serious one. Industry influence on health research, clinical practice guidelines, clinical practice, and patient information is pervasive, and acting in these interests is inimical to patient and public health. Industry bias can lead to unreliable research results. Yet, although I don’t think anyone has studied it, the reverse – anti-industry bias – could also render research unreliable, by the same mechanisms: spin and selectivity in questions, methods, and reporting, for example. Neither would be in patients’ interests.
In this post, I use the terms pro- and anti-industry bias as shorthand for opposing ends of a complex and variegated spectrum, with what antagonists call “industry shills” at one end, and “industry-bashing” at the other. Both pro- and anti-industry bias lead to problems like motivated reasoning and fear mongering. Motivated reasoning, according to Lewandowsky, “refers to the discounting of information or evidence that challenges one’s prior beliefs accompanied by uncritical acceptance of anything that is attitude-consonant.” (Motivated reasoning was described by Ziva Kunda in 1990 [PDF].) Fear mongering is recognizable by frequent repetition of dangers (for the one side, of disease, for the other, of treatment), casting isolated incidents as trends, and misdirection.
There are differences of course, too: commercially motivated actions might tend to be more deliberate. Whereas ideology and solidarity to comrades blind you to your own errors of judgment, bias, and the harm you’re doing – I speak here from painful personal experience. Those differences, though, are irrelevant for patients when harm is being done.
Extremes of anti-industry bias can be harmful in other ways, too. For one, by casting a cloud of doubt around research results that challenge the ideology, or are favorable to a drug or vaccine that is a current punching bag. For another, it could make research so unfeasible, or so untrusted, that we’re stuck forever in the situation the Cochrane Collaboration sought to tackle in the first place. This is Iain Chalmers and Adrian Grant nailing it back in 1996 [PDF]:
For 70 years, the proponents of various drugs and drug cocktails have hurled disdainful abuse at each other from separate mountain tops, secure in the knowledge that no strong evidence existed that could undermine any one of their multitude of conflicting opinions.
This cartoon is from my reader’s guide to conflicts of interest in biomedicine. In it, I talk about non-financial conflicts of interest. A few months later, Lisa Bero and Quinn Grundy published a paper called, “Why having a (nonfinancial) interest is not a conflict”. First up, a disclosure: Bero is a friend. Conflict of interest (COI) has been a major area of scholarship and action for her. One of her claims to fame is being a co-author of The Cigarette Papers. Another is being chair of the Collaboration – at the time the current COI policy was finalized. Years of discussion and deliberation went into formulating Cochrane’s current policy, and its funding arbiter system.
I think bias from non-financial interests is a big deal. But Bero and Grundy convinced me that if you go past clearly justified and objective commercial interests as the only conflict, you open up a door where anything goes, everyone can be dismissed as being conflicted, and no one is trusted. We’re seeing that happen with the Cochrane HPV vaccine review (for example, in this string here).
We have a long way to go, though, to be able to recognize and reduce biases well – our own, first of all. Some forms of ideological bias are fairly easy to defend ourselves from. It’s the more sophisticated kind that can take us in – where there is so much that is reasonable and rigorous-sounding and true, that the omissions, spin, and other untrustworthy parts mixed in with them just slide past.
We have to increase our skills at detecting bias, error, and the signs of fear mongering – and remember that it’s dangerously easy to be led astray by someone else’s passionately held conviction.
I’m tracking key events and sources in the Cochrane situation at my personal website, hildabastian.net.
Disclosures: I led the development of a fact sheet and evaluation of evidence on HPV vaccine for consumers in 2009 for Germany’s national evidence agency, the Institute for Quality and Efficiency in Healthcare (IQWiG), where I was the head of the health information department. We based our advice on this 2007 systematic review including 6 trials with 40,323 women, and an assessment of those trials. The findings were similar to those of the 2018 Cochrane review. I have no financial or other professional conflicts of interest in relation to the HPV vaccine. My personal interest in understanding the evidence about the HPV vaccine is as a grandmother (of a boy and a girl).
I am one of the members of the founding group of the Cochrane Collaboration and was the coordinating editor of a Cochrane review group for 7 years, and coordinator of its Consumer Network for many years. I am no longer a member, although I occasionally contribute peer review on methods. I often butt heads with the Cochrane Collaboration (most recently as a co-signatory to this letter in the BMJ). I have butted heads on the subject of bias with authors of the Copenhagen critique.
26 September: In light of developments, some further disclosures which I did not realize may relate to this controversy and the theories around it, when I first started writing about the Cochrane HPV vaccine review. I was invited to speak at Evidence Live, and my participation was supported by the organizers, a partnership between the BMJ and the Centre for Evidence-Based Medicine (CEBM) at the University of Oxford’s Nuffield Department of Primary Care Health Sciences – the director of the CEBM is the editor of BMJ EBM. Between 2011 and 2018, I worked on PubMed projects at the National Center of Biotechnology Information (NCBI), which is part of the US National Institutes of Health. I am currently working towards a PhD on some factors affecting the validity of systematic reviews.
[Updates 26 September 2018]: As well as expanding my disclosures as the scope and criticisms related this controversy have widened, I added an explanation abut using the terms pro- and anti-industry bias that reads:
In this post, I’ll use the terms pro- and anti-industry bias as shorthand for opposing ends of a complex and variegated spectrum, with what antagonists call “industry shills” at one end, and “industry-bashing” at the other.
Rather than relying solely on the links in the original, I added these expansions on the terms motivated reasoning and fear mongering:
Motivated reasoning, according to Lewandowsky, “refers to the discounting of information or evidence that challenges one’s prior beliefs accompanied by uncritical acceptance of anything that is attitude-consonant.” (Motivated reasoning was described by Ziva Kunda in 1990 [PDF].) Fear mongering is recognizable by frequent repetition of dangers (for the one side, of disease, for the other, of treatment), casting isolated incidents as trends, and misdirection.
To make it more precise, I edited a sentence which originally read:
The final straw for the organization, the board said, was “repeated, seriously bad behaviour” to staff.
I shortened “Some of them are asking” to “Some are asking”.
I edited and added a link to an example in a sentence that originally read:
But Bero and Grundy convinced me that if you go past clearly justified and objective commercial interests, you open up a door where anything goes, everyone can be dismissed as having a conflict, and no one is trusted. We’re seeing that happen with the Cochrane HPV vaccine review.
[Update 28 September] I added links to an example of going to an extreme about who can be trusted in relation to scientific assessment of evidence of the HPV vaccine.