Fall, 2004
This is an edited transcript of a forum presented by the Harvard Medical School Division of Medical Ethics in February 2004. The forum was moderated by Marcia Angell, MD, senior lecturer in social medicine at Harvard Medical School, editor emeritus, New England Journal of Medicine and author of The Truth About the Drug Companies: How they Deceive Us and What to Do About It.
Marcia Angell, MD The Union of Concerned Scientists (UCS) an independent organization focusing on technical issues, has recently issued a report1 charging the Bush Administration with systematically manipulating scientific evidence to support its policy goals. The New York Times (Scientists accuse White House of distorting facts. Feb. 18, 2004) described the report this way: "More than 60 influential scientists including 20 Nobel Laureates issued a statement yesterday asserting that the Bush Administration had systematically distorted scientific fact in the service of policy goals on the environment, health, biomedical research and nuclear weaponry at home and abroad." The UCS accuses the Administration of repeatedly censoring and suppressing reports by its own scientists, staffing advisory committees with unqualified political appointees, disbanding government panels that provide unwanted advice, and refusing to seek any independent scientific expertise in some cases. The report cites many examples ranging from suppressing evidence of global warming and industrial pollution; distorting information about condom use versus abstinence to prevent teenage pregnancy and HIV transmission; and stacking government advisory committees with ideologues or members with financial interests in the committee's work.
I have personal knowledge of one of their examples-the Bush Administration's censorship of the National Cancer Institute's (NCI's) Web site. The NCI was instructed to eliminate the information that there is no good evidence that abortions increase the risk of breast cancer, and replace it with the suggestion that there might be such evidence. Scientists at the NCI were outraged at this distortion of the evidence.
The problems that the UCS cites come mainly from the political right and accordingly they serve corporate interests and free market and conservative religious ideologies. But, as the UCS admitted, the right does not have a monopoly on this sort of thing. The left also sometimes distorts and suppresses scientific evidence to satisfy its very different agendas, often to serve what its proponents see as the greater good of public health or greater social equality. One example I am familiar with is the controversy over silicon gel breast implants, a controversy that came mainly from the left and that raged in the early 1990s. You may remember that in the utter absence of any evidence that breast implants caused the diseases they were said to cause, they were pulled off the market. There was a tidal wave of litigation, and women were awarded multimillion dollar jury verdicts. What was in play here was a combination of a form of feminism that sees women as perpetual victims, an antiindustry bias that more or less assumed breast implants were dangerous, and a selfinterested plaintiff's bar that was only too willing to exploit the situation.
The panelists we have selected today represent a broad political spectrum and even broader range of experiences.
Joshua Sharfstein, MD, member of the Democratic staff of the Government Reform Committee for Congressman Henry A. Waxman, Democrat of California. As a medical student at Harvard Medical School he published a controversial paper in the New England Journal of Medicine that found the American Medical Association Political Action Committee had contributed more on average to House of Representatives members who favored tobacco export promotion and the gag rule on abortion counseling and contributed less on average to supporters of handgun control.
Politics and science have always coexisted. Politicians decide on research budgets, set broad national priorities for study, provide basic ethical guidelines and oversee their implementation. The relationship between politics and science, however, can turn sour. When the imposition of a political or ideological agenda threatens scientific freedom or integrity, science-based policy loses its bearings. The consequences can be measured in cures not found, lives not saved and damage to the public health and environment.
This concern is not hypothetical. In August our staff released a report entitled Politics and Science in the Bush Administration. 3 The report documented misleading statements by the president, inaccurate responses by cabinet secretaries to Congress, altered Web sites, suppressed agency reports, and erroneous international communications. Beneficiaries of this interference were consistently the supporters of the president, including social conservatives and powerful industry groups. Let me give you a few examples.
In 2002 the Bush Administration dropped three national lead poisoning experts from the national Centers for Disease Control and Prevention's advisory panel that recommended the threshold level of concern for lead in the blood. That threshold had been 10 micrograms per deciliter since the early 1990s, and a number of leading experts believe it should be even lower. In place of these three experts, who have dozens of publications among them, the administration appointed several individuals including William Banner, MD. Dr. Banner has testified on the behalf of the lead paint industry that a lead level of 70 mcg/dl is safe for children's brains. [Gasp from audience.] When I talk about this and I hear a gasp like that, I know there is a pediatrician in the audience! Dr. Banner has no public health experience in lead poisoning, and his claim ignores two decades of research and scientific consensus about the impact of lead on the brain.
Across the federal government, the Bush Administration is pressing agencies to treat abstinence-only education as the most effective way to prevent teen pregnancy and HIV infection. When asked about the lack of scientific evidence to support this position, one of the president's top advisors on welfare responded "Values trumps data." 4
The Bush Administration is objecting strongly to a report by the World Health Organization (WHO) addressing obesity. The WHO report 5 has found that there is a probable association between soft drink consumption and weight gain. The United States position has been that there is no evidence for this association, and has specifically asked WHO to take out any mention of soft drinks from the report. This position defies the evidence. It defies the U.S. Surgeon General. It defies the USDA dietary guidelines. It even defies the technical document relied upon by WHO, which was coauthored by the leading obesity expert in the CDC.
The scientific community has not kept quiet. Editorials in major medical and scientific journals have decried political litmus tests on scientific advisors, ideological interference with research, and the distortion of information to the public. As the UCS report put it, "Successful application of science has been a large part of the policies that have made the United States of America the world's most powerful nation and its citizens increasingly prosperous and healthy. Although scientific input to the government is rarely the only factor in public policy decisions, this input should always be weighed in an objective and impartial perspective to avoid careless consequences. Indeed this principle has long been adhered to by presidents and administrations of both parties in forming and implementing policies."
There is too much at stake to let a narrow political and ideological agenda from any perspective undermine the integrity and credibility of the United States' premier health agencies.
Sally Satel, MD, resident scholar at the American Enterprise Institute6 in the W. H. Brady Program in Culture and Freedom, staff psychiatrist of the Oasis Clinic in Washington, D.C., and member of the Advisory Committee of the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration. Satel is author of the 2001 book, PC MD, How Political Correctness is Corrupting Medicine and of the 1999 book, Drug Treatment, the Case for Coercion. She is also coauthor of a forthcoming book, One Nation Under Therapy.
Much of what Dr. Sharfstein has told us and what we read in the UCS report is certainly worrisome. There is no question about that. By no means do they represent the last word on politics and science in this administration but their commentaries are very powerful stimuli for further investigation.
Now, I don't know anything about global warming and wetlands conservation and the other topics mentioned in the UCS report. I think i know a little something about endangered species...that would be me: a Republican psychiatrist, but I do have my own informed opinions about some other areas touched on by the report. To me what they suggest is that there is nothing new under the sun. Ideology has long held sway in many quarters in health and medicine. When facts got distorted, it was wrong then. And when facts get distorted, it is wrong now. It happened before President Bush, but I think in some ways it was less noticeable and I am going to show why I think that is the case.
Let's talk about the composition of boards and committees. Let's take the case of psychologist William Miller, PhD, an addiction researcher at the University of New Mexico. Miller developed a technique called motivational interviewing, which is a very fine therapy for drug addicts and alcoholics, especially those who aren't sure they want to enter recovery. He is a first-rate addiction researcher and excellent methodologist. About once a month in 2000 and 2001, after President Bush had come in, I would get a call from an aide at Health and Human Services (HHS), saying "I have a list of names of people who we're thinking of recruiting to some of these advisory committees. What do you think of them?" Bill Miller was one of the names and I said he is excellent. He is a careful researcher. He is much published, well regarded. The aide said to me, "Did he vote for Bush?" I said I had no idea if he voted for Bush. He asked me what Bill Miller thought about abortion, and I said I had no idea what Bill Miller thought about abortion; he asked me what Bill Miller thought about needle exchange, but still I didn't know what Bill Miller thought about needle exchange. I thought all of these questions were irrelevant and I told the aide that and he said thank you.
Now imagine that a Democratic aide is going to do some vetting and he asks whether you are pro-choice or whether you voted for clinton. What is the likely answer to be among people in our field? We know that most people in the health services field are liberal or leftist-centered. So, their answers are probably going to be yes, I voted for Clinton and yes, I think abortion rights are fine and yes, I am for needle exchange. So, the opportunity for those kinds of clashes aren't going to come up as much or, I suspect perhaps, those questions aren't even asked because it is safe to assume what the answer will be. I think those are irrelevant questions in a leftist-centered administration. But it is obvious that the opportunity for clashes, when a litmus test is applied, are going to be greater when a Republican administration considers staffing its committees with qualified professionals who may tend to have more liberal pedigrees.
I want to give you another example showing how a shared ideology between the administration and potential appointees can influence the research agenda. I don't know how many of you are familiar with the Center for Substance Abuse Prevention (CSAP)-part of the Substance Abuse and Mental Health Services Administration (SAMHSA) of HHS. It is notorious among substance abuse prevention researchers for funding projects that are often very poorly executed and have little usable data. Some of the staff who oversee the projects have been properly said to be scientifically illiterate. I will just give you one example.
As an aside, I should say that as of 2001 Charles Curie became the new director at SAMHSA and he is well aware of some of these problems. But when I was looking into CSAP 10 years ago during the Clinton administration, a $1 million, five-year grant went to something called the West Dallas Community Center. It was for a substance abuse prevention program for young African American men-its goal was to build selfesteem. Now, this self-esteem-building program was necessary according to the West Dallas project director because, as he wrote in his grant, "Scientific colonialism and the institution of racism had defeated young men to the point where they turned to drugs." That doesn't sound very objective for a grant proposal but what about the program? What was the content of that program? Well, part of the self-esteem enhancement curriculum of the West Dallas program included lectures to teach the boys revisionist history, teaching them that Africa was the origin of architecture, mathematics, maritime travel and that white people had tried to deny them this knowledge, deprive them of their source of pride. Pedagogical malpractice aside, did teaching such "history" have any impact on substance abuse prevention? What did the results look like? Unfortunately many students did not either have a pretest or post-test or lacked both, thus change could not be measured. In other words, no results, a complete waste of taxpayer funds.
My point is, where was Representative Waxman when these illconceived, clumsily executed studies happened at the CSAP? The answer is no one pulled the alarm because the conceptual bent of the West Dallas project was compatible with CSAP leadership and grant review members' ideology, which is to say an aggressive multicultural agenda that trumped careful planning of the project and its analysis. There is enough politics to go around, right, left, liberal, conservative. I would argue that Representative Waxman missed a few things.
If you ask me whether this political climate is hostile to certain kinds of research, I definitely say yes: consider the current proscription of federal funding for stem cell research on non-designated lines. But I would quickly remind everyone that in the previous political climate there were political and ideological pressures brought to bear as well.
David Guston, PhD, associate professor and director of the Public Policy Program of the Bloustein School of Planning and Public Policy at Rutgers, North American editor of Science and Public policy, and chair elect of the American Association for the Advancement of Science, Section on Societal Impacts of Science and Engineering. His book, Between Politics and Science, Assuring the Integrity and Productivity of Research was awarded the 2002 Don K. Price Prize by the American Political Science Association for the best book on science and technology policy.
Three hundred fifty three years ago, Thomas Hobbes wrote, "Which is the cause that the doctrine of right and wrong is perpetually disputed, both by the pen and the sword, whereas the doctrine of lines and figures is not so because men care not in that subject what be truth as a thing that crosses no man's ambition, profit or lust for I doubt not but, if it had been a thing contrary to any man's right of dominion that the three angles of a triangle should be equal to two angles of a square, that doctrine should have been, if not disputed, yet by the burning of all books of geometry suppressed as far as he whom it concerned was able." Hobbes's observation that science, of which geometry was the paradigm in his time, would be viciously disputed if it "crossed any man's passions, ambition, profit or lust" was of course born out; it strikes me as odd that in some conversations about this, people act very much like Claude Rains character in the movie, Casablanca, where he is "... shocked, shocked to find ..." We are shocked, shocked to find that politics is going on in and about our scientific establishment.
The question is not whether science is politicized but what are the appropriate institutional channels for political discourse to influence science. Additionally, we should ask not whether science is politicized but if it is democratized.
The founding dean of the Kennedy School, a political scientist named Don K. Price, gave us a template for thinking about the relationship between politics and science. He recognized the spectrum from truth to power and divided this conceptual space between the political enterprise and the scientific enterprise into four "estates," each with different functions.
The scientific estate's function was to pursue truth. Next to it was something that he called the professional estate; its mission was to apply what was found in that scientific estate according to rules that were determined by private organizations and private values. Next along the spectrum was the estate of the professions; the function of the professions was to apply what was learned in those other estates according to public rules. Finally on the end of the spectrum was the political estate that Price fully recognized as being about the pursuit of power. Price developed a two-fold law of responsibility and accountability that ran the transactions among these different estates. He said that the closer you were to the pursuit of truth, the greater autonomy you should have and the closer you were to the pursuit of power, the greater responsibility and democratic accountability you should have. As a normative issue this sits pretty well with most people. We like to think of scientists being able to pursue truth where they will. We like certainly to think about people who are capable of exercising power to be subject to democratic accountability.
Yet this spectrum from truth to power runs aground in a couple of places. It misses Hobbes's insight that, at least in the contemporary world, the connection between science and power is much closer than two opposite ends of the spectrum might envision. Price said that what kept this spectrum functioning well in American society was a tradition of treating it with respect. Politicians are supposed to recognize their pragmatic interests in an independent scientific establishment; similarly, the folks who are seeking truth are meant to be contained by a variety of private and publicly promulgated rules.
I think we have to recognize that politics happens in science, in the scientific establishment at all levels, without dismissing it, without suppressing it, without denying it. We need to begin to concentrate on the provision of transparency and accountability in the conduct of this science politics. Finally I think we need to build institutions that attempt to balance political and scientific interests. These are the places that the debate needs to go to in order to transform a fairly unproductive discussion about the politicization of science into a more productive discussion about the democratization of science.
Marcia Angell:I would like to ask Dr. Sharfstein to respond to Dr. Satel: is there really a difference in this administration, as compared to others?
Joshua Sharfstein:I appreciate Dr. Satel confirming the Bill Miller story, that there was an outrageous political litmus test applied to a leading substance abuse expert. Yet she doesn't give a single example of political level distortion of science in the Clinton-Gore administration. I am somewhat perplexed that she somehow concludes it was just as bad because we have reported over 25 well-documented, specific examples of political manipulation of science. We have statements from officials in the Nixon, Ford, Reagan and the first Bush administration either condemning what is going on or saying it is much worse now than it ever was in their time, and we have the statement of 20 Nobel Laureates and many other scientists saying that this is unprecedented. So, there is a lot on one side and there just does not seem to be much on the other.
Dr. Satel mentioned a few specific research studies but I think she is missing the point. There may be good or bad scientific studies in any field that are funded. There may be ones that are terrible in design and funded anyway. Those are scientific issues, within the world of science. That is not political domination of the science. It is not rewriting the conclusions of things. It is a problem within the science. So, I don't consider those in any way to be parallel to political appointees rewriting conclusions of reports and drastically misrepresenting what scientists are doing.
Marcia Angell:Dr. Satel, do you mean to characterize the difference between the interference in past administrations and the current administration as merely a difference in ideology between the scientific community and the administration?
Sally Satel:I think there are more discrete examples in existence than are being presented today. I don't know how long Dr. Sharfstein spent on his report or how long the UCS spent on their report. These kinds of allegations take an enormous amount of work, hundreds of interviews, maybe even subpoenaing records, looking at old memos, interviewing hundreds of people. It takes a very long time, so I am skeptical of the completeness of their reports. I think that the phenomenon certainly takes place on both sides.
Marcia Angell:Professor Guston, if we reduce the barriers between politics, policymaking, and science, how do we avoid conflicts of interests?
David Guston:Through balanced types of inquiry, there are ways of creating the kinds of politically relevant, technically competent science advice that we are all looking for. Let me give you a local example. The Health Effects institute (HEI) is an organization that does this at the interface between the Environmental Protection Agency and the regulated industry with an autonomously run peer review system. In that process, neither side has an interest in overly politicizing the research results and both agree on the review processes. The HEI ends up producing research that fares very well in the regulatory environment.
Footnotes
1 Scientific Integrity in Policymaking: An investigation into the Bush Administration's Misuse of Science. Cambridge, MA: Union of Concerned Scientists, 2004. (http://www.ucsusa.org/global_environment/rsi/page.cfm?pageID=1322).
2 Sharfstein JM, Sharfstein SS. Campaign contributions from the American Medical Political Action Committee to members of Congress. For or against the public health? N Engl J Med 1994; 330(1):32-7.
3 (www.house.gov/reform/min/politicsandscience).
4 Wingert P. Sex education: values trumps data. In periscope. Newsweek 2002;Feb. 11:8
5 Diet, nutrition and the prevention of chronic diseases. World Health Organ Tech Rep Ser 2003;916:i-viii,1-149, back cover.
6 The American Enterprise Institute for Public Policy Research is dedicated to preserving and strengthening the foundations of freedom- limited government, private enterprise, vital cultural and political institutions, and a strong foreign policy and national defense.
This Medical Ethics Forum was edited by Walter M. Robinson, MD, MPH, Assistant Professor of Pediatrics and Medical Ethics, Harvard Medical School.
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
