The Rightful Place Project

Orac of Respectful Insolence Says…

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If you’ve browsed the redesigned front page of ScienceBlogs, you’ll see that our benevolent ScienceBlogs Overlords at Seed Magazine have started a project that they have so humbly termed The Rightful Place Project: Reviving Science in America, which is described thusly:

In his first speech as President-elect last November, Barack Obama reminded us of the promise of “a world connected by our own science and imagination.” He recently stated, “promoting science isn’t just about providing Resources–it’s about protecting free and open inquiry… It’s about listening to what our scientists have to say, even when it’s inconvenient — especially when it’s inconvenient.” And in his inaugural address on January 20, President Obama cemented his commitment to this ethos and culture by vowing to “restore science to its rightful place.”

At Seed Media Group, we are firmly committed to President Obama’s vision and will work to make it a reality. To this end, we have launched a new initiative we’re calling The Rightful Place Project. We are inviting a national discussion around the President’s idea of a “rightful place” for science.

All this project involves, at least from a blog perspective, is answering a deceptively simple-sounding question: What is science’s rightful place?

Anyone can play, but, because I happen to have been part of the ScienceBlogs Collective for nearly three years now and I am nothing if not a loyal Borg–I mean ScienceBlogger–I thought I’d give it a whirl. I will admit one thing, though. I didn’t answer this right away because I wasn’t sure I wanted to. For one thing, any ideas for responses that I came up with sounded relentlessly pretentious. Yes, I realize that many will ask the question, ” So what? Who would be able to tell the difference?” Suffice it to say that I would. Another reason I may have procrastinated is because I hate going along with the crowd (well, too much). Finally, I wasn’t really sure what I could say that others hadn’t already said better in the few days I dithered.

But, hey, this is Orac we’re talking about. When dozens of bloggers write about a story before me, does that stop me? Hell, no! (Well, actually, sometimes it does.) Blogging is nothing if not a self-indulgent process, and obviously I have become the quintessential blogger. (Just look at the long, self-indulgent prelude to this post.) In any case, it takes an enormous ego to think that anyone gives a rodent’s posterior about what one writes day after day, and fortunately (or unfortunately) you, my loyal readers, have rewarded that ego with awards and nominations for awards; so you’re stuck with my pontifications indefinitely. Just think of the last two or three paragraphs as just one more self-indulgent (but hopefully sufficiently amusing that you haven’t already stopped reading) passage that I’ll edit out if I ever turn my blog into a book.

On to the answer to the great question of Life, the Universe, and Everything! (And this time it’s not forty-two.)

The first of my pontifications involves the question itself, “What is science’s rightful place?” Rightful place where? The answer to the question depends upon where, in what context. Policy-making? At first I assumed that’s what’s meant by the question, but it’s left open-ended. Perhaps it was intentional, but it was annoyingly so. After all, the role of science might vary depend on what area of policy-making, because different areas of policy have different levels of requirement for science. For example, deciding upon a director for the National Endowment for the Arts doesn’t really require much, if any, science. The second bit of confusion was what the heck the second part of the project meant, namely reviving science in America. In that, I’m totally with Isis; it’s an extraneous and rather depressing addition to a straightforward project, namely because I don’t know that science needs to be “revived.” The U.S. still has a healthy scientific endeavor, and the government is not the be-all and end-all of science. Unfortunately, the logo and the concept behind the Rightful Place Project seem to imply that it is, particularly given that President Obama’s statements about science were the inspiration for the project.

Let’s get one thing straight right here: “Revitalizing” science, whatever that means, does not depend upon government. It does not depend upon Barack Obama. There is no doubt that the government is very important as a funder of science, particularly biomedical science, and that the President can do a lot to support science in the U.S., but it is Americans doing science who determine how vital the scientific endeavor in this country is, not the government.

Now that I have that minor rant out of the way, I’ll try to answer the question more directly. Among all my fellow ScienceBloggers, several of whom are accomplished scientists in their own right, I do have a perspective that none of them have. Alone among ScienceBloggers, I’m the only clinician-scientist. It’s true that we have some budding clinician scientists, such as Jake and Mark, but thus far I’m the only one who is actually an independent investigator with NIH funding who does translational and clinical research. I have little doubt that Jake and Mark will develop into good clinician-scientists in their own right, but that will be years in the future given that they are both still in medical school.

So what does my perspective tell me? I don’t claim that it gives me any particularly brilliant insight, but it does bring to mind an analogy. Unless you’re a brand new reader who just happened upon this blog on a day when I felt like doing an EneMan post or a post about Holocaust deniers, you know that one of the overarching themes here is science-based medicine. Consider what science-based medicine means, and you will have a fairly good analogy for the role of science in government and society. It’s by no means a perfect analogy, but it’s pretty good.

Medicine is not a “pure” science. It can’t be. In fact, it’s a messy collaboration between doctor and patient constrained by limited resources and technology and clouded by often incomplete information. Sometimes the treatments that end up being chosen are not the best or most efficacious based on science. The reasons for this may be legion, but that does not mean science doesn’t have a huge role to play in medicine. Science, through basic investigations and then later through clinical trials, provides the groundwork for everything we do as physicians. It sets the guidelines. It tells us what works and what doesn’t, what is possible and what is probably not, what works better than something else, and what the relative risks of two courses of action are. What it doesn’t tell us is what we value–what we want.

Consider a case I frequently confront, that of early stage breast cancer. Consider the case of a woman with a small breast cancer, estrogen-receptor positive, with no evidence of spread to the lymph nodes under her arm or any place else. This would be a stage I tumor. Now consider the options after the tumor has been surgically excised. Once the tumor is excised, we offer various adjuvant therapies to try to reduce the risk of recurrence. Radiation therapy is very effective in reducing the rate of local recurrence; i.e., recurrence in the spot where the tumor was excised. The decision making process for that is not so difficult. However, consider the case of chemotherapy and antiestrogen therapy (usually Tamoxifen or, in the case of post-menopausal women, drugs called aromatase inhibitors are becoming more and more commonly used). The absolute benefit of chemotherapy is modest at best, on the order of a few percent increase at most in the chances of survival after five years, at the cost of considerable unpleasantness and the risk of complications. So what should a woman do? That depends upon what she values. Does she value her own life so much that will pay any price and bear any burden to increase her odds of survival by a couple of percent? Many women say yes. Indeed, there are surveys out there that indicate that most women would accept chemotherapy for even a 1% better chance of survival. Is that wrong? Is it irrational? No, it’s neither. Either decision could be correct, depending upon what the woman values.

The same could be said for antiestrogen therapy. In estrogen-responsive tumors, drugs like Tamoxifen or aromatase inhibitors are the mainstay of adjuvant therapy and give at least as much bang for the buck as chemotherapy. Now consider a patient I took care of very early in my career. She underwent successful surgery for a stage I breast cancer and the recommended course of treatment was Tamoxifen for five years. However, she had really bad meonopausal symptoms on Tamoxifen: hot flashes, the whole lot of them. Dose adjustment was tried, but she ultimately decided that she did not want to take the Tamoxifen, despite a lot of cajoling from her medical oncologist. Was she wrong? No. She happened to have worse symptoms than most women on Tamoxifen and decided that enduring the symptoms simply weren’t worth the extra few percent chance of survival. Her decision, when you come down to it, was primarily a rational calculation of whether she viewed the potential benefit to be worth the cost. Indeed, we can generalize that to society as well. For example, if chemotherapy only produces a 2-3% absolute increase in survival in women with stage I breast cancer, do we pay for it, given that it is expensive and might prevent us from paying for other forms of care, such as preventative care. That is not a question that science can answer. It can only tell us the potential risks and benefits of each treatment; economics tells us how much each costs; and we have to decide how to allocate our limited health care resources.

Science should function in society and government much as it does when properly used in medicine. It cannot tell society what it values, but it can provide it with estimates of the likely outcomes of various courses between which society must choose. Take the example of second hand smoke. Science tells us that it increases the risk of heart and lung disease by a factor of approximately 1.3 in workers exposed to it eight or more hours a day. What we as a society do with that information depends upon what we value. Do we value the autonomy of the bar and restaurant owner more than the modestly increased risk of disease in nonsmokers who work in that owners’ bar or restaurant? Or do we value protecting workers from this risk more than the freedom of patrons to smoke and bar owners to choose to allow smoking in their bars? That is the political decision based on our values as a society. Libertarians argue that freedom of interference by government in a restaurant owner’s business trumps the risk smoking poses to workers as long as workers know about the risk and choose to accept it. proponents of smoking bans might say that workers should not be forced to make such a choice and that nonsmokers should not have to put up with the annoyance caused by a minority. Both are arguments based on what one believes and values. It’s a similar situation for anthropogenic global warming. Science can tell us it’s happening, how fast it’s happening, and what we might do to slow it down. It can also put error bars around all the estimates. What it cannot tell us is what to do about it. It can only give us options and the likely outcomes of such options based on what we know. We through our elected officials have to decide what, if anything, we will do about it.

Back in the 1990s, I was a huge fan of Babylon 5. I still am. For those of you not familiar with this particular science fiction show, in it the human race and many alien races found themselves caught in the middle of a conflict between two old and powerful races who were originally supposed to cooperate to watch over the younger races and guide their development. However, each had decided that its way was the best. To boil it all down, one race, the Vorlons, preferred order and duty as a strategy for development, while the other race, the Shadows, preferred chaos and struggle, in which the “fittest” would destroy other races and evolve into something better and stronger. One of the recurring incidents in the show is that the Vorlons would always ask humans, “Who are you?” and the Shadows would always ask them, “What do you want?”

Science can’t really answer either of those questions.

It can, however, help us as a society to decide both who we are and what we want. At its best, science is the trusted advisor that tells us the situation as accurately as humanly possible, based on the best humans have to offer in terms of inquisitiveness, intelligence, and creativity and informs us what the options are and what the likely outcome of choosing each option is. The choice after that is up to us.

(Looking back on that post that really was pretentious. Oh, well, it’s too late now; I don’t have time to write something different.)

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