345
amiss, but how helpful is popperian thought to the research clinic and laboratory of the 1990s? No idea, Popper argues, cannot be improved upon. "Truth" is a mirage, and scientists have to settle for hypothesis, constantly challenging and refining and even discarding-but always choosing some medium less lasting than tablets of stone to set it out. As Alan Ryan notes,2 this process requires two virtues: "a readiness to make bold guesses and the honesty to recognise when they are wrong". Neither virtue is much in evidence these days. The Lancet has been receiving formal hypotheses for about thirty years, yet they are often nothing of the sort, being little more than miniature reviews or anodyne restatements of current thinking. Those who have genuine ideas will often wait nervously until their own experiments confirm that they are not way off beam, or they hold on to the notion for even less worthy reasons. Rare is that quantum leap of imagination bridging two come
of evidence that no-one before has connected-and when such papers arrive they may be greeted by unimaginative referees with those dread phrases "mere speculation" or "interesting idea, but where’s the hard evidence?". So, is the journal about to abandon the hypothesis section? No, but more boldness and conciseness would be welcome: "the more rigid and therefore more at-risk theory to be viewed as preferable to the more flexible (or more flabby)".1 Propagators of hypotheses are never wrong—or they do not admit it, preferring to wriggle on the end of the hook. If well and trully gaffed, they will claim that a wrong idea has nonetheless led to much useful work and discussion, which may even be true sometimes. Most papers do not carry at the end of the introduction a clear-cut hypothesis that is about to be tested, and when they do no-one can be sure that the words were not written when the data were already in-a reflection of the defects of the
pathways
I(ntroduction),M(ethods),R(esults),A(nd),D(iscussion) convention that Medawar was so scathing about. There is a strong case for public deposition of hypotheses, lodged in advance of execution of a study. At a statistical level, falsification is proving elusive. Clinically relevant results are, rightly, now accompanied by confidence intervals. The result of a drug trial-null hypotheses, by the way, do seem totally non-popperian in their functional lack of inspiration-may be conventionally significant in favour of A while not excluding a small benefit in favour of B. Apparently negative studies are far worse. X and her colleagues, using very similar methods, seem not to confirm the findings and/or hypothesis of Y and his group, yet lack of confidence leaves the loophole that Y could just be right after all. Narrowing this uncertainty via meta-analysis or overview takes, as we all now know, years of effort. Even though strict popperian thinking may be more for disciplines that lack the biological and ethical restraints of clinical medicine, room must somehow be left for it in the training of biomedical scientists.
1. Bondi H. The philosopher for science. Nature 1992; 358: 363. 2. Ryan A. Carrying the beacon of reason. Times July 28, 1992: 10. 3. Popper K. Unended quest. London: Fontana/Collins, 1976. 4. Magee B. Popper. London: Fontana/Collins, 1973.
5. Medawar P. Pluto’s republic. Oxford: Oxford University Press, 1982. 6. Medawar PB. Induction and intuition in scientific thought. London: Methuen, 1969.
When
a
patient
says
no
The patient who is adult and competent yet refuses that doctors think necessary, even lifesaving, poses difficulties enough for the health professions. The Jehovah’s Witness is the example that comes most immediately to mind. The dilemma often arises in a setting that is urgent. Much medical, legal, and ethical discussion has appeared in the journals over the past few years and looks likely to continue with the case known as T. We do not know what this 20-year-old woman has said or will have to say to her medical attendants upon recovery after treatment that she had declined before falling unconscious but which her father and her doctors had wanted and the courts have allowed. If her response is gratitude and a recognition that she had been under pressure when she refused, the reaffirmation by the Court of Appeal1 that doctors could go ahead with care deemed in her best interests will seem wise and an excellent precedent. The three judges in the case gave their reasons a few days later, a privilege of leisure not accorded clinicians. More important, they have provided guidelines.2How many doctors now, when a Jehovah’s Witness, for example, says no to a recommended blood transfusion make no effort at persuasion? In the end, however, they do respect such wishes-and have had the verdict against a wellintentioned Canadian doctor to remind them of what might happen if they were to over-rule such a request.3 T is not a Jehovah’s Witness but seems to have been influenced by her mother, who was. The Appeal Court judges were shocked at the disclaimer form T signed. The consequences of refusal should be treatment
expressed be
done
more
"forcibly", they insist;
more must
that refusals that seem to doctors are made in the face of incomprehensible the full facts; and hospital staff from now on will have to check that no undue influence has been brought to bear. If that influence comes from a parent at the bedside, as in T, the court’s directions will be easy to follow. But what of other pressures, less obvious but no less powerful? Young people can come under bizarre influences and take up weird beliefs without being so disturbed that mental health legislation could be brought into play. Although Lord Donaldson and his colleagues may have taken the right view in T, they may have compounded an already very difficult clinical problem. to
ensure
1. Brahams D. Right to refuse treatment. Lancet 1992; 340:297. 2. Tan YH. Decision on treatment did not cover emergency. Independent, July 31, 1992: 22. 3. Brahams D. Unwanted life-sustaining treatment. Lancet 1990; 335: 1210.
amiss, but how helpful is popperian thought to the research clinic and laboratory of the 1990s? No idea, Popper argues, cannot be improved upon. "Truth" is a mirage, and scientists have to settle for hypothesis, constantly challenging and refining and even discarding-but always choosing some medium less lasting than tablets of stone to set it out. As Alan Ryan notes,2 this process requires two virtues: "a readiness to make bold guesses and the honesty to recognise when they are wrong". Neither virtue is much in evidence these days. The Lancet has been receiving formal hypotheses for about thirty years, yet they are often nothing of the sort, being little more than miniature reviews or anodyne restatements of current thinking. Those who have genuine ideas will often wait nervously until their own experiments confirm that they are not way off beam, or they hold on to the notion for even less worthy reasons. Rare is that quantum leap of imagination bridging two come
of evidence that no-one before has connected-and when such papers arrive they may be greeted by unimaginative referees with those dread phrases "mere speculation" or "interesting idea, but where’s the hard evidence?". So, is the journal about to abandon the hypothesis section? No, but more boldness and conciseness would be welcome: "the more rigid and therefore more at-risk theory to be viewed as preferable to the more flexible (or more flabby)".1 Propagators of hypotheses are never wrong—or they do not admit it, preferring to wriggle on the end of the hook. If well and trully gaffed, they will claim that a wrong idea has nonetheless led to much useful work and discussion, which may even be true sometimes. Most papers do not carry at the end of the introduction a clear-cut hypothesis that is about to be tested, and when they do no-one can be sure that the words were not written when the data were already in-a reflection of the defects of the
pathways
I(ntroduction),M(ethods),R(esults),A(nd),D(iscussion) convention that Medawar was so scathing about. There is a strong case for public deposition of hypotheses, lodged in advance of execution of a study. At a statistical level, falsification is proving elusive. Clinically relevant results are, rightly, now accompanied by confidence intervals. The result of a drug trial-null hypotheses, by the way, do seem totally non-popperian in their functional lack of inspiration-may be conventionally significant in favour of A while not excluding a small benefit in favour of B. Apparently negative studies are far worse. X and her colleagues, using very similar methods, seem not to confirm the findings and/or hypothesis of Y and his group, yet lack of confidence leaves the loophole that Y could just be right after all. Narrowing this uncertainty via meta-analysis or overview takes, as we all now know, years of effort. Even though strict popperian thinking may be more for disciplines that lack the biological and ethical restraints of clinical medicine, room must somehow be left for it in the training of biomedical scientists.
1. Bondi H. The philosopher for science. Nature 1992; 358: 363. 2. Ryan A. Carrying the beacon of reason. Times July 28, 1992: 10. 3. Popper K. Unended quest. London: Fontana/Collins, 1976. 4. Magee B. Popper. London: Fontana/Collins, 1973.
5. Medawar P. Pluto’s republic. Oxford: Oxford University Press, 1982. 6. Medawar PB. Induction and intuition in scientific thought. London: Methuen, 1969.
When
a
patient
says
no
The patient who is adult and competent yet refuses that doctors think necessary, even lifesaving, poses difficulties enough for the health professions. The Jehovah’s Witness is the example that comes most immediately to mind. The dilemma often arises in a setting that is urgent. Much medical, legal, and ethical discussion has appeared in the journals over the past few years and looks likely to continue with the case known as T. We do not know what this 20-year-old woman has said or will have to say to her medical attendants upon recovery after treatment that she had declined before falling unconscious but which her father and her doctors had wanted and the courts have allowed. If her response is gratitude and a recognition that she had been under pressure when she refused, the reaffirmation by the Court of Appeal1 that doctors could go ahead with care deemed in her best interests will seem wise and an excellent precedent. The three judges in the case gave their reasons a few days later, a privilege of leisure not accorded clinicians. More important, they have provided guidelines.2How many doctors now, when a Jehovah’s Witness, for example, says no to a recommended blood transfusion make no effort at persuasion? In the end, however, they do respect such wishes-and have had the verdict against a wellintentioned Canadian doctor to remind them of what might happen if they were to over-rule such a request.3 T is not a Jehovah’s Witness but seems to have been influenced by her mother, who was. The Appeal Court judges were shocked at the disclaimer form T signed. The consequences of refusal should be treatment
expressed be
done
more
"forcibly", they insist;
more must
that refusals that seem to doctors are made in the face of incomprehensible the full facts; and hospital staff from now on will have to check that no undue influence has been brought to bear. If that influence comes from a parent at the bedside, as in T, the court’s directions will be easy to follow. But what of other pressures, less obvious but no less powerful? Young people can come under bizarre influences and take up weird beliefs without being so disturbed that mental health legislation could be brought into play. Although Lord Donaldson and his colleagues may have taken the right view in T, they may have compounded an already very difficult clinical problem. to
ensure
1. Brahams D. Right to refuse treatment. Lancet 1992; 340:297. 2. Tan YH. Decision on treatment did not cover emergency. Independent, July 31, 1992: 22. 3. Brahams D. Unwanted life-sustaining treatment. Lancet 1990; 335: 1210.
