The Sicily Evidence-Based Healthcare Conference was a treat, and not just because of the glorious location and hospitality. It was big enough…
“Never have heroes” – I’ve heard some version of that a lot in the last couple of months, from people disillusioned by John Ioannidis’ contributions to the research and debate around Covid-19. Meanwhile, others are still calling him an EBM or science hero.
It sounds like it should be a contradiction in terms, doesn’t it? – “EBM hero”. The essence of evidence-based medicine (EBM), after all, is meant to be the rejection of eminence-based medicine – believing something just because someone up high says it is so, with a bunch of cherry-picked citations.
But I think there can be, and indeed are, EBM and science heroes. I found a 2011 conceptual analysis of heroism and altruism by Zeno Franco and colleagues helpful for thinking this through. Which is seriously ironic, since one of the authors is Philip Zimbardo – an emeritus Stanford professor of notoriety because of that prison experiment!
Reading the article, though, crystallized how I, personally, think of heroism: it’s prosocial behavior, that’s altruistic, struggling against odds, and despite serious risks to the individual. It’s not hard to think of scientists, and healthcare providers struggling to ensure care is evidence-based, who fit that bill and are totally worthy of the label, hero.
While I was in the late stages of writing this post, Stuart Ritchie posted on the same theme, arguing “There should never be heroes in science”. He drew parallels from a couple of examples of scientists who achieved a lot of fandom and then fell, heavily, from grace in different ways: Hans Eysenck and Ioannidis. A common thread he pointed to, first in Eysenck, was that he “loved argument, loved controversy — and most importantly, refused in almost any case to back down under criticism”. Lately, he wrote, Ioannidis has sounded Eysenckian.
I won’t recap the recent Ioannidis episode – you can catch up on it in Ritchie’s excellent recap if you haven’t been following it closely. Ioannidis, he concludes, “gives the impression of someone who has taken a position and is now simply defending it against all comers”. I agree with that.
What’s interesting to me, though, is that not only isn’t this new, but people have been cheering Ioannidis on for doing just this for a long time. People used words for this kind of thing, like “heretic” and “iconoclast”, admiringly. I think those are the words we should be unpacking, more than the word “hero”.
Back in 2002, I wrote about how I had come to see “iconoclasm” as anathema to science and collaboration. It was after watching a bruising battle with another person many call(ed) a hero, but have recently grappled with disillusion about, Peter Gøtzsche. Iconoclasm, I wrote, has had a powerful side, but destruction and violence are also part of that word’s heritage: “Being brave and fighting for beliefs is easy to applaud. Yet, there is nothing valuable necessarily for humanity in doing it – not in itself. This behaviour does not necessarily have integrity, either. But there is always harm in fighting”.
The word “heretic” isn’t straightforward either in the science context. There’s a “contrarian” element to it, but a heretic is a proponent of a set of beliefs. And that’s a problem, whether it’s ideologically based or whether it’s a case that’s mounted in the way Ritchie describes for Ioannidis with Covid-19.
Jeanne Lenzer and Shannon Brownlee wrote a defense of Ioannidis, saying that he “will almost certainly emerge from this imbroglio with his reputation as a rigorous researcher restored”. I doubt that. David Freedman wrote that while Ioannidis’ legacy had recently “seemed unassailable”, speaking to a class of medical students this year he wondered, “To them Ioannidis may always be the fringe scientist who pumped up a bad study that supported a crazy right-wing conspiracy theory in the middle of a massive health crisis”.
I think the reality will include both those poles, but something else, too. Ioannidis’ work has always been of variable quality, but his status and reputation meant that would often be overlooked, or his rebuttals of criticisms too easily accepted. I don’t think that’s going to come back on that scale, and that’s a good thing.
Back in the before times, when we used to have lots of conferences, I would often either be in the audience when Ioannidis was speaking, or, from time to time, on the podium speaking alongside him. At first, I’d just be beguiled and energized by the rousing and erudite performances. But then a crack would appear – a statement I knew to be strongly contradicted by the evidence – and then another, and another. And they’d all be based on self-citations, building the case he was arguing.
Sometimes it would indeed be a very strong case – he does a lot of excellent work. But sometimes it was shot full of holes, yet with so many citations swirling past it seemed very evidence-based. It would be hard to refute without considerable effort: a scientific version of a gish gallop. I wrote about an example of this last year. When the Covid-19 writing began, for me, it was a case of “here we go again”, the early stages of motivated reasoning, with the studies on the way to backfill it. Once you’ve seen through it, an illusion stays broken; the former magic won’t work so easily the next time.
To me, the moral of these stories isn’t to not have heroes. It’s to learn a few things: to pick your heroes more carefully; to be wary of the champions of causes as well as anyone who is “against” something on the regular; to watch carefully how people respond to their critics; and to be on guard against the effects of charisma. And if you have a hero, don’t give their science a free pass.
Disclosures: I’ve both collaborated with, butted heads with, and written critically about, both John Ioannidis’ work (starting here and here on Covid-19, and here in 2013 and here in 2019) and Peter Gøtzsche (see here).