Nearly half a million applications for asylum submitted by refugees were processed by German authorities in 2015, according to the German Federal Office for Refugees and Migration. The number of people who were officially registered in Germany as potential asylum seekers was even far higher-roughly one million in 2015 – which suggests that Germany anticipates an even higher number of official asylum applications for 2016. Chancellor Angela Merkel has defied many critics even in her own party and cabinet by emphasizing that Germany can and will take on more refugees, most of whom are coming from war-torn countries such as Syria, Iraq and Afghanistan. “We can do it!” (“Wir schaffen das!”) was the phrase she used in September of 2015 to convey her optimism and determination in the face of ever-growing numbers of refugees and the gradual rise of support for far right extremist demonstrations and violent attacks by far right extremists on refugees centers in Germany.
The German media and right wing populists are currently obsessing about statistics such as the fact that the far right and libertarian party AfD (Alternative für Deutschland – Alternative for Germany) will garner 10% of the popular vote or that the vast majority of the refugees are male and could lead to a demographic gender shift if they remain in Germany. While such statistics serve as an important barometer of the political climate in the German electorate or to prepare for the challenges faced by the refugees and German society in the next years, they do not address the fundamental philosophical questions raised by this refugee crisis. In the latest issue of the popular German philosophy periodical “Philosophie Magazin“, the editors asked philosophers and other academic scholars to weigh in on some of the key issues and challenges in the face of this crisis.
Should we be motivated by a sense of global responsibility when we are confronted with the terrible suffering experienced by refugees whose homes have been destroyed? The sociologist Hartmut Rosa at the University of Jena responds to this question by suggesting that we should focus on Verbundenheit (“connectedness”) instead of Verantwortung (“responsibility”). Demanding that those of us who lead privileged lives of safety and reasonable material comfort should feel individually responsible for the suffering of others can lead to a sense of moral exhaustion. Are we responsible for the suffering of millions of people in Syria and East Africa? Are we responsible for the extinction of species as a consequence of climate change? Instead of atomizing – and thus perhaps even rendering irrelevant – the abstract concept of individual responsibility, we should become aware of how we are all connected.
We are connected with the children of Syria and Somalia by virtue of the fact that they are fellow humans who deserve to live, learn and love. We are connected to the species facing extinction by climate change because we share the ecosystems of this planet and our species may also face extinction. For Rosa, the sense of connectedness is what motivates us to help the refugees without trying to precisely determine our relative global responsibility.
Are rational thoughts or emotions a better guide for how to respond to the refugee crisis? The philosopher Volker Gerhardt from the Humboldt University of Berlin emphasizes the importance of balancing rational and emotional responses. Rationally calculating the economic cost of taking on refugees and the benefit of increasing the younger workforce once the refugees are granted permission to settle and work in Germany does not do justice to the issues. Gerhardt is aware of his own background as the child of a refugee mother after World War II who were both cared for by their relatives. Every time he sees a photo of a refugee child, it evokes memories of his own past and serves as a motivation to help. But he is also aware of the limits of such emotional and rational willingness to help. Currently, hundreds of thousands of German citizens are volunteering to help and welcome the refugees by donating their time, money and other essentials but the German government needs to realize that this spirit of charity may become exhausted if the influx of refugees is not restricted. Hilde Landweer is a philosopher at the Free University of Berlin who studies the philosophy of emotions. She explains the underlying mechanisms which allow us to feel empathy for refugees. According to Landweer, there are three components which allow to feel empathy: 1) we have to feel a sense of similarity towards the other person, 2) we have to be able “experience” their situation and 3) we have to realize that one day, we might be able to also find ourselves in such a situation. Germany’s leadership role in its willingness to help the refugees when compared to other developed countries – Britain is planning on taking in 5,000 Syrian refugees per year, the USA only 1,000 to 1,500 – may be rooted in the fact that Germans can identify with the plight of the Syrian refugees. Millions of Germans experienced expulsion and forced resettlement from their homelands after World War II when post-war Germany was carved up. Landweer believes that empathy can be nurtured by meeting refugees and hearing about their personal narratives. But empathy needs to be more than shared pain, it needs to also include looking forward to how one can restore security and joy. This positive vision is what ultimately motivates us to help.
Does Germany have a unique historic responsibility when responding to the refugee crisis? Aleida Assmann is a professor of literary and cultural studies at the University of Konstanz who studies collective memory and its impact on German culture. Assmann refers to the Erinnerungskultur – the culture of remembrance – in Germany. Contemporary Germans are aware of the fact that their ancestors either actively participated or passively ignored the mass murder of millions of Jews, Slavs, gypsies and other ethnicities. According to Assmann, this historic responsibility is sometime summarized as “Auschwitz should never occur again!” but she takes a broader view of this responsibility. The root of Auschwitz was the labeling of fellow humans as fremd – foreign, alien or “other” – which did not deserve respect, empathy and help. Our historic responsibility requires that we avoid the trap of viewing refugees as fremd and instead encounter them with a sense of fellowship. The inherited burden of the Nazi past becomes an opportunity for Germany to define its future: Do we want to become a society that closes its doors to fellow humans in despair or do we want to welcome them in order to build a future society characterized by caring and sharing.
These are just some of the responses given by the philosophers in the Philosophie Magazin issue but they filled me with hope. As a German living in the USA, I often fall into the trap of reading clickbait and sensationalist news articles about the refugee crisis such as the rise of crimes committed by both right wing extremists and refugees in Germany, the imagery of refugees “flooding” German cities and the political gossip about Merkel’s future. But thinking more deeply about the core issues reminds us that what is at stake in Germany is our humanity. Yes, it will be challenging to integrate millions of refugees and provide them with a new Heimat – homeland – but our history and culture compels us to act in a humane fashion and not ignore the plight of fellow human beings.
Hearing about the HannoverGEN project made me feel envious and excited. Envious, because I wish my high school had offered the kind of hands-on molecular biology training provided to high school students in Hannover, the capital of the German state of Niedersachsen. Excited, because it reminded me of the joy I felt when I first isolated DNA and ran gels after restriction enzyme digests during my first year of university in Munich. I knew that many of the students at the HannoverGEN high schools would be similarly thrilled by their laboratory experience and perhaps even pursue careers as biologists or biochemists.
What did HannoverGEN entail? It was an optional pilot program initiated and funded by the state government of Niedersachsen at four high schools in the Hannover area. Students enrolled in the HannoverGEN classes would learn to use molecular biology tools typically reserved for college-level or graduate school courses in order to study plant genetics. Some of the basic experiments involved isolating DNA from cabbage or how learning how bacteria transfer genes to plants, more advanced experiments enabled the students to analyze whether or not the genome of a provided maize sample had been genetically modified. Each experimental unit was accompanied by relevant theoretical instruction on the molecular mechanisms of gene expression and biotechnology as well as ethical discussions regarding the benefits and risks of generating genetically modified organisms (“GMOs”). The details of the HannoverGEN program are only accessible through the the Wayback Machine Internet archive because the award-winning educational program and the associated website were shut down in 2013 at the behest of German anti-GMO activist groups, environmental activists, Greenpeace, the Niedersachsen Green Party and the German organic food industry.
Why did these activists and organic food industry lobbyists oppose a government-funded educational program which improved the molecular biology knowledge and expertise of high school students? A press release entitled “Keine Akzeptanzbeschaffung für Agro-Gentechnik an Schulen!” (“No Acceptance for Agricultural Gene Technology at Schools“) in 2012 by an alliance representing “organic” or “natural food” farmers accompanied by the publication of a critical “study” with the same title (PDF), which was funded by this alliance as well as its anti-GMO partners, gives us some clues. They feared that the high school students might become too accepting of biotechnology in agriculture and that the curriculum did not sufficiently highlight all the potential dangers of GMOs. By allowing the ethical discussions to not only discuss the risks but also mention the benefits of genetically modifying crops, students might walk away with the idea that GMOs could be beneficial for humankind. The group believed that taxpayer money should not be used to foster special interests such as those of the agricultural industry which may want to use GMOs.
A response by the University of Hannover (PDF), which had helped develop the curriculum and coordinated the classes for the high school students, carefully analyzed the complaints of the anti-GMO activists. The author of the anti-HannoverGEN “study” had not visited the HannoverGEN laboratories, nor had he had interviewed the biology teachers or students enrolled in the classes. In fact, his critique was based on weblinks that were not even used in the curriculum by the HannoverGEN teachers or students. His analysis ignored the balanced presentation of biotechnology that formed the basis of the HannoverGEN curriculum and that discussing potential risks of genetic modification was a core topic in all the classes.
Unfortunately, this shoddily prepared “study” had a significant impact, in part because it was widely promoted by partner organizations. Its release in the autumn of 2012 came at an opportune time for political activists because Niedersachsen was about to have an election. Campaigning against GMOs seemed like a perfect cause for the Green Party and a high school program which taught the use of biotechnology to high school students became a convenient lightning rod. When the Social Democrats and the Green Party formed a coalition after winning the election in early 2013, nixing the HannoverGEN high school program was formally included in the so-called coalition contract. This is a document in which coalition partners outline the key goals for the upcoming four year period. When one considers how many major issues and problems the government of a large German state has to face, such as healthcare, education, unemployment or immigration, it is mind-boggling that de-funding a program involving only four high schools received so much attention that it needed to be anchored in the coalition contract. In fact, it is a testimony to the influence and zeal of the anti-GMO lobby.
Once the cancellation of HannoverGEN was announced, the Hannover branch of Greenpeace also took credit for campaigning against this high school program and celebrated its victory. The Greenpeace anti-GMO activist David Petersen said that the program was too cost intensive because equipping high school laboratories with state-of-the-art molecular biology equipment had already cost more than 1 million Euros. The previous center-right government which had initiated the HannoverGEN project was planning on expanding the program to even more high schools because of the program’s success and national recognition for innovative teaching. According to Petersen, this would have wasted even more taxpayer money without adequately conveying the dangers of using GMOs in agriculture.
The scientific community was shaken up by the decision of the new Social Democrat-Green Party coalition government in Niedersachsen. This was an attack on the academic freedom of schools under the guise of accusing them of promoting special interests while ignoring that the anti-GMO activists were representing their own special interests. The “study” attacking HannoverGEN was funded by the lucrative “organic” or “natural food” food industry! Scientists and science writers such as Martin Ballaschk or Lars Fischer wrote excellent critical articles stating that squashing high-quality, hand-on science programs could not lead to better decision-making. How could ignorant students have a better grasp of GMO risks and benefits than those who receive relevant formal science education and thus make truly informed decisions? Sadly, this outcry by scientists and science writers did not make much of a difference. It did not seem that the media felt this was much of a cause to fight for. I wonder if the media response would have been just as lackluster if the government had de-funded a hands-on science lab to study the effects of climate change.
In 2014, the government of Niedersachsen then announced that they would resurrect an advanced biology laboratory program for high schools with the generic and vague title “Life Science Lab”. By removing the word “Gen” from its title which seems to trigger visceral antipathy among anti-GMO activists, de-emphasizing genome science and by also removing any discussion of GMOs from the curriculum, this new program would leave students in the dark about GMOs. Ignorance is bliss from an anti-GMO activist perspective because the void of scientific ignorance can be filled with fear.
From the very first day that I could vote in Germany during the federal election of 1990, I always viewed the Green Party as a party that represented my generation. A party of progressive ideas, concerned about our environment and social causes. However, the HannoverGEN incident is just one example of how the Green Party is caving in to ideologies, thus losing its open-mindedness and progressive nature. In the United States, the anti-science movement, which attacks teaching climate change science or evolutionary biology at schools, tends to be rooted in the right wing political spectrum. Right wingers or libertarians are the ones who always complain about taxpayer dollars being wasted and used to promote agendas in schools and universities. But we should not forget that there is also a different anti-science movement rooted in the leftist and pro-environmental political spectrum – not just in Germany. As a scientist, I feel that it is becoming increasingly difficult to support the Green Party because of its anti-science stance.
I worry about all anti-science movements, especially those which attack science education. There is nothing wrong with questioning special interests and ensuring that school and university science curricula are truly balanced. But the balance needs to be rooted in scientific principles, not political ideologies. Science education has a natural bias – it is biased towards knowledge that is backed up by scientific evidence. We can hypothetically discuss dangers of GMOs but the science behind the dangers of GMO crops is very questionable. Just like environmental activists and leftists agree with us scientists that we do not need to give climate change deniers and creationists “balanced” treatment in our science curricula, they should also accept that much of the “anti-GMO science” is currently more based on ideology than on actual scientific data. Our job is to provide excellent science education so that our students can critically analyze and understand scientific research, independent of whether or not it supports our personal ideologies.
“It’s empathy that makes us help other people. It’s empathy that makes us moral.” The economist Paul Zak casually makes this comment in his widely watched TED talk about the hormone oxytocin, which he dubs the “moral molecule”. Zak quotes a number of behavioral studies to support his claim that oxytocin increases empathy and trust, which in turn increases moral behavior. If all humans regularly inhaled a few puffs of oxytocin through a nasal spray, we could become more compassionate and caring. It sounds too good to be true. And recent research now suggests that this overly simplistic view of oxytocin, empathy and morality is indeed too good to be true.
Many scientific studies support the idea that oxytocin is a major biological mechanism underlying the emotions of empathy and the formation of bonds between humans. However, inferring that these oxytocin effects in turn make us more moral is a much more controversial statement. In 2011, the researcher Carsten De Dreu and his colleagues at the University of Amsterdam in the Netherlands published the study Oxytocin promotes human ethnocentrism which studied indigenous Dutch male study subjects who in a blinded fashion self-administered either nasal oxytocin or a placebo spray. The subjects then answered questions and performed word association tasks after seeing photographic images of Dutch males (the “in-group”) or images of Arabs and Germans, the “out-group” because prior surveys had shown that the Dutch public has negative views of both Arabs/Muslims and Germans. To ensure that the subjects understood the distinct ethnic backgrounds of the target people shown in the images, they were referred to typical Dutch male names, German names (such as Markus and Helmut) or Arab names (such as Ahmed and Youssef).
Oxytocin increased favorable views and word associations but only towards in-group images of fellow Dutch males. The oxytocin treatment even had the unexpected effect of worsening the views regarding Arabs and Germans but this latter effect was not quite statistically significant. Far from being a “moral molecule”, oxytocin may actually increase ethnic bias in society because it selectively enhances certain emotional bonds. In a subsequent study, De Dreu then addressed another aspect of the purported link between oxytocin and morality by testing the honesty of subjects. The study Oxytocin promotes group-serving dishonesty showed that oxytocin increased cheating in study subjects if they were under the impression that dishonesty would benefit their group. De Dreu concluded that oxytocin does make us less selfish and care more about the interest of the group we belong to.
These recent oxytocin studies not only question the “moral molecule” status of oxytocin but raise the even broader question of whether more empathy necessarily leads to increased moral behavior, independent of whether or not it is related to oxytocin. The researchers Jean Decety and Jason Cowell at the University of Chicago recently analyzed the scientific literature on the link between empathy and morality in their commentary Friends or Foes: Is Empathy Necessary for Moral Behavior?, and find that the relationship is far more complicated than one would surmise. Judges, police officers and doctors who exhibit great empathy by sharing in the emotional upheaval experienced by the oppressed, persecuted and severely ill always end up making the right moral choices – in Hollywood movies. But empathy in the real world is a multi-faceted phenomenon and we use this term loosely, as Decety and Cowell point out, without clarifying which aspect of empathy we are referring to.
Decety and Cowell distinguish at least three distinct aspects of empathy:
1. Emotional sharing, which refers to how one’s emotions respond to the emotions of those around us. Empathy enables us to “feel” the pain of others and this phenomenon of emotional sharing is also commonly observed in non-human animals such as birds or mice.
2. Empathic concern, which describes how we care for the welfare of others. Whereas emotional sharing refers to how we experience the emotions of others, empathic concern motivates us to take actions that will improve their welfare. As with emotional sharing, empathic concern is not only present in humans but also conserved among many non-human species and likely constitutes a major evolutionary advantage.
3. Perspective taking, which – according to Decety and Cowell – is the ability to put oneself into the mind of another and thus imagine what they might be thinking or feeling. This is a more cognitive dimension of empathy and essential for our ability to interact with fellow human beings. Even if we cannot experience the pain of others, we may still be able to understand or envision how they might be feeling. One of the key features of psychopaths is their inability to experience the emotions of others. However, this does not necessarily mean that psychopaths are unable to cognitively imagine what others are thinking. Instead of labeling psychopaths as having no empathy, it is probably more appropriate to specifically characterize them as having a reduced capacity to share in the emotions while maintaining an intact capacity for perspective-taking.
In addition to the complexity of what we call “empathy”, we need to also understand that empathy is usually directed towards specific individuals and groups. De Dreu’s studies demonstrated that oxytocin can make us more pro-social as long as it benefits those who we feel belong to our group but not necessarily those outside of our group. The study Do you feel my pain? Racial group membership modulates empathic neural responses by Xu and colleagues at Peking University used fMRI brain imaging in Chinese and Caucasian study subjects and measured their neural responses to watching painful images. The study subjects were shown images of either a Chinese or a Caucasian face. In the control condition, the depicted image showed a face being poked with a cotton swab. In the pain condition, study subjects were shown a face of a person being poked with a needle attached to syringe. When the researchers measured the neural responses with the fMRI, they found significant activation in the anterior cingulate cortex (ACC) which is part of the neural pain circuit, both for pain we experience ourselves but also for empathic pain we experience when we see others in pain. The key finding in Xu’s study was that ACC activation in response to seeing the painful image was much more profound when the study subject and the person shown in the painful image belonged to the same race.
As we realize that the neural circuits and hormones which form the biological basis of our empathy responses are so easily swayed by group membership then it becomes apparent why increased empathy does not necessarily result in behavior consistent with moral principles. In his essay “Against Empathy“, the psychologist Paul Bloom also opposes the view that empathy should form the basis of morality and that we should unquestioningly elevate empathy to virtue for all:
“But we know that a high level of empathy does not make one a good person and that a low level does not make one a bad person. Being a good person likely is more related to distanced feelings of compassion and kindness, along with intelligence, self-control, and a sense of justice. Being a bad person has more to do with a lack of regard for others and an inability to control one’s appetites.”
I do not think that we can dismiss empathy as a factor in our moral decision-making. Bloom makes a good case for distanced compassion and kindness that does not arise from the more visceral emotion of empathy. But when we see fellow humans and animals in pain, then our initial biological responses are guided by empathy and anger, not the more abstract concept of distanced compassion. What we need is a better scientific and philosophical understanding of what empathy is. Empathic perspective-taking may be a far more robust and reliable guide for moral decision-making than empathic emotions. Current scientific studies on empathy often measure it as an aggregate measure without teasing out the various components of empathy. They also tend to underestimate that the relative contributions of the empathy components (emotion, concern, perspective-taking) can vary widely among cultures and age groups. We need to replace overly simplistic notions such as oxytocin = moral molecule or empathy = good with a more refined view of the complex morality-empathy relationship guided by rigorous science and philosophy.
De Dreu, C. K., Greer, L. L., Van Kleef, G. A., Shalvi, S., & Handgraaf, M. J. (2011). Oxytocin promotes human ethnocentrism. Proceedings of the National Academy of Sciences, 108(4), 1262-1266.
De Dreu, C., Greer, L., Van Kleef, G., Shalvi, S., & Handgraaf, M. (2011). Oxytocin promotes human ethnocentrism Proceedings of the National Academy of Sciences, 108 (4), 1262-1266 DOI: 10.1073/pnas.1015316108
Decety J, & Cowell JM (2014). Friends or Foes: Is Empathy Necessary for Moral Behavior? Perspectives on psychological science : a journal of the Association for Psychological Science, 9 (5), 525-37 PMID: 25429304
Shalvi S, & De Dreu CK (2014). Oxytocin promotes group-serving dishonesty. Proceedings of the National Academy of Sciences of the United States of America, 111 (15), 5503-7 PMID: 24706799
Xu X, Zuo X, Wang X, & Han S (2009). Do you feel my pain? Racial group membership modulates empathic neural responses. The Journal of neuroscience : the official journal of the Society for Neuroscience, 29 (26), 8525-9 PMID: 19571143
“The goal of privacy is not to protect some stable self from erosion but to create boundaries where this self can emerge, mutate, and stabilize. What matters here is the framework— or the procedure— rather than the outcome or the substance. Limits and constraints, in other words, can be productive— even if the entire conceit of “the Internet” suggests otherwise.
We cherish privacy in health matters because our health has such a profound impact on how we interact with other humans. If you are diagnosed with an illness, it should be your right to decide when and with whom you share this piece of information. Perhaps you want to hold off on telling your loved ones because you are worried about how it might affect them. Maybe you do not want your employer to know about your diagnosis because it could get you fired. And if your bank finds out, they could deny you a mortgage loan. These and many other reasons have resulted in laws and regulations that protect our personal health information. Family members, employers and insurances have no access to your health data unless you specifically authorize it. Even healthcare providers from two different medical institutions cannot share your medical information unless they can document your consent.
The recent study “Privacy Implications of Health Information Seeking on the Web” conducted by Tim Libert at the Annenberg School for Communication (University of Pennsylvania) shows that we have a for more nonchalant attitude regarding health privacy when it comes to personal health information on the internet. Libert analyzed 80,142 health-related webpages that users might come across while performing online searches for common diseases. For example, if a user uses Google to search for information on HIV, the Center for Disease Control and Prevention (CDC) webpage on HIV/AIDS (http://www.cdc.gov/hiv/) is one of the top hits and users will likely click on it. The information provided by the CDC will likely provide solid advice based on scientific results but Libert was more interested in investigating whether visits to the CDC website were being tracked. He found that by visiting the CDC website, information of the visit is relayed to third-party corporate entities such as Google, Facebook and Twitter. The webpage contains “Share” or “Like” buttons which is why the URL of the visited webpage (which contains the word “HIV”) is passed on to them – even if the user does not explicitly click on the buttons.
Libert found that 91% of health-related pages relay the URL to third parties, often unbeknownst to the user, and in 70% of the cases, the URL contains sensitive information such as “HIV” or “cancer” which is sufficient to tip off these third parties that you have been searching for information related to a specific disease. Most users probably do not know that they are being tracked which is why Libert refers to this form of tracking as the “Invisible Web” which can only be unveiled when analyzing the hidden http requests between the servers. Here are some of the most common (invisible) partners which participate in the third-party exchanges:
EntityPercent of health-related pages
What do the third parties do with your data? We do not really know because the laws and regulations are rather fuzzy here. We do know that Google, Facebook and Twitter primarily make money by advertising so they could potentially use your info and customize the ads you see. Just because you visited a page on breast cancer does not mean that the “Invisible Web” knows your name and address but they do know that you have some interest in breast cancer. It would make financial sense to send breast cancer related ads your way: books about breast cancer, new herbal miracle cures for cancer or even ads by pharmaceutical companies. It would be illegal for your physician to pass on your diagnosis or inquiry about breast cancer to an advertiser without your consent but when it comes to the “Invisible Web” there is a continuous chatter going on in the background about your health interests without your knowledge.
Some users won’t mind receiving targeted ads. “If I am interested in web pages related to breast cancer, I could benefit from a few book suggestions by Amazon,” you might say. But we do not know what else the information is being used for. The appearance of the data broker Experian on the third-party request list should serve as a red flag. Experian‘s main source of revenue is not advertising but amassing personal data for reports such as credit reports which are then sold to clients. If Experian knows that you are checking out breast cancer pages then you should not be surprised if this information will be stored in some personal data file about you.
How do we contain this sharing of personal health information? One obvious approach is to demand accountability from the third parties regarding the fate of your browsing history. We need laws that regulate how information can be used, whether it can be passed on to advertisers or data brokers and how long the information is stored.
· Provide you with access to particular tools and services;
· Respond to your inquiries and send you administrative communications;
· Obtain your feedback on our sites and our offerings;
· Statistically analyze user behavior and activity;
· Provide you and people with similar demographic characteristics and interests with more relevant content and advertisements;
· Conduct research and measurement activities;
· Send you personalized emails or secure electronic messages pertaining to your health interests, including news, announcements, reminders and opportunities from WebMD; or
· Send you relevant offers and informational materials on behalf of our sponsors pertaining to your health interests.
Perhaps one of the most effective solutions would be to make the “Invisible Web” more visible. If health-related pages were mandated to disclose all third-party requests in real-time such as pop-ups (“Information about your visit to this page is now being sent to Amazon“) and ask for consent in each case, users would be far more aware of the threat to personal privacy posed by health-related pages. Such awareness of health privacy and potential threats to privacy are routinely addressed in the real world and there is no reason why this awareness should not be extended to online information.
Does morality depend on the time of the day? The study “The Morning Morality Effect: The Influence of Time of Day on Unethical Behavior” published in October of 2013 by Maryam Kouchaki and Isaac Smith suggested that people are more honest in the mornings, and that their ability to resist the temptation of lying and cheating wears off as the day progresses. In a series of experiments, Kouchaki and Smith found that moral awareness and self-control in their study subjects decreased in the late afternoon or early evening. The researchers also assessed the degree of “moral disengagement”, i.e. the willingness to lie or cheat without feeling much personal remorse or responsibility, by asking the study subjects to respond to questions such as “Considering the ways people grossly misrepresent themselves, it’s hardly a sin to inflate your own credentials a bit” or “People shouldn’t be held accountable for doing questionable things when they were just doing what an authority figure told them to do” on a scale from 1 (strongly disagree) to 7 (strongly agree). Interestingly, the subjects who strongly disagreed with such statements were the most susceptible to the morning morality effect. They were quite honest in the mornings but significantly more likely to cheat in the afternoons. On the other hand, moral disengagers, i.e. subjects who did not think that inflating credentials or following questionable orders was a big deal, were just as likely to cheat in the morning as they were in the afternoons.
Understandably, the study caused quite a bit of ruckus and became one of the most widely discussed psychology research studies in 2013, covered widely by blogs and newspapers such as the Guardian “Keep the mornings honest, the afternoons for lying and cheating” or the German Süddeutsche Zeitung “Lügen erst nach 17 Uhr” (Lying starts at 5 pm). And the findings of the study also raised important questions: Should organizations and businesses take the time of day into account when assigning tasks to employees which require high levels of moral awareness? How can one prevent the “moral exhaustion” in the late afternoon and the concomitant rise in the willingness to cheat? Should the time of the day be factored into punishments for unethical behavior?
One question not addressed by Kouchaki and Smith was whether the propensity to become dishonest in the afternoons or evenings could be generalized to all subjects or whether the internal time in the subjects was also a factor. All humans have an internal body clock – the circadian clock- which runs with a period of approximately 24 hours. The circadian clock controls a wide variety of physical and mental functions such as our body temperature, the release of hormones or our levels of alertness. The internal clock can vary between individuals, but external cues such as sunlight or the social constraints of our society force our internal clocks to be synchronized to a pre-defined external time which may be quite distinct from what our internal clock would choose if it were to “run free”. Free-running internal clocks of individuals can differ in terms of their period (for example 23.5 hours versus 24.4 hours) as well as the phases of when individuals would preferably engage in certain behaviors. Some people like to go to bed early, wake up at 5 am or 6 am on their own even without an alarm clock and they experience peak levels of alertness and energy before noon. In contrast to such “larks”, there are “owls” among us who prefer to go to bed late at night, wake up at 11 am, experience their peak energy levels and alertness in the evening hours and like to stay up way past midnight.
It is not always easy to determine our “chronotype” – whether we are “larks”, “owls” or some intermediate thereof – because our work day often imposes its demands on our internal clocks. Schools and employers have set up the typical workday in a manner which favors “larks”, with work days usually starting around 7am – 9am. In 1976, the researchers Horne and Östberg developed a Morningness-Eveningness Questionnaire to investigate what time of the day individuals would prefer to wake up, work or take a test if it was entirely up to them. They found that roughly 40% of the people they surveyed had an evening chronotype!
If Kouchaki and Smith’s findings that cheating and dishonesty increases in the late afternoons applies to both morning and evening chronotype folks, then the evening chronotypes (“owls”) are in a bit of a pickle. Their peak performance and alertness times would overlap with their propensity to be dishonest. The researchers Brian Gunia, Christopher Barnes and Sunita Sah therefore decided to replicate the Kouchaki and Smith study with one major modification: They not only assessed the propensity to cheat at different times of the day, they also measured the chronotypes of the study participants. Their recent paper “”The Morality of Larks and Owls: Unethical Behavior Depends on Chronotype as Well as Time of Day” confirms that Kouchaki and Smith findings that the time of the day influences honesty, but the observed effects differ among chronotypes.
After assessing the chronotypes of 142 participants (72 women, 70 men; mean age 30 years), the researchers randomly assigned them to either a morning session (7:00 to 8:30 am) or an evening session (12:00 am to 1:30 am). The participants were asked to report the outcome of a die roll; the higher the reported number, the more raffle tickets they would receive for a large prize, which served as an incentive to inflate the outcome of the roll. Since a die roll is purely random, one would expect that reported average of the die roll results would be similar across all groups if all participants were honest. Their findings: Morning people (“larks”) tended to report higher die-roll numbers in the evening than in the morning – thus supporting the Kouchaki and Smith results- but evening people tended to report higher numbers in the morning than in the evening. This means that the morning morality effect and the idea of “moral exhaustion” towards the end of the day cannot be generalized to all. In fact, evening people (“owls”) are more honest in the evenings.
Not so fast, say Kouchaki and Smith in a commentary published to together with the new paper by Gunia and colleagues. They applaud the new study for taking the analysis of daytime effects on cheating one step further by considering the chronotypes of the participants, but they also point out some important limitations of the newer study. Gunia and colleagues only included morning and evening people in their analysis and excluded the participants who reported an intermediate chronotype, i.e. not quite early morning “larks” and not true “owls”. This is a valid criticism because newer research on chronotypes by Till Roenneberg and his colleagues at the University of Munich has shown that there is a Gaussian distribution of chronotypes. Few of us are extreme larks or extreme owls, most of us lie on a continuum. Roenneberg’s approach to measuring chronotypes looks at the actual hours of sleep we get and distinguishes between our behaviors on working days and weekends because the latter may provide a better insight into our endogenous clock, unencumbered by the demands of our work schedule. The second important limitation identified by Kouchaki and Smith is that Gunia and colleagues used 12 am to 1:30 am as the “evening condition”. This may be the correct time to study the peak performance of extreme owls and selected night shift workers but ascertaining cheating behavior at this hour is not necessarily relevant for the general workforce.
Neither the study by Kouchaki and Smith nor the new study by Gunia and colleagues provide us with a definitive answer as to how the external time of the day (the time according to the sun and our social environment) and the internal time (the time according to our internal circadian clock) affect moral decision-making. We need additional studies with larger sample sizes which include a broad range of participants with varying chronotypes as well as studies which assess moral decision-making not just at two time points but also include a range of time points (early morning, afternoon, late afternoon, evening, night, etc.). But the two studies have opened up a whole new area of research and their findings are quite relevant for the field of experimental philosophy, which uses psychological methods to study philosophical questions. If empirical studies are conducted with human subjects then researchers need to take into account the time of the day and the internal time and chronotype of the participants, as well as other physiological differences between individuals.
The exchange between Kouchaki & Smith and Gunia & colleagues also demonstrates the strength of rigorous psychological studies. Researcher group 1 makes a highly provocative assertion based on their data, researcher group 2 partially replicates it and qualifies it by introducing one new variable (chronotypes) and researcher group 1 then analyzes strengths and weaknesses of the newer study. This type of constructive criticism and dialogue is essential for high-quality research. Hopefully, future studies will be conducted to provide more insights into this question. By using the Roenneberg approach to assess chronotypes, one could potentially assess a whole continuum of chronotypes – both on working days and weekends – and also relate moral reasoning to the amount of sleep we get. Measurements of body temperature, hormone levels, brain imaging and other biological variables may provide further insight into how the time of day affects our moral reasoning.
Why is this type of research important? I think that realizing how dynamic moral judgment can be is a humbling experience. It is easy to condemn the behavior of others as “immoral”, “unethical” or “dishonest” as if these are absolute pronouncements. Realizing that our own judgment of what is considered ethical or acceptable can vary because of our internal clock or the external time of the day reminds us to be less judgmental and more appreciative of the complex neurobiology and physiology which influence moral decision-making. If future studies confirm that the internal time (and possibly sleep deprivation) influences moral decision-making, then we need to carefully rethink whether the status quo of forcing people with diverse chronotypes into a compulsory 9-to-5 workday is acceptable. Few, if any, employers and schools have adapted their work schedules to accommodate chronotype diversity in human society. Understanding that individualized work schedules for people with diverse chronotypes may not only increase their overall performance but also increase their honesty might serve as another incentive for employers and schools to recognize the importance of chronotype diversity among individuals.
We often laud intellectual diversity of a scientific research group because we hope that the multitude of opinions can help point out flaws and improve the quality of research long before it is finalized and written up as a manuscript. The recent events surrounding the research in one of the world’s most famous stem cell research laboratories at Harvard shows us the disastrous effects of suppressing diverse and dissenting opinions.
The infamous “Orlic paper” was a landmark research article published in the prestigious scientific journal Nature in 2001, which showed that stem cells contained in the bone marrow could be converted into functional heart cells. After a heart attack, injections of bone marrow cells reversed much of the heart attack damage by creating new heart cells and restoring heart function. It was called the “Orlic paper” because the first author of the paper was Donald Orlic, but the lead investigator of the study was Piero Anversa, a professor and highly respected scientist at New York Medical College.
Anversa had established himself as one of the world’s leading experts on the survival and death of heart muscle cells in the 1980s and 1990s, but with the start of the new millennium, Anversa shifted his laboratory’s focus towards the emerging field of stem cell biology and its role in cardiovascular regeneration. The Orlic paper was just one of several highly influential stem cell papers to come out of Anversa’s lab at the onset of the new millenium. A 2002 Anversa paper in the New England Journal of Medicine – the world’s most highly cited academic journal –investigated the hearts of human organ transplant recipients. This study showed that up to 10% of the cells in the transplanted heart were derived from the recipient’s own body. The only conceivable explanation was that after a patient received another person’s heart, the recipient’s own cells began maintaining the health of the transplanted organ. The Orlic paper had shown the regenerative power of bone marrow cells in mouse hearts, but this new paper now offered the more tantalizing suggestion that even human hearts could be regenerated by circulating stem cells in their blood stream.
A 2003 publication in Cell by the Anversa group described another ground-breaking discovery, identifying a reservoir of stem cells contained within the heart itself. This latest coup de force found that the newly uncovered heart stem cell population resembled the bone marrow stem cells because both groups of cells bore the same stem cell protein called c-kit and both were able to make new heart muscle cells. According to Anversa, c-kit cells extracted from a heart could be re-injected back into a heart after a heart attack and regenerate more than half of the damaged heart!
These Anversa papers revolutionized cardiovascular research. Prior to 2001, most cardiovascular researchers believed that the cell turnover in the adult mammalian heart was minimal because soon after birth, heart cells stopped dividing. Some organs or tissues such as the skin contained stem cells which could divide and continuously give rise to new cells as needed. When skin is scraped during a fall from a bike, it only takes a few days for new skin cells to coat the area of injury and heal the wound. Unfortunately, the heart was not one of those self-regenerating organs. The number of heart cells was thought to be more or less fixed in adults. If heart cells were damaged by a heart attack, then the affected area was replaced by rigid scar tissue, not new heart muscle cells. If the area of damage was large, then the heart’s pump function was severely compromised and patients developed the chronic and ultimately fatal disease known as “heart failure”.
Anversa’s work challenged this dogma by putting forward a bold new theory: the adult heart was highly regenerative, its regeneration was driven by c-kit stem cells, which could be isolated and used to treat injured hearts. All one had to do was harness the regenerative potential of c-kit cells in the bone marrow and the heart, and millions of patients all over the world suffering from heart failure might be cured. Not only did Anversa publish a slew of supportive papers in highly prestigious scientific journals to challenge the dogma of the quiescent heart, he also happened to publish them at a unique time in history which maximized their impact.
In the year 2001, there were few innovative treatments available to treat patients with heart failure. The standard approach was to use medications that would delay the progression of heart failure. But even the best medications could not prevent the gradual decline of heart function. Organ transplants were a cure, but transplantable hearts were rare and only a small fraction of heart failure patients would be fortunate enough to receive a new heart. Hopes for a definitive heart failure cure were buoyed when researchers isolated human embryonic stem cells in 1998. This discovery paved the way for using highly pliable embryonic stem cells to create new heart muscle cells, which might one day be used to restore the heart’s pump function without resorting to a heart transplant.
The dreams of using embryonic stem cells to regenerate human hearts were soon squashed when the Bush administration banned the generation of new human embryonic stem cells in 2001, citing ethical concerns. These federal regulations and the lobbying of religious and political groups against human embryonic stem cells were a major blow to research on cardiovascular regeneration. Amidst this looming hiatus in cardiovascular regeneration, Anversa’s papers appeared and showed that one could steer clear of the ethical controversies surrounding embryonic stem cells by using an adult patient’s own stem cells. The Anversa group re-energized the field of cardiovascular stem cell research and cleared the path for the first human stem cell treatments in heart disease.
Instead of having to wait for the US government to reverse its restrictive policy on human embryonic stem cells, one could now initiate clinical trials with adult stem cells, treating heart attack patients with their own cells and without having to worry about an ethical quagmire. Heart failure might soon become a disease of the past. The excitement at all major national and international cardiovascular conferences was palpable whenever the Anversa group, their collaborators or other scientists working on bone marrow and cardiac stem cells presented their dizzyingly successful results. Anversa received numerous accolades for his discoveries and research grants from the NIH (National Institutes of Health) to further develop his research program. He was so successful that some researchers believed Anversa might receive the Nobel Prize for his iconoclastic work which had redefined the regenerative potential of the heart. Many of the world’s top universities were vying to recruit Anversa and his group, and he decided to relocate his research group to Harvard Medical School and Brigham and Women’s Hospital 2008.
There were naysayers and skeptics who had resisted the adult stem cell euphoria. Some researchers had spent decades studying the heart and found little to no evidence for regeneration in the adult heart. They were having difficulties reconciling their own results with those of the Anversa group. A number of practicing cardiologists who treated heart failure patients were also skeptical because they did not see the near-miraculous regenerative power of the heart in their patients. One Anversa paper went as far as suggesting that the whole heart would completely regenerate itself roughly every 8-9 years, a claim that was at odds with the clinical experience of practicing cardiologists. Other researchers pointed out serious flaws in the Anversa papers. For example, the 2002 paper on stem cells in human heart transplant patients claimed that the hearts were coated with the recipient’s regenerative cells, including cells which contained the stem cell marker Sca-1. Within days of the paper’s publication, many researchers were puzzled by this finding because Sca-1 was a marker of mouse and rat cells – not human cells! If Anversa’s group was finding rat or mouse proteins in human hearts, it was most likely due to an artifact. And if they had mistakenly found rodent cells in human hearts, so these critics surmised, perhaps other aspects of Anversa’s research were similarly flawed or riddled with artifacts.
At national and international meetings, one could observe heated debates between members of the Anversa camp and their critics. The critics then decided to change their tactics. Instead of just debating Anversa and commenting about errors in the Anversa papers, they invested substantial funds and efforts to replicate Anversa’s findings. One of the most important and rigorous attempts to assess the validity of the Orlic paper was published in 2004, by the research teams of Chuck Murry and Loren Field. Murry and Field found no evidence of bone marrow cells converting into heart muscle cells. This was a major scientific blow to the burgeoning adult stem cell movement, but even this paper could not deter the bone marrow cell champions.
The skeptics who had doubted Anversa’s claims all along may now feel vindicated, but this is not the time to gloat. Instead, the discipline of cardiovascular stem cell biology is now undergoing a process of soul-searching. How was it possible that some of the most widely read and cited papers were based on heavily flawed observations and assumptions? Why did it take more than a decade since the first refutation was published in 2004 for scientists to finally accept that the near-magical regenerative power of the heart turned out to be a pipe dream.
One reason for this lag time is pretty straightforward: It takes a tremendous amount of time to refute papers. Funding to conduct the experiments is difficult to obtain because grant funding agencies are not easily convinced to invest in studies replicating existing research. For a refutation to be accepted by the scientific community, it has to be at least as rigorous as the original, but in practice, refutations are subject to even greater scrutiny. Scientists trying to disprove another group’s claim may be asked to develop even better research tools and technologies so that their results can be seen as more definitive than those of the original group. Instead of relying on antibodies to identify c-kit cells, the 2014 refutation developed a transgenic mouse in which all c-kit cells could be genetically traced to yield more definitive results – but developing new models and tools can take years.
The scientific peer review process by external researchers is a central pillar of the quality control process in modern scientific research, but one has to be cognizant of its limitations. Peer review of a scientific manuscript is routinely performed by experts for all the major academic journals which publish original scientific results. However, peer review only involves a “review”, i.e. a general evaluation of major strengths and flaws, and peer reviewers do not see the original raw data nor are they provided with the resources to replicate the studies and confirm the veracity of the submitted results. Peer reviewers rely on the honor system, assuming that the scientists are submitting accurate representations of their data and that the data has been thoroughly scrutinized and critiqued by all the involved researchers before it is even submitted to a journal for publication. If peer reviewers were asked to actually wade through all the original data generated by the scientists and even perform confirmatory studies, then the peer review of every single manuscript could take years and one would have to find the money to pay for the replication or confirmation experiments conducted by peer reviewers. Publication of experiments would come to a grinding halt because thousands of manuscripts would be stuck in the purgatory of peer review. Relying on the integrity of the scientists submitting the data and their internal review processes may seem naïve, but it has always been the bedrock of scientific peer review. And it is precisely the internal review process which may have gone awry in the Anversa group.
Just like Pygmalion fell in love with Galatea, researchers fall in love with the hypotheses and theories that they have constructed. To minimize the effects of these personal biases, scientists regularly present their results to colleagues within their own groups at internal lab meetings and seminars or at external institutions and conferences long before they submit their data to a peer-reviewed journal. The preliminary presentations are intended to spark discussions, inviting the audience to challenge the veracity of the hypotheses and the data while the work is still in progress. Sometimes fellow group members are truly skeptical of the results, at other times they take on the devil’s advocate role to see if they can find holes in their group’s own research. The larger a group, the greater the chance that one will find colleagues within a group with dissenting views. This type of feedback is a necessary internal review process which provides valuable insights that can steer the direction of the research.
Considering the size of the Anversa group – consisting of 20, 30 or even more PhD students, postdoctoral fellows and senior scientists – it is puzzling why the discussions among the group members did not already internally challenge their hypotheses and findings, especially in light of the fact that they knew extramural scientists were having difficulties replicating the work.
“I think that most scientists, perhaps with the exception of the most lucky or most dishonest, have personal experience with failure in science—experiments that are unreproducible, hypotheses that are fundamentally incorrect. Generally, we sigh, we alter hypotheses, we develop new methods, we move on. It is the data that should guide the science.
In the Anversa group, a model with much less intellectual flexibility was applied. The “Hypothesis” was that c-kit (cd117) positive cells in the heart (or bone marrow if you read their earlier studies) were cardiac progenitors that could: 1) repair a scarred heart post-myocardial infarction, and: 2) supply the cells necessary for cardiomyocyte turnover in the normal heart.
This central theme was that which supplied the lab with upwards of $50 million worth of public funding over a decade, a number which would be much higher if one considers collaborating labs that worked on related subjects.
In theory, this hypothesis would be elegant in its simplicity and amenable to testing in current model systems. In practice, all data that did not point to the “truth” of the hypothesis were considered wrong, and experiments which would definitively show if this hypothesis was incorrect were never performed (lineage tracing e.g.).”
Discarding data that might have challenged the central hypothesis appears to have been a central principle.
According to the whistleblower, Anversa’s group did not just discard undesirable data, they actually punished group members who would question the group’s hypotheses:
“In essence, to Dr. Anversa all investigators who questioned the hypothesis were “morons,” a word he used frequently at lab meetings. For one within the group to dare question the central hypothesis, or the methods used to support it, was a quick ticket to dismissal from your position.“
The group also created an environment of strict information hierarchy and secrecy which is antithetical to the spirit of science:
“The day to day operation of the lab was conducted under a severe information embargo. The lab had Piero Anversa at the head with group leaders Annarosa Leri, Jan Kajstura and Marcello Rota immediately supervising experimentation. Below that was a group of around 25 instructors, research fellows, graduate students and technicians. Information flowed one way, which was up, and conversation between working groups was generally discouraged and often forbidden.
Raw data left one’s hands, went to the immediate superior (one of the three named above) and the next time it was seen would be in a manuscript or grant. What happened to that data in the intervening period is unclear.
A side effect of this information embargo was the limitation of the average worker to determine what was really going on in a research project. It would also effectively limit the ability of an average worker to make allegations regarding specific data/experiments, a requirement for a formal investigation.“
This segregation of information is a powerful method to maintain an authoritarian rule and is more typical for terrorist cells or intelligence agencies than for a scientific lab, but it would definitely explain how the Anversa group was able to mass produce numerous irreproducible papers without any major dissent from within the group.
In addition to the secrecy and segregation of information, the group also created an atmosphere of fear to ensure obedience:
“Although individually-tailored stated and unstated threats were present for lab members, the plight of many of us who were international fellows was especially harrowing. Many were technically and educationally underqualified compared to what might be considered average research fellows in the United States. Many also originated in Italy where Dr. Anversa continues to wield considerable influence over biomedical research.
This combination of being undesirable to many other labs should they leave their position due to lack of experience/training, dependent upon employment for U.S. visa status, and under constant threat of career suicide in your home country should you leave, was enough to make many people play along.
Even so, I witnessed several people question the findings during their time in the lab. These people and working groups were subsequently fired or resigned. I would like to note that this lab is not unique in this type of exploitative practice, but that does not make it ethically sound and certainly does not create an environment for creative, collaborative, or honest science.”
Foreign researchers are particularly dependent on their employment to maintain their visa status and the prospect of being fired from one’s job can be terrifying for anyone.
This is an anonymous account of a whistleblower and as such, it is problematic. The use of anonymous sources in science journalism could open the doors for all sorts of unfounded and malicious accusations, which is why the ethics of using anonymous sources was heavily debated at the recent ScienceOnline conference. But the claims of the whistleblower are not made in a vacuum – they have to be evaluated in the context of known facts. The whistleblower’s claim that the Anversa group and their collaborators received more than $50 million to study bone marrow cell and c-kit cell regeneration of the heart can be easily verified at the public NIH grant funding RePORTer website. The whistleblower’s claim that many of the Anversa group’s findings could not be replicated is also a verifiable fact. It may seem unfair to condemn Anversa and his group for creating an atmosphere of secrecy and obedience which undermined the scientific enterprise, caused torment among trainees and wasted millions of dollars of tax payer money simply based on one whistleblower’s account. However, if one looks at the entire picture of the amazing rise and decline of the Anversa group’s foray into cardiac regeneration, then the whistleblower’s description of the atmosphere of secrecy and hierarchy seems very plausible.
The investigation of Harvard into the Anversa group is not open to the public and therefore it is difficult to know whether the university is primarily investigating scientific errors or whether it is also looking into such claims of egregious scientific misconduct and abuse of scientific trainees. It is unlikely that Anversa’s group is the only group that might have engaged in such forms of misconduct. Threatening dissenting junior researchers with a loss of employment or visa status may be far more common than we think. The gravity of the problem requires that the NIH – the major funding agency for biomedical research in the US – should look into the prevalence of such practices in research labs and develop safeguards to prevent the abuse of science and scientists.
The family of cholesterol lowering drugs known as ‘statins’ are among the most widely prescribed medications for patients with cardiovascular disease. Large-scale clinical studies have repeatedly shown that statins can significantly lower cholesterol levels and the risk of future heart attacks, especially in patients who have already been diagnosed with cardiovascular disease. A more contentious issue is the use of statins in individuals who have no history of heart attacks, strokes or blockages in their blood vessels. Instead of waiting for the first major manifestation of cardiovascular disease, should one start statin therapy early on to prevent cardiovascular disease?
If statins were free of charge and had no side effects whatsoever, the answer would be rather straightforward: Go ahead and use them as soon as possible. However, like all medications, statins come at a price. There is the financial cost to the patient or their insurance to pay for the medications, and there is a health cost to the patients who experience potential side effects. The Guideline Panel of the American College of Cardiology (ACC) and the American Heart Association (AHA) therefore recently recommended that the preventive use of statins in individuals without known cardiovascular disease should be based on personalized risk calculations. If the risk of developing disease within the next 10 years is greater than 7.5%, then the benefits of statin therapy outweigh its risks and the treatment should be initiated. The panel also indicated that if the 10-year risk of cardiovascular disease is greater than 5%, then physicians should consider prescribing statins, but should bear in mind that the scientific evidence for this recommendation was not as strong as that for higher-risk individuals.
Using statins in low risk patients
The recommendation that individuals with comparatively low risk of developing future cardiovascular disease (10-year risk lower than 10%) would benefit from statins was met skepticism by some medical experts. In October 2013, the British Medical Journal (BMJ)published a paper by John Abramson, a lecturer at Harvard Medical School, and his colleagues which re-evaluated the data from a prior study on statin benefits in patients with less than 10% cardiovascular disease risk over 10 years. Abramson and colleagues concluded that the statin benefits were over-stated and that statin therapy should not be expanded to include this group of individuals. To further bolster their case, Abramson and colleagues also cited a 2013 study by Huabing Zhang and colleagues in the Annals of Internal Medicine which (according to Abramson et al.) had reported that 18 % of patients discontinued statins due to side effects. Abramson even highlighted the finding from the Zhang study by including it as one of four bullet points summarizing the key take-home messages of his article.
The problem with this characterization of the Zhang study is that it ignored all the caveats that Zhang and colleagues had mentioned when discussing their findings. The Zhang study was based on the retrospective review of patient charts and did not establish a true cause-and-effect relationship between the discontinuation of the statins and actual side effects of statins. Patients may stop taking medications for many reasons, but this does not necessarily mean that it is due to side effects from the medication. According to the Zhang paper, 17.4% of patients in their observational retrospective study had reported a “statin related incident” and of those only 59% had stopped the medication. The fraction of patients discontinuing statins due to suspected side effects was at most 9-10% instead of the 18% cited by Abramson. But as Zhang pointed out, their study did not include a placebo control group. Trials with placebo groups document similar rates of “side effects” in patients taking statins and those taking placebos, suggesting that only a small minority of perceived side effects are truly caused by the chemical compounds in statin drugs.
Admitting errors is only the first step
Whether 18%, 9% or a far smaller proportion of patients experience significant medication side effects is no small matter because the analysis could affect millions of patients currently being treated with statins. A gross overestimation of statin side effects could prompt physicians to prematurely discontinue medications that have been shown to significantly reduce the risk of heart attacks in a wide range of patients. On the other hand, severely underestimating statin side effects could result in the discounting of important symptoms and the suffering of patients. Abramson’s misinterpretation of statin side effect data was pointed out by readers of the BMJ soon after the article published, and it prompted an inquiry by the journal. After re-evaluating the data and discussing the issue with Abramson and colleagues, the journal issued a correction in which it clarified the misrepresentation of the Zhang paper.
Fiona Godlee, the editor-in-chief of the BMJ also wrote an editorial explaining the decision to issue a correction regarding the question of side effects and that there was not sufficient cause to retract the whole paper since the other points made by Abramson and colleagues – the lack of benefit in low risk patients – might still hold true. Instead, Godlee recognized the inherent bias of a journal’s editor when it comes to deciding on whether or not to retract a paper. Every retraction of a peer reviewed scholarly paper is somewhat of an embarrassment to the authors of the paper as well as the journal because it suggests that the peer review process failed to identify one or more major flaws. In a commendable move, the journal appointed a multidisciplinary review panel which includes leading cardiovascular epidemiologists. This panel will review the Abramson paper as well as another BMJ paper which had also cited the inaccurately high frequency of statin side effects, investigate the peer review process that failed to identify the erroneous claims and provide recommendations regarding the ultimate fate of the papers.
Reviewing peer review
Why didn’t the peer reviewers who evaluated Abramson’s article catch the error prior to its publication? We can only speculate as to why such a major error was not identified by the peer reviewers. One has to bear in mind that “peer review” for academic research journals is just that – a review. In most cases, peer reviewers do not have access to the original data and cannot check the veracity or replicability of analyses and experiments. For most journals, peer review is conducted on a voluntary (unpaid) basis by two to four expert reviewers who routinely spend multiple hours analyzing the appropriateness of the experimental design, methods, presentation of results and conclusions of a submitted manuscript. The reviewers operate under the assumption that the authors of the manuscript are professional and honest in terms of how they present the data and describe their scientific methodology.
In the case of Abramson and colleagues, the correction issued by the BMJ refers not to Abramson’s own analysis but to the misreading of another group’s research. Biomedical research papers often cite 30 or 40 studies, and it is unrealistic to expect that peer reviewers read all the cited papers and ensure that they are being properly cited and interpreted. If this were the expectation, few peer reviewers would agree to serve as volunteer reviewers since they would have hardly any time left to conduct their own research. However, in this particular case, most peer reviewers familiar with statins and the controversies surrounding their side effects should have expressed concerns regarding the extraordinarily high figure of 18% cited by Abramson and colleagues. Hopefully, the review panel will identify the reasons for the failure of BMJ’s peer review system and point out ways to improve it.
It is difficult to obtain precise numbers to quantify the actual extent of severe research misconduct and fraud since it may go undetected. Even when such cases are brought to the attention of the academic leadership, the involved committees and administrators may decide to keep their findings confidential and not disclose them to the public. However, most researchers working in academic research environments would probably agree that these are rare occurrences. A far more likely source of errors in research is the cognitive bias of the researchers. Researchers who believe in certain hypotheses and ideas are prone to interpreting data in a manner most likely to support their preconceived notions. For example, it is likely that a researcher opposed to statin usage will interpret data on side effects of statins differently than a researcher who supports statin usage. While Abramson may have been biased in the interpretation of the data generated by Zhang and colleagues, the field of cardiovascular regeneration is currently grappling in what appears to be a case of biased interpretation of one’s own data. An institutional review by Harvard Medical School and Brigham and Women’s Hospital recently determined that the work of Piero Anversa, one of the world’s most widely cited stem cell researchers, was significantly compromised and warranted a retraction. His group had reported that the adult human heart exhibited an amazing regenerative potential, suggesting that roughly every 8 to 9 years the adult human heart replaces its entire collective of beating heart cells (a 7% – 19% yearly turnover of beating heart cells). These findings were in sharp contrast to a prior study which had found only a minimal turnover of beating heart cells (1% or less per year) in adult humans. Anversa’s finding was also at odds with the observations of clinical cardiologists who rarely observe a near-miraculous recovery of heart function in patients with severe heart disease. One possible explanation for the huge discrepancy between the prior research and Anversa’s studies was that Anversa and his colleagues had not taken into account the possibility of contaminations that could have falsely elevated the cell regeneration counts.
Improving the quality of research: peer review and more
Despite the fact that researchers are prone to make errors due to inherent biases does not mean we should simply throw our hands up in the air, say “Mistakes happen!” and let matters rest. High quality science is characterized by its willingness to correct itself, and this includes improving methods to detect and correct scientific errors early on so that we can limit their detrimental impact. The realization that lack of reproducibility of peer-reviewed scientific papers is becoming a major problem for many areas of research such as psychology, stem cell research and cancer biology has prompted calls for better ways to track reproducibility and errors in science.
One important new paradigm that is being discussed to improve the quality of scholar papers is the role of post-publication peer evaluation. Instead of viewing the publication of a peer-reviewed research paper as an endpoint, post publication peer evaluation invites fellow scientists to continue commenting on the quality and accuracy of the published research even after its publication and to engage the authors in this process. Traditional peer review relies on just a handful of reviewers who decide about the fate of a manuscript, but post publication peer evaluation opens up the debate to hundreds or even thousands of readers which may be able to detect errors that could not be identified by the small number of traditional peer reviewers prior to publication. It is also becoming apparent that science journalists and science writers can play an important role in the post-publication evaluation of published research papers by investigating and communicating research flaws identified in research papers. In addition to helping dismantle the Science Mystique, critical science journalism can help ensure that corrections, retractions or other major concerns about the validity of scientific findings are communicated to a broad non-specialist audience.
In addition to these ongoing efforts to reduce errors in science by improving the evaluation of scientific papers, it may also be useful to consider new pro-active initiatives which focus on how researchers perform and design experiments. As the head of a research group at an American university, I have to take mandatory courses (in some cases on an annual basis) informing me about laboratory hazards, ethics of animal experimentation or the ethics of how to conduct human studies. However, there are no mandatory courses helping us identify our own research biases or how to minimize their impact on the interpretation of our data. There is an underlying assumption that if you are no longer a trainee, you probably know how to perform and interpret scientific experiments. I would argue that it does not hurt to remind scientists regularly – no matter how junior or senior- that they can become victims of their biases. We have to learn to continuously re-evaluate how we conduct science and to be humble enough to listen to our colleagues, especially when they disagree with us.
Neutrality is prized by scientists and journalists. Scientists are supposed to report and analyze their scientific research in a neutral fashion. Similarly, journalistic professionalism requires a neutral and objective stance when reporting or analyzing news. Nevertheless, scientists and journalists are also aware of the fact that there is no perfect neutrality. We are all victims of our conscious and unconscious biases and how we report data or events is colored by our biases. Not only is it impossible to be truly “neutral”, but one can even question whether “neutrality” should be a universal mandate. Neutrality can make us passive, especially when we see a clear ethical mandate to take action. Should one report in a neutral manner about genocide instead of becoming an advocate for the victims? Should a scientist who observes a destruction of ecosystems report on this in a neutral manner? Is it acceptable or perhaps even required for such a scientist to abandon neutrality and becoming an advocate to protect the ecosystems?
Science bloggers or science journalists have to struggle to find the right balance between neutrality and advocacy. Political bloggers and journalists who are enthusiastic supporters of a political party will find it difficult to preserve neutrality in their writing, but their target audiences may not necessarily expect them to remain neutral. I am often fascinated and excited by scientific discoveries and concepts that I want to write about, but I also notice how my enthusiasm for science compromises my neutrality. Should science bloggers strive for neutrality and avoid advocacy? Or is it understood that their audiences do not expect neutrality?
One way to increase objectivity and neutrality in science writing is to provide balanced views. When discussing a scientific discovery or concept, one can also cite or reference scientists with opposing views. This underscores that scientific opinion is not a monolith and that most scientific findings can and should be challenged. However, the mandate to provide balance can also lead to “false balance” when two opposing opinions are presented as two equivalent perspectives, even though one of the two sides has little to no scientific evidence to back up its claims. More than 99% of all climatologists agree about the importance of anthropogenic global warming, therefore it would be “false balance” to give equal space to opposing fringe views. Most science bloggers would also avoid “false balance” when it comes to reporting about the scientific value of homeopathy since nearly every scientist in the world agrees that homeopathy has no scientific data to back it up.
But how should science bloggers decide what constitutes “necessary balance” versus “false balance” when writing about areas of research where the scientific evidence is more ambivalent. How about a scientific discovery which 80% of scientists think is a landmark finding and 20% of scientists believe is a fluke? How does one find out about the scientific rigor of the various viewpoints and how should a blog post reflect these differences in opinion? Press releases of universities or research institutions usually only cite the researchers that conducted a scientific study, but how does one find out about other scientists who disagree with the significance of the new study?
3. Anonymous Sources
Most scientific peer review is conducted with anonymous sources. The editors of peer reviewed scientific journals send out newly submitted manuscripts to expert reviewers in the field but they try to make sure that the names of the reviewers remain confidential. This helps ensure that the reviewers can comment freely about any potential flaws in the manuscript without having to fear retaliation from the authors who might be incensed about the critique. Even in the post-publication phase, anonymous commenters can leave critical comments about a published study at the post-publication peer review website PubPeer. The comments made by anonymous as well as identified commenters at PubPeer played an important role in raising questions about recent controversial stem cell papers. On the other hand, anonymous sources may also use their cover to make baseless accusations and malign researchers. In the case of journals, the responsibility lies with the editors to ensure that their anonymous reviewers are indeed behaving in a professional manner and not abusing their anonymity.
Investigative political journalists also often rely on anonymous sources and whistle-blowers to receive critical information that would have otherwise been impossible to obtain. Journalists are also trained to ensure that their anonymous sources are credible and that they are not abusing their anonymity.
Should science bloggers and science journalists also consider using anonymous sources? Would unnamed scientists provide a more thorough critical appraisal of the quality of scientific research or would this open the door to abuse?
I hope that you leave comments on this post, tweet your thoughts using the #scioStandards hashtag and discuss your views at the Science Online conference.
Here is an excerpt from my latest post on the 3Quarksdaily blog:
Beware of what you share.Employers now routinely utilize internet search engines or social network searches to obtain information about job applicants. A survey of 2,184 hiring managers and human resource professionals conducted by the online employment website CareerBuilder.com revealed that 39% use social networking sites to research job candidates. Of the group who used social networks to evaluate job applicants, 43% found content on a social networking site that caused them to not hire a candidate, whereas only 19% found information that that has caused them to hire a candidate. The top reasons for rejecting a candidate based on information gleaned from social networking sites were provocative or inappropriate photos/information, including information about the job applicants’ history of substance abuse. This should not come as a surprise to job applicants in the US. After all, it is not uncommon for employers to invade the privacy of job applicants by conducting extensive background searches, ranging from the applicant’s employment history and credit rating to checking up on any history of lawsuits or run-ins with law enforcement agencies. Some employers also require drug testing of job applicants. The internet and social networking websites merely offer employers an additional array of tools to scrutinize their applicants. But how do we feel about digital sleuthing when it comes to relationship that is very different than the employer-applicant relationship – one which is characterized by profound trust, intimacy and respect, such as the relationship between healthcare providers and their patients?
The Hastings Center Report is a peer-reviewed academic bioethics journal which discusses the ethics of “Googling a Patient” in its most recent issue. It first describes a specific case of a twenty-six year old patient who sees a surgeon and requests a prophylactic mastectomy of both breasts. She says that she does not have breast cancer yet, but that her family is at very high risk for cancer. Her mother, sister, aunts, and a cousin have all had breast cancer; a teenage cousin had ovarian cancer at the age of nineteen; and that her brother was treated for esophageal cancer at the age of fifteen. She also says that she herself has suffered from a form of skin cancer (melanoma) at the age of twenty-five and that she wants to undergo the removal of her breasts without further workup because she wants to avoid developing breast cancer. She says that her prior mammogram had already shown abnormalities and she had been told by another surgeon that she needed the mastectomy.
Such prophylactic mastectomies, i.e. removal of both breasts, are indeed performed if young women are considered to be at very high risk for breast cancer based on their genetic profile and family history. The patient’s family history – her mother, sister and aunts being diagnosed with breast cancer – are indicative of a very high risk, but other aspects of the history such as her brother developing esophageal cancer at the age of fifteen are rather unusual. The surgeon confers with the patient’s primary care physician prior to performing the mastectomy and is puzzled by the fact that the primary care physician cannot confirm many of the claims made by the patient regarding her prior medical history or her family history. The physicians find no evidence of the patient ever having been diagnosed with a melanoma and they also cannot find documentation of the prior workup. The surgeon then asks a genetic counselor to meet with the patient and help resolve the discrepancies. During the evaluation process, the genetic counselor decides to ‘google’ the patient.
The genetic counselor finds two Facebook pages that are linked to the patient. One page appears to be a personal profile of the patient, stating that in addition to battling stage four melanoma (a very advanced stage of skin cancer with very low survival rates), she has recently been diagnosed with breast cancer. She also provides a link to a website soliciting donations to attend a summit for young cancer patients. The other Facebook page shows multiple pictures of the patient with a bald head, suggesting that she is undergoing chemotherapy, which is obviously not true according to what the genetic counselor and the surgeon have observed. Once this information is forwarded to the surgeon, he decides to cancel the planned surgery. It is not clear why the patient was intent on having the mastectomy and what she would gain from it, but the obtained information from the Facebook pages and the previously noted discrepancies are reason enough for the surgeon to rebuff the patient’s request for the surgery.
If you want to learn more about how ethics experts analyzed the situation and how common it is for psychologists enrolled in doctoral programs to use search engines or social networking sites in order to obtain more information about their patients/clients, please read the complete article at 3Quarksdaily.com.
There have been a series of interesting comments on Twitter about the ethical dilemma involved in prescribing male contraceptives, prompted by my recent essay for Aeon Magazine. Here is the relevant excerpt from the Aeon essay:
The discontinuation of the WHO/CONRAD trial was a major setback in bringing male contraceptives to the market. It also raised difficult ethical questions about how to evaluate side effects in male contraceptive trials. Since all medications are bound to exhibit some side effects, what side effects should be sufficient to halt a trial? Female contraceptives have been associated with breakthrough bleeding, mood changes, increased risk of blood-clot formation, as well as other side effects. Why should we set a different bar for male contraceptives?
The twist here is that female contraceptives prevent unintended pregnancies in the person actually taking the contraceptive. Since a pregnancy can cause some women significant health problems, the risk of contraceptive side effects can be offset by the benefit of avoiding an unintended pregnancy. However, men do not directly experience any of the health risks of pregnancy — their female partners do. Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men.
The usage of female hormonal contraceptives has been associated with a higher risk of blood clot formation, but pregnancies carry an even higher risk for blood clot formation and other medical complications. Doctors can make the reasonable argument that the benefits of a contraceptive outweighs the risks for their patient – and prescribe it.
The situation is a bit different when it comes to male contraceptives. I will try to illustrate this with a hypothetical scenario, in which there is a male contraceptive on the market.
Mr. Solo has an appointment with his family physician Dr. Crusher, who informs him that he is in perfect health. Mr. Solo then asks if he could receive a prescription for the newly approved male contraceptive. Dr. Crusher explains to him that this new male contraceptive has a 1% risk of causing side effects such as major depression.
Mr. Solo responds that he and his partner Ms. Amidala-Skywalker have decided not to get pregnant – at least not in the near future. Mr. Solo is very concerned about Ms. Amidala-Skywalker’s family history because her mother had a very difficult pregnancy and even died during childbirth. Ms. Amidala-Skywalker is not as worried about her pregnancy as Mr. Solo is and she does not want either of them to be permanently sterilized, but she and Mr. Solo have agreed to at least postpone having children for a few years. Ms. Amidala-Skywalker has been on an oral hormonal contraceptive for the past years.
Just prior to seeing Dr. Crusher, Mr. Solo was browsing some reading material in the waiting room and came across the magazine “Women’s Health” in which he read that women who regularly use hormonal contraceptives are at a higher risk for blood clot formations and maybe even strokes. All these years, his partner has been taking hormonal contraceptives and exposing herself to this higher risk. Since they both agreed not to have children at this point in time, Mr. Solo feels that it would only be fair if he now started using a male contraceptive and gave his partner a break. He does not mind the 1% risk of side effects, after all, she has been taking the “pill” for so many years and he believes that a true partnership is based on an equitable sharing of risks.
Dr. Crusher tries to dampen his enthusiasm. She says that she respects his desire to be fair towards his partner and she also wants to be supportive of their decision not to have a baby. She understands their concerns about the health risks that Ms. Amidala-Skywalker would face if she became pregnant.
However, Dr. Crusher explains to Mr. Solo that she has a doctor-patient relationship only with him – not with his partner. Dr. Crusher feels comfortable prescribing a medication for a patient when the patient derives a net health benefit from it. She agrees that Ms. Amidala-Skywalker’s well-being is important, but the health of Mr. Solo’s partner (or of any other family member) is not her primary concern. She does not see how she can justify subjecting him to a 1% risk of side effects and declines to prescribe it.
I am not suggesting that this is the best way or the only way to analyze the ethics of prescribing a male contraceptive pill which has some side effects. Not everyone has to agree with Dr. Crusher’s choice to focus only on the risks and benefits for her patient and to ignore the greater good or the medical benefits for his partner. These are the kinds of ethical dilemmas that physicians have to grapple with when it comes to addressing the issue of side effects associated with male contraceptives. Concerns about such ethical dilemmas and potential legal repercussions can act as deterrents for physicians and pharmaceutical companies.
But this does not mean that we should abandon the quest for male contraceptives. Doctors perform cosmetic surgeries without any medical benefits, despite the fact that some of the procedures can result in major complications. Physicians prescribe Viagra for men without a clearly defined medical indication even though Viagra can cause significant side effects.
If patients, healthcare professionals and the general public can find ways to ethically justify the risks of cosmetic surgery, it should be possible to resolve the dilemmas surrounding the prescription of male contraceptives. Instead of just maintaining the status quo in which women shoulder most of the burden and responsibility of contraception, we have to educate ourselves about alternatives and address the scientific, medical, ethical, political and cultural obstacles that prevent the development of newer male contraceptives.