“Messing with nature”: a worldview

Dear Anti-Vaxxers: You Want Pure Nature? OK, Die Young“, opines Jeffrey Kluger in a scathing piece in Time published today.

The article quotes an interview in Mother Jones with Dr. Stacia Kenet Lansman, a Tufts-graduated MD pediatrician, homeopath, herbalist, energy healer, and anti-vaxxer sympathizer who fears that vaccines are somehow disturbing the balance of nature and contributing to the rise of diseases like autism:

“I think we’re just messing with nature, and we really don’t know what we’ve created. We’ve reduced or largely eliminated many infectious diseases. But in their place, we have an epidemic of chronic illnesses in children. The incidence of asthma, allergies, and autism spectrum disorders has dramatically increased since the 1990s. And the reason for this we don’t know. But my concern is that vaccines have played a role.”

She spins her support of lax vaccination policies as “open-minded.” I see the view as falling in a long tradition of close-minded conservatism.

There are two separate aspects to this kind of worldview.

The first is an “appeal to nature.” This rhetorical device implies that if something is natural, then it is good. If something is unnatural, then it is bad. The “logic” is pervasive and extends to a preference not just for nature, but for the status quo in human society. The “status quo bias” afflicts human decisions almost by default, perhaps, according to “system justification theory,” due to a psychological need for stability in ones experience of life.

An appeal to nature can be a useful rule of thumb to determining what is good or useful, until one starts dismissing or ignoring contrary evidence. To do so would committing a fallacy of sweeping generalization. To ignore evidence is to become an ideologue. The key issue that separate the reasonable people and the crazies is determining when the evidence is good enough for you to believe something.

That brings us to the second aspect of this worldview I’m trying to describe: noncredulity. Noncredulity is exemplified by the following quote from former Congressman Willard Duncan a century ago, which originated Missouri’s sobriquet of the “Show-Me state”:

“I come from a state that raises corn and cotton and cockleburs and Democrats, and frothy eloquence neither convinces nor satisfies me. I am from Missouri. You have got to show me.”

Subscribers to this worldview are reluctant to believe something in the absence of adequate evidence.

By itself, noncredulity does not point to either conservative or progressive thinking. Noncredulity without a bias towards or against the natural could manifest as agnosticism or ambivalence. Noncredulous people with an irrational predisposition against the status quo could include extremist demagogues, paranoid anarchists, or hipsters who disavow anything mainstream. In contrast, unshakable noncredulity combined with a strong preference for what is natural or the status quo creates the special kind of conservative worldview espoused by Dr. Kenet Lansman.

Noncredulity and a strong bias towards a certain ideology is Donald Rumsfeld proclaiming there are “unknown unknowns” so we should invade Iraq in the absence of any evidence for or against WMD, just in case, because that’s what all my neo-conservative advisors say is right.

Noncredulity and ideological bias is Ann Coulter asserting that there is no credible or definitive evidence for evolution all while depicting intelligence design as serious “science.”

Noncredulity and ideological bias is a G. W. Bush aide tampering with government climate reports to sprinkle in phrases like “significant and fundamental uncertainties” about global warming, resigning after being outed, and then promptly getting re-hired by the fossil fuel lobby that he came from.

The extremes of noncredulity is denialism, including such mind-boggling phenomena as Holocaust denialism, AIDS denialism, and tobacco industry advertisements sowing seeds of doubt against the link between smoking and lung cancer.

The don’t-mess-with-nature anti-vaxxers are not ideologues like most of these examples in the traditional, political sense of the term. But I do think they are subscribing to a similar kind of thinking, one that happens to over-value one’s fears and current subjective experience of the world against contrary evidence.

My bias is towards the opposite. I’m a transhumanist, an early adopter, and an agitator. A few examples will suffice.

1) I like medicine because the whole point is to “mess with nature.” Biological discoveries and technological innovations provide solutions for the ailments that mother nature hands us, solutions that were unimaginable just decades ago. As doctors, we are helping people  live longer and better lives than the natural lottery would hand them. Just as medicine can treat disease, so too I think the future of medicine’s purview should include the enhancement of so-called normal human function. What I mean by enhancement ranges from the relatively benign, such as vaccines that enhance our immune resistance to pathogens, to the more controversial, such as stimulants (from caffeine to Adderall) and nootropics that could enhance attention and cognitive performance.

2) If you feel a gut uneasiness when it comes to the thought of someday taking pills that change your brain chemistry, consider the following example of non-pharmacologic modulation of your brain. When I first started using Anki to manage my knowledge in medical school more than a year ago, a friend of mine expressed reluctance, his concerns two-fold:

  1. How 1o you know it works? (noncredulity)
  2. It seems so un-human, like you’re just programming facts into your head. I prefer learn the human way, the way I’ve been learning for 20 years, because I know it works. (appeal to nature)

I thought, the point of tools like Anki is precisely that, a technological enhancement of the fallible capacity of the human mind to retain knowledge. Because there was so much evidence supporting the effect of spaced repetition and testing in educational psychology, I thought I had only made a small leap of faith that those studies would translate to med school in real life, so I drastically changed my study habits in adopting Anki.

3) Adopting a spaced repetition review program represented a shift away from the typical cycle of cram-and-ditch, binge-and-purge knowledge acquisition with which students are intimately familiar. It was a shift away from holding up whatever the lecturer and course materials taught as the sole gold standard of knowledge. I moved away from thinking that these courses had excellent external validity, i.e. exam performance could tell me that I’m going to be a good, knowledgeable doctor. The traditional view of education I ditched was that of students as empty vessels to be filled to the brim with knowledge that our teachers provide. The paradigm I liked, the model that medical education is moving towards slowly, is of med students as self-directed adult learners. Adult learners can think critically on a meta level: what are we learning and why are we learning it? They can consult multiple sources of information and assess their credibility. Self-directed learners know how they learn best and take effective action to assimilate the high-yield (most important and most likely to be true) knowledge. Once self-directed learners identify the meta-objective, the long-term goals, they do not require constant external motivation to get them to study on a daily basis. Now obsolete is the relentless stick and carrot approach of graded exams that functions mostly to discriminate fine differences between similarly capable students and to appease educators by enforcing 90%+ memorization of their provided material.

Imagine my unsurprised dismay when I found out a few weeks ago that the senior-most faculty at my school voted against adopting pass/fail grading for all preclinical courses.

The committee being semi-secret (to students anyway), I don’t know what their reasoning was. I imagine it went like this:

  1. There isn’t any convincing evidence that changing to pass/fail will not hurt student performance or outcomes. There isn’t any convincing evidence that the changing to pass/fail will help stress levels averaged over time when you still have the big stressors of Step 1 and third-year clerkships on the horizon. There isn’t any convincing evidence that pass/fail reduces competition and improve the learning environment. There’s not enough information, or I don’t believe the information. Since we’re planning to make various other little changes with the curriculum, the desired outcomes are a moving target so we should hold off on this for now.
  2. Med school has had grades since time immemorial. Generations of successful students have passed through in the current system. I came through this system and I sure know I learned more than I would have in a pass/fail system. I taught students in a different school/time under pass/fail and I’m sure they learned less than they would have with grades.

Noncredulity: Noncredulity in the face of published studies from many schools, enough to warrant a systematic review and then a multi-institutional study. Noncredulity that anyone else knows what they’re doing, even though almost all the top schools have already moved to pass/fail and is the single most common preclinical grading system among all MD schools, the Americal Medical Association officially acknowledges the benefits of preclinical pass/fail, and the American Medical Student Association “strongly urges” all medical schools to adopt preclinical pass/fail. Other schools see the rapidly shifting landscape; last month, Brown announced a change effective immediately to preclinical pass/fail after less than half a year of decision-making processes.

Appeal to nature: It’s been this way forever, and students are doing great. If it ain’t broke, don’t fix it. Especially don’t try to modify multiple things at once, even though some med schools have successfully changed to pass/fail as part of a whole package of concurrent curricular changes to improve student well-being. That would be too drastic and upset the stability of my worldview of medical education.

Show-Me state indeed.

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