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\nTradition is forgetfulness of origins…<\/font><\/strong><\/em><\/div>\nEdmund Husserl<\/div>\n<\/blockquote>\nIt must be kind of fun to be a philosopher, thinking about the nuts and bolts of something like "Tradition<\/font><\/strong><\/em>." I’m not constructed for that kind of fun – only an observer from afar. But fortunately for me, there’s always another philosopher that comes along to explain [and argue with] what the last one said – like here<\/a>: <\/div>\n\n"For Merleau-Ponty, the fact that geometry propagates itself from generation to generation in an anonymous sense as a set of human operations that began at no particular time in the past and which will be developed further in the present in order to arrive at a more developed science in the future is precisely what tradition is. “Tradition is forgetfulness of origins as empirical origins in order to be an eternal origin”. So tradition, according to Merleau-Ponty, essentially involves forgetfulness of empirical origins with the formation of a sense that can be transmitted over time and involving no conception of an origin..<\/font><\/strong><\/em>. <\/div>\n<\/blockquote>\nI got onto this line of thought pondering the notion that "Conflict of Interest is not a problem if it is acknowledged."<\/font><\/strong><\/em> I can’t imagine thinking that or how it came to be. Last year when New England Journal of Medicine<\/font> editor Jeffrey Drazen wrote Revisiting the Commercial–Academic Interface<\/a>, followed by a series suggesting that authors with financial conflicts of interest could write objective expert editorials and reviews, there was a reassuring collective groan heard throughout the land [see a narrative…<\/a>, not so proud…<\/a>, the real editors speak out…<\/a>]. In this case, the origins of the of the NEJM excluding "tainted" authors from editorials and reviews were actually not totally forgotten. The ban originated with former editor Arnold Relman’s 1980 article, The new medical-industrial complex<\/a>, and subsequent NEJM policy, but they had come to represent something like a "Tradition<\/font><\/strong><\/em>", at least in my mind. Our "next" philosopher cleared that point up: <\/div>\n\nHusserl’s account, as we have laid it out, however does not seem to necessitate such a reading. It is certainly not clear whether Husserl means to say that tradition essentially involves forgetfulness. Husserl does suggest that in order to uncover the structure of traditionality one does not have to concern oneself with empirical facts involving the names of the first geometers and the dates of their achievement. Traditions can develop in the absence of any factual knowledge of the founders of the tradition and the time of its founding. But this certainly does not imply that traditions necessarily require a forgetfulness of the empirical origins of that tradition. Husserls account does not seem to support the stronger claim made by Merleau-Ponty, in this regard…<\/div>\n<\/blockquote>\nWhat about other medical traditions, like primum non nocere<\/font><\/strong><\/em> ["First, do no harm<\/font>"]? We identify it as the Hippocratic Oath from the dawn of medical history. But there are a wealth of articles suggesting that’s a post-hoc revision. Many of those articles locate it in its current form to the mid-nineteenth century with varying attributions. That would fit other evidence. It was a period when puerperal fever [the Doctor’s Plague<\/font><\/em>, Childbed Fever] was epidemic [women dying after childbirth or miscarraige]. Ignaz Semmelweis noted that the incidence was remarkably less in women with home deliveries and suspected what was then called contagion<\/font><\/em>, instituting handwashing and other hygienic measures with dramatic results. In spite of his success, the notion that doctors were the cause was rejected by his colleagues and he died in a mental institution [not long before Pasteur’s and Lister’s germ theory of disease exonerated him, and revived Semmelweis’s recommendations]. Around that same time, Oliver Wendell Holmes Sr., a proponent of the emerging germ theory, said<\/a>:<\/div>\n\n"If the whole material medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind — and all the worse for the fishes."<\/div>\n<\/blockquote>\nHighlighting the focus on iatragenic illnesses ["of or relating to illness caused by medical examination or treatment<\/em>"]. So it would make sense that "First, Do no harm<\/font><\/em>" originated or gained prominence in that era [at least it makes a good story]. <\/div>\n
\nIn my first 20 years in medicine [1963-1983], I can’t recall any physicians I knew or worked with having a financial relationship with a pharmaceutical company. The first time was a Grand Rounds that was what I would now call an Infomercial – shortly before I left the University [1983-ish]. Checking back in 25 years later, it seems like everyone had multiple such connections. I have no sense of how that happened. It was the same with industry sponsored clinical trials in mainstream academic journals – from never<\/em> to every<\/em>. Of course there were doctors who worked for industry, but they weren’t the same ones that populated academic departments. I never recall thinking about it, but I think I assumed it was a "tradition<\/font><\/strong><\/em>" of medicine. I’ve looked around for some account of how all of that changed, and haven’t found a thing.<\/p>\n
Similarly, I’ve tried to find some history of where "Conflict of Interest is not a problem if it is acknowledged"<\/font><\/strong><\/em> specifically came from. While I agree that if a financial COI<\/font> is present, acknowledged<\/font><\/em> is better<\/font><\/em> than secret<\/font><\/em>. But "not a problem<\/font><\/em>"? Not hardly! Whether a guest·<\/font>author, an employee·<\/font>author, or a ghost·<\/font>writer, the problem is the same. None of those categories are synonyms for the meaning of the word "author<\/font><\/em>" that includes "originator<\/font><\/em>" or "creator<\/font><\/em>" – that implies an independent opinion. I might even be willing to go along with "<\/font><\/strong>Conflict of Interest is not <\/font>always<\/font><\/strong> a problem if it is acknowledged<\/font> and there is no money or other direct or indirect benefit involved<\/font><\/strong>."<\/em><\/p>\n
\nIn medical education, one doesn’t start out feeling like you’re a doctor. You’re an outsider looking in. The identity part arrives much later, if it does, indeed, arrive at all. It’s not easy to describe what I mean by that. I know I’m not talking about Evidence-Based Medicine, or the Biological Medical Model of Disease as, for example, the anti-biologists or anti-psychiatrist might explain. It has to do with an ethical tradition<\/font><\/strong><\/em> that is learned largely through example, by apprenticeship. While it may seem a paradox, the loudest criticisms of physicians come when that ethical tradition<\/font><\/strong><\/em> is absent – criticisms I find myself agreeing with most of the time. And there is simply no room in that ethical tradition<\/font><\/strong><\/em> for "Conflict of Interest is not a problem if it is acknowledged"<\/font><\/strong><\/em> no matter what argument follows. <\/p>\n
Rather than further lament the lost idealism of a former time when the integrity of academic physicians could be assumed, where there was an ethical tradition <\/font><\/strong><\/em>that more or less assured us that our literature could be trusted, it’s time to accept the fact that it has eroded to a point where it’s time to rethink the system. We can no longer look at the name, academic rank, or institutional affiliation of the author of an article [or the publishing journal] and use that as evidence for the opinion it expresses. The obvious solution is a regulatory system that has enough ongoing oversight to insure that it’s not being gamed. We think our Petition<\/a> fits the bill in the area of industry funded clinical trials [which is why I can’t seem to stop talking about it]. We back up primum non nocere<\/font><\/strong><\/em> with oversight and laws. Time to put similar teeth into the tradition of academic medical integrity<\/font><\/strong><\/em>…<\/p>\n
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