Balancing our moral and empiric imperatives

Revisiting the importance of drawing a line between our values and our data.

Happy new year everyone. I am starting the year leaning into hope, even as challenges globally and domestically swirl. We shall reflect on those during the year I am sure.

Meanwhile, I wanted to start the year with a reflection on values, and how those who think about health can balance moral and empiric inputs. This seems particularly germane given some of the recent swirl in the public conversation that has been pushing the idea that somehow academic work should exist in a moral vacuum, and that values do not, or should not inform the work of idea generation. 

I start by going back a few years. In 2018, I wrote a piece for The Milbank Quarterly called “The Complicity of the Population Health Scientist.” The piece argued that those of us who work in population health science have a moral responsibility to address the ways the world does not generate health and that to do less is to be partly complicit in the persistence of these inequities. I wrote:

“Acceptance of the growing role of socioeconomic factors in shaping health and health gaps that is not linked to remedial action is complicit acquiescence to a status quo that should be anything but acceptable. Population health workers should be focusing all their energy on understanding the broader societal forces—especially political and economic forces—that are driving these widening inequities.”

I stand by these words. I have long argued that we do what we do, ultimately, for moral reasons, out of a deep commitment to the health of the public. We aspire to build a healthier world by building a better world, one founded on a basis of justice, equity, and compassion. This commitment nudges us beyond a neutral role that concerns itself purely with the generation of knowledge alone and pushes us into the realm of activism. At the same time, we are scientists. What we do is informed by data. We owe it to the future we hope to create to ensure that these data are as sound as possible and that we listen, always, to what our science is telling us.

This is, I realize, a very particular view of the role of the population health scientist, putting in the foreground our purpose, even while recognizing that what we do is, has to be, built on data and truth. This marriage of science and mission-driven purpose may seem like an obviously correct mix to a reader who is steeped in the goals of public health, as I have long been, animated by a commitment to the aspirations of the field. However, it is important not to lose sight of how radical this conception of our work is. For one, it is divergent from the traditional role of the dispassionate scientist who is doing their work uninfluenced by their feelings about the outcome of their data. For another, it pushes us to ask how we get to clarity on our moral imperatives, and how that clarity balances with what emerges from our data.

It also raises the possibility of tension arising between our science and our public statements in support of the vision of the world we wish to see. This is the case, for example, when our understanding of climate change—that it is real, that it is caused by humans, and that it poses an existential threat to the future and to health—is complicated by the nuance of climate science. While our general understanding of climate change is overwhelmingly supported by the scientific consensus, there is still much to be learned about the drivers of climate change, and the areas where human activity does and does not play a significant role. This has led to some scientists who are broadly accepting of the scientific consensus, and some who are less so, being called out for suggesting that this consensus might not be as clear-cut as it is sometimes presented. These controversies reflect the challenges that can arise when we aim to balance our science and our moral commitments, working not just to understand the world but to change it for the better.  

As I mentioned at the outset, I am aware that this model of our work can be subject to criticism, and that there has been substantial criticism of the very idea that values may inform science in recent weeks. There are some who would say that there should always be a wall of separation between science and activism. There are others who might say we should be wholly activist, and that whatever gets us to political “wins” should always take priority over other considerations.

Let me address first why I think our approach—one that strikes a balance between moral and empiric considerations—advances both our science and the cause of health. I will then address some challenges this approach can pose and how we might engage with them.

First, to say public health aspires to a balance of moral and empiric imperatives is to speak the truth about how we have long operated, and the truth can never, should never, conflict with a science-based endeavor. We are well served, then, by being honest about what we do. Those concerned with the health of the public are, well, concerned with the health of the public. This concern is rooted in a passion for creating a better world. This mitigates against an approach to our work where we hold ourselves aloof from the implications of our science. We are trying to create a better world for ourselves, for our family and friends, for our children. This goal is different from trying to create a new technology, or measure a chemical reaction, or deepen our knowledge about an area of less immediate relevance to the health of populations. This is not to in any way minimize these pursuits. It is simply to say that it is in the nature of our work to engage with our hearts as well as our heads, and it is in our interest to be honest about this—to hold ourselves accountable, to be clear about what we are doing and why we are doing it.

Second, it is simply false to say that scientists in general are not driven by motivations that are outside their field of inquiry. The ideal of pure objectivity is just that—an ideal. The function of an ideal is to serve as something to strive for, even as we understand we will always to some degree fall short of it. We all bring biases to our work, but, even more so, we come to our work because we care about aspects of it. Speaking for myself, I did not initially choose to work in public health because of a process of scientific reasoning. I came to public health because of a deep wish to help create a better world, a wish informed by personal experience of how the world is not yet as healthy as it should be. I suspect that this is a common path to a commitment to public health. It is a story I hear versions of each year, as new students join our school community, animated by a desire to help build a healthier world, a desire shaped by, first and foremost, a concern for people and the common good. From this starting point, we engage with the work of public health, including public health science.

Third, it is right by the world to take this approach. It is an enormous privilege to have the opportunity to do work that advances the health of the public, and it would be a disservice not to keep that front and center in all we do. There is nothing wrong with being who we are as long as we are honest about who we are. This means wearing our activism on our sleeve, as a central, guiding value of our field. If public health were about science alone, or activism alone, it could not pursue its mission as effectively as it can when it balances these two focus areas. We should not pursue our mission with one arm tied behind our back. We are in a moment that demands the best that public health has to offer. As we begin what will likely be a challenging, unsettled year, we need the passion that sustains our efforts and the data that guide effective action. We should remember, always, who we are, keeping close the values that anchor our field. We owe it to the populations we serve to be the best we can possibly be in this moment. 

Accepting that a balance of moral and empiric imperatives is the right approach for public health does not mean eliding the fact that this can pose challenges for what we do. I would argue that the following points reflect areas where we should take care that this approach does not threaten the integrity of our efforts.

First, it is worrisome of course to say that we are driven by a moral imperative, because of the concern that this may influence our science. To be clear, nothing should influence our science as much as we can help it. Acknowledging our biases does not mean surrendering to them, and we should work, as individuals and as a community, to ensure our science is as free from bias as possible. This includes creating a context in which researchers do not feel they must toe a particular line to get published and advance their careers. This constitutes, I would argue, a level of bias we should not accept, an institutionalization of what may well occasionally appear in our science but which we should not regard as welcome or desirable. Avoiding such pitfalls means continuing to be clear and upfront about our moral precommitments so that we can quickly recognize when they may be unduly influencing our science and work to correct this when it happens.

Second, even when our moral concerns are not influencing our science, it can appear that they are, which can be in many ways as problematic as when this perception reflects reality. The perception of bias undermines the public’s trust in what we do, and casts doubt on our findings. It is an irony worth noting that, if we wanted to advance a certain narrative, biasing our science would be the worst way to do it. If all our science is skewed in a certain direction, it creates space for some to dismiss it and tune out what our field is saying. Both the perception and the reality of bias diminish our field and its potential impact. This makes it critical for scientists of health to take the steps to, whenever possible, keep a wall between, for example, their perspective pieces and public writing and their science, and to make sure that the latter is not seen as influenced by the former.

Third, it is all well and good to aim for a balance between moral and empiric imperatives, but what should we do if and when they conflict? Science, to put it bluntly, is not always politically correct. If we find our science never complicates or runs counter to our preferred narratives, it is likely we are doing it wrong. Yet doing it right can be difficult. There are scientific data, and, indeed, whole areas of study that can complicate, challenge, and even undercut our preferred narratives. For example, there has been much written in recent years about the role of neighborhood factors (eg, neighborhood cohesion) in generating health outcomes, but what if they do not matter as much as we have come to think they do? Or what about even more challenging lines of inquiry like the role of genetics in shaping the physical and psychological factors that influence health outcomes? As our understanding of this area of study deepens, it raises the possibility that we will have to reckon with the reality of group differences based in genetics, a politically fraught and deeply controversial topic, but one which nevertheless has profound implications for our efforts to shape a healthier world. Is our field mature enough to engage with such topics honestly, while maintaining our commitment, always, to compassion, equity, and the pursuit of justice? The alternative is to leave to others the work of engaging with data that we do not find palatable. This runs the double risk of making us appear biased, as dishonest brokers, as we hand to those who might not share our moral vision—who may even oppose it—solid data for them to make their case. This poses a challenge that everyone involved in science needs to address. When science is published, it should be seen as a call to revise our understanding of what we think matters for health. For it to carry this weight, it should be conducted with dispassion, as we make every effort to separate our biases from our data—what we believe from what we know.

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Also this week.

Thoughts on how to write and present an academic paper in population health science.