It bears conversation

On the value of engaging with difficult ideas from disagreeable sources

The U.S. health-care system, and research that has aimed to study this system, has long been stymied by challenges in sharing personal records over different platforms and systems. Scholars have observed the potential of research using shared data access platforms, including, for example, efforts in Europe to track persons across different health systems. In some ways this has felt like yet another intractable problem that is insoluble and that challenges U.S. health care.

But what if there were a solution? And what if that solution were announced by a sitting president who has, in his first six months in office, done much to undermine the cause of health? Well, that is exactly what President Trump announced recently, i.e., a health-care records system that would allow the sharing of personal health information for providers, including across different systems. Clearly there are many details that would need to be worked out — that is true of any new idea that tackles a long-standing status quo — but surely one would expect that we might have a chorus of enthusiasm from those in health and health care for the effort to address a difficult problem?

Not so much, it turns out, and the commentary on this system has largely been colored by concerns about privacy and thoughts on how this idea probably would not work. All legitimate, but all seeming to miss the point that other countries have done it, and that a proposal is on the table to do something truly worthwhile.

I thought the emergence of this idea, and the cautious skepticism of those of us in health, captured well a central dilemma of the moment. Given an administration that has just passed a bill that will likely undo many of the gains of the Affordable Care Act, that has put the entire scientific research establishment into chaos through withholding of funds, upended the global infrastructure that has long provided lifesaving care to low-income countries, and has substantially cut into staffing of core public health agencies such as the CDC, can there possibly also be good ideas that are emerging? And can we see the needle of good ideas for the haystack of more problematic ones? And does the manner in which some of the administration’s actions have been carried out preclude a good faith conversation about the virtues and drawbacks of some of these ideas?

There is no question that the moment is presenting us with challenging ideas. But when faced with some of these challenging ideas, can we have the presence of mind to ask whether any of these ideas bear conversation? Is it possible for us to engage with these ideas, to learn from them, even as these conversations may be catalyzed by political changes that are actively harming the health of the public? How can we learn from these conversations and separate that learning from the “how” of the current moment that is often capricious and oblivious to human harm?

Answering these questions means first tackling the core issue of whether we should choose to run the risks of conversation at all, of engaging with all manner of topics, even those that may unsettle us, even when they are espoused by those who may not have the health of the public as a leading priority. I would argue that we should do so, even with the risks involved, because, fundamentally, there is a substantial moral and intellectual hazard to silencing debate on contentious issues. In “On Liberty,” John Stuart Mill wrote:

“The peculiar evil of silencing the expression of an opinion is, that it is robbing the human race; posterity as well as the existing generation; those who dissent from the opinion, still more than those who hold it. If the opinion is right, they are deprived of the opportunity of exchanging error for truth: if wrong, they lose, what is almost as great a benefit, the clearer perception and livelier impression of truth, produced by its collision with error.”

We need open and honest conversation about important topics because we need to be exposed to both truth and error in our engagement with issues, understanding that this exposure helps to bolster the ultimate integrity of any conclusions produced by our investigations. Engaging from this perspective is not easy. It takes humility to consider that ideas with which we disagree could be worth hearing out, could even contain some value. It takes still more humility to remain open to the possibility that our own ideas could be misguided or even wrong. Yet to eschew this humility and the conversations it can support will likely have the effect of ensuring any confidence we have in our ideas is unfounded, setting us up for errors and missteps in our work. In such a context, our confidence runs the risk of tipping into hubris, which is not good for anyone — not good for us, nor for the populations we seek to make healthier.

To again quote Mill, “All silencing of discussion is an assumption of infallibility.” We should, of course, never assume we are infallible. Doing so is inimical to a scientific engagement with the world, which depends on reason, analysis, and being open to new information. The moment we assume we know everything, that we are undoubtedly on the right side of a given issue, we risk closing our minds to important information. Not hearing out other points of view — even extreme ones, even in health — creates blind spots in our knowledge, and openings in the public debate that can be filled by bad faith actors.

The fact is, progress is often driven by the emergence of difficult ideas, ideas that may initially face suppression and hostility from established authorities. We often harken to the story of Galileo and the scientific revolution all the way through the emergence of research challenging the idea that smoking was once considered safe. But in these stories, we see science as the hero, bucking “evil” forces in this case of church or commercial interests. But what if it is the scientific establishment itself that is the obstacle to progress? Take the example of Marshall and Warren’s once-controversial claim that most peptic ulcers are caused by bacteria. Initially ridiculed by the medical establishment, their hypothesis — dismissed as an extreme view against the consensus that stress or spicy food caused ulcers — bore fruit through dogged experimentation. Marshall famously drank a bacteria culture to prove his point, developing gastritis that he then treated with antibiotics. This led to further science that showed that they were right (leading to a Nobel Prize in 2005).

This work reflects how, at its best, a healthy marketplace of ideas, supported by the tenets of small-l liberalism (free speech, open debate, and a civil engagement with those with whom we disagree) can play an essential role in driving progress.

An objection to this may be that it is all well and good to engage with difficult ideas. But what about when this engagement is forced on us by acts of zero-sum political gamesmanship? This objection is understandable. However, it is worth remembering that a central reason we find ourselves in this position of vulnerability is that we never had these difficult conversations when we had the chance. In addition to this being a misstep for our field, it played a key role in seeding the backlash that we are seeing so that, when we look around for the public’s support in our hour of need, we find it is lacking. The way back to a position of strength — perhaps the only way — is to stop betting the viability of our field on the outcome of presidential elections and start having the conversations that the public is so clearly demanding that we have. Having such conversations at this late hour is, admittedly, not ideal. But it is never too late to do what is right, particularly when what is right aligns with what it necessary.

So, how can we become better at hearing difficult, even radical, ideas — particularly in the context of health? Certainly, at the heart of this must be cultivating intellectual humility and resilience in the face of uncomfortable information. This means remembering that listening — really listening — can be difficult, and is a skill to be practiced, much like critical thinking or empathy. Medicine has done a good job of institutionalizing some of this, for example, through morbidity and mortality conferences that openly discuss errors or adverse outcomes, knowing that productive discomfort leads to learning. By analogy, should we do the same with public policies and actions that are testable and contested? Can we ask ourselves difficult questions. Does public health infrastructure need rethinking? Should we have been more forthright about the potential risks of vaccines? Have we indeed struggled to engage with voices that challenge us in recent years? Importantly, it is possible to engage with such questions without giving ground to voices that spread misinformation. We need not agree that the world is flat to be willing to participate in a discourse that occasionally puts us in contact with fringe views. Rather, we should be willing to fully participate in the marketplace of ideas, confident that the truth will win out, yet humble enough to recognize that we are not always the ones in possession of it.

I will give the last word to John Milton’s who wrote, “Let [Truth] and Falsehood grapple; who ever knew Truth put to the worse, in a free and open encounter?”