The #NoakesHearing, and social media ethics for (medical) professionals

Last Tuesday, I gave a talk at the UCT medical school on the ethics of social media for medical professionals, which focused in part on the Health Professions Council hearings with regard to the ‘unprofessional conduct’ of Prof. Tim Noakes.

While I’ve presented a half-dozen or so talks on the philosophy and ethics of science for dietitians in the last couple of years – usually for continuing professional development (CPD) points – this one attracted more than the usual amount of attention, thanks to the imminent resumption of the Noakes hearings. Continue reading “The #NoakesHearing, and social media ethics for (medical) professionals”

HPCSA Hearings regarding Prof. Tim Noakes resume

As those of you who are following the discussions and arguments regarding “Banting” or the LCHF diet would know, the hearings with regard to Professor Tim Noakes’ giving “unconventional advice” on Twitter resumed (after convening for one day, in June) on Monday.

I attended much of the first day, and the morning of the second, and hope to return for much of the rest. At the bottom of this post, you’ll find a couple of embedded interviews I gave on Monday.

The full set of my posts on Prof. Noakes are here, and Banters coming here to proselytize should at least read my Quixotic note regarding Noakes, lest they end up missing the point of my interventions. For serious reporting from the hearings, read Rebecca Davis at the Daily Maverick, rather than cheerleader sites like BizNews.

So, in summary: Noakes is being characteristically savvy in leveraging these hearings into an opportunity to present the case for the LCHF diet (or “lifestyle”, if you’re a devotee). His legal team are ruthless and very well-prepared, in complete contrast to the floundering of the HPCSA team, who constantly need to be corrected on procedure and the like.

But that’s not what the hearings are meant to be about – they are meant to be about this tweet, and whether it constitutes unconventional or inappropriate advice:

As I said in my previous post on the hearings, while I think it’s unconventional, I don’t think it’s significantly problematic, in that it’s no different to the sort of advice we hear regularly on radio shows, or see suggested in other media.

I don’t think it’s reasonably interpreted as a “prescription” to a patient, and I think that it’s ambiguous enough to allow for a moderate interpretation, for example breast-feeding for 6 months before gradually converting your child to Banting (and perhaps introducing them to Jesus at the same time, while you’re at it).

So, the hearings are to my mind a huge waste of time and money, and will serve only as a PR opportunity for Noakes. The actual charge can be dispensed with in half an hour, and should be – the hearings are backfiring on the complainant in that Noakes is going to emerge stronger, in the sense that a win will validate his and his supporters feelings of martyrdom and being the victims of conspiracy.

All the worst aspects of the psychology of devout Banters have been on display – from the bullying and often condescending (arguably sexist) treatment of the initial complainant by one of Noakes’ legal team, to Marika Sboros following said complainant around to get photos of her in distress, others referring to her “falling apart”, and the ridiculously partisan nature of what’s being reported by those tweeting in support of Noakes.

As I was saying in a few of my occasional tweets from the hearings, if you want to play a game of fallacy-bingo, these hearings – and especially the input from van der Nest (acting for Noakes) were a goldmine. The conversations around medical ethics were absurdly superficial also – and if you add to that the manifestations of character I mention above, it’s really a frustrating thing to witness.

Arguments can be had here, and as objective readers (including some Banters) know, it’s those arguments I’ve been trying to air over the years. This isn’t a “trial” or a persecution, even though it might be a waste of time or even misguided, as I say in the interview with John Maytham below.

Just as Noakes is, in my view, utterly sincere about what he says (whether or not he’s right or wrong), the complainant in this case is sincere also, as the witnesses are in general, I imagine. For all talk of “science” the Banting crowd engage in, it’s a pity that their actions seldom manifest the careful, objective deliberations that science demands, preferring instead to perceive and/or provoke rather demeaning personal squabbles and character assassinations.

A few quick bites (on Noakes, diet and celebrity science)

It’s been a few months since I last posted anything about diet and Prof. Tim Noakes, but being reminded of the hearing that’s set to resume next month led me to check in on his Twitter echo chamber, which in turn leads to my presenting these few morsels to you.

First up, Austin Bradford Hill, who (according to Noakes, at least) taught that association only provides evidence for causation when a study’s Hazard Ratio (HR) is above 2.0. With the assistance of this factoid, Noakes has been dismissing inconvenient results with quips about “Bradford Hill turning in his grave” and so forth.

The Hill paper that Noakes cites (the text of a speech in this case) is indeed very good. It cautions us that systematic errors are prevalent enough in our research that we should be wary of placing too much faith in statistical significance as a guarantee of anything, and that health-related interventions need to be thought about carefully, in light of potential costs and benefits (rather than only with reference to what the evidence tells us).

And then, there’s this:

None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required as a sine qua non.

In other words, Hill is explicit that he’s not offering a hard-and-fast rule, but rather some useful rules of thumb. Here’s a lovely application of those rules of thumb to chiropractic, for those who don’t want to read the Hill speech itself.

The point, of course, is that Hill is here being misrepresented as a dogmatist, in order to give Noakes another of his stock-phrase putdowns (“cognitive dissonance”, “The Anointed”, “follow the money”, “go ahead, make my day” and so forth).

The misrepresentation is significant also because in this particular case, Hill might not be on Noakes’s side of the argument at all. As argued in this Phillips and Goodman paper, one of Hill’s central points was that “we need to consider more than the degree of certainty that there is some health hazard, and act based on the expected gains and losses, with or without statistical certainty.”

So, if it’s still the consensus view that limiting saturated fat (or rather, replacing it with unsaturated fat or whole grains rather than refined grains) is a good idea to minimise cardiovascular disease risk, it seems to me that Hill would accept the “violation” of his (non) rule for the sake of prudence.

But that exact study linked above (the actual paper is open-access, so you can read it if you like) is one of those that we should “pay no attention to”, “as Bradford Hill taught”.

Don’t get me wrong – of course it’s true that it’s difficult to establish causation from association. But it’s also true that absence of evidence is not evidence of absence – and that we need to apply our standards consistently, and honestly.

Hill didn’t give us a rule (that’s the honesty bit), and even if he had done so, I’m pretty sure that a trawl through Noakes’s timeline would give us many examples of him uncritically linking to pro-Banting literature that violates the rule (that’s the consistency bit).

Speaking of consistency, and the Banting-brigade’s fondness for accusing critics of being in the pockets of Big Potato (or compromised by some nefarious interest), I wonder how they feel about Nina Teicholz, lobbyist extraordinaire, being bankrolled by a billionaire?

I don’t think it necessarily a problem at all – as I’ve said in previous posts, we need to separate the claims from the funding – but if conflict of interest is a problem (as Banters claim), you don’t get to ignore it just because you like what the person is saying.

To repeat a point I’ve now made many times over the years, the issue for me is not the science – that’s evolving, as it tends to do, and there are still many unanswered questions related to diet and its effect on health, weight and so forth. The issue I am concerned with is misrepresentation, cherry-picking, logic and the substitution of soundbites and celebrity for scientific rigour (on that, here’s a good piece by Sarah Wild).

And then, in conclusion: here’s a new systematic review of recent RCTs on low-carbohydrate diets and Type 2 diabetes, which concludes that

Recent studies suggest that low carbohydrate diets appear to be safe and effective over the short term, but show no statistical differences from control diets with higher carbohydrate content and cannot be recommended as the default treatment for people with type 2 diabetes.

The authors also note that “passion in science is an infallible marker of lack of evidence” – and while I think that overstates the matter somewhat, it’s again a useful rule of thumb.

Someone linked my tweet of that study to Noakes earlier today. His response perfectly captures the problem, and that response is a) to ignore it in favour of cherry-picked alternatives; and b) to suggest malice or bias on the part of those who disagree with him.

Screen Shot 2015-10-15 at 10.00.03

Screen Shot 2015-10-15 at 10.00.21

To answer the “why” in that last tweet: because I’m linking to the review of RCTs mainly to demonstrate that the evidence is contested, and that there’s no room for dogmatism in this debate (or in any scientific debate that isn’t settled).

If there was as prominent and influential a scientist as Noakes arguing as dogmatically on another topic that I’m interested in, articles on that topic would attract a similar amount of attention, at least from me.

The “why” is of course not sincere at all, but instead simply an opportunity for disciples to dismiss contrary evidence as conspiracy. If you’re looking for a textbook example of motivated reasoning, the Noakes timeline is pure gold.

You can science too – it’s easy!

mouse-801843_1280If you’ve always wanted a career in science, but never got around to studying biology, physics or whatever it is that you’re interested in, don’t fear – being (treated as) an authority is easier than you might think.

First, find a conclusion you like. Let’s say, for example, the claim that sugar is addictive. Then, find a study that supports that conclusion, and publicise it:

In this study, conducted on rats, we are told that sugar is addictive – a line that Prof. Tim Noakes repeats with some regularity. It’s of course more complicated than that, but let’s not be negative – this is a post about how easy science is, after all.

Next, what you need is a way to discredit studies that say things that don’t support your conclusions. Don’t worry about being consistent at this point – it’s fine if you apply one standard to research that supports your conclusion, and another standard to research that doesn’t.

A mouse model shows that eating high-fat diets during pregnancy might ‘program’ your baby to be fat? Rubbish – mice are not women!

There’s a mouse study that shows high-carb diets lead to as long and healthy a life as any other diet? Rubbish – mice are not men!

(Some of you might, upon reading confounding studies, be tempted to think that science is complicated, and rarely – if ever – suitable for justifying dogmatism. Eliminate that negativity – there’s no place for it in sciencing!)

Now, what do you do when someone praises you as a lifesaver, but in doing so, also endorses avoiding conventional doctors, seeking out naturopaths, regarding “almost all” drugs as “toxic” and vaccines as “highly dangerous”?

natureboyrr_2015-Jul-15

Well, you retweet them, of course (while perhaps reciting your mantra that science is not religion). And if someone calls you out for endorsing vaccine quackery, do not fear – dismiss their question with an insult and an appeal to authority:

Like Ms. Child, I’m also not an expert on immunology. And no, I haven’t read the book, which apparently “needs to be read by everyone with an opinion on vaccination debate”.

But why would one read this book when a cursory Google search results in extensive, well-referenced accounts of (at least) 11 flat-out misrepresentations of data in that book?

Or, when you discover that the only places the author is taken seriously is sites like quack-central Mercola? If you’re still not convinced that you’d be wasting your time reading it, what if you learned that the author is sympathetic to homeopathy?

You’d think of her as a quack herself, I’d wager, and you’d certainly not endorse her as an authority. Unless, of course, you have a conspiracy story to tell about big pharma and the medical establishment colluding to sell you drugs, while hiding “the truth” from you.

But let’s imagine you ignore all that instead. Now, you know that the public are rather upset to hear anti-vaccine messages – after all, didn’t around 170 people get measles just this year (so far) in the USA, mostly thanks to being unvaccinated?

Also, you’ve been in trouble for appearing to endorse anti-vaxx messages before, when tweeting a link to a video featuring Andrew Wakefield on how the CDC arranged a cover-up of evidence relating to vaccines and autism.

(Maybe, you also think of that pesky HPCSA hearing coming up later this year, and how it might complicate things for you to appear to be supporting a viewpoint that is widely believed to indirectly kill people, especially babies.)

So, let’s just deny that the book is anti-vaccination, instead calling it something more grand, like a “unique historical analysis”.

Except, how do you square that with the publisher’s own description of the book, which tells us that the book argues that vaccines are not “responsible for the increase in lifespan and the decline in mortality from infectious diseases”, or accounts of her work like this one, from Dr. David Gorski?

I suppose you just hope that people take your word for it. While, perhaps, reciting your mantra that science is not religion, and calling anyone who disagrees with you a “troll”.

If you are happier and healthier on LCHF, great, I’m happy for you. But you can, and should, expect more from those who you take as your authorities on diet and more importantly, the scientific method.

As I’ve said before, I think the jury is out on the diet questions. It’s not out on vaccinations, and hasn’t been for quite some time now.

It’s shamefully irresponsible to suggest otherwise, and disingenuous to pretend that this isn’t what you’re doing in recommending books like those of Humphries.

Postscript

Noakes is asking “have you read the book?” to anyone challenging him on this on Twitter. You don’t need to read the book – there are many interviews with this author available online, including an outline of the arguments in the book on sites like Mercola’s.

Asking if you’ve read the book is mostly serving Noakes as a way to refuse to contemplate the dereliction of common-sense that is anti-vaccination endorsement on this scale. But even if he refuses to contemplate that, you nevertheless can.

Here’s something else that might interest you, on the author in question, linking to various other strange views she holds.

“Witch hunts”, Tim Hunt, and sexism in science

tim-huntAs with “shirtgate”, where Rosetta scientist Matt Taylor was in the news for wearing a shirt depicting naked scantily-clad women, the Tim Hunt case has prominently featured Richard Dawkins, telling us how to understand feminism and the issue of sexism in science.

In his letter to The Times (paywalled, so – sorry – I’m linking to the Daily Mail‘s quotes of the letter), Dawkins says:

Along with many others, I didn’t like Sir Tim Hunt’s joke, but “disproportionate” would be a huge underestimate of the baying witch-hunt that it unleashed among our academic thought police: nothing less than a feeding frenzy of mob-rule self-righteousness.

‘A writer in the Guardian even described it as “a moment to savour”. To “savour” a moment of human misery – to “savour” the hounding of one of our most distinguished scientists – goes beyond schadenfreude and spills over into cruelty.’

One might hope that Dawkins is demonstrating “disproportionateness” via example, but he’s no doubt serious in this one-sided portrayal of events. Not only that, he’s perpetuating a misunderstanding he found in the libertarian Reason.com in his “moment to savour” quote – the Guardian quote, in context, reads:

Yet this is a moment to savour. Hunt has at last made explicit the prejudice that undermines the prospects of everyone born with childbearing capabilities.

In other words, it’s not the Hunt resignation that the author is savouring, but rather the opportunity it provides for discussing the ingrained sexism that is still experienced by women in professional settings such as laboratories (not to mention elsewhere).

When the speaker of the offensive remarks has felt the need to apologise, fully acknowledging that the remarks were inappropriate, seeing a senior male scientist like Dawkins describing reaction to those as a “feeding frenzy of mob-rule self-righteousness” is unlikely to reassure anyone who has concerns regarding perceived or actual sexist treatment of women in the workplace.

Yes, it’s true that some on social media had strong words to say about and to Tim Hunt. I don’t think it clear that this forced his dismissal, though. As usual, one can find evidence to support the case you want to make – Hunt and his wife claim that he was “hung out to dry” by University College London, and UCL say that he resigned (from an honorary, not paid, position) before they had a chance to speak with him about the incident.

He says he was joking when he made the remarks. And it’s true that many of the quotes of his remarks have left out the “now seriously” he utters in the second paragraph below:

It’s strange that such a chauvinist monster like me has been asked to speak to women scientists. Let me tell you about my trouble with girls. Three things happen when they are in the lab: you fall in love with them, they fall in love with you, and when you criticise them they cry. Perhaps we should make separate labs for boys and girls?

Now seriously, I’m impressed by the economic development of Korea. And women scientists played, without doubt an important role in it. Science needs women and you should do science despite all the obstacles, and despite monsters like me.

But the issue is not whether he was joking or not. No reasonable person could doubt that he was intending to make a joke. The issue is what jokes you regard as appropriate or not, in which contexts. In a professional context such as this, addressing a room full of female scientists who have most likely encountered plenty of glass ceilings, this was a stupid and insensitive joke to make.

Furthermore, what Dawkins and others are perhaps not reading is the non-baying-mob part of the Internet, for example these tweets from someone who interviewed Hunt just after he made the remarks in question. Here’s one of the tweets:

Blum goes on to record that Hunt said “he was trying to be honest about the problems” – meaning he perhaps does have the sexist attitudes that the “joke” was purportedly ironising. If so, why should UCL want him in an honorary position?

I don’t know all the facts – very few of us do. And yes, I agree that social media can bring an unreasonable mob to your door. Another speaker at the same event (who confirms Blum’s account) Blum perhaps puts it best, though, in saying:

I do have sympathy for anyone caught in the leading edge of a media storm. But if we are ever to effect change, sometimes we need the winds to howl, to blow us out of our comfort zones. Because the real point here isn’t about individuals, isn’t about Tim Hunt or me.

The real point is our failure, so far, to make science a truly inclusive profession. The real point is that that telling a roomful of female scientists that they aren’t really welcome in a male-run laboratory is the sound of a slamming door. The real point is that to pry that door open means change. And change is hard, uncomfortable, and necessary.

#NoakesHearing, day 1: Reflections on futility

hpcsaAs anyone who clicked through to this piece probably knows, yesterday saw the start of a Health Professionals Council of South Africa (HPCSA) hearing to assess whether Prof. Tim Noakes is guilty of unprofessional conduct. The charge against Prof. Noakes states:

That you are guilty of unprofessional conduct or conduct which, when regard is had to your profession, in that during the period between January 2014 and February 2014 you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet/s).

I attended all of yesterday’s session, and offer some thoughts on what transpired, below. I have not attempted to catalogue everything that happened – if you want a more detailed account, the News24 live-blog offers an accurate summary.

On futility – once more with the distinctions

It continues to exasperate that I can think of only one person a handful of people who understand that there are (at least) two distinct issues at play in the general discussion around Noakes, LCHF and Banting. The first is the set of questions related to diet, and which is healthier for you.

In this set of questions, I’m bundling in long-term vs. short-term, treatment for obesity and diabetes, what proportion of population X are insulin-resistant and so forth. I do not, in general, comment on those issues. They are not a field of expertise for me. As I’ve repeatedly said, Noakes might well end up being a frontrunner in what eventually becomes scientific consensus.

The second set of questions relates to logic and philosophy of science, and to our responsibilities as educators, or journalists, or health professionals to discourage sloppy thinking on matters of significance (well, on all matters, but the stakes are sometimes higher than others).

So, I’ve consistently (with a few lapses, I’m sure) focused on the quality of argument that emerges from the Banting camp, rather than on the superiority of any particular conclusion. If you don’t care about those issues (you of course should), then you shouldn’t be reading my comments on them.

You certainly shouldn’t be asking me to present evidence that low-carb is bad, because that’s not what I’m claiming. You also shouldn’t be telling me that “there’s so much more bad science for the consensus” or somesuch, because maybe there is, and maybe there isn’t, but that’s not what I’m talking about. The fact that someone else (proponents of the consensus view) also does things wrong doesn’t give anyone else a free pass to be sloppy in their reasoning.

On futility II – the hearing that never happened

We spend the entire day hearing arguments about the constitution of the panel that was set to hear the case, and proceedings were eventually terminated at around 15:30 when it was agreed that the panel was improperly constituted. Proceedings will resume on November 23, assuming nothing else interferes with the process.

Should this hearing be happening at all?

I have mixed feelings about this. As with so many of our policies (and even heuristics related to social interaction), there’s a vast difference between what made sense in a pre-digital era and what makes sense now. Noakes is often to be found on Twitter – he’s written an ode to it, in fact, and his fans love him for how much he engages there.

The point of highlighting the pre/post-digital era is of course it would be irresponsible for a physician to encounter you in the street and tell you what your baby should eat, unless your advice is something rather generic and consensus-based. Even if the consensus is wrong, as Noakes thinks it is, it does sit with an advantage here – his job is to create a new consensus, after which he’ll get the same advantages.

But perhaps Twitter is different, in that it’s a broad discussion or sounding board for ideas, in which we shouldn’t expect people to view what Noakes tweets as prescriptions in the medical sense. That’s presumably what he thinks. I think he’s wrong in practice, because people do view them as prescriptions, and he should know that and act accordingly.

However, it’s possible that holding him to account for all possible consequences of his tweets does overstate the importance and role of Twitter, and also paternalise his Twitter following. For example, a non-prejudicial look at the tweet that started all the trouble is consistent with slowly weaning a child onto LCHF, perhaps in a manner that doesn’t run the risk of causing the complications the complainants in this case claim it would.

So, this case is raising very important background issues related to the appropriateness (or not) of how people with positions of influence engage on social media.It’s not going to be a waste of time, but is rather going to force everyone to resolve what I think are important issues.

It’s a great shame that many of Noakes’ supporters are struggling to see anything beyond a vendetta or bad faith here, and also that Noakes himself misses the point that it’s not about freedom of speech, but rather about the responsibilities of healthcare professionals to avoid causing harm.

He’d retort that it’s the Association for Dietetics in South Africa’s (ADSA) advice that causes the harm, but even if true (and even if he’s even representing what their advice is accurately), that’s something you demonstrate in journals, not with other people’s babies.

Is Noakes speaking “outside his field of expertise”?

One of the things that caused a fuss during the hearing was a statement made by the HPCSA’s lawyer that Noakes was operating or speaking as if he were a dietician, and that this is not his field of expertise. To briefly return to my futility theme, this was immediately leapt on by the Noakes-supporters as an attempt to suppress Noakes’ freedom to research and write on nutrition, while it was in fact nothing of the sort.

The argument was simply that because he’s operating outside of the “normal” General Practitioner (GP) set of ideas but rather as a dietician, it makes sense to include a dietician on the panel. Nevertheless, the motivated reasoning in response to this was quite something to behold, as it was immediately taken up as further evidence of the conspiracy against Noakes, who was now “not allowed” to talk about diet.

The clue as to what GPs do is in the name – they consult on a general set of health-related concerns, one of which is diet. But the claim made by the HPCSA lawyer was that Noakes was presenting himself as more than a generalist, but rather as a specialist in this area, and he should thus be assessed by a specialist also.

What was the problem with the panel composition?

The technical problem that (rightly) led to the cessation of the hearing was that the panel was lacking one particular member as per the regulations, where that member needed to be in Noakes’ profession, i.e. a GP. There was one GP on the panel, who was also a pediatrician, as well as a dietician (who I’ll return to in a moment), but there needed to be another Medical and Dental Board-registered GP present for a properly constituted panel.

What was interesting about the debate on the panel composition?

Both sides seemed intent on creating as favourable a panel as they could, which should of course be no surprise. The complainants argued strongly for the presence of a dietician, and Noakes’ lawyers argued strongly against. Noakes, of course, thinks that the dieticians exemplify bad science in this area, and he’d probably argue that they aren’t competent to assess the evidence he’ll present.

However, the problem with ruling them out is two-fold: one, it presents a circular argument, in that it assumes they are incompetent (or rather, cedes the argument regarding their competence) as reason to rule them out as assessors of the evidence; and two, if they are as incompetent as he thinks, surely it would be a simply matter to demonstrate this in the course of the hearing?

There’s the risk of a strategic blunder from the Noakes team here – the more intent they appear on trying to rule a dietician out as a panelist, the more people might wonder what they are so concerned about. If they are as scientifically backward as Noakes would have us believe, why not publicly expose that via the hearings?

And then….

The strange case of Prof. Blaauw

The dietician panelist, Prof. Blaauw, was initially considered a perfectly acceptable member of the panel, until we discovered two things about her (and the second, only rather late in the day). Over lunch, she informed the (superb) Chair of proceedings, Joan Adams, that she had once co-supervised an ethics thesis on the “media implications of Tim Noakes”. This was claimed to not impair her objectivity, and the Noakes legal team seemed happy with her, despite this knowledge.

Later on, though, we discovered that she was also a member of ADSA, whose President in fact laid the complaint against Prof. Noakes. This caused significant dissent around her suitability, as you’d expect it to given the conflict of interest.

Debate then ensued as to whether she was in fact legally part of the panel at all, as given that it had already been ruled that the panel was improperly constituted, she could not officially or automatically be considered part of a future, properly constituted panel either. Noakes’ lawyers went as far as to say that they might consider taking this issue to the High Court, if Prof. Blaauw ended up remaining on that future panel.

Bad faith and Tex bars

In an amusing turn of events, we reconvened after lunch to find that some prankster had placed Tex bars (a chocolate) on the desks in front of each panelist. Some of the Noakes supporters on Twitter immediately assumed that this was ADSA’s doing, which seemed to fit the generally uncharitable attitude on the #NoakesHearing hashtag, which also included some fat-shaming of various members of the complainant’s party.

Yes, these are emotive issues, and I can understand why people feel that someone they respect and admire for standing up to orthodoxy is being unfairly singled-out, but you don’t make an effective case for his virtue by demonstrating a lack of virtue yourselves. Even if “the other side” sometimes do the same, that does not make your doing so more appropriate either.

One of the Noakes supporters seems to have cottoned on to the reality that people like me don’t have a vendetta, but is rather simply interested in the arguments and ethics of how we debate them. But there’s still far too much ad hominem, and accusations of trolling put in terms that are themselves distinctly trollish. This is the problem of the filter bubble, as I’ve argued before, and I’ll again simply suggest that there is a conversation to be had here, and some of us are having it in good faith – whatever you might believe.

In conclusion

The Noakes legal team seem better prepared, and certainly appeared more effective in their rhetoric and argumentation. Now that the hearings have been extended to run for 7 days, I suspect that the complainants are going to have a difficult time competing. And, at the end of the day, Noakes will “win” on any permutation.

If he is (in the extreme scenario) struck off the roll and disallowed from practicing medicine, that’s of little consequence to his main interest, which is research and (mostly public) dissemination of findings related to diet. And, he and his supporters will have further “evidence” of his persecution.

And if he wins, that will of course serve as his – and the Banting diet’s – most significant tipping point towards public acceptance yet…

Screen Shot 2015-06-05 at 09.50.27

P.S.: The screenshot above is from Noakes’ Real Meal Revolution website, and you might find the last bullet-point of interest.

Sugar given Carte Blanche to cause panic

When you (by which I mean, the average person) thinks about something as being “addictive”, I think we mean that the substance or activity in question is particularly likely to cause you to develop some combination of dependence, tolerance, cravings and withdrawal symptoms.

You’d also, if addicted, go to significant lengths to obtain the thing that you are addicted to. On a trivial end of this spectrum, people who smoke cigarettes might walk out into a cold and rainy evening to go and purchase cigarettes, instead of staying under the duvet like any sensible (i.e., non-addicted) person would.

When you think of addiction, in other words, I’d guess that you typically don’t mean that you know this fellow, George, who has become so obsessed with playing Minecraft that you describe Minecraft as addictive, as opposed to acknowledging that people can become “addicted” to Minecraft.

sugarThe distinction is important, and points to one of the significant problems in discourse around sugar “addiction”, as recently portrayed on the South African current affairs show, Carte Blanche. It’s important because the things we like are rewarding at the level of the brain, in that they result in dopamine release – but this does not necessarily mean that they are addictive in the stronger sense that we tend to reserve for things that you can’t help but find rewarding.

In other words, there’s almost zero chance of my becoming addicted to running, because I don’t like doing it, and tend not to do it. But there’s a significant chance – and a similar chance to your chance – of my becoming addicted to heroin, if either of us were to try it.

We’re using the word “addictive” in a very broad sense when we describe the Internet, exercise, and sugar as addictive. In fact, the sense in which it’s being used is broad enough as to mostly lose its meaning, by contrast to the strong sense in which certain substances are very likely to result in the sorts of reactions mentioned above, for many people.

Most of us exercise, use sugar or the Internet, and have sex quite unproblematically (in terms of addiction, Beavis). More of us use things like heroin or cocaine unproblematically than the standard sorts of addiction panics claim also, but that’s a story for another day. The point I’m making here is quite simply that any claim that sugar is “addictive” is using the word “addictive” in a misleading and hyperbolic way.

Long-term addiction is the exception, not the rule – we suffer from a confirmation bias here in the sense that we don’t get to hear about the people who live with addictions that are largely under control and remitting (in other words, most of them). We hear about the horror-stories, of people struggling with a demon, and (sometimes) heroically fighting it off.

And, as the cases and science detailed in Johann Hari’s Chasing the Scream persuasively suggest, the primary vehicle we have for escaping addiction is to give ourselves a sense of purpose and above all, agency – and agency is last thing that panics around things like sugar addiction have time for. Instead, the narrative is all about you being a victim of conspiracy.

You can watch the Carte Blanche insert yourself, in which you’ll be told that “sugar may be as addictive as nicotine and hard drugs”, that sugar can “hijack the brain” and so forth. But what you’ll mostly see is three self-described (and apparently self-diagnosed) sugar addicts telling you how addictive it is.

Their primary scientific resource, Prof. Nicole Avena, doesn’t even herself support the strong addiction claim, saying “a little bit of sugar won’t hurt you. It’s not a bad thing in general, it’s just the way we are consuming it is a bad thing”. The “we” is perhaps too broad there, in the sense that many of us who aren’t on LCHF-type diets have been restricting added sugars for our entire lives already, given that warnings about refined sugars have been a staple of dietary advice for quite some time now.

Nevertheless, I’d agree that people are eating too much sugar. And, people who are prone to compulsive behaviour might well find themselves becoming “addicted” to sugar – and you wouldn’t be surprised to find (as you do in one of the three cases presented in the show) that these people can become “addicted” or even addicted to a range of things over the course of their lives.

The problem, in short, might be with their lives and their circumstances – at least in large part – rather than in the substances or activities. We should not be surprised that our brains find food rewarding, and that we seek it out. We’d be surprised if it was any other way. But if we can (typically, as with most consumers of sugar) control the impulse to eat too much of it, then addicts need to shoulder a large portion of the responsibility themselves, and not hand it over to sugar.

But, say some (and as presented at 2m21s in the video, with an unfortunate reference to quack-central Natural News), studies prove that sugar is more addictive than cocaine. Unfortunately, studies prove what you want them to, depending on which studies you read, and which you ignore.

Plus, of course, how attentively you read them can be an issue – as I’ve noted before, Avena and others are far more circumspect and tentative than they are presented to be by the media and vested interests. Her own oft-cited paper is full of scare-quotes for the word “addiction”, and stresses that “whether or not it is a good idea to call this a “food addiction” in people is both a scientific and societal question that has yet to be answered.”

The hyperbole in blogs and online news sources, never mind repositories of the worst sorts of pseudoscience like Natural News, don’t help resolve these issues. Neither do personal anecdotes, regardless of our compassion for people who struggle with compulsive behaviour of various sorts. Movies like Fed Up are of little use also, in that they simply populate the scaremongering filter-bubble with cherry-picked and misrepresented data.

If you want to read about why the Lenoir et. al. study quoted in Natural News doesn’t resolve my doubts about sugar addiction, not to mention comparing rat data to human experience – especially given the fact that psychological rather than physiological factors seem most relevant to addiction – I’d recommend reading this Scicurious post closely.

That post points out that there’s perhaps a vast difference between the self-administration of drugs in humans compared with rats, who can’t reason about their choices like we can. It also notes that the study doesn’t measure a progressive ratio – in other words, it doesn’t tell us what the rat prefers when it really has to work to get its reward. When things get tough, will it prefer sugar, or will it quit trying?

We don’t yet have good human data for sugar addiction. What we do seem to have is limited evidence for “eating addiction“, but as I’ve stressed above, an addictive behaviour is not the same thing as an addictive substance. People who are addicted to eating might well find foods – including sugar – deeply rewarding, but it’s premature to blame the sugar itself.

To conclude: there’s no problem with saying we find sugar rewarding. Of course we do, as we would exercise and so forth. To say it’s addictive makes a far stronger claim, and that claim is the suggestion that it’s a sinister substance that’s out to get you, rather than something you’re free to enjoy in moderation, just as you can alcohol or any other drug, depending on the legislation where you live, and your own personal risk-tolerance.

One thing I’m quite concerned about, though, and have noted before, is that it seems quite likely to me that your risk-tolerance can only be compromised through being treated like a perpetual victim – and that believing your food is out to kill you seems a wholehearted embracing of that victimhood.

Saturated fat not exonerated in 2015 US dietary guidelines

I’m traveling back from giving a talk to a room full of dieticians about their social responsibilities, in which I emphasised that one of their important tasks is to try to beat back the surge of hyperbole and exaggeration coming out of the Banting and LCHF camps.

There are plenty of posts here on Synapses on the topic, many dealing with Professor Tim Noakes and how his confirmation bias has led him to re-tweeting false and potentially dangerous claims. You’d recall him “just asking questions” on vaccines and autism, or spreading the (false) idea that Sweden had become the first nation to “officially” adopt LCHF as their diet.

imagesAs I’ve said many a time, and repeated at the talk last night, some of the ways in which we can aid the spread of scientific literacy is through simply reminding people of the virtues of not overstating the evidence we have for our claims, and also through encouraging people to be consistent in their judgements – if something is wrong in one case, it’s usually wrong in similar cases also.

A recent example of salesmanship trumping science arrived in time to include in my remarks, and I also want to note it here for folks who have been following the topic. Yesterday morning, Prof. Noakes tweeted

The text of the tweet is a quote from the linked post, so not Noakes’ words, but I am fairly confident that he endorses the sentiment seeing as he’s frequently said similar things. Many times, they have in fact been described as “tipping points”, which makes one wonder how many tipping points are necessary before whatever it is actually gets around to tipping.

Anyway – if you go read the post that is linked to in the Tweet, you’ll find that it’s a smug “I told you so” by Dr Malcolm Kendrick, author of “The Cholesterol Con”. What he wants to gloat about is that he was right all along, and that in short, “cholesterol is healthy, saturated fat is healthy, salt is healthy and sugar is unhealthy”. Speaking of the 2015 Dietary Guidelines Advisory Committee’s (DAG) report, he says:

The entire report, I believe, stretches to about a bazillion pages. However, here are four of the highlights.

Cholesterol is to be dropped from the ‘nutrients of concern’ list. [I love that phrase ‘nutrient of concern’].

Saturated fat will be… ‘de-emphasized’ from nutrients of concern, given the lack of evidence connecting it with cardiovascular disease.’ [Whatever de-emphasizing may be. Pretending you never said it in the first place, I suppose].

There is concern over blanket sodium restriction given the… ‘growing body of research suggesting that the low sodium intake levels recommended by the DGAC (Dietary Guidelines Advisory Committee) are actually associated with increased mortality for healthy individuals.’

And… ‘The identification and recognition of the specific health risks posed by added sugars represents an important step forward for public health.’

The entire report does indeed stretch to a bazillion pages, or close enough at 571 pages. I presume that’s why Kendrick hasn’t read it, and therefore goes on to substantially misrepresent what it says.

To say that “cholesterol is healthy” is misleading because while dietary cholesterol has been de-emphasised, the DAG has not concluded that cholesterol in the blood is unproblematic – contrary to what Noakes’ journalist has reported.

To say that saturated fat will be “de-emphasised” is literally false, as that line comes from the Academy of Nutrition and Dietetics, who (this press release is even pasted in Kendrick’s post) say that they support “the DGAC in its decision to drop dietary cholesterol from the nutrients of concern list and recommends it deemphasize saturated fat from nutrients of concern” (my emphasis).

So, the Academy of Nutrition and Dietetics say to DGAC “good work, but you could do better” (on their model, of course). But the report does not say what Kendrick says it does, and the US Guidelines will continue to warn against overconsumption of saturated fat. If you read it, or even do a simply word-search for “saturated”, you’d know that, because you’d read that they recommend “less than 10 percent of total calories from saturated fat per day”.

I didn’t read up on the sodium commentary, and agree that added sugars are problematic (while not being addictive), so will say nothing about those last two bullet points, except to quote the report in saying “the DGAC also found that two nutrients—sodium and saturated fat—are overconsumed by the U.S. population relative to the Tolerable Upper Intake Level set by the IOM or other maximal standard and that the overconsumption poses health risks.” Go figure.

But before wrapping up by giving you a few quotes from the DGAC report’s conclusions, I’d like to note the double-standards at play in endorsing the Academy of Nutrition and Dietetics’ comment to the report, as Kendrick does and Noakes would likely do also, seeing as he’s explicitly told us that saturated fat is not a concern.

When the Association for Dietetics in South Africa (ADSA) decided to report Noakes to the Health Professions Council for “unprofessional conduct”, he and his supporters had a field day on Twitter looking at ADSA’s list of sponsors, and then dismissing ADSA’s case on the grounds that they had had financial dealings with Kelloggs and other (allegedly) evil corporations.

Why is the same standard not applied to the Academy of Nutrition and Dietetics, who have been the subject of a Senate enquiry thanks to their pharmaceutical connections, and who have a list of sponsors and funders a mile long, including Sarah Lee (makers of evil carb products!), Coca Cola (so very evil!) and evil Monsanto (the Great Satan!).

It can’t simply be because they say the right things, can it? Because that’s not how science works, as the Doctor and Professor surely know.

Lastly, seeing as the Noakes’ echo chamber on Twitter is in full swing with “see, he’s vindicated!” types of comments following the release of the DAG report, I’ll leave you with this quote from it. Make up your own minds as to whether it supports Banting, or whether it’s largely the same advice as ever.

The dietary patterns associated with beneficial outcomes for cardiovascular disease:

Dietary patterns characterized by higher consumption of vegetables, fruits, whole grains, low-fat dairy, and seafood, and lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages relative to less healthy patterns; regular consumption of nuts and legumes; moderate consumption of alcohol; lower in saturated fat, cholesterol, and sodium and richer in fiber, potassium, and unsaturated fats.

The dietary patterns associated with beneficial outcomes for obesity:

Dietary patterns that are higher in vegetables, fruits, and whole grains; include seafood and legumes; are moderate in dairy products (particularly low and non-fat dairy) and alcohol; lower in meats (including red and processed meats), and low in sugar-sweetened foods and beverages, and refined grains; higher intakes of unsaturated fats and lower intakes of saturated fats, cholesterol, and sodium.

Dietary patterns in childhood or adolescence that are higher in energy-dense and low-fiber foods, such as sweets, refined grains, and processed meats, as well as sugar-sweetened beverages, whole milk, fried potatoes, certain fats and oils, and fast foods are associated with an increased risk.

(But the diet’s not for everyone, only for the insulin resistant!) The dietary patterns associated with beneficial outcomes for Type 2 diabetes:

Dietary patterns higher in vegetables, fruits, and whole grains and lower in red and processed meats, high-fat dairy products, refined grains, and sweets/sugar-sweetened beverages.

 

Flu vaccines might be ineffective, so try… water (otherwise known as Oscillococcinum)?

A friend forwarded a press release issued by “LeBron Health” to me, and the quackery it contains is too delightful to keep to myself. But because the press release also trades on fear-mongering of a rather pathetic sort, it’s also an reminder of how uninformed or unethical some medical “professionals” are, and of how quackery can harm in scaring people away from effective treatment.

The press release discusses the upcoming flu season in South Africa, and in particular, how to cope with the H3N2 strain of influenza. The H3N2 strain of influenza is indeed deadly, having reportedly killed dozens of children during the most recent US winter. That’s not good, of course – we’d like the number of deaths to either be 0, or much closer to 0 than that.

However, the number of deaths and hospitalisations this winter have not been significantly out of the normal range – the flu is not killing more people than it typically does. Furthermore, it’s also quite routine for the CDC to “issue a health warning to doctors”, as they are reported by the press release to have done. A “health warning” is not an advisory broadcast regarding an impending apocalypse, but (typically) simply information that the CDC thinks practitioners might find useful.

The health warning itself also reports something quite mundane on an aggregate level (though of course not mundane at all if you’re someone who has had flu-related illness or death in the family). It simply says that the current vaccine can’t compete effectively against H3N2, and that everyone should be prepared for a bad flu season.

This is also routine – vaccine developers select flu strains in January to May (for the US), based on which strains they predict will be most prevalent, and vaccination then begins in October. Things can change between those two phases – they are 5 months or more apart, after all – and one of the things that can change is the seriousness with which you could have (with perfect hindsight) regarded the threat of a particular influenza strain.

But you can’t know, 6 months in advance, and so you make the most informed predictions you can. Some years, the vaccine works very well, because you picked the right strains, and other years it works far less well.

And here’s the frustrating thing: in December last year (when the flu season hit the USA), the same scaremongering was prevalent. We read that the CDC had “admitted” that the vaccine doesn’t work, just as in this local press release’s headline, which claims that “flu vaccines may not work”.

Well, the CDC admitted nothing of the sort, and the flu vaccine “works” just fine, within the parameters of how it normally works, where the reasonable standard is never “perfectly”.

Even though this might be a particularly bad year for the vaccine’s efficacy, it’s still going to be better at helping you to avoid influenza than certain other “remedies” would be. It will help more than prayer, it will help more than avoiding cellphone towers, and it will certainly help more than homeopathy (with the caveat that hydration is good, so homeopathy in extreme quantities might help a little bit, because water).

Homeopaths disagree, as you might expect them to. One of those homeopaths is Dr Erika Coertzen, who suggests that we take a “reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France”.

homeopath
This box contains as much medicine as a microscopic box of Oscillococcinum does.

That quote tells us that Dr Coertzen and my understanding of what the word “reputable” means is as orthogonal as our understanding of the word “medicine”. We can also note that a “medicine’s” popularity is only relevant to sales, profit, and analysis of marketing and gullibility – it tells us nothing about efficacy.

As with all homeopathic “remedies”, there is no good clinical data to support the claims made in favour of Oscillococcinum as treatment for influenza. It’s not going to help you to “rebalance and heal”, and even if it is true (no citation is given for this claim) that a “majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time”, if this is in comparison to patients who take nothing, then the placebo effect is a perfectly good explanation for this observation.

But I suspect that the data is more… what’s the technical term?… made up than that, or that it at the least involves some fairly extravagant inferences being made from a poor data set. Dr Coertzen says that patients “symptoms show improvement or resolution of symptoms after reduced time” – if this is true, the data should support this claim. Unfortunately, they don’t.

As assessed by the Cochrane Collaboration, where trials do show favourable results for Oscillococcinum, “the overall standard of research reporting was poor, and thus many aspects of the trials’ methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum® in the prevention or treatment of flu and flu‐like illness.”

Amusingly, the Oscillo.com website – of course not a neutral scientific arbiter – claims that “unlike other flu medicines, Oscillococcinum does not cause drowsiness or interact with other medications”. Given that Oscillococcinum is a homeopathic “remedy”, therefore containing nothing that might cause drowsiness or negative interactions, this claim only gains traction if you’re able to persuade people that homeopathy is at all respectable or efficacious – surely nothing that any “reputable” healthcare practitioner would do?

In her defence, Dr Coertzen isn’t ever quoted as directly suggesting that you not take real medicine also, which might be the only thing that prevents the Health Professions Council (HPCSA) Medicines Control Council (MCC) from chastising her for this batshittery.

However, if she is the “medical expert” quoted in the headline, telling the public that vaccines might not work and that they should consider alternatives does seem to be a direct encouragement to forsake medicine in favour of homeopathy, and I do hope that a complaint is laid so that the MCC HPCSA can then rule against this idiocy.

Briefly, on Oscillococcinum itself, you’d be amused to read up on it, as the story of its origins and composition is quite the catalogue of pseudoscience in action. While there might be nothing that trumps Scientology for batshittery, Oscillococcinum gives it a damn good try…

 

PRESS RELEASE (source)

Flu vaccines may not work, consider alternatives — medical expert

Global health authorities have cautioned that current flu vaccines may not prevent a severe new strain of influenza, highlighting the need to seek alternative ways to protect against falling ill this winter.

The US Centers for Disease Control and Prevention (CDC) issued a health warning to doctors during the northern hemisphere winter about the severity of the 2015 flu season. It said the current flu vaccination protects against three or four strains but is not a match for the dangerous H3N2 strain which has mutated and has contributed to more deaths and hospitalisations of children and the elderly. (See: http://www.health24.com/Medical/Flu/Preventing-flu/Flu-vaccine-missing-its-mark-20150112)

Nearly 30 children died in one of the worst flu outbreaks in the US over their winter. In SA, a new modified vaccine is now available to match two of three new strains, including H3N2. However flu can still be contracted if other strains are not covered by the vaccine (See: http://www.health24.com/Lifestyle/Winter-Wellness/South-Africans-warned-of-severe-flu-strains-20150420).

SA doctor and homeopath, Dr Erika Coertzen, suggests boosting the immune system naturally by following a healthy, nutritious and balanced diet, getting enough sleep, regular exercise and taking preventative natural or homeopathic medicines to counter the onset of flu symptoms.

“A reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France, has shown to help alleviate flu symptoms such as body aches, pains, chills and fever without drowsiness or the worry of negative interaction with other medication. Oscillococcinum works with the body to help rebalance and heal, and is suitable for all ages. Oscillococcinum’s efficacy in reducing the severity and duration of flu-like symptoms is well-known. A majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time” she said.

For product info visit http://www.lebron.co.za/, www.oscillo.com or call 021-403-6390.

Assisted dying: not only God can decide – in fact, She can’t decide at all

It’s doubtful that you’d be able to find any medical school that still uses early translations of the Hippocratic oath, never mind the original Greek version. But if you read the unrevised English version, it would open with something like this:

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract.

It will furthermore ask that physicians comport themselves in a “Godly manner”, and do so without “seeking reward”. The point, in short, is that it’s nothing like the modern understanding of the oath, where that understanding is typically summarised in the phrase “first do no harm”.

This, in turn, means that when you appeal to the Hippocratic Oath to justify (or to rule out) some course of action, you’re already appealing to an interpretation of that Oath – and you’ve already admitted that the Oath is therefore a guiding principle, rather than an absolute rule.

Which, in the context of a discussion about euthanasia, means that we are able to discuss further interpretations of that principle, including the question of whether more harm might be caused by keeping someone alive if they are in pain versus allowing them to die – or even hastening their death.

We are not obliged, in short, to think that a life ending is automatically and always a harm that trumps any other possible harm.

6f1216d4022843899161cdba9aeee7f0Not only because interpreting the oath as offering guiding principles rather than absolute rules allows for “avoiding harm” to (on balance) mean “cessation of life”, but also because physicians already don’t follow the oath to the letter anyway. I don’t know about you, but if I heard my surgeon swearing to Apollo, I’d try to find a new one before the anaesthetic kicked in.

Which brings me to Health Minister Aaron Motsoaledi, who seems to think Apollo is still relevant to modern medicine. Well, he talks about “God”, so it’s difficult to be sure that he’s talking about Apollo, but whichever God he means, he seems convinced of the fact that it’s God who gets to decide when you die. As quoted in the link above, he says:

“Doctors are human and make mistakes too. They can say a person has a few weeks left to live, based on medical observation, but only God can decide when a person dies,” Motsoaledi said.

He said as much as doctors played an important role in bringing life to this world, “they should not be given the right to end it because they did not create it in the first place”.

“When doctors begin their career, they take the Hippocratic Oath and pledge to do all they can to preserve life and not do anything that will intentionally harm or result in the death of a patient. Nowhere in the medical curriculum were doctors taught to kill,” he said.

This is all in response to the ruling on Robin Stransham-Ford, last week, in which Stransham-Ford was granted permission to seek assistance in dying, and the Judge furthermore ruled that the physician who so assisted him would not be prosecuted. Motsoaledi intends to make sure this does not set a precedent, for the reasons summarised in the quotes above.

Minister Motsoaledi has, on the whole, been a very competent, and even often an excellent, Health Minister. On this matter, however, he’s letting us down. Here’s why:

  • South Africa is a secular country. While the Health Minister can believe in whatever god(s) he likes, he has a responsibility to make laws that allow for secular justifications. When he speaks as Minister, he should not be suggesting that a certain policy should be motivated by anything to do with what a god might hypothetically want or not want.
  • He’s arguably wrong on the facts, and is relying on an uninformed gut feel rather than the evidence regarding the consequences of assisted dying being legal. He claims that we’ll soon see “families colluding with doctors to end the life of their loved ones because they wanted to cash in on insurance policies”, but as far as we can tell from the Netherlands and Belgium, you can eliminate much of this risk through devising legal safeguards for when assisted suicide is permitted and when not.
  • To that, he might say that safeguards are not enough – that risking even one death for this sort of profit motive is one death too many. And here is where our interpretations of “harm” are directly relevant – physicians are always or at least very often making decisions about treatment that might cause harm, but on balance are thought to stand the best chance of avoiding harm. Ending a life is one option in a range of interventions, for the purpose of serving that same goal.
  • And, ending a life can only be treated as uniquely forbidden as a form of “treatment” if we hold the view that life is somehow “sacred”, which we cannot do in a secular country.

As for the “playing God” sort of argument, Minister, it’s entirely spurious. We all play God when we walk across a street wearing our spectacles, because without them, the bus that God hypothetically sent to run us over would have succeeded in its mission. We play God when we take antibiotics, or when we fly to foreign countries in devices we’ve invented and constructed for that purpose.

With assisted dying, we get the chance to play God in a way that She doesn’t seem that interested in, and we should seize the chance to do so. In this case, we can – and should – play God through alleviating the pain of someone who is dying, and who wants their life to end.

It is to God’s discredit if she doesn’t want to permit or condone this course of action. And it is to our discredit also, if we instead choose to rely on self-serving interpretations of a centuries-old Oath, to evade the moral responsibility of eliminating suffering wherever we can.