I’ve been thinking about “right to try” laws, the ones that are trying to open up access to not-yet-approved drugs for patients who wish to take their chances with them. There are a lot of practical considerations that bear on this idea (differences with existing “compassionate use” programs, effect on clinical trial enrollment, the ability of companies of various sizes to satisfy demand, etc.) But recent events, and the fact that this is an election year, have me thinking about a larger issue that this one is just a part of. Bear with me – it’s a holiday weekend coming up, so this will be a long post. The issues I’m discussing have been thought about since the ancient Greeks at the very least, but I’m not up for a formal survey of epistemology and I’ll bet you aren’t either. So here goes.
The Appeal To Experts
The big underlying question here is “Who gets to make the decisions?” Right-to-try advocates would say that the patients themselves should be making those calls (presumably with some advice from their physicians). Others would say no, we need an FDA, some sort of regulatory authority to make sure that the therapies people are choosing from are actually worth choosing. Another argument is that the underlying medical and clinical issues are complex enough to make some sort of expert review worthwhile, and that we can’t necessarily expect “informed consent” to always be informed enough under some of the more wide-open proposals. Choosing among unapproved drug therapies, in this view, may not be within the range that we can expect people to operate in usefully.
And that takes us to the general phenomenon of distrust of experts, which has cropped up many times in recent years. Inevitably, a big triple slug of politics gets poured into this particular blender, because people on any side of a given issue are generally happy to adduce the support of experts (and to question the credentials of the experts brought in by the other camps). We’ve seen an awful lot of people using scientific evidence in particular (or the other side’s lack of understanding of same) as a club to beat over the heads of their political or policy opponents. It happens in both directions: there are people on the right who think that all climate-change data is a devious hoax, and there are people on the left who think that all evidence in favor of GMO crops is an evil Monsanto conspiracy.
Calling on expert evidence is a tricky business, because even if everyone involved is still appealing to expertise, not all experts are created equal. Many of the “experts” you can bring in are not above trading on their affiliations or degrees, even when those don’t have very much to do with the issue under discussion (“. . .in much the same way that the ocean is not above the clouds”, as Douglas Adams put it). The proliferation of junk pay-to-publish journals means that (to the untrained eye) both sides of a medical issue, even one that’s ridiculously lopsided, can appear to cite perfectly scholarly papers in support of their position. One side might be real journals and real research and the other side might be J. Steaming Manure and Wire Transfer Lett., but if you don’t know anything much about the subject, you can’t tell. It looks just as convincing as the real stuff to you.
The Limits of Expertise
Past that, though, you run into the folks who aren’t even bothering to appeal to experts at all, because they simply don’t trust them much and don’t believe what they have to say. Here, too, we have gradations. If we’re talking about the Poincaré Conjecture, to pick an issue on one end of the scale, the only people that will be of much use while discussing the details of Grigori Perelman’s proof of it will be those who have devoted serious time to the study of topology. No one who is not comfortable dropping the phrase “Riemannian manifold” into their conversational flow can really have a seat at that table. Even world-renowned prize-winning scientists from many other fields are not going to able to pull up a chair. Now, since many of these people do have a fair amount under the hood, if they wanted to take a year’s sabbatical and devote themselves full-time to advanced mathematics, some of them could indeed come back and at least contribute intelligent remarks, but very, very few (if any) could do it cold.
For a topic like that one, or any similarly advanced topic in any field, there is really no substitute for expertise. The origins of Basque declensions? Pulse sequences for four-dimensional NMR experiments? Anomalous element distributions in globular cluster star populations? You’d better know what you’re talking about, and it’s going to take some time to get to the point where you do. No one’s born knowing this stuff. We’re not going to take a poll and get the answer; the wisdom of crowds will be of no help at all unless it’s a pretty damned weird crowd. This category I will call, naturally enough, “Matter for Experts”.
Now let’s go to the other end of the scale. There are actually several different other ends; this is not a one-dimensional problem that fits on one line. One class of nonexpert evidence is in matters of pure fact, about which there can be little argument. Expertise is not a big issue when we’re discussing if the sun is shining or not. Many people will try to drag other arguments into this realm, at least rhetorically, but “What is to be done about climate change?” or “What is the best policy regarding the Syrian War?” are not the same sorts of questions as “What day of the week is it”, no matter what you think about those topics or how much you might like for your preferred answers to be in this category, which I’ll refer to as “Just Plain Facts”.
Then you have situations where there are no facts to be established – that is, when something is unknowable. “When exactly will this carbon-14 atom I have here decay?” is an example of that sort of question, although you need a bit of expertise to understand why. But there are plenty of examples, both complex and trivial. Taking a poll of what’s in this here sealed box here will probably not be of much use, because I could have all sorts of junk in there, and I’m not aware of any random-sealed-box expertise to be had. But you have to make sure of the unknowability: at one point, everyone would have told you that the question “What is the Nth digit of pi?” (without just calculating out that far) was a perfect example in this same category, but in 1995, to everyone’s surprise, that changed. I’m going to call this category “Flat-Out Unknowable”.
A third “no-fact” place where expertise starts to break down is in matters of pure opinion. “Who is the greatest baseball starting pitcher of all time?” is an example of this sort of topic, partly because it immediately devolves to an argument about the meaning of the word “greatest”. But expertise is not totally valueless here – you can adjust your respect for the answers that might come out. Experts are people who presumably know a lot of facts about a subject, but there’s such a thing as expert opinion, too. Someone who proposes “Ethelred the Unready” or “Sofia Vergara” to answer the above question is not worth taking as seriously compared the people who immediately start arguing about Nolan Ryan versus Grover Cleveland Alexander versus Sandy Koufax versus Cy Young versus Bob Gibson versus Warren Spahn and so on. These folks are never going to come to an agreement, because the question is intrinsically unsettleable, but they clearly at least have some idea of what they’re talking about. A vast poll for a question like this might be of interest, assuming that the people who are motivated to vote in it are baseball fans and not a bunch of internet zanies who have been waiting to write in good ol’ Ethelred, Sofia, or Pitchy McPitchface. I’ll call this category “Matters of Opinion”.
Update: as a reader pointed out, a good example of this category is English usage. In fact, the way that people speak and write any language is a sort of continuous public opinion poll, and there are, in the end, very few “facts” to be established. A good article on this is David Foster Wallace’s “Authority and American Usage”, which appears in his collection Consider the Lobster and can also be found here, and in its original magazine version here.
The Battle of the Categories
These categories, then, matter a great deal when it comes to expert versus lay opinion. This means that many people will like to think that their particular topic of interest is surely not in the “Matters of Opinion” or “Flat-Out Unknowable” areas. They might talk as if it’s in the “Just Plain Facts” one, although most things aren’t, but it’s almost for certain that they’ll also act as if it’s in the “Matter for Experts” one. I would like to propose (this is not an original suggestion) that a lot of time, effort, and oxygen is actually spent arguing about these categories and their boundaries rather than arguing the questions per se. That includes trying to move a question from one category to another, or denying that a particular category has any real validity. For example, a religious fundamentalist (pick your religion here) will tend to put anything that has any connection to any part of their preferred sacred text in the “Just Plain Facts” category, like those bumper stickers I used to see once in a while (“God said it, I believe it, and that settles it”), while nonbelievers will not have any of this at all.
How Much Is An Expert Worth?
It’s the “Matter for Experts” category that’s getting a real workout these days. Even if people take it as a valid category and are willing to fight within its borders, we then get mighty disputes about the experts themselves. The anti-vaccination crowd and the glyphosate-is-poisoning-everyone crowd are often both examples of this. The counterarguments are often “We have our own experts, and yours are wrong and stupid and corrupt!” There’s another common counterargument, though, that denies expertise from the start, as in “Your ‘medical experts’ are worthless. I don’t care what all these doctors have to say, I’m a mother and I know that this shot gave my child autism”. To do a full swan dive into politics, Donald Trump’s entire campaign partakes deeply of the whole “down with the so-called experts” view. (Someone really needs to rush out a new campaign edition of Ortega y Gasset’s Revolt of the Masses, but I digress).
You don’t have to set the value of expertise to zero – you can argue about its value versus other considerations as well. The arguments for “right to try” laws are at least partly based on the premise that expertise, in the form of clinicians and the FDA, is not worth as much as we’ve been saying it is, and that a patient’s right to be able to use experimental drugs is actually of more immediate import. Similarly, the recent vote by the UK to leave the European Union partly hinged on whether a given voter believed the economic experts, who largely warned that this would be a costly mistake, and/or whether they believed that other concerns (which the experts had, in this view, failed to consider or value properly) still outweighed those in the end. Not everyone was devoting this much thought to the question (on either side of the vote), but many did.
So how much are experts really worth? At this point, I should note that there are, in fact, experts who aren’t so sure of the answer to that general question. I would take opinions like those seriously, given that the default setting, when an expert is asked such a question, is a reflexive attempt to show that, gosh, they’re actually worth even more than you think and should be valued accordingly. Expertise, for all its value, has its downside, and as that link illustrates, a big downside can the inhibition of new ideas in a given field of study. But if it’s going to be worth something, it’s going to be worth the most in just the sorts of highly technical areas that I used as examples earlier in the “Matter for Experts” category. This will be seen, perhaps, as special pleading, but I tend to think that choices of medical therapies fall into this area. Not everyone agrees, or agrees on the barriers to entry.
Run Along Now
But you have to be careful when starting this category fight, because you risk getting the opposite result from what you intended. In the same way that a religious fundamentalist is not going to persuade people that his stuff is all “Just Plain Facts”, you can have a hard time making the case that your stuff is in the “Matter for Experts” pile. Persuading people that you’re an expert, or that there are actually experts, or that their opinions might be worthwhile, is a delicate business. (In fact, as mentioned here, it’s been found that trying to push straight ahead with these claims often hardens the opposition to them). That, I think, was a big factor in the recent EU vote. I don’t often find myself agreeing with Matt Taibbi, who’s well to the left of me politically, but I think he’s right on target in this article:
Were I British, I’d probably have voted to Remain. But it’s not hard to understand being pissed off at being subject to unaccountable bureaucrats in Brussels. Nor is it hard to imagine the post-Brexit backlash confirming every suspicion you might have about the people who run the EU.
Imagine having pundits and professors suggest you should have your voting rights curtailed because you voted Leave. Now imagine these same people are calling voters like you “children,” and castigating you for being insufficiently appreciative of, say, the joys of submitting to a European Supreme Court that claims primacy over the Magna Carta and the Bill of Rights.
The overall message in every case is the same: Let us handle things.
We have plenty of that sort of thing here, as well, from both ends of the political spectrum. Run along, little people, your betters have work to do. This tension is built into any democracy – even a republic, where the idea is that the people vote for representatives to work on these decisions on their behalf. Such a buildup, I and many others think, is one of the big reasons that we have Donald Trump’s candidacy at all.
But let’s talk about that. As much as I would like to think, as much as it would make things simpler for me, that people who are voting for Trump are just morons doing moron things off in moron-land, that’s not going to cut it. I do think that they’re disproportionately low-information voters, and I certainly do think that voting for Trump is a serious mistake, but there are also plenty of reasons to be pissed off at some of the things that the opinions of the great and the good (of both major parties) have wrought. His voters see these reasons as perfectly legitimate ones, and in a few cases, I actually agree with them, although God knows I don’t think that Trump is the answer. It’s also true that many of these reasons are, in my view, dumb ones, and some of them are based on completely wrong information, but not every single one of them is either of those, and I can’t just make myself feel better by assuming that they all are.
I’m always struggling between my libertarian impulses to let people make their own decisions and my feelings when those decisions include things like voting for Trump, but I can’t pretend that I can have one without having the other. That doesn’t mean I’m voting for the guy (not that I can stand Hillary very far, either, damn it all), but if I want to keep anyone from voting that way, I’ll have to think of a way to do that without coming across like I’m lecturing to the Great Unwashed about what they’d be doing if only they were smarter. Because that, like the EU vote, is one of the big factors that got us here. It’s the same impulse that makes a person just go off on a rant about people who buy electro-clustered super water, or use magnets to deactivate the Monsanto gluten genes in their food (I made that up, but it’s probably out there), or think that vaccines are a poisonous UN plot or something. Believe me, I feel like ranting about these folks, too, but it doesn’t really do much good. The choir’s been preached to many times already.
Facts and Politics
Political issues are especially prone to the category fights I’ve mentioned. Some of these really are “Matter for Experts”, but not all of them are, and if you try to pretend that all of politics is that way, you’re making the same mistake as people (such as the religious types mentioned) who try to drag more stuff into the “Just Plain Facts” category. I would, as mentioned, also like to think that medical questions are far more “Matter for Experts” driven than most political questions, but I have to take into account that I myself would be seen by most people as one of those experts, so my point of view has a real chance of being skewed. (“Skewed? Knowing something about a subject makes your opinion about it skewed?”)
In the end, then, I think that there are several stages in dealing with such problems. First off, you have to make sure that the issue under discussion is in a category where expertise is valuable (or available at all). Then you have to make sure that the experts you’ve found really are such, and not charlatans or people who are hoping to charge you a consulting fee, and you have to see if there are equally plausible people who would disagree with them. Then you have to weigh those expert opinions versus all the other factors you can think of, deciding what each is worth and how much it should be part of the final decision. This is not a brief process, nor is it a lot of fun. Just arguing with people or making fun of your opponents, on the other hand, is fun (at least for many people when they’re in the mood for it). So it’s no surprise that things tend to slide off in that direction a lot of the time.
What to do, then, about “Matter for Experts” decisions where the people affected by them aren’t experts themselves? That’s where the “right to try” laws fit, I believe, and many other issues as well in a large, developed country like ours. The only recommendations I have are to (1) hold the line on it really being an area that expertise is valuable in, but (2) try to lower the barriers as much as possible to letting people get enough knowledge to at least see the outlines of the problem, while (3) not making them feel as if they’re being railroaded or mocked. This is work. To use my earlier example, not everything is as hard as the Poincaré Conjecture (although math has a lot harder stuff than that waiting for you), but I think even in that case that a hand-waving-level explanation can be gotten across to an intelligent person inside of a half hour (although not of Perelman’s proof, I would have to think). The reaction of said listener is fairly likely to be “Who cares?”, but they’ll at least have some idea of the question.
There are whole books written to lead nonexperts through things like Gödel’s Proof and the Riemann Hypothesis, and political and medical issues are not, in the end, as bad as those. Not everyone is going to want to hear about the details, but if a good-faith effort is made to supply them (and they’re then still rejected), that’s a point in favor of one side of the issue already. Perhaps the deal to be made is “I’ll listen to how you feel if you’ll listen to how I think”. I realize, though, that good faith seems to be in short supply this year. . .