What is freedom of “academic” expression? Without the freedom to offend, it ceases to exist.
Mr Chairman Sir, ladies and gentlemen, I am not here today to extol the virtues of anyone’s political views, perspective, or Weltanschauung (worldview). I am not here today to wax on lyrically, relentlessly, and mellifluously over the merits or demerits of any military campaign or international injustice perpetuated by any government or global plot against any one particular population or religion—even though by the end of what I have to share, you may have some idea of where I stand on these matters.
I am, however, here today to speak about freedom of speech in general, about academic freedom in particular, and about misunderstandings and clarifications regarding the concept of boundary violations among medical professionals and institutions, including medical publications. My aim today is to prove to you that medical publications which may promote political agendas do have a place in scientific and medical journalism. However, and perhaps most importantly, I am here to state categorically and unequivocally that even if you do not agree with me on this last-mentioned point, academics and medical professionals should emphatically not refrain from publishing in such journals.
Issue One: Medical publications which may promote political agendas do have a place in scientific and medical journalism
Medical professionals are the recipients of respect that is due to them from society by virtue of the unwritten social contract that the community has with doctors. Thus, physicians are allowed to undress patients, make deep body incisions with knives, remove organs, and probe the innermost intimate issues with patients during a consultation. This agreement is coupled with the duty to relieve pain and suffering and to manage disease and disability.2
It is imperative, however, that physicians maintain the boundaries of this interaction so that the patient/society can interact in a safe atmosphere with a physician who is completely in sync with the patient and clear of any presumptive political orientation or grandstanding. Any political barrier that is placed between the two interferes with the special and unique interaction owed to the patient. Physicians need to desist from involvement “as physicians” in areas that supersede medical practice and refuse to employ their training and professional skills in areas where they do not belong, such as torture as defined in the Declaration of Tokyo. This would apply as well to physician assistance in interrogation, profiling, electoral candidate character assassination, or anything else unrelated to the purpose for which the doctor underwent medical training.3,4
But—and this is a big but—physicians can and should be involved in aspects of the political process; however, this should only be in order to obtain better conditions and resources for their patients. Furthermore they may assist in engendering better education of the public with respect to illness prevention and optimal treatment as well as insisting on equality of health care for all.3,5 Gruen and colleagues6 have referred to such a role as “advocacy for and participation in improving the aspects of communities that affect the health of individuals.” Several examples of such socio-political involvement exist over the past century, including the celebrated Polish doctors in the early 1900s.7 Similarly, during the Nazi era, doctors had this duty; unfortunately, only on rare occasions did they speak out against the atrocities extended to the mentally ill. The mind boggles at the thought of what might have been, had the physicians during that era spoken out; remember, it took close to two years to halt the gassing of the mentally ill—all before the Holocaust “officially” began—and only after a very few individuals spoke out against the process. Although Hitler had given permission to physicians to kill their patients, he officially stopped the program to gas the mentally ill, which had been ongoing from 1939 to 1941. Hitler himself never ordered the process!8 Physicians need to speak out in the context of medical publications on issues they feel to be of profound relevance to public health and well-being.
Another way of understanding this process is by considering the interface of facts and values. An archaeological or physics journal deals with the facts only—it has to by nature. A medical journal, however, is different; it deals with well-being, values, virtue, interaction, sociological phenomena, and cultural competence. This is by nature what is of importance to medicine—this is what is demanded today from a medical journal in order to inject more of an emphasis on virtue in the field. One may consider that this is in keeping with a “post-modern” approach to academia and information, which is predicated on the presumption that not everything is “factual,” rather all is subjective. The question arises in medicine whether it is in fact possible to separate facts from values. From the perspective of Thomas Kuhn, this is impossible. Even if it were possible to separate facts from values, is this what we want in medicine? Is this what we want from a flagship international journal of the medical field? It is imperative that a medical journal appeals to virtues and open discussion of issues even if uncomfortable and confrontational to some. I argue, however, that facts need to be facts and virtues need to be virtues; it is not “anything goes.” That is how we develop as discerning doctors, by learning and gaining the skills to know what are facts and what are authentic values, and to develop a Weltanschauung for ourselves in the field. I implore my opposing speaker: Please don’t limit me on that.
Mr Chairman Sir, refraining from publishing in any particular publication weakens the merit of values; boycotting removes values from the field even if the absence of such rash measures opens the door to vastly different opinions. Dialogue is essential to the field. I ask you: did anyone seek to boycott the Journal of Medical Ethics after it published what many considered to be an extremely offensive article justifying “after-birth abortion?”9 No, Sir! Instead, it affords me with the opportunity of matching their non-factual opinion-based argument with a dialogue on virtue and values that trumps their approach. I succeed in both accounts— I combat their view, I introduce debate on a high level around the value of life and the physician’s responsibility, and I relish and bask in the glory of a civilized debate over issues of critical importance to society and medicine.
I would ask you, ladies and gentlemen, is there not in fact a parallel between opposing articles of vastly differing opinions existing side by side in a journal and the profound contrast, well known to Israeli medicine, where emergency rooms and hospital wards commonly have terrorists and terror victims lying side-by-side as recipients of the identical state-of-the-art medical standards and attention so characteristic of Israeli medicine and values? Should we not entertain similar values and ethical discourse in the medical literature? It is the conscience of the doctor in medicine that is important—we do this by encouraging dialogue and at times even challenging the status quo in society regarding issues of relevance and importance to public health in policy and well-being. Who would not have wanted able-bodied confident doctors to speak out in 1939 against the policies of the German T4 program regarding “life not worth living” and the subsequent euthanasia of approximately 200,000 mentally ill people. No doctors spoke out in the international literature to any significant extent, although some did in the USA, albeit to support much of the theoretical underpinnings of the program.10 How apt are the words of the great American poet and author Ella Wheeler Cox: “To sin by silence, when they should protest, makes cowards of men.” It should be remembered that it was the British, the Canadians, and the Americans who were at the forefront of the eugenics movement and not the Germans. However, it was the German doctors who actualized the eugenics program based on synergistic goals of the medical professionals and broader political forces. How different history may have looked had physicians openly protested in the medical literature regarding the euthanasia program—on which many would argue the Holocaust was based.
I therefore want to go above and beyond politics. Medical publications need to address fundamental concepts including issues of conscience and virtue. This even includes trying, at times, to cultivate a healthy skepticism towards our own points of view (and that, ladies and gentlemen, is a direct quote from the written words of our very own chairman of the debate, Professor Glick, in a 1994 paper he authored and published in the Journal of Medical Ethics).11 This is an example of an issue that is more than “just” about me as an individual or me as an Israeli doctor. Einstein once quipped: “Try not to become a man of success, but rather try to become a man of value.”
Mr Chairman Sir, I am not asking you to agree with any partisan political rhetoric of any particular medical journal. I am not asking you to condone any falsehoods, inaccuracies, offensiveness, etc. However, I am asking you to agree that medical professionals have the ethical right to stand up and make an issue of public health where they may feel one exists. If they do so, I submit to you that this has to be carried out within the context of a medical infrastructure such as a conference, journal, or institution and not through traditional political structures. To carry it out through political structures would be a boundary violation and considered an egregious infringement of medical ethics and professionalism. However, addressing a medical journal with a problem affecting public health is a duty of medical professionals as described above.
I would, however, agree with Daniel Patrick Moynihan that “everyone is entitled to his own opinion, but not to his own facts.” In the words of Chesterton, “to have a right to do a thing is not at all the same as to be right in doing it.” As Hubert H. Humphrey so aptly put it, “the right to be heard does not automatically include the right to be taken seriously.”
Herein lies the crunch—do not fear taking on such viewpoints. Do not fear exposing opposing views in the medical literature, whether they are with a political stance or not, for what they are—be they factually, ethically, numerically, statistically, or philosophically incorrect. Samuel Johnson once remarked that “every man has a right to utter what he thinks truth, and every other man has a right to knock him down for it.”
It may be that you, like me, do not want to be associated with such people, but I also don’t want to limit their speech in any way because that’s one of the things freedom requires. As Rand Paul once quipped, “even if we allow people to be boorish and uncivilized, that doesn’t mean we approve of it.” Bryant McGill said, “Do not make the mistake of thinking that you have to agree with people and their beliefs to defend them from injustice.”12 Take them on at their own game. However, this is very, very different to that very dirty “B” word: boycott.
Issue Two: Medical professionals should emphatically not refrain from publishing in such journals
And this brings me to my second point as elucidated earlier on—even if you do not agree with me that medical publications with political content have a place in medical journalism, I wish to prove to you that medical professionals should emphatically not
refrain from publishing in such journals.
It is generally accepted as an axiom that the progress of science and knowledge is dependent on the open exchange of ideas between academics.13 An official statement of the principle has even been formulated for scientists by the International Council of Science (ICSU). Statute 5, referred to as the “Principle of Universality of Science,” clearly states:
The Principle of Universality (freedom and responsibility) of Science: the free and responsible practice of science is fundamental to scientific advancement and human and environmental well-being. Such practice, in all its aspects, requires freedom of movement, association, expression and communication for scientists, as well as equitable access to data, information, and other resources for research. It requires responsibility at all levels to carry out and communicate scientific work with integrity, respect, fairness, trustworthiness, and transparency, recognising its benefits and possible harms.
In advocating the free and responsible practice of science, ICSU promotes equitable opportunities for access to science and its benefits, and opposes discrimination based on such factors as ethnic origin, religion, citizenship, language, political or other opinion, sex, gender identity, sexual orientation, disability, or age.13
Thus, the open values of science encourage debate and discussion on the way to the truth and preclude any form of embargo or sanctions based on the opinions of others. Mr Chairman Sir, this could not be stated more clearly!!
This Principle of Universality of Science clearly stands in tension with the practice of academic boycotts of individuals or journals. An academic boycott embraces the “systematic withholding of normal professional relations from academics as a means to achieving some goal, typically either punishment or the bringing about of some change in behavior or policy.”12 Many examples of boycotts of Israeli academics exist around the world, including the Annual Congress of the University and College Union (UCU) in the United Kingdom in 2007. And now, Mr Chairman Sir, the proposing speaker today is suggesting we do the same. Is the very respectable professor from Beer-Sheva aware of what he is proposing? Do we not hold ourselves up to a higher standard of ethical norms?
May I submit to you that boycotting a medical publication based on its publication of relevance to public health despite overt political content would directly conform to the moral impermissibility of academic boycotts.
Professional discrimination is unfitting when it is based on deliberations extraneous to ethical principles and quality standards such as political factors and affronts to one’s sensitivities. Open dialogue, on the other hand, is demanded, and it is there that such an offense or even outrage needs to be confronted and purged.
The Principle of Universality is based on two considerations: the extent to which universality contributes to the value of science and academia, and the rights of academics and their institutes, including journals, to be free from inappropriate methods of discrimination.14 Thus, boycotting an academic journal based on its publication of literature deemed to be inappropriate, no matter how offensive, would be downright unethical and in direct contravention of the ethical principles of scientific endeavor and professional values of medicine.
Advances in science and learning are essential to society and its well-being. A critical aspect of this fundamental good is that it is social and collaborative. Hence, academic endeavor by definition inculcates, as crucial features, interaction, communication, and diffusion—a phenomenon that boycotting comes to obliterate. It is true that at times there are publications that may be accused of falsification of facts, poor science, political boundary violations, etc. However, to take a stance on boycotting every time a publication of such ilk sees the light of day, as the proposer states, would be the height of idiocy and misguided vigor. Boycotts are proscribed because they diminish or destroy the value inherent in science and learning. Boycotts deliberately obstruct interaction and cooperation, and therefore establish impediments to scientific advancement.14
There is, in addition, a further aspect to consider regarding the dangers inherent in the significant risk of the exploitation of any boycott. Since no benchmarks for the absolute rationalization for boycotts exist, any boycott may be exploited as an example by questionable individuals or organizations to back other politically motivated and groundless boycotts. In this manner, supporting or justifying any boycott complicates the quest to combat unwarranted and damaging boycotts in other situations.14
As both Jews and Israelis we have been the victims of such injustice in many such circumstances. For example, I can point to Nazi Germany and the contemporary Boycott, Divestment and Sanctions Movement (BDS Movement) as such examples in the academic arena!
Furthermore, why is refraining from publishing in any particular journal so problematic in humanistic terms? It is because the long-term consequences of publishing any particular academic work cannot be known. Thus, if Israeli researchers, albeit limited in number, decided to abstain from academic interaction in the international arena such as certain prominent medical journals, this might result in undue consequences for medical and/or academic advancement. Even if the boycotting of a journal by Israeli academics would lead only to postponement of a breakthrough (theoretically a possibility), this would still be unethical due to potential effects on well-being for some.
I would like to propose, as the scholarly and eminent Rodin and Yudkin14 have before, that there are three tests to be used when judging whether the probable welfare contribution of a proposed boycott is sufficient to outweigh the harms and risks, and whether or not the boycott is likely to be justified according to ethical and professional norms.
First, a boycott can only be acceptable if there is a good chance that it will succeed in combatting the moral malevolence at which the boycott was aimed. If not, the boycott fails to meet the standards of the Principle of the Universality of Science discussed earlier, with resultant consequences, for no matching advantage. Mr Chairman Sir, ladies and gentlemen, do you really believe that an academic boycott by Israeli academics of any medical journal, be it the New England Journal of Medicine or the “Ugandan Journal of Snow Science” would have any affect? Even if you suggest that publication of anti-Israel rhetoric is clearly masquerading as modern-day anti-Semitism in disguise, and that all Jewish academics around the world should shun the journal—do you really think that we could muster up an international cabal of Jewish scholars with the support of all the elders of Zion and their protocols, and that this would have any influence on ingrained anti-Semitic international Jewish control conspiracies?
There is absolutely no evidence that prior academic boycotts have significantly contributed to the dissolution of serious iniquities. Many have referred to the example of the academic boycott of my home country, South Africa. Most would argue that the academic boycott in this case did nothing to enhance the end of apartheid. On the contrary, as noted by Rodin and Yudkin,14 it may have contributed to what Neville Alexander later termed “the scholarly backwardness of South Africa today.”
The second moral argument that a boycott must satisfy is that it be necessary and that there is no other alternative that could realistically project the preferable outcome with less moral expenditure. If other approaches are available to attenuate the “moral evil” such as dialogue and debate, then these should be followed, rather than the option of boycott. Boycotts should not be warranted until other more reasonable approaches have been exhausted. In this manner, boycotting should be left to the auspices of state entities, not academics or scientists.14
Since the fundamental importance and significance of academia and knowledge is so profound, and the consequences of interfering are so stark, the third moral argument of Rodin and Yudkin states that a boycott could be vindicated only if it is an “exceptional response to a grave evil.”14 If it would be decided to engage in boycotts in unremarkable situations, the complete organization of collaborative science and learning would be compromised. Furthermore, universalizability demands an ethical requirement for academic boycotts in every circumstance in which the defining principles for a boycott exist. Hence, any country with any form of considered injustice, no matter how severe the injustice, needs to be boycotted. This would destroy the whole fabric of academic dialogue and interchange of ideas. An important practical corollary to this suggestion is that it is ethically problematic to boycott against ethical violations of less significant consequence whilst desisting from boycott against evils of a much greater level. Is it more important to boycott a medical journal publishing an incendiary political piece, than an academic journal from a country planning to drop a nuclear bomb on Israel? Where do you draw the line?
Mr Chairman Sir, may I submit to you that the academic boycott of a medical journal fails on all three of these ethical standards despite the potential egregious nature of published material in such a journal.
Boycotting locks in the biased article—with no commensurate response in the offing. Publications often make errors—they need to stand to be corrected not boycotted. I ask you, would it be wise to boycott the New York Times after it published an incorrect article about crack babies? Would you boycott Time magazine after it erred and falsely accused Ariel Sharon of planning the Sabra and Shatilla massacre? Even though the latter magazine was proven wrong in court, it stubbornly refused to retract. Boycotting, however, closes off the possibility of correction and betterment of important sources of knowledge.
Thus, given that boycotts are a deviation from well-grounded moral principles (as I have argued), the burden of proof should reasonably fall on those who propose and support boycott measures. Based on the opening argument of Professor Clarfield today, such measures are clearly unfounded under the circumstances.
My aim today is not to discuss the merits or demerits of any particular published piece of literature in any medical journal. Rather my goal is to reaffirm the value of open debate about critical topics that, although politically charged, entail profound effects for health around the world. Medical journals need to address issues of value even if in so doing they challenge the sensibilities of some and fail in their aim of fostering virtue in the field. Attacks on journals for publishing authors’ concerns on issues of public health with political undertones threaten the integrity and independence of all scientific journals dealing with medicine and community health in general, and values and virtue in the medical field in particular. As John Howard once quipped, “It’s too much to expect in an academic setting that we should all agree, but it is not too much to expect discipline and unvarying civility.” It is also not too much to expect unwavering professionalism and a commitment to profound tolerance and forbearance.
I thank you.