Fuelled by the explosion of media outlets, information circulates at a dizzying pace, oscillating between black and white, absolute and relative, while the twenty-first century celebrates this new status quo. Freed from responsibility, the medium of transmission becomes indistinguishable from the message. The ordinary reader gradually becomes a consumer, an authority, a beneficiary, or a victim, depending on the moment.
On 30 March 2016, the online edition of the Daily Mail tabloid, which attracts at least 100 million visitors a month and is the second best-selling newspaper in the UK, published an article entitled “Vegetarian diet ‘raises risk of heart disease and cancer'”, which had been shared over 9,300 times by 25 May 2016. The article sparked heated debate both on the source website and on social media.[1] The Facebook post about the article also included the subtitle “Bad news for vegetarians”. In fewer than 300 words, the article offered an interpretation of a study’s key findings, a third-party opinion, and references to various other findings that appeared to corroborate the study’s implications. This was followed by a video containing “tips for a healthy vegetarian diet”.
What difference does it make that—besides the misleading use of quotation marks in the headline, the complete absence of bibliographical references of any kind, and the ambiguous presentation of unsupported arguments[2]—some of the authors of the study on which the article was based felt compelled, a week later, through a much less widely read communication channel[3], to state that the MailOnline article was “a misrepresentation of our findings”? What significance does it hold that the same source has previously published articles either praising the protective effects of a vegetarian diet against the same set of diseases[4] or claiming that coffee has either a protective or carcinogenic effect[5][6]? And last but not least, what does the popularity of that article say about how easily a pseudoscientific idea can be accepted?
More important, however, are the reactions of readers. “April Fool’s joke”, “One way or another, you’re going to die anyway”, “There’s nothing scientific about this article”, “What are we going to do now? Are we going to stop eating?”, are just a few examples of comments on the article in question. Clearing up this sort of confusion on such an important topic requires a return to school.
Models
Very early on in their six-year course, medical students are faced with a question that they must answer quickly and decisively, even though they certainly lack the full picture at that moment. What sort of doctor must you be? The question is phrased in the present tense whilst containing an imperative: You must decide now! As with any rhetorical question, the student is denied the time to react and is confronted with models of the doctor–patient relationship.[7]
The first model is the paternalistic one, which has defined much of the history of medicine. However, it is currently a model “in decline”, adopted only by practitioners who grew up in a simpler, more altruistic, and trusting society. In this model, doctors determine which interventions will benefit the patient based on their professional experience and the knowledge acquired during their training. The patient is considered a layperson and simply accepts the doctor’s decisions, either before or after the medical procedure. It is assumed that the doctor and patient share a common set of values that define medical benefit and that the doctor will prioritise the patient’s welfare over their own interests, consulting other specialists when their expertise is exceeded. Thus, the paternalistic model places all decision-making power in the hands of the doctor, who “knows what is best for the patient”.
Apart from emergency situations, the Western medical community has moved away from this type of relationship due to its high degree of subjectivity, the risk of abuse of authority, and the resulting lack of patient autonomy. The most serious risk stems from the tendency of some medical professionals to defend the unhealthy aspects of their own lifestyle by downplaying their impact, and to promote therapeutic measures that are not scientifically supported but based on personal or professional experience. This results in contradictory advice regarding the consumption of coffee, alcohol, or saturated fats, for example, with the expectation that patients will comply unconditionally.
The following two models—the informative model and the interpretative model—represent evolutionary stages in the search for an optimal solution. In the former, the doctor describes the diagnosed condition to the patient and provides a full list of possible interventions. They maintain an objective distance from the options and place full responsibility for the choice on the patient. In the interpretative model, the doctor’s role expands further to establish a link between the patient’s values and the available treatments. The doctor suggests a course of treatment based on the patient’s “way of being”, acting much like a neutral counsellor in any other field.
While this is an improvement on the first model, it undermines the essential qualities of effective medical care. The informative model transforms the “healer” into a cold, detached, and indifferent web page or medical manual, placed in the hands of the “client” (this model is also known as the “consumer” model). The patient is left entirely responsible for the decision, and is deprived of advice, empathetic support, and preventive encouragement to improve their lifestyle. Furthermore, an “interpretive” doctor will not be able to ask the patient to stop consuming fizzy drinks, fast food, or drugs, as this would contradict or undermine some of the patient’s values—values defined by their preference for a particular lifestyle.
The fourth option is the desirable answer to the raised question: the deliberative model. In this scenario, the doctor plays the dual role of guide and negotiator. They guide the patient through the complex web of medical information and question harmful practices, preferences, or values. Based on what has been discussed, they negotiate the optimal approach to the health problem. The patient is encouraged to make judgements and ask for explanations, while the doctor is obliged to provide explanations and persuasion backed by scientific evidence. The effectiveness of this approach lies in the fact that it is the only one in which the doctor has a duty to act as a scientist. They are not a parent, judge, infallible authority, dictionary, adviser, or facilitator, but first and foremost a scientist with both the duty and inclination to ensure the individual’s physical, mental, and social well-being.[8]
Illness leaves patients in a state of maximum vulnerability, where fear of the unknown, powerlessness, and despair dominate their experience. This vulnerability is also evident in the growing emphasis placed on preventative education and information, an activity that should form part of any medical graduate’s “toolkit”. If the question posed to a medical student were posed to the general public, it would take the following form: Who should you trust at a time of greatest vulnerability?
Evidence-based medicine
The deliberative model is, as mentioned, grounded in this concept, according to which clinical decisions must be supported by data—preferably from ethical, well-planned, transparent, reproducible research that has withstood scrutiny by experts in the field. This modern principle eliminates subjectivity and myth from the decision-making process because even the most experienced clinician may act to the detriment of the patient if they are under the illusion or recent influence of selected cases that lack statistical significance.[9]
A prominent and influential voice in this field is that of epidemiologist Ben Goldacre. He is the author of books[10] and articles on pseudoscience and the irresponsible sensationalism of newspapers and magazines, whether online or in print, which disseminate medical information with an air of authority. This information ranges from the comical to the alarming. Dr Goldacre also campaigns for transparency within the scientific community[11] and against institutions with financial interests capitalising on collective ignorance. This can include pharmaceutical corporations and researchers with questionable credentials who publish articles containing profound scientific errors. Such articles have led to an alarming drop in vaccination rates, for example.
For the moment, the whole endeavour seems like a losing battle against sensationalist headlines that appeal to instinct and emotion, so popular in the online world.[12] A PhD thesis entitled “Establishing the evidence informing the conduct and reporting of systematic reviews of randomised controlled trials” cannot compete with an article such as “Health alert: exercise makes you fat!” on social media. In a rare moment of defeatism, Goldacre describes a World Cancer Research Fund study in which “half of all respondents said they thought scientists and doctors were constantly changing their minds about healthy-living advice, although in reality healthy-living advice hasn’t changed at all for at least a decade (don’t smoke, do some exercise, eat more fruit and veg). And a quarter of all respondents said that because scientists keep changing their minds, you might as well eat whatever you want, because it won’t make any difference anyway. Have another pastry and put the telly on.”[13]
One issue that Goldacre consistently analyses in his books and presentations is the cognitive or logical fallacy known as confirmation bias, or “confirmation favouritism”.[14] Both medical researchers[15] and patients or individuals receiving preventive health advice can be guilty of this fallacy. When people believe in a concept or live by certain pre-existing principles or ideas, they seek out and accept only evidence or arguments that support that paradigm whilst contradicting or ignoring contradictory evidence. For example, someone who frequently eats sweets will welcome an article that downplays the harmful effects of this habit, but will overlook any argument that might prompt them to change. Similarly, someone who regularly spends late hours on social media will enthusiastically skip over an article about the negative effects of chronic fatigue.
Clickbait
Modern sources of information are well aware of this fallacy and exploit it to their advantage. The realm of curiosity between what people know and what they would like to know can easily be monetised through clickbait headlines. The content is of secondary importance and what matters is the headline, which, in most cases, will be forwarded to friends and relatives without further verification to entertain, confirm, or contradict, and ultimately generate traffic and revenue for the source.
Borrowed from the world of tabloid journalism, this form of bypassing reason would, at most, be amusing and worth noting when it concerns juicy details from the life of a public figure. However, it becomes destructive and even fatal in the field of health information. Returning to models of the doctor–patient relationship, we might ask whether we would trust a paternalistic, know-it-all, authoritarian, subjective doctor who dictates our well-being without explaining their motivations, sources of information, reasoning, or expectations. But what if the source of information or interpretation had not even passed through a relevant educational system or taken the “primum non nocere” oath?[16]
Journey vs. destination
The ultimate argument hinges on a significant detail: science is primarily concerned with the way in which conclusions are reached, not the conclusions themselves.[17] Of course, scientific endeavour requires questions to be formulated, followed by a search for answers. However, the validity of these answers inevitably depends on how the conclusion was reached. In a sincere and transparent search for truth, we have a duty to critically analyse the sequence of arguments that led to a conclusion, especially if it saves or kills. Given our extreme vulnerability in the face of illness and death, we may also react strongly against selfishness and falsehoods. This reaction is grounded in reliable sources, clear judgement, and a willingness to make positive changes, even when the truth we discover is inconvenient.
