[The author, Seamus O’Mahony, is a recently retired hospital consultant (gastroenterology) of 35 years’s experience, who worked both in England and Ireland. He was kind enough to agree to be one of the plenary speakers at the (now postponed) Medicine 360 festival. He is also the author of two acclaimed books, The Way We Die Now (2016) and Can Medicine Be Cured? (2019) Richard Smith, the ex-editor of The British Medical Journal called the latter ‘The most devastating critique of medicine since Medical Nemesis by Ivan Illich in 1975.’ (BMJ 13/02/19) He has another book due out next year, The Ministry of Bodies: a year of life and death in a modern hospital.]
I retired from clinical medicine on February 7, 2020. Four days later, the WHO gave the name “Covid-19” to the virus causing the pandemic. I had been a hospital consultant for nearly twenty-four years, specialising in gastroenterology, but also doing “general” medicine. I had many plans for the first months of my “new life”, and like everyone else, I have had to re-calibrate my expectations. Now, I start each day with a five-mile walk, a circle around the small rural village where I live. I often meet neighbours on this walk, and since February, there has only been one topic of conversation. Even though I am retired, and have little or no expertise in virology or epidemiology, my neighbours always respectfully seek my opinion on developments with the pandemic. Irish country people still have an old-fashioned deference to the professions; or maybe they are just being kind, bolstering the self-esteem of an old(ish) man no longer at the front-line.
The phrases I hear myself saying are usually: “I don’t really know”; “I’m not sure” and “I’m not sure anyone knows”. A journalist friend phoned me several weeks ago, and was disappointed when I told him that having retired from active practice, I didn’t have a feel for what was happening at the front-line, that most of what I knew came from news media. “Yes, yes”, he said impatiently, “but you’re an acknowledged expert in medicine.” I had to think about this. Do I now have expertise in anything? This prompted me to re-read Harry Collins’s short 2014 book Are We All Scientific Experts Now?, which I reviewed at the time for the Dublin Review of Books. If you haven’t heard of this book, I strongly recommend it. Collins, a professor of social sciences at Cardiff University, is a sociologist of science, and an expert on expertise; he has studied gravitational wave physicists as Margaret Mead studied Samoans.
In my work as a gastroenterologist, I was — according to Collins’s classification of expertise — a “contributory” expert:
A contributory expert is someone who makes a contribution to an area of expertise and is, generally, what people think of when they hear the word ‘expert’. How does one become a contributory expert? By working with other contributory experts and picking up their skills and techniques — their tacit knowledge of how to do things. One become a contributory expert by being an apprentice.
Although I might persuade a judge hearing a medical negligence case that I am still an “expert”, as far as I and my former gastroenterology colleagues are concerned, I ceased to be a contributory expert the minute I drove out the back gate of Cork University Hospital on February 7th.
Then there is “interactional” expertise, which according to Collins “is acquired by engaging in the spoken discourse of an expert community to the point of fluency but without participating in the practical activities or deliberately contributing to those activities.” Collins himself, having studied gravitational wave physicists for decades, is familiar with most of the concepts they discuss; he is thus an “interactional” expert, but because he doesn’t actually do gravitational wave physics, he is not a “contributory” expert. Finally, there is “meta-expertise”: “used to judge and choose between other experts; in principle, this kind of expertise can be good enough to guide one through the decisions one has to make in the contemporary technological world.” I used to think that I possessed this expertise, but with the infodemic that has closely followed the pandemic, I’m not so sure.
The experts advising the politicians in Europe seem to be mainly interactional experts; there are a few contributory experts, such as Sweden’s Anders Tegnell, who worked with the WHO during the 1995 Ebola virus outbreak in Zaire. This morning, I listened on the radio to Prof. Gerry Killeen, who argues that the Irish government’s strategy is wrong, that restrictions should not be lifted until the virus has been completely eliminated. Killeen was recently appointed “AXA Research Chair in Applied Pathogen Ecology” at the School of Biological, Earth and Environmental Sciences at University College Cork (of which I am a graduate). I confess I had never heard of Prof. Killeen, so I looked him up. He has an impressive publications record, with a high citation count and h-index. He has worked mainly in malaria control, but also has experience with the Zika and Dengue viruses. My meta-expertise suggests that Prof Killeen is a true contributory expert, but I don’t like his stark message.
Ireland’s chief medical officer, Dr Tony Holohan, is currently the country’s most powerful expert voice. He is an interactional expert, with a background in primary care and public health. He is relatively hard-line on the lifting of restrictions, but nowhere near as hard-line as Prof. Killeen. As I write, he still recommends a 2-metre social distancing, and has also advised the government that visitors to Ireland should be required to self-isolate for two weeks at “a designated facility”. Meanwhile, our economy has collapsed, education is in limbo, and people are desperate to return to “normal” life. Our politicians have used the weaselly excuse of “we took the medical advice” to justify every unpopular decision, but sooner or later they will have to admit that politicians make political decisions.
Lord Sumption, the distinguished jurist and historian, argued in his 2019 Reith Lectures that public confidence in democratic institutions was draining away, that the law courts were increasingly making decisions that should be made by politicians. Writing on Covid-19 for The Sunday Times, he argued that we citizens are partly to blame for this new risk-averse politics:
The lesson of Covid-19 is brutally simple and applies generally to public regulation. Free people make mistakes and willingly take risks. If we hold politicians responsible for everything that goes wrong, they will take away our liberty so that nothing can go wrong. They will do this not for our protection against risk, but for their own protection against criticism.
The article provoked a storm of criticism, which he responded to in The Spectator by explaining the basis of his own meta-expertise:
One reason why people listen to me is that I was once a Supreme Court judge. But that is because judges, like other lawyers, are trained to analyse complex technical facts objectively, especially in areas where expert opinion conflicts, as it does with Covid-19. I have spent my whole professional life doing that.
What are we non-experts and ex-experts to make of it all? How do we reconcile the science and the politics? I cannot improve on this blog written by Venki Ramakrishnan, Nobel laureate and President of the Royal Society (now there’s interactional and meta-expertise for you)
At the frontiers of science, there is always uncertainty . . . Given such uncertainties, ministers need to make the best decisions they can now, but also be prepared to change tack later, in light of new evidence. Being able to do that requires an openness and honesty with the public. The public will feel misled if ministers use “the science” as a prop to create a false sense of security and certainty only to change tack later. It will lead to an erosion of public trust precisely at a time when long-term trust is needed to allow the hard choices ahead. Ultimately, as has been pointed out, advisers advise, ministers decide. In these decisions, science advice is often only one of the things they need to consider. Considering science advice is not the same as simply “following the science”. Moreover, there is often no such thing as following “the” science. Reasonable scientists can disagree on important points, but the government still has to make decisions.
In their 2008 book Rethinking Expertise, Harry Collins and Robert Evans wrote: “In general, the speed of politics exceeds the speed of scientific consensus formation. As a result, too much greed for scientific authority is bad for science, forcing scientists to act in scientifically inauthentic ways.”
Covid-19 has forced scientists and politicians to work together. Science and politics are both human endeavours and thus, fallible; neither can give us the certainty we yearn for. They should be honest about that, and we should be able to handle that truth.
Seamus O’Mahony, June 2020, for medicine360.co.uk