K·A·C Communications is delighted that Ronald W. Dworkin, M.D., Ph.D. will be delivering the Michael Russell Oration this year. Dr. Dworkin is a practising anaesthesiologist, holds a doctorate in political philosophy and teaches in the George Washington University Honors Program. In addition, he is a Senior Fellow at Hudson Institute in Washington D.C., a public policy research organisation.
In a recent article for The American Interest, Dr. Dworkin had some interesting - and controversial - things to say about some public health advocacy. We interviewed him ahead of the conference to find out what he’s planning to bring to the event in his address, Interests and Ideology in Harm Reduction.
We’re delighted that you’re attending GFN 2019 to deliver the Michael Russell Oration. Michael Russell’s formative work in the field of tobacco harm reduction remains an inspiration to many of us. Your work brings together the worlds of science, medicine and political philosophy. Who inspires you?
That's a good question, because to synthesize the worlds of science, medicine, and political philosophy, one needs inspiration, as the American employment structure does not lend itself to such a synthesis. In college I was interested in medicine and science; I was also interested in history and philosophy; but there was no set program that would allow me to pursue the two interests simultaneously, let alone combine them. Indeed, after college, I went to medical school and did my residency in anesthesiology with every intention of returning to school to study political philosophy, which I did while working as a doctor full-time; but all during that period I never really told anyone about my plan. The few times I did, people thought it was strange. Some of my medical professors, when I alluded to what I wanted to do, suspected me of not being a committed physician. The reaction was uniformly negative because in the U.S., as in most places, I suppose, one is expected to have one field of endeavor in life, especially if that field is a highly scientific and technical one like anesthesiology. Even C.P. Snow's famous lecture on the two cultures—science and the humanities—which I read in college and which might have been a logical source of inspiration for me, was not really a call to combine the two cultures, but, instead, simply a call to give humanities students a little more exposure to science in their curriculum. Although it broke with the style of education passed down from the Victorian era, it made no effort to synthesize the two cultures on a high level. So, to be honest, I mostly groped my way toward my current career without any obvious source of inspiration—initially writing about political philosophy while also practicing medicine, but assuming the two subjects were independent of one another. Only later did I stumble onto ways to combine them.
In a recent piece for The American Interest called The arrogance of public health advocacy, you state: “Public health activists are clever enough to understand the scientific method, but they are not clever enough to understand its limits. Their minds are crowded curiosity shops where science, ideology, and hubris all find a place.” Where do the limits lie with the scientific method – and how is that reflected in the public health debate over tobacco harm reduction?
The 17th century represents the dawn of the scientific method. Sir Isaac Newton used the method to explain the basic laws of the universe; Thomas Hobbes used it to discover the basic laws of society. Both men used the method to strip away what they perceived to be redundancies and discover fundamental truths. But over the last century, the scientific method has entered the everyday spheres of life—for example, in public policy, human science, psychology, and, yes, public health. The problem is that the scientific method demands a closed system with a finite number of easily observable variables to be useful. When dealing with everyday life and the human personality, the system is anything but closed and the variables are infinite. This is the problem with applying the scientific method to the debate over tobacco harm reduction: what motivates people to smoke or to vape, or to stop smoking or to stop vaping, is so complex that the subject is worthy of a novelist more than a scientist. Scientific categories of thought are too simplistic. True, such gross generalizations are very useful in chemistry, physics, and astronomy, but to explain human motivation and behavior, they offer poor guides to action. The public health establishment prides itself on using the scientific method, and in certain areas, such as infectious disease, the method does work well. But in trying to push a particular policy on smoking or vaping, that method fails. People are simply too complicated; it is silly to declare with certainty, as some in public health do, that "If we get rid of vaping, people will also continue to stop smoking." The issue is much more complicated. Public health, when it makes such sweeping statements, ceases to be science and instead becomes ideology—a belief system that thrives on over-simplification.
How would you characterise the challenges faced by Americans who want to quit tobacco but are put off by the narratives criticising vaping? Would you agree that ‘first, do no harm’ could naturally be extended to ‘or, do less harm’?
You are right to be concerned with the narratives that Americans are getting about vaping. Those narratives are mostly critical. Indeed, my own teenage daughter, when she heard I was speaking at a conference on vaping, said that vaping is dangerous and that it preys on kids. When I asked her where she learned that, she said, "That's what people at my school say." For the vaping community to focus attention on the regulatory agencies and officials who make decisions about e-cigarette policy is obviously important, but more important is to focus attention on the organs of public opinion. In the U.S., to put it bluntly, government is not sovereign. Public opinion is sovereign. And although public opinion in the U.S. moves slowly, when it does move it is decisive. The problem in the American market is that the opponents of vaping understand this, and therefore have focused public opinion's attention on the issue of vaping among teenagers. Many Americans don't even realize that the purpose of vaping is to help people quit tobacco. They think of it more as a recreational drug, no different from "whippets" (canned nitrous oxide) or even cocaine. The fact that e-cigarettes are flavored in ways that instinctively make Americans think of children (e.g., mango and chocolate, as opposed to menthol, or even the more "adult-like" espresso), further cements in their minds the prejudice that vaping is geared toward children and, as such, has something nefarious about it. Many Americans are only dimly aware of the debate between "first, do no harm" and "or, do less harm." To get to that point, American public opinion must be moved in a new direction—and soon, before the current attitude solidifies. This means emphasizing the harm reduction aspect of vaping, while making sure that nothing interferes with that important message.
The conference theme is ‘It’s time to talk about nicotine’. What kind of conversations do you hope to have at the event?
I'd like to talk to people about their operational strategies for shifting the public conversation from usage in teens to harm reduction in adults. This seems critical to me, for without the shift, e-cigarettes will end up, at least in the U.S., as a prescription drug, which will inevitably marginalize vaping. Supporters of cannabis, in contrast, have been much shrewder. Although their agent of choice is more mind-altering and more dangerous than nicotine, they seem to understand public opinion more, and have pushed to legalize cannabis as primarily an over-the-counter medical drug that helps people cope with nausea and other medical symptoms. They studiously avoided describing it as a recreational drug among adults, let alone among teenagers, which is ironic, since cannabis was traditionally the recreational drug of choice among teenagers. I want to know if people at the conference are thinking along the same lines.
I'd also like to talk to people about the science of nicotine itself and the current direction of research. Much has been published about nicotine's relative safety, but there is a certain defensiveness in this work; it carries the burden of proving a negative—that nicotine does not harm—to earn greater acceptance of vaping. I was wondering if new work was being done on whether any salutary benefits to nicotine exist. The alcohol industry moved in this direction several decades ago, for example, when it demonstrated the benefits of red wine (although the benefits are still being disputed). The finding helped move public opinion on the issue.
Finally, in my speech I will be discussing the role of the scientific method in social science more generally—and somewhat critically. The scientific method, social science experiments based on one or two variables, the role of "big data"—all this has limits in public policy, I believe. I'd like to hear people's thoughts on the subject.
Thank you for your time!