Consensus among Experts: The Unholy Grail

Abstract

CONSENSUS AMONG EXPERTS: THE UNHOLY GRAIL LOUIS LASAGNA, M.D: Mr. Gordon: . . . Ifelt a cold coming on sometime ago and I dosed myself with a lot of vitamin C, but it did not stop the coldfrom coming. I must confess, however, that after I got the cold, I took some of my wife's chicken soup. It did a much betterjob than the vitamin C. Dr. Katz: Well, there is no question, Mr. Gordon, that hot chicken soup ¿s very good. Hot drinks ofany sort, hot tea, hot cocoa, hot chocolate, hot milk, hot toddy, anything hot is ofgreat value in upper respiratory infection. . . . [Hearing before the Subcommittee on Monopoly of the Select Committee on Small Business, Washington, D.C, December 5, 1972] . . . the uncertainty, under which we still remain, in regard to the virtue ofthe waters ofBath. Few medicines have been more repeatedly tried under the inspection ofsuch numerous and ablejudges; andyet we have had in the present age a dupute between those who by their experience and sagacity were best qualified to decide this question, in which one side asserted that paralytic patients were cured, and the other that they were killed, by the use of these waters. Such contrary decisions, so disreputable to physicians, and so perplexing to the sick, could never have happened after so long a trial, if a very smallpart ofthose, whose practice had afforded themfrequent opportunities ofobserving the effects ofBath waters, had told the public what in theirjudgment was to be hoped orfearedfrom them. It is probable that in some cases it would have been almost unanimously determined they do good: in others, that they do no harm, though it might be doubtful whether they be of much use: in a third sort they would be generally condemned: and in a fourth class of dueases, some mightjudge them to be beneficial, and others detrimental. [William Heberden, Commentaries on the Hhtory and Cure ofDueases, 1802] A century ago the Swùs hhtorian Burckhardtforesaw that ours would be the age of "the great simplifiers, and that the essence of tyranny was the denial ofcomplexity. . . .It is the great corruptor, and must be resKted with purpose and with energy. [Daniel Moynihan, farewell speech to the president's cabinet, 1970] It is not surprising that experts disagree. We are accustomed, in almost every walk of life, to hear amazingly discrepant opinions and rec- *Departments ofPharmacology and Toxicology and ofMedicine, University ofRochester School of Medicine and Dentistry, Rochester, New York 14642. Perspectives in Biology and Medicine · Summer 1976 I 537 ommendations. Every week we read in our newspapers that the recession is over and that it is not. Economists provide little comfort for the average citizen when they make diametrically oppositejudgments about why the world faces fiscal chaos. The news media also carry abundant evidence of such disagreement among experts in the field of science and medicine. We are told that saccharine and cyclamates are carcinogenic and that they are not (and the government bars the latter but not the former); that we are an overmedicated society and that we are undermedicated; that U.S. medical care is unexcelled and that it is seriously defective when compared with other, less affluent nations; that research and training support is seriously inadequate and that it is excessive; that physicians are generally hard working and competent and that they are greedy, unfeeling, irresponsible , and therapeutically Cro-Magnon in orientation. Two editions of a fascinating book, Controversy in Internal Medicine, have been built around the ease with which experts can be found to debate the pros and cons of a series of vital issues in the diagnosis and treatment of some of our most common and important ailments. The Food and Drug Administration (FDA) is taken to court simultaneously for being too lax and too strict in its regulation ofdrug usage. The list of examples is almost endless. Let us, then, grant the existence of the phenomenon: experts not only can disagree, they can be expected to disagree. So what? The answer to that question is the reason for this essay. It is my purpose first to document , in data from an actual survey, the extraordinary extent of disagreement about a number...