Seeking expert medical advice? The Internet seems to invite us to dispense altogether with consulting a doctor in person. When I Googled “expert advice” and medicine, I got 1,650,000 hits. “Expert advice” and “psychology” garnered 950,000. (Your results may differ.) Sites such as Kasamba (www.kasamba.com) and AllExperts (http://allexperts.com) offer expert counsel on just about any subject. We cannot avoid relying on expert opinion. We simply do not have the factual knowledge required to answer all of our questions. Certain fields are so technical, moreover, that only a true expert’s opinion will do–and especially for medical decisions, a doctor’s advice is crucial. But our very need for such advice is also why claims of expertise so easily lend themselves to abuse, much to the detriment of the person looking for help. Professionals in the advertising industry are well aware of the persuasive powers of such appeals to authority. Consequently, they spend billions of dollars on advertising and employ ostensibly trustworthy–or not so trustworthy–experts who try to lure us into buying products or services. Its one thing to be on our guard when watching commercials, however, and quite another to evaluate the credibility of Web sites, self-help books and the like. How do we know whom to trust? What makes someone an authority? And what are the limits of expert advice? Following are some guidelines. Know Who Knows Relevant expertise. The first question to ask of any claim of competence is this: Is the claimant actually knowledgeable in the relevant field? Behind too many such claims lies a fallacy called argumentum ad verecundiam, Latin for “argument to shame” or “argument to respect.” More commonly, this misleading position is called an “inappropriate,” or “irrelevant,” appeal to authority. The fallacy occurs when the authority making a claim or cited to justify a claim is not a specialist in the proper field, such as when a podiatrist advocates a cholesterol-lowering drug. Neutrality. Advice is most reliable when it helps the person seeking guidance without providing undue financial gain or other advantage for the expert. We should be wary of an expert who has a vested interest, such as a physician who is affiliated with a company that sells the drug he or she is recommending. Of course, it is unrealistic to expect complete neutrality: a doctor may have participated in researching the drug being recommended, and this experience may have convinced him or her of the medicine’s efficacy. Therefore, we must research and evaluate an experts credentials with care. Verifying Bona Fides Degree. Most of the medical Web sites I have visited do not tell you anything about the doctors who provide the advice or the area of medicine in which they specialize. That warrants a background check. It is crucial to look into the institutions where proclaimed experts have received their degrees. The paths of accreditation have been muddled by several hundred “diploma mills”–nonaccredited institutions where a diploma can be purchased or earned with very little work. Diploma mills operate largely online, making it sometimes difficult to determine whether they actually have a physical (and thereby traceable) presence somewhere or which classes (if any) must be passed to obtain the degree. Many diploma mills have names that resemble those of major research institutions, and because an Internet domain name can be purchased for less than $100, it is all too easy to be misled. The U.S. Department of Education provides a list of all accredited institutions. Affiliations. Most doctors have an affiliation with a hospital, a medical group, a university or some other research group. Such associations are preferable over connections to pharmaceutical companies or industry-funded research institutes (which may indicate a bias). Also, certain relationships, such as those with major research universities, are more prestigious than others are. Publications. To earn status in their profession, experts often participate in research and publish articles on the subject in question. Most researchers affiliated with a university now list their publications on their department or faculty Web site; Google Scholar (http://scholar.google.com) also lists some articles. Another database for professional publications is PubMed, a service of the National Library of Medicine (www.pubmed.gov). Scholarly publications in professionally recognized, edited and refereed research journals are, naturally, preferable to newspaper or magazine articles aimed at the lay audience. The latter, while they can be informative, are usually not proof of expertise. Furthermore, because the readers of newspapers and magazines include potential patients, the publication may serve the self-interest of the expert. In scholarly journals, the intended audience consists mostly of fellow researchers. And although there is usually some monetary payment for scholarly books, the compensation for journal articles consists largely of prestige and reputation. The most reliably representative research articles are those that have been peer-reviewed by other recognized experts in the field. Whereas such studies themselves cannot be replicated in the peer-review process, the referees have knowledge of other studies and articles in the same research area, as well as familiarity with the research methods and controls necessary to exclude errors. The layperson does not have to understand the content of the expert’s articles: that the work has passed the peer-review process is itself a good indicator that it meets the rigorous standards of the scientific community. Successful publication also confirms that an expert really has know-how in the subject at hand. Limits of Advice Not all medical or psychological questions can be answered definitively. For example, should a person in a permanent vegetative state (PVS) be disconnected from a feeding tube? Should such a person become an organ donor? Medical expertise and information alone, even if trustworthy and accurate, cannot determine the answers to these questions. That does not mean we have no resources to tap, however. A patient diagnosed with PVS has irreversible damage to one of the hemispheres of the brain, but the brain stem–which regulates basic functioning–is still intact. This pattern of damage is why PVS patients usually breathe on their own and may even open their eyes and appear to cry. But because the part of the brain that is responsible for conscious thought and perception is irreversibly destroyed, the current medical opinion is that these reactions are merely reflexes. A PVS patient is not considered brain-dead. In a brain-dead patient, the entire brain, including the brain stem, has ceased functioning; brain death therefore constitutes the legal death of a person. As a result, PVS patients, as well as those entrusted with their care, are often placed in a moral limbo. Beyond the diagnosis itself, no amount of expert medical opinion can determine whether or not such a person should be disconnected from a feeding tube. The situation is further complicated if there is no living will, because the patients own wishes are not obvious. In such cases, people might consider turning to a “soft expert”–a person who can offer advice based on experience with similar instances or who has studied the moral concerns and other considerations that accompany these cases. A soft expert may be a religious leader or a philosopher–such people often serve on medical ethics advisory boards for precisely those reasons. Other soft experts, such as nurses or care practitioners, can provide context and insights that may not readily occur to laypersons. When considering our example of the PVS person, a Catholic priest may be aware that Pope John Paul II explicitly spoke out against withholding basic medical care, including nutrition, from such patients. He saw it as nearly impossible to achieve medical certainty that a patient may never recover. A Catholic may thus wish to err on the side of caution and request to disconnect the feeding tube only in those rare instances in which a physician can guarantee that no hope of recovery exists. In contrast, a soft expert who is trained in philosophy may emphasize the distinction between “killing” (an act of commission) and “letting die” (an act of omission). To use drugs to stop the heart is to kill a person, whereas to disconnect a respirator or a feeding tube is to let unassisted nature take its course. Some philosophers therefore argue that disconnecting a PVS patient from a feeding tube is not morally wrong. As the challenges of wrestling with these decisions suggest, ultimately no amount of expert advice, however useful, can replace our own reflection on a given subject. Only we are in a position to know the values, beliefs and wishes most important to a loved one or to ourselves. This unique vantage point is especially critical when, and also because, we are the ones that must live with the consequences of our actions. Having to defer our choices to someone else limits our autonomy and puts our well-being into the hands of the experts we picked. That is a lot to give up. What we do not have to surrender, however, is the power to choose–and the capacity to choose well–who that person will be.
We cannot avoid relying on expert opinion. We simply do not have the factual knowledge required to answer all of our questions. Certain fields are so technical, moreover, that only a true expert’s opinion will do–and especially for medical decisions, a doctor’s advice is crucial. But our very need for such advice is also why claims of expertise so easily lend themselves to abuse, much to the detriment of the person looking for help. Professionals in the advertising industry are well aware of the persuasive powers of such appeals to authority. Consequently, they spend billions of dollars on advertising and employ ostensibly trustworthy–or not so trustworthy–experts who try to lure us into buying products or services. Its one thing to be on our guard when watching commercials, however, and quite another to evaluate the credibility of Web sites, self-help books and the like.
How do we know whom to trust? What makes someone an authority? And what are the limits of expert advice? Following are some guidelines.
Know Who Knows Relevant expertise. The first question to ask of any claim of competence is this: Is the claimant actually knowledgeable in the relevant field? Behind too many such claims lies a fallacy called argumentum ad verecundiam, Latin for “argument to shame” or “argument to respect.” More commonly, this misleading position is called an “inappropriate,” or “irrelevant,” appeal to authority. The fallacy occurs when the authority making a claim or cited to justify a claim is not a specialist in the proper field, such as when a podiatrist advocates a cholesterol-lowering drug.
Neutrality. Advice is most reliable when it helps the person seeking guidance without providing undue financial gain or other advantage for the expert. We should be wary of an expert who has a vested interest, such as a physician who is affiliated with a company that sells the drug he or she is recommending. Of course, it is unrealistic to expect complete neutrality: a doctor may have participated in researching the drug being recommended, and this experience may have convinced him or her of the medicine’s efficacy. Therefore, we must research and evaluate an experts credentials with care.
Verifying Bona Fides Degree. Most of the medical Web sites I have visited do not tell you anything about the doctors who provide the advice or the area of medicine in which they specialize. That warrants a background check. It is crucial to look into the institutions where proclaimed experts have received their degrees. The paths of accreditation have been muddled by several hundred “diploma mills”–nonaccredited institutions where a diploma can be purchased or earned with very little work. Diploma mills operate largely online, making it sometimes difficult to determine whether they actually have a physical (and thereby traceable) presence somewhere or which classes (if any) must be passed to obtain the degree. Many diploma mills have names that resemble those of major research institutions, and because an Internet domain name can be purchased for less than $100, it is all too easy to be misled. The U.S. Department of Education provides a list of all accredited institutions.
Affiliations. Most doctors have an affiliation with a hospital, a medical group, a university or some other research group. Such associations are preferable over connections to pharmaceutical companies or industry-funded research institutes (which may indicate a bias). Also, certain relationships, such as those with major research universities, are more prestigious than others are.
Publications. To earn status in their profession, experts often participate in research and publish articles on the subject in question. Most researchers affiliated with a university now list their publications on their department or faculty Web site; Google Scholar (http://scholar.google.com) also lists some articles. Another database for professional publications is PubMed, a service of the National Library of Medicine (www.pubmed.gov). Scholarly publications in professionally recognized, edited and refereed research journals are, naturally, preferable to newspaper or magazine articles aimed at the lay audience. The latter, while they can be informative, are usually not proof of expertise. Furthermore, because the readers of newspapers and magazines include potential patients, the publication may serve the self-interest of the expert. In scholarly journals, the intended audience consists mostly of fellow researchers. And although there is usually some monetary payment for scholarly books, the compensation for journal articles consists largely of prestige and reputation.
The most reliably representative research articles are those that have been peer-reviewed by other recognized experts in the field. Whereas such studies themselves cannot be replicated in the peer-review process, the referees have knowledge of other studies and articles in the same research area, as well as familiarity with the research methods and controls necessary to exclude errors. The layperson does not have to understand the content of the expert’s articles: that the work has passed the peer-review process is itself a good indicator that it meets the rigorous standards of the scientific community. Successful publication also confirms that an expert really has know-how in the subject at hand.
Limits of Advice Not all medical or psychological questions can be answered definitively. For example, should a person in a permanent vegetative state (PVS) be disconnected from a feeding tube? Should such a person become an organ donor? Medical expertise and information alone, even if trustworthy and accurate, cannot determine the answers to these questions. That does not mean we have no resources to tap, however.
A patient diagnosed with PVS has irreversible damage to one of the hemispheres of the brain, but the brain stem–which regulates basic functioning–is still intact. This pattern of damage is why PVS patients usually breathe on their own and may even open their eyes and appear to cry. But because the part of the brain that is responsible for conscious thought and perception is irreversibly destroyed, the current medical opinion is that these reactions are merely reflexes.
A PVS patient is not considered brain-dead. In a brain-dead patient, the entire brain, including the brain stem, has ceased functioning; brain death therefore constitutes the legal death of a person. As a result, PVS patients, as well as those entrusted with their care, are often placed in a moral limbo. Beyond the diagnosis itself, no amount of expert medical opinion can determine whether or not such a person should be disconnected from a feeding tube. The situation is further complicated if there is no living will, because the patients own wishes are not obvious.
In such cases, people might consider turning to a “soft expert”–a person who can offer advice based on experience with similar instances or who has studied the moral concerns and other considerations that accompany these cases. A soft expert may be a religious leader or a philosopher–such people often serve on medical ethics advisory boards for precisely those reasons. Other soft experts, such as nurses or care practitioners, can provide context and insights that may not readily occur to laypersons.
When considering our example of the PVS person, a Catholic priest may be aware that Pope John Paul II explicitly spoke out against withholding basic medical care, including nutrition, from such patients. He saw it as nearly impossible to achieve medical certainty that a patient may never recover. A Catholic may thus wish to err on the side of caution and request to disconnect the feeding tube only in those rare instances in which a physician can guarantee that no hope of recovery exists.
In contrast, a soft expert who is trained in philosophy may emphasize the distinction between “killing” (an act of commission) and “letting die” (an act of omission). To use drugs to stop the heart is to kill a person, whereas to disconnect a respirator or a feeding tube is to let unassisted nature take its course. Some philosophers therefore argue that disconnecting a PVS patient from a feeding tube is not morally wrong.
As the challenges of wrestling with these decisions suggest, ultimately no amount of expert advice, however useful, can replace our own reflection on a given subject. Only we are in a position to know the values, beliefs and wishes most important to a loved one or to ourselves. This unique vantage point is especially critical when, and also because, we are the ones that must live with the consequences of our actions. Having to defer our choices to someone else limits our autonomy and puts our well-being into the hands of the experts we picked. That is a lot to give up. What we do not have to surrender, however, is the power to choose–and the capacity to choose well–who that person will be.
