Beyond the Teachable Moment

Biomedical research is advancing at a fantastic pace, regularly yielding new diagnostic tools and treatment approaches. “Personalized medicine” at last seems to be a realistic research product in the not-too-distant future. Yet despite great biomedical advances that continue to be applauded by the public, there is increased tension in the broader relationship between science and the rest of society. This tension is a symptom of at least 2 factors: a lack of understanding by the general public related to the nature of science and scientific evidence, with a concomitant reluctance to demand an evidence base for medical treatments and the increasing encroachment of science on issues related to core human values and beliefs. For science to truly serve society, biomedical scientists need to take advantage of all opportunities to engage more fully with the public.

The acceptance by at least one-third of adults¹ in the United States of so-called alternative therapies that either are not science-based or are completely untested reflects a long-standing trend. In part frustrated by the relatively slow pace of science and its application, many individuals rush to alternative treatments for their illnesses; in these cases, hope for rapid relief trumps the need for evidence-based care.

Yet this preference for alternative therapies is not only a reflection of impatience or inability to wait for new and better treatments. Frequently, people do not know the difference between evidence-based and non–evidence-based treatments. Even as the public is reminded that “the plural of anecdote is not evidence,” widespread publicity for the purported effectiveness of nonscientific treatments perpetuates the trend and undermines the call for adherence to the science base. However, a call for an evidence base need not undermine patient choices, alternative strategies, or a holistic, individualized approach to health care. The National Institutes of Health recognized this when it established the National Center for Complementary and Alternative Medicine, which has supported high-quality research on “alternative” approaches to health care and has brought focus to what science can reveal about alternative and complementary medical strategies, including what works and what is safe.

However, most individuals have little understanding of the nature of science and thus cannot tell the difference between what is and is not science based. According to a 2006 survey, 60% of Americans believe in extrasensory perception, one-third believe that astrology is at least somewhat scientific, 49% believe that humans did not evolve from an earlier animal species, and 54% are unable to explain how an experiment is conducted.^{2 (p7.17-7.22)} In the medical realm, some US parents, fearful of seeming to endorse premarital sex, resist providing their daughters with the first human cancer vaccine, although the American Academy of Pediatrics describes this vaccine as “highly effective” at preventing 4 types of human papillomavirus infection, the major cause of cervical cancer.³ Similarly, rumors of a link between the measles-mumps-rubella vaccine and autism remain unsubstantiated, yet public fears persist.

This lack of fundamental understanding by the public about the nature of science and about scientific evidence, and why that evidence is so critical, represents a major and growing obstacle to the ability of biomedical research to do its job. It also is a significant source of the escalating tension in the broader relationship between science and society. The issue is less about understanding specific scientific facts and theories and more about understanding the very nature of the scientific enterprise and its products.

Another major source of tension in the science-society relationship arises from the increasing encroachment of science on issues related to core human values and strongly held beliefs. This is not a new problem—think back to conflicts between Galileo and the Roman Catholic Church—but more and more instances seem to be arising. At times it appears that an almost antiscientific attitude is prevailing, although science need not be at odds with religion. Recent studies have shown that 50% of Americans feel that “we depend too much on science and not enough on faith” and 56% agree that “scientific research these days doesn't pay enough attention to the moral values of society.”^{2 (p7.23-7.24)}

The conflict between evolution and creationism is a well-publicized example. Influential groups of religious advocates have repeatedly attempted to introduce the teaching of creationism or its offshoots, including intelligent design, into science classrooms. These advocates hold that evolution conflicts with a literal interpretation of the Bible and, therefore, their religious beliefs, and they claim that creationism and intelligent design are scientific theories. Members of the general public who know little about the nature and requirements of science have little chance of realizing that there is no science base behind creationism and intelligent design. This complexity reiterates the need for the public to better understand the nature of science.

Human embryonic stem cell research is a somewhat different example because the issue is not that the public does not understand enough about embryonic stem cell research or even the nature of science. Many individuals do understand the basic research concept; they just do not like it. They see a clear conflict between their religious beliefs about when life begins and the need to destroy human embryos to conduct the research. If someone believes that life begins at the moment of fertilization, any research that might destroy an embryo becomes unacceptable. If, on the other hand, someone believes that life begins later in gestation, research on early embryos can be acceptable.

Another emerging example can be found in neuroscience. Researchers using modern imaging techniques can now “look” into the brains of living, awake humans while they engage in a variety of behaviors—watching their minds in action. The implications of these techniques are tremendous, including expanding the understanding of the underpinnings of thought and behavior, as well as the nature of the human mind and traditional concepts of mind, body, and soul. How would individuals react if researchers concluded that their minds or souls are only a reflection of the physical activities in their brains? Or, as a specific example, what are the policy implications of understanding that addiction is a brain disease? For instance, if criminal behavior results from a brain disease, can addicted perpetrators be held responsible?

Both biomedical researchers and practitioners can do something about these science-society problems and thereby increase the impact and effectiveness of their own work. The first step must be education, and both researchers and practitioners have many opportunities to educate the public.

But educational efforts need to go beyond the traditional approach of teaching patients about specific research findings or the organ systems affected by their ailments. In a recent report, the Institute of Medicine Roundtable on Evidence-Based Medicine identified public education as one of the most pressing needs for improving health care and emphasized specifically the need for “ . . . improved communication about the nature of evidence and its development, and the active roles of both patients and healthcare professionals in evidence development and dissemination.”⁴ Practitioners and researchers have numerous opportunities to discuss science and scientific evidence with their patients, families, friends, and others, whether in one-on-one conversations or through participation in community groups.

Fully addressing the need will require more than an expanded form of education alone, however. To take it one step further, teachable moments should be converted to “engagement moments.” Public engagement with science is a relatively new way to conceptualize science-society interactions, well-characterized in 2003 by Yankelovich⁵ and many subsequent articles, most recently in a report from the European Commission's European Research Advisory Board (EURAB).⁶

The fundamental principles of public engagement are to recognize the legitimate perspectives of the public and to view interactions as opportunities for science-society dialogues in which both sides listen and learn. Experience has shown that tension points may not be fully resolved; for example, individuals who object to embryonic stem cell research on religious grounds likely will not change their minds no matter the quality of dialogue. Experience also demonstrates that there is much more common ground than biomedical professionals might expect, however, and that the scientific community has much to learn from listening to diverse public perspectives.

The EURAB report⁶ provides numerous examples of productive public engagement dialogues, including “medical relief workers learning from local customary homeopathic practices, or surgeons recognizing the importance of faith in a patient's recovery process. Patient groups can and do provide valuable information (via their observations) about living with diseases.”⁶ But ultimately, what public engagement means at its core is to listen as well as to educate patients. This basic principle, while seemingly simple, is deceptively difficult to implement.

By better understanding points of common ground and points of irreducible conflict, researchers and practitioners can do a better job both of anticipating other potential instances of science-society tension and of preparing the potential recipients for the products of their work. The extensive public engagement activities surrounding the Human Genome Project exemplify how well this approach can work to the benefit of all.

Effective public engagement is an acquired skill and, unfortunately, not a routine part of either research or clinical training. But a variety of core principles can help guide these efforts.⁷ One of the most important is to be clear about the nature of science. Transparency in discussing both the criteria for something to be considered scientific and the limitations of science is necessary. For example, science is limited to natural explanations of the natural world, and science should not be expected to be able to answer questions about the supernatural. Relatedly, no one should fall prey to the temptation to pit science or medicine against religion, since they negotiate different domains.

Another important principle is to stick to the scientific evidence. Many issues, like stem cells, involve both factual and values components. When speaking as such, scientists are expected to leave their personal values and beliefs behind them and focus on the facts. This is extremely important for the sake of ensuring credibility and also is difficult to do well, since scientists are also human and have personal values that are often strongly held.

Whenever possible, making issues individually meaningful to participants is critical. One strategy toward that end calls for “glocal” outreach, or taking a global issue and making it meaningful at the local level.⁷ Global climate change is one example of glocalized public engagement, as compelling dialogues are being initiated by researchers and communities on local effects and possible solutions.

The most important principle is for researchers and practitioners to really listen to what advocates, patients, and other stakeholders have to say. Although listening will often be a challenge—scientists and practitioners are much more accustomed to a traditional, pedagogical approach—the public has much to say, and biomedical scientists have much to learn.

This approach for engaging with others, including patients, research participants, advocates, and other stakeholders, requires significant attitudinal shifts and some behavior change. But the arguments for trying it in a serious way are compelling. First, the public engagement approach has been tried, studied, and found to be promising in Canada, Europe, the United Kingdom, and, to a limited degree, the United States, where the approach is beginning to take hold.⁸ Second, traditional approaches for communication and engagement are not working well enough, and the science-society relationship is in a particularly fragile period. It is time to evolve current strategies for engaging and communicating with the public. This will enable biomedical researchers and practitioners to serve society more fully at the same time that science is advancing.