sity appointment. Second, our most fruitful research has been done by dedicated amateurs who asked for little but a place to work. The discovery of insulin, for example, cost very little. Finally, in 1975, Ontario alone registered more than 300 physicians from overseas, a practice undeniably cheaper than producing home-grown physicians. But times are changing. The private practitioner finds that an hour of unpaid teaching at a medical school, although intellectually rewarding, is penalized by the expense of his idle office. Research, like open tennis, has become too competitive and expensive for the dedicated amateur. Developing countries and the National Health Service of Great Britain will not indefinitely foot the bill for the training of a large proportion of our doctors. Medical education in this country needs direction. Since governments are "paying the shot", leadership to some extent must come from them, without endangering academic freedom. Medical schools must be centred where the action is: in community hospitals with extensive outpatient activities capable of providing primary, secondary and tertiary care. Medical staff at these hospitals should be chosen for their
clinical competence and their interest in academic medicine. Support must be provided, sufficient to remove financial insecurity yet retaining clinical or research incentive. The clinical teacher must be based in the hospital in order to be available to his students, yet have extensive community, primarycare or referral responsibilities, and so provide a continuing flow of patients to maintain the clinical relevance of medical education. Researchers must function in the hospital to expose students to the frontiers of medical science and yet remain in touch with the local medical scene. Restraint or no, can we not make better use of existing institutions by giving our clinical staff a base from which to teach? Offices in the hospital with expanded outpatient facilities could be provided. Clinical scientists could be equipped with laboratory facilities near the object of their ultimate interest: patients. Incentives to teach, innovate, administrate and research should be rewarded by academic advancement. This should depend not upon the flamboyance of one's specialty or the sheer weight of one's publications, but on the individual's exemplary patient care, his contribution to the
education of medical students, and the excellence of his research. Finally, medical research must be supported. The current freeze in research funds suggests a government misapprehension that we don't need to do research in Canada, that we can rely on that of others. Aside from the immorality of such a "cop-out", the danger is that, with the collapse of medical research, our standards of clinical science wiH decline, breeding a generation of physicians unable to interpret or implement advances made elsewhere. This attitude indicates a lack of perception of the inherent value of research in medical education. Thus, our university hospitals must become our medical schools. University and hospital administrations should work as one to achieve the best standard of medical care while ensuring that the finest teachers and medical scientists are available to the student. Such an endeavour needs to be vigorously supported by the government, the profession and the people, who surely have no interest in the decline and fall of medical education. W. GRANT THOMPSON, MD, FRCP[C]
Associate professor Department of medicine Ottawa Civic Hospital and University of Ottawa Ottawa, ON
Physicians, the scientific community and the future of science While it may be useful from time to time to check the bylaws, as it were, of the scientific community, it also may be desirable to examine the basic structure of this community and to scrutinize its general rules as they appear today. If scientists, physicians included, do not pay enough attention to this problem, others will, and it might then turn out that the whole construction is in need of some adjustments. Physicians, who must interpret many of the advances of medical science to their patients, particularly must pay heed to this problem. Physicians have long had a kind of guild with a high degree of independence and self-perpetuation. The same might be said of scientists. It cannot be denied that scientific training, at least at the higher levels, is administered by a relatively small group of leading men, who accept, guide, evaluate and promote the disciples who are looking for a future in the field. This means also that the problems selected by the masters, and offered to the disciples, will be selected by the same individuals who
are well acquainted with the situation and the frontiers of research. Their judgement will determine which research problems should be given priority. There are certain tendencies now - as has probably always been the case - to favour certain branches of research that appear to be fashionable. It is, of course, not wrong to join the herd that is grazing in a popular field or, to give a specific example, to enjoy a new, sophisticated and often expensive type of apparatus or equipment, but it may indicate some lack of independence. If a large number of parallel studies are made in a field enjoying temporarily special popularity, often much time and money may be wasted. Unfortunately, granting committees seem to think that the scientist then is working on problems of high priority, which might pave the way for research grants. Much of this behaviour could be avoided or prevented if the granting committees exercised more restriction in supporting such work. There is also a tendency to support work of limited
significance only if it promises to yield results useful for their statistics. Such work mostly can be expected to give results simply because it does not involve too many uncertain factors; hence it may be looked on as a good investment. Granting committees, however, should consider more earnestly withholding support to unnecessary work in a fashionable field and instead supporting significant new work involving greater risks. If the future of science is not to degenerate into the future of scientists, such tendencies should be looked for and corrected. Some scientists seem to identify themselves with the idea of science and to think that they are part of a suprastructure of almost magical qualities.1 The results of the scientific inquiry, it may be believed, then possess their own intrinsic value, distinct from the scientists producing the results. One may ask, To what extent are the consequences of scientific work and of knowledge gained by science a matter of responsibility for the scientist? Fran-
CMA JOURNAL/MAY 8, 1976/VOL. 114 751
cis Bacon2 maintained that "the roads to human power and to human knowledge lie close together and are nearly the same". In other words, the greater the knowledge, the greater the power. Thus, the individuals and institutions commanding the greatest knowledge also continue to give society new powers to influence or transform its life, whether this be their intention or not. As Gilkey3 has pointed out, it is for this reason that "knowers", scientific and others, are valued as well as revered by their society. Their knowledge confers power, and the vast potential that is latent in scientific knowledge is the justification for the status and role of science and the scientist. In essence, the situation is similar to that in a primitive society in which the tribe's magician or medicine man enjoys an awe-mingled respect based on the recognition that he has knowledge shared by none or by only a few. But the responsibility that should go with this power can sometimes be eroded by other side-issues. A reassessment of science in our cultural life is thus necessary, and scientists themselves should not forget to analyse soberly the situation. It is easy for the scientist to shroud himself in the distinguished robe of the disinterested world citizen who seeks the truth and devotes his efforts to gaining knowledge that, it is true, often benefits others. The vocabulary of this field provides further radiance to the aura that crowns science and offers the scientist both status and a feeling of spiritual integrity. This is unrealistic. As Heilbroner,4 himself a social scientist, has suggested, the future is likely to bring a return to a static traditional culture in which scientific inquiry will play a controlled, subservient and less glamorous role. He even argues that science and technology have become destructive of nature, of her resources and so of our common chance of survival. This is a pessimistic forecast, perhaps, but it emphasizes the need for the scientific community to consider carefully its future path. Never before have social aspects and concern for one's fellow men claimed so much attention as today, and it would be unwise to believe that this is a passing
trend. The established structure of scientific activity surely will not disintegrate, but some new windows may have to be opened and some reconstruction work can be foreseen. The scientists may disclaim responsibility for the manner in which his discoveries and other achievements are used. His only aim is to find the truth. It cannot, however, have escaped even the most academic scientist that some persons are only too willing to use new discoveries and the benefits of technology for their own purposes, and these may not be acceptable to the originator. It is then a philosophical or moral question whether the scientist should let such contingencies influence his choice of scientific inquiry or determine whether he should make his results generally known. Few scientists today would regard it as advisable to conduct scientific research in a field in which the results can potentially involve hazards for the community of which the scientist is also a member. To claim this right might be intellectually acceptable but it is not morally acceptable. The problem is, who is to decide whether the subject for the scientific approach is acceptable or not? There are some recent comments on this problem. Thus, with respect to genetic screening, the US National Academy of Sciences5 recommends great caution, holding that it is not yet time for mass screening. And Stetten6 has delineated some doubtful areas by asking five pertinent questions: What are the genetic contributions to intelligence? What kinds of experiments may properly be performed on adults? May one screen infants for a variety of genetic defects, some with known, others with currently unknown clinical consequences? Under what circumstances may one tamper with the genetic process, as by the introduction of foreign genetic material into the genome? When may one meddle with human conception and pregnancy as by artificial insemination, abortion, cloning, in vitro fertilization or the use of surrogate mothers? To none of these questions are there simple answers. New problems of comparable importance will no doubt arise and lead to
new discussions. Some of the problems seem to lend themselves to science fiction or have already been exploited. But then we can suspect on the basis of previous experience that they may become a reality tomorrow. It is hard to believe that the human scientific mind could in the end resist prying into these areas. The apple in the garden of Eden still exerts a strong attraction. Whatever the hazards and pitfalls, science and scientific work are a great adventure that should not be unduly stripped of its spiritual joy but should allow ingenuity and curiosity, which are parts of the human mind, to flourish. This does not exclude scientific discipline, as a regulatory factor, from being exercised in order to prevent distortions, just as the wisdom of the somatic body is manifested in the homeostatic mechanism. By analogy, discipline might be applied as a most useful homeostatic mechanism for the mind. And, as Selye7 has remarked, "The capacity to contemplate the harmonious elegance of nature, at least with some degree of understanding, is one of the most satisfactory experiences of which man is capable. This is a noble and gratifying aim itself, quite apart from any material advantages it may offer. But actually it does help us in our everyday life, very much in the same way as a deep religious faith or a well-balanced philosophic outlook helps us". Our problems are for us to recognize and then to solve. ULF VON EULER, MD
Karolinska Institute Stockholm, Sweden Nobel laureate in medicine and physiology, 1970
References 1. GYLLENSTEN L: Ur mm offentliga sekior, Stockholm, Aldus-Bonniers, 1971, p 26 2. BACON F: The New Organon and Related Writings, FULTON FH (ed), Indianapolis, Bobbs, 1960, p 122 3. GILKEY L: The future of science. Presented at 1975 Nobel Conference, Gustavus Adoiphus College, St Peter, MN, Oct 1-2, 1975 4. HEILBRONER RS: An inquiry into the human prospect, op cit 5. National Research Council, Assembly of Life Sciences, Division of Medical Sciences, Committee for the Study of Inborn Errors of Metabolism: Genetic Screening. Programs, Principles, and Research, Washington, DC, NatI Acad Sci, 1975, p 18 6. STETrEN D: Freedom of enquiry. Science 189:
953, 1975 7. SELVE H: From Dream to Discovery: on Being a Scientist, New York, McGraw, 1964, p9
AVAILABLE TO MEDICAL FELLOWS Fellows of the Royal College of Physicians and Surgeons of Canada in the medical specialties who are interested in receiving the Canadian Journal of Surgery can do so without charge. Send your request for a free subscription to: Division of fellowship affairs Royal College of Physicians and Surgeons of Canada 74 Stanley Ave. Ottawa, ON KIM 1P4 752 CMA JOURNAL/MAY 8, 1976/VOL. 114
clinical competence and their interest in academic medicine. Support must be provided, sufficient to remove financial insecurity yet retaining clinical or research incentive. The clinical teacher must be based in the hospital in order to be available to his students, yet have extensive community, primarycare or referral responsibilities, and so provide a continuing flow of patients to maintain the clinical relevance of medical education. Researchers must function in the hospital to expose students to the frontiers of medical science and yet remain in touch with the local medical scene. Restraint or no, can we not make better use of existing institutions by giving our clinical staff a base from which to teach? Offices in the hospital with expanded outpatient facilities could be provided. Clinical scientists could be equipped with laboratory facilities near the object of their ultimate interest: patients. Incentives to teach, innovate, administrate and research should be rewarded by academic advancement. This should depend not upon the flamboyance of one's specialty or the sheer weight of one's publications, but on the individual's exemplary patient care, his contribution to the
education of medical students, and the excellence of his research. Finally, medical research must be supported. The current freeze in research funds suggests a government misapprehension that we don't need to do research in Canada, that we can rely on that of others. Aside from the immorality of such a "cop-out", the danger is that, with the collapse of medical research, our standards of clinical science wiH decline, breeding a generation of physicians unable to interpret or implement advances made elsewhere. This attitude indicates a lack of perception of the inherent value of research in medical education. Thus, our university hospitals must become our medical schools. University and hospital administrations should work as one to achieve the best standard of medical care while ensuring that the finest teachers and medical scientists are available to the student. Such an endeavour needs to be vigorously supported by the government, the profession and the people, who surely have no interest in the decline and fall of medical education. W. GRANT THOMPSON, MD, FRCP[C]
Associate professor Department of medicine Ottawa Civic Hospital and University of Ottawa Ottawa, ON
Physicians, the scientific community and the future of science While it may be useful from time to time to check the bylaws, as it were, of the scientific community, it also may be desirable to examine the basic structure of this community and to scrutinize its general rules as they appear today. If scientists, physicians included, do not pay enough attention to this problem, others will, and it might then turn out that the whole construction is in need of some adjustments. Physicians, who must interpret many of the advances of medical science to their patients, particularly must pay heed to this problem. Physicians have long had a kind of guild with a high degree of independence and self-perpetuation. The same might be said of scientists. It cannot be denied that scientific training, at least at the higher levels, is administered by a relatively small group of leading men, who accept, guide, evaluate and promote the disciples who are looking for a future in the field. This means also that the problems selected by the masters, and offered to the disciples, will be selected by the same individuals who
are well acquainted with the situation and the frontiers of research. Their judgement will determine which research problems should be given priority. There are certain tendencies now - as has probably always been the case - to favour certain branches of research that appear to be fashionable. It is, of course, not wrong to join the herd that is grazing in a popular field or, to give a specific example, to enjoy a new, sophisticated and often expensive type of apparatus or equipment, but it may indicate some lack of independence. If a large number of parallel studies are made in a field enjoying temporarily special popularity, often much time and money may be wasted. Unfortunately, granting committees seem to think that the scientist then is working on problems of high priority, which might pave the way for research grants. Much of this behaviour could be avoided or prevented if the granting committees exercised more restriction in supporting such work. There is also a tendency to support work of limited
significance only if it promises to yield results useful for their statistics. Such work mostly can be expected to give results simply because it does not involve too many uncertain factors; hence it may be looked on as a good investment. Granting committees, however, should consider more earnestly withholding support to unnecessary work in a fashionable field and instead supporting significant new work involving greater risks. If the future of science is not to degenerate into the future of scientists, such tendencies should be looked for and corrected. Some scientists seem to identify themselves with the idea of science and to think that they are part of a suprastructure of almost magical qualities.1 The results of the scientific inquiry, it may be believed, then possess their own intrinsic value, distinct from the scientists producing the results. One may ask, To what extent are the consequences of scientific work and of knowledge gained by science a matter of responsibility for the scientist? Fran-
CMA JOURNAL/MAY 8, 1976/VOL. 114 751
cis Bacon2 maintained that "the roads to human power and to human knowledge lie close together and are nearly the same". In other words, the greater the knowledge, the greater the power. Thus, the individuals and institutions commanding the greatest knowledge also continue to give society new powers to influence or transform its life, whether this be their intention or not. As Gilkey3 has pointed out, it is for this reason that "knowers", scientific and others, are valued as well as revered by their society. Their knowledge confers power, and the vast potential that is latent in scientific knowledge is the justification for the status and role of science and the scientist. In essence, the situation is similar to that in a primitive society in which the tribe's magician or medicine man enjoys an awe-mingled respect based on the recognition that he has knowledge shared by none or by only a few. But the responsibility that should go with this power can sometimes be eroded by other side-issues. A reassessment of science in our cultural life is thus necessary, and scientists themselves should not forget to analyse soberly the situation. It is easy for the scientist to shroud himself in the distinguished robe of the disinterested world citizen who seeks the truth and devotes his efforts to gaining knowledge that, it is true, often benefits others. The vocabulary of this field provides further radiance to the aura that crowns science and offers the scientist both status and a feeling of spiritual integrity. This is unrealistic. As Heilbroner,4 himself a social scientist, has suggested, the future is likely to bring a return to a static traditional culture in which scientific inquiry will play a controlled, subservient and less glamorous role. He even argues that science and technology have become destructive of nature, of her resources and so of our common chance of survival. This is a pessimistic forecast, perhaps, but it emphasizes the need for the scientific community to consider carefully its future path. Never before have social aspects and concern for one's fellow men claimed so much attention as today, and it would be unwise to believe that this is a passing
trend. The established structure of scientific activity surely will not disintegrate, but some new windows may have to be opened and some reconstruction work can be foreseen. The scientists may disclaim responsibility for the manner in which his discoveries and other achievements are used. His only aim is to find the truth. It cannot, however, have escaped even the most academic scientist that some persons are only too willing to use new discoveries and the benefits of technology for their own purposes, and these may not be acceptable to the originator. It is then a philosophical or moral question whether the scientist should let such contingencies influence his choice of scientific inquiry or determine whether he should make his results generally known. Few scientists today would regard it as advisable to conduct scientific research in a field in which the results can potentially involve hazards for the community of which the scientist is also a member. To claim this right might be intellectually acceptable but it is not morally acceptable. The problem is, who is to decide whether the subject for the scientific approach is acceptable or not? There are some recent comments on this problem. Thus, with respect to genetic screening, the US National Academy of Sciences5 recommends great caution, holding that it is not yet time for mass screening. And Stetten6 has delineated some doubtful areas by asking five pertinent questions: What are the genetic contributions to intelligence? What kinds of experiments may properly be performed on adults? May one screen infants for a variety of genetic defects, some with known, others with currently unknown clinical consequences? Under what circumstances may one tamper with the genetic process, as by the introduction of foreign genetic material into the genome? When may one meddle with human conception and pregnancy as by artificial insemination, abortion, cloning, in vitro fertilization or the use of surrogate mothers? To none of these questions are there simple answers. New problems of comparable importance will no doubt arise and lead to
new discussions. Some of the problems seem to lend themselves to science fiction or have already been exploited. But then we can suspect on the basis of previous experience that they may become a reality tomorrow. It is hard to believe that the human scientific mind could in the end resist prying into these areas. The apple in the garden of Eden still exerts a strong attraction. Whatever the hazards and pitfalls, science and scientific work are a great adventure that should not be unduly stripped of its spiritual joy but should allow ingenuity and curiosity, which are parts of the human mind, to flourish. This does not exclude scientific discipline, as a regulatory factor, from being exercised in order to prevent distortions, just as the wisdom of the somatic body is manifested in the homeostatic mechanism. By analogy, discipline might be applied as a most useful homeostatic mechanism for the mind. And, as Selye7 has remarked, "The capacity to contemplate the harmonious elegance of nature, at least with some degree of understanding, is one of the most satisfactory experiences of which man is capable. This is a noble and gratifying aim itself, quite apart from any material advantages it may offer. But actually it does help us in our everyday life, very much in the same way as a deep religious faith or a well-balanced philosophic outlook helps us". Our problems are for us to recognize and then to solve. ULF VON EULER, MD
Karolinska Institute Stockholm, Sweden Nobel laureate in medicine and physiology, 1970
References 1. GYLLENSTEN L: Ur mm offentliga sekior, Stockholm, Aldus-Bonniers, 1971, p 26 2. BACON F: The New Organon and Related Writings, FULTON FH (ed), Indianapolis, Bobbs, 1960, p 122 3. GILKEY L: The future of science. Presented at 1975 Nobel Conference, Gustavus Adoiphus College, St Peter, MN, Oct 1-2, 1975 4. HEILBRONER RS: An inquiry into the human prospect, op cit 5. National Research Council, Assembly of Life Sciences, Division of Medical Sciences, Committee for the Study of Inborn Errors of Metabolism: Genetic Screening. Programs, Principles, and Research, Washington, DC, NatI Acad Sci, 1975, p 18 6. STETrEN D: Freedom of enquiry. Science 189:
953, 1975 7. SELVE H: From Dream to Discovery: on Being a Scientist, New York, McGraw, 1964, p9
AVAILABLE TO MEDICAL FELLOWS Fellows of the Royal College of Physicians and Surgeons of Canada in the medical specialties who are interested in receiving the Canadian Journal of Surgery can do so without charge. Send your request for a free subscription to: Division of fellowship affairs Royal College of Physicians and Surgeons of Canada 74 Stanley Ave. Ottawa, ON KIM 1P4 752 CMA JOURNAL/MAY 8, 1976/VOL. 114
