Funding will make you free
http://www.100md.com
《英国医生杂志》
1 Department of Medicine, University of Wales College of Medicine, Cardiff CF14 4XN alcolado@btinternet.com
Academic freedom does not exist and has probably always been a myth. Wright and Wedge raise several important issues regarding the autonomy of clinical academics but, perhaps wisely, are careful not to provide a clear definition of "freedom."1 Freedom is not just an absence of physical restraint but also the lack of psychological compulsion. The central issue is the extent to which institutions and society are willing to tolerate some degree of freedom (or self indulgence) by academic physicians.
In the United Kingdom, we are already reigned in by the General Medical Council; its booklet on standards in medical research sets boundaries to what we may or may not do.2 Failure to heed its advice could result in the ultimate sanction of removing our freedom to practise medicine at all. Our freedom to perform clinical studies is further limited by the local research ethical committees. Even if their approval is obtained, individual NHS trusts may veto projects by refusing permission via their research and development committees. Just because I want to do a study and it is ethical, that doesn't mean my hospital has to make the facilities available. The presence of clinicians, academics, ethics specialists, lay members, patients, and perhaps representatives of the pharmaceutical industry on these committees may provide the balance required to resolve the disputes envisaged by Wright and Wedge.
Although we would all agree that resolution of conflicts between our university and clinical roles should occur in a forum that acknowledges the primacy of patient's welfare, the key question is: who ultimately decides what is in the best interest of patients? Currently everyone looks at it from a different perspective. The university is motivated by research income and the next research assessment exercise; the individual academic is motivated by the desire to succeed; the local research ethical committee tries to make a moral judgment; and the hospital has to consider whether the research will benefit the institution in a climate where "balancing the books" and reducing length of stay are paramount. All of these would say they have the patient's best interest at heart—but how easy would it be to limit a clinician's academic freedom with some spurious concern about patients' welfare?
Yale University may promulgate the "right to think the unthinkable, discuss the unmentionable, and challenge the unchallengeable," but I have no right to expect funding or resources to help confirm my hypothesis. If I cannot find funding, my academic freedom is but a vapour. Although I have recourse to the mass media and the internet, I have no real freedom to have my ideas published in mainstream medical journals. I recently submitted a hypothesis article to the Lancet that was rejected by the editor without external peer review. Is this an infringement of my academic freedom?
Ideally, individual workers and dissidents should not only have the freedom to voice their opinions but also have some resources (financial or clinical, or both) to help them challenge orthodoxy. Society has to empower individuals to exercise their freedom. In clinical science it is funding, not truth, that will make you free. Minority academic views have always had to struggle. Galileo had to contend with the Vatican; today some of us will be urged to recant at the altar of big business and the research funding bodies.
Funding: None.
Competing interests: None declared.
References
Wright JG, Wedge JH. Clinicians and patients' welfare: where does academic freedom fit in? BMJ 2004;329: 795-6.
Research: the role and responsibilities of doctors. London: General Medical Council. 2002. www.gmc-uk.org/standards/research.htm (accessed 20 Sep 2004).(John C Alcolado, senior l)
Academic freedom does not exist and has probably always been a myth. Wright and Wedge raise several important issues regarding the autonomy of clinical academics but, perhaps wisely, are careful not to provide a clear definition of "freedom."1 Freedom is not just an absence of physical restraint but also the lack of psychological compulsion. The central issue is the extent to which institutions and society are willing to tolerate some degree of freedom (or self indulgence) by academic physicians.
In the United Kingdom, we are already reigned in by the General Medical Council; its booklet on standards in medical research sets boundaries to what we may or may not do.2 Failure to heed its advice could result in the ultimate sanction of removing our freedom to practise medicine at all. Our freedom to perform clinical studies is further limited by the local research ethical committees. Even if their approval is obtained, individual NHS trusts may veto projects by refusing permission via their research and development committees. Just because I want to do a study and it is ethical, that doesn't mean my hospital has to make the facilities available. The presence of clinicians, academics, ethics specialists, lay members, patients, and perhaps representatives of the pharmaceutical industry on these committees may provide the balance required to resolve the disputes envisaged by Wright and Wedge.
Although we would all agree that resolution of conflicts between our university and clinical roles should occur in a forum that acknowledges the primacy of patient's welfare, the key question is: who ultimately decides what is in the best interest of patients? Currently everyone looks at it from a different perspective. The university is motivated by research income and the next research assessment exercise; the individual academic is motivated by the desire to succeed; the local research ethical committee tries to make a moral judgment; and the hospital has to consider whether the research will benefit the institution in a climate where "balancing the books" and reducing length of stay are paramount. All of these would say they have the patient's best interest at heart—but how easy would it be to limit a clinician's academic freedom with some spurious concern about patients' welfare?
Yale University may promulgate the "right to think the unthinkable, discuss the unmentionable, and challenge the unchallengeable," but I have no right to expect funding or resources to help confirm my hypothesis. If I cannot find funding, my academic freedom is but a vapour. Although I have recourse to the mass media and the internet, I have no real freedom to have my ideas published in mainstream medical journals. I recently submitted a hypothesis article to the Lancet that was rejected by the editor without external peer review. Is this an infringement of my academic freedom?
Ideally, individual workers and dissidents should not only have the freedom to voice their opinions but also have some resources (financial or clinical, or both) to help them challenge orthodoxy. Society has to empower individuals to exercise their freedom. In clinical science it is funding, not truth, that will make you free. Minority academic views have always had to struggle. Galileo had to contend with the Vatican; today some of us will be urged to recant at the altar of big business and the research funding bodies.
Funding: None.
Competing interests: None declared.
References
Wright JG, Wedge JH. Clinicians and patients' welfare: where does academic freedom fit in? BMJ 2004;329: 795-6.
Research: the role and responsibilities of doctors. London: General Medical Council. 2002. www.gmc-uk.org/standards/research.htm (accessed 20 Sep 2004).(John C Alcolado, senior l)