Objectivity, bias and belief…

Objectivity and post-it notes

Many years ago, I wrote an article called ‘objectivity and post-it notes.’ (Wickham 2003).

I had observed the move which was occurring at that time towards having people declare competing interests underneath papers in medical and scientific journals.

I agreed with many colleagues that this was a good thing.

But I questioned the fact that we were focused on detailing a narrow range of competing interests, while others went unmentioned.

For example, authors were expected to declare it if they were paid by pharmaceutical companies, but not if their wife or husband was on the board of the same company.

I’m not saying this is right or wrong. I was just noting this as a phenomenon. 

I also pointed out that no-one was expected to declare if they had experienced something in their own lives that might affect the way they thought, wrote, researched or spoke about things.

Now let me add that I think this would be intrusive, and I’m not suggesting it becomes the standard. We’re all entitled to privacy, and there is already an unreasonable inequity where women who work in the field of pregnancy and birth are often expected to share about their own experiences and family situation, while men aren’t. I’m again simply pointing it out as a feature of our culture. I think it’s especially relevant to be aware of in a world where so many people spend so much time on social media.

This is particularly relevant in a world where comments on social media posts are sometimes extreme and reflective of unusual and/or extraordinary experiences and opinions, rather than being a balanced reflection of the views of people in general.

Declaring competing interests

Declaring competing interests is, I wrote in 2003, a jolly good thing. (Here’s an example of me doing it, though admittedly a bit less seriously than in medical journal articles.)

It is logical to assume that a person whose research (or holiday/vacation) is funded by a company manufacturing drug or technology products may feel duty-bound to present those products in a good light. Or just feel more positive about the company.

Which is why we need to be open and honest.

Where objectivity is seen as paramount in producing and evaluating evidence, the ethical researcher or clinician will attempt to avoid bias.

But, again, I think bias is inevitable. So that’s why it can be useful that people declare their bias so that others can decide for themselves whether the information presented may be tainted by the author’s interests.

A bit of pushback

Back when the move to declare competing interests began, though, there was also a bit of pushback.

As I wrote at the time, “authors of papers in the British Medical Journal have recently declared the following tongue-in-cheek competing interests:

• Their friendship with carpet factory managers who may lose out from research which causes asthma sufferers to consider installing wooden floors (Seaton 2003, who shares his pride about the fact that, in 30 years, he has received nothing but plastic biros from pharmaceutical companies).
• Their feelings about the relationship between keeping up-to-date with ‘the scientific literature’ and whether this leaves them with enough time to practise medicine (Lagnado and Kholl 2003).
• That they like hammers and power tools (Michelson 2003; in the context of being an orthopaedic surgeon who does not feel he needs an RCT to tell him that hitting his thumb with one will be painful).” (Wickham 2003).

All of these articles (as you might guess from their titles in the reference list) are discussing the merits – or otherwise – of evidence-based practice.

By contrast, the authors of those articles that evaluate the hard-core clinical and pharmaceutical interventions remained relatively silent about their competing interests. Only the most blatant interests – such as membership of a related committee or pressure group – were declared.

My own journey

The complacency was partly because this was, at the time, a new idea.

Before I wrote the 2003 article, I was as guilty as anyone of being tempted by the free post-it pads and CD holders. Following some research I did into a particular pharmaceutical substance, it entertained me (in an ironical, British kind of way) to assemble as much stationery with the name of this product on as I can. I never used this in front of pregnant women, but it amused me to use it on books, and write notes on it to medical and midwifery friends who would get the joke.

But I saw the problem and ceased my stationery collecting. Ever since, I’ve taken pains in my books and other work to explain my background, and be clear about my position. Which doesn’t mean that everyone will read it, but it’s there for those who want to.

At the same time, I began to realise that there was a bigger issue.

The emotion of story

It struck me that there were far more important competing interests which could impact what somebody writes than I had ever seen acknowledged in print.

Nobody ever declares in an academic paper that they have a uterus, or a penis, or are pregnant, for instance.

Or that they have been pregnant, or have a partner who is pregnant, or might one day become pregnant.

We know that some people have amazing, happy birth experiences, and some have difficult, painful, or tragic ones.

These may well affect one’s viewpoint, and colour what you would write or think afterwards.

If you’ve ever been on birth-related social media accounts, you might have seen comments from people who have had a one in a million experience and who post emotively about it wherever they can because they have a passion to warn others away from a particular option.

Some people form charities, or pressure groups, because of a negative experience.

It’s entirely understandable, and it’s also troubling. It means that campaigning is sometimes very biased towards one end of the decision making spectrum. Emotive stories can be used to try and persuade. If the reader knew the full story behind the comment, or could hear the other nine hundred thousand stories which didn’t end in disaster, would it change their perception? Is it fair, or ethical?

Lastly, no-one points out that what researchers find out or write might be affected by their experiences, or affect the options that are open to them and their family in the future.

Why not declare ideological bias?

While I have seen papers which declare that the authors see birth as a natural and normal life event, I have never seen a declaration that openly stated that the personal ideology (or belief system) of the researcher was rooted in the fear of disaster or litigation. (Although I can think of some very famous and well-cited examples where this is probably the case).

In fact, I can’t recall many pieces of research which admit that the author is even a member of society, and so might have an interest in the way that society is run, or the way health and ill-health are viewed and treated, or the ethical principles on which health care practice are based.

It is easy to forget that we are also human, and that being alive and having experiences, thoughts and feelings are competing interests in themselves.

So perhaps it is just not our competing interests we should be declaring, given that we all have so many of them, but our opinion about the extent to which we feel we can be objective about developing or evaluating evidence in the first place?

Ongoing conversations

Over the two decades since I first wrote about this, the declaring of competing interests has become a normal part of writing about research.

But, from time to time, the topic comes up for discussion.

In, for instance, an article in the British Medical Journal entitled “Why religious belief should be declared as a competing interest”.

In that piece, Richard Smith and Jane Blazeby suggested that people’s faith can have a profound effect on their views. For example on matters such as assisted dying and abortion.

That’s not a problem.

But they argued that disclosure of religious belief is essential to provide the reader of an article with a full context for interpretation.

An important point

This is another important point.

Again, as well as matters such as assisted dying and abortion (which are the focus of the feature in the BMJ), our beliefs, values and experiences can have a significant impact upon the way we see many things in life. No matter whether we are religious, humanistic, scientific, technocratic, holistic, atheistic, or passionate about a topic or cause. (Like birth).

And when we work in an area which involves sharing written or verbal information with others, then we have a responsibility to let people know ‘where we are coming from’ ideologically.

Including me, and you

Yes, again, including me.

That’s why I have an about page and why my book ‘What’s Right For Me: making decisions in pregnancy and childbirth’ includes a section in which I describe my own experience and beliefs. I have smaller sections in many of my other books as well.

I don’t mind whether anyone agrees with me or not.

And I certainly don’t think I’m right about any or all of this.

This blog post isn’t a statement of what I think is right for everyone. It’s an offering of some thoughts, in the hope that they might stimulate conversations, which might help others think about the issues too.

I just want to ensure that people are able to evaluate the basis of my information in the same way that I encourage people to evaluate the basis of any other information they come across.

I’d love to encourage others to do the same.

If you’re a midwife, doctor, other health professional, or birth worker, I hope you’ll give some thought to how you let people know about your own biases and beliefs.

Because we all have them.

No-one is unbiased.

So context is important.

And knowing the context of information that we’re looking at can help us all better make the decisions that are right for us.

What’s Right For Me?

Lagnado M and Kholl S (2003) Seven steps to evidence based general practice. BMJ 2003: 326:933

Michelson, J (2003) Evidence B(i)ased Medicine. BMJ 2003: 326:6

Seaton A (2003) “There’s none so blind as the double blind.” Discuss. BMJ 2003;326:889

Wickham S (2003). Objectivity and post-it notes. TPM 6(6):41.

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