Proceedings of the Sixty-Sixth Annual Meeting of

The American Society for Clinical Investigation, Inc.

Atlantic City, New Jersey, 6 May 1974

PRESIDENTIAL ADDRESS

The Individual, Science, and SocietyEDWARDC. FRAII.UN

From Irvington House Institute and the Department of Medicine, New York UniversityMedical Center, NewYork 10016

The planning of the Presidential Address is an excitingas well as humiliating experience. In reading the ad-dresses of one's predecessors, one finds much profoundand often unremembered wisdom concerning most as-pects of biology and medicine. These pleasures arecounterbalanced by the fears that there is little roomleft for originality. Wehave heard it all before ! Whenone contemplates returning to the precedent of startingthe Monday meeting with a scientific report, relief isonly temporary, since a talk on amyloid or heavy chaindisease might raise serious questions about the criteriathe president used in selecting the program from themany exciting abstracts submitted.

At one moment of desperation-after I had lookedat the sketches that Dr. Mark Podwal, a former studentof mine (now turned half-time dermatologist and half-time artist) had made to illustrate an early draft-Iwas tempted to dispense with words and to rely en-tirely on his pictures. The fear that this might beinterpreted by the membership as dereliction of dutyand, in our current political atmosphere, result in im-peachment proceedings, made me stick to tradition.Perhaps the pictures by Dr. Podwal and the dedicatedintellectual and editorial collaboration of my wife, Dr.Dorothea Zucker-Franklin, and a few close friends willhelp provide us with some novel insights into the im-portance of the individual in science and the steps wemust take to preserve his role.

In these difficult times, clinical investigation and sci-ence in general face so many profound problems that

one can exercise a wide choice in picking a subject todiscuss. My most recent predecessors have enumerated,bewailed, and on occasion, offered solutions to themany threats facing clinical investigation. Most of theobvious ones, such as the temporary curtailment of re-search funds, abrogation of training grants, stringentsupervision of research in the guise of ethical con-trol, and threats to peer review, serious though theymay appear, are only symptoms of a much more pro-found illness affecting society. What undermines ourwell-being and gnaws at the very foundations of ourinstitutions is a feeling of distrust: distrust amongothers of science and of the motives of scientists, sus-picion of medicine, and unfortunately, of the motives ofphysicians. This sickness is subtle, difficult to define, andhence more disturbing, for it cannot be cured by simplemeasures, such as the release of impounded funds orthe pro forma reinstatement of review panels.

About the turn of the century, Max Weber observedthat "the belief in the value of scientific truth isnot derived from nature but is a product of definitecultures", and the sociologist, Merton, has recentlyadded that "this belief can be readily transmuted intodoubt and disbelief" (1). Indeed, today a series of de-ceptions allows the seeds of doubt and disbelief to ger-minate. Corruption has been unmasked at the highestlevels of government. Prevaricated oil shortages havemocked consumers waiting for hours at the pumpsuntil prices had risen sufficiently to allow a suddenreturn to normalcy. Billboards of healthy, suntanned

The Journal of Clinical Investigation Volume 53 June 1974-1755-1760 1755

cowboys cavorting in the great outdoors are designedto imply that their wholesome activities and the beautiesof nature are related to the cigarette, when it is gen-erally known that smoking is one of the major killersand pollutants of our time. Under such circumstances,why should the products of scientific investigation betaken at face value? To rephrase Weber's statement:a culture accustomed to deceit is ill-prepared to acceptscientific truth. Alas, false promises -and widely propa-gandized crash programs aimed at the cures of majordiseases have also been used to advertise the benefitsof research. Needless to say, the public, unaware thatsuch programs are doomed to fail for lack of basicknowledge and well-defined tools, is left with the feel-ing that large sums of money have been dissipated fornaught, and has been led to the erroneous belief thatscience must be better organized and centrally directedif it is to achieve its goals. Steps are being taken totell us not only what we should do, but also how weshould do it. It is my firm conviction that this approachmay destroy the productive research community, andas a consequence, result in the stagnation of medicalprogress. To fully understand the possible effects whichcentral direction may have on clinical investigation, letus first examine the principles underlying biomedicalresearch and the complex factors motivating investiga-tors to embark on a research career. Only then will itbecome possible to focus on the steps that we, as in-dividuals and as a society, can take to reverse thisdestructive process.

What are the overall goals of the biomedical orclinical investigator ? I believe that all of us are stillprimarily motivated by a spark of good, honest, adoles-cent idealism, namely the desire to understand and tocure disease. It is true that often we like to think ofourselves as pure scientists in an era when the con-tributions of molecular biology are judged supreme; but

FU1Tcnaisgol o sci nts

FIGURE 1 The clinical investigator--clinician or scientist?

FIGURE 2 The path to achieve our goals is rarely direct.

in our laboratories, isn't reality more like what is de-picted in Fig. 1? On a broader scale, we strive toenrich our culture "not only with technically importantfindings, but also with humanly significant ideas" (2).Unfortunately, as illustrated in Fig. 2, the path to thesegoals is rarely direct. Since the complexity of biologyseldom allows a direct approach to the solution ofproblems, we are usually forced to grope, often blindly,for clues. Sentiments like these have led Jacques Monod(3), like others before him, to emphasize that "rationalintelligence is an instrument of knowledge especiallydesigned for mastering inert matter but utterly in-capable of apprehending life's phenomena." Instinct andintuition serve as additional major tools in our questto answer questions in the realm of living matter. Un-fortunately, the public, and even many physicians whohave not had the opportunity to participate in research,do not always appreciate the crucial importance of theseintangible factors. Straight-jacketed centrally directedprograms would leave no room for these essentialingredients.

Let us try to paint a picture of the implications ofcentrally directed research. One possibility, widelyfavored at the moment, would be the organization ofpanels of experts in a specialized area with instructionsto identify important problems and then to outlineappropriate programs for their solution. The next stepwould be to advertise and to solicit research protocolsfrom individuals and corporations anxious to applytheir efforts to these programs. Since each suggestionwould assume an air of immediate urgency, such an-nouncements would set off a flurry of activity by ahorde of individuals, who would ultimately be in the

1756 Edward C. Franklin

intellectual if not the actual employ of the scientificplanners. They would in turn hire others to preparereports on their diligent labors, most likely on compli-cated forms lending themselves to analysis by com-puters and efficiency experts, but baffling to any logicalmind (Fig. 3). Science would be planned by themethods of systems analysis and future funding woulddepend on the completion of the prescribed work asjudged by a new class of individuals who might becalled "scientific coordinators". What could be expectedfrom such a rigidly controlled system? At best, if bychance the initial premise were correct, it would yieldanswers to the questions posed, albeit through vastexpenditures of energy and money. If past experiencecan serve as a guide, the areas chosen and the toolsemployed would be those currently in fashion, andthere would be little likelihood of making an originaldiscovery or developing a really novel concept. If thegroup of planners were less sagacious, or perhaps lessfortunate, and if, for example, viruses were shown notto be the cause of cancer or cholesterol, not to be in-volved in atherosclerosis, we would at best come upwith some information that might be applicable toanother subject. Soon more and more of the fundswould be channeled to docile intellectual slaves suchas those shown (Fig. 4), who are willing to followinstructions. The truly creative individual would be atotal misfit in such a system. The bulk of talent of thescientific community would be diverted from originalthinking to piecework and many capable young in-dividuals would choose other potentially more interest-ing professions, guaranteeing them greater independenceand freedom. Are we beginning to see the first signs ofthis in the shunning of research by our most able stu-dents and house officers? Is there perhaps a greateropportunity for self-expression and independence in thearea of "health care delivery", which is now eagerlysought by many of brightest young physicians?

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FIGURE 3 The monthly progress report-the nightmare ofthe investigator threatened by directed research.

FIGURE 4 Docile intellectualfrom above.

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slaves instructions

To be fair, we must not deny the value of targetedresearch in occasional instances when the availablebasic information allows a-direct attack on an impor-tant -health problem, or when we wish to stimulateresearch in areas neglected because they are eitherobscure or unattractive. As all of us know, this israrely necessary, since scientists, in their scramble forsuccess and recognition, rarely leave interesting solubleareas unexplored.

An alternative approach being implemented at thisvery time is the creation of centers for the study ofcertain diseases. Superficially, this may seem somewhatless destructive, since the locations of such centerswould be influenced to some extent by the intellectualtalents already available. However, they would also beguided by the need for equal geographic distribution, theillnesses prevalent among the relatives of the legislatorsinvolved in their creation, and the pressures exerted byvested interests. Since any center worthy of its namewould have to be mammoth in size, this approachwould be likely to result in the support of mediocreprojects riding on the coattails of the better ones, andwould often force the investigator in search of funds toengage in intellectual acrobatics to- fit his project intothe program of the local center. Indeed, "the mass ofmediocrity will displace the meritorious few" (4). Anadditional threat posed by this form of scientific sup-port is the risk of creating yet another group of pro-fessionally powerful scientific administrators, liable to

Presidential Address 1757

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upset the departmental structures and loyalties of theuniversity.

If we agree that "the act of scientific creation, noless than any intellectual creation, is largely an in-dividual act" (5), we cannot accept either of these twoalternatives. Therefore, we must defend our belief inthe time-tested process of investigator-initiated research,evaluated by peer review and funded solely on scien-tific merit, in which we "encourage the single scientistto be independent and the body of scientists to betolerant" (6).

The major factors motivating an individual to em-bark on a career in research are curiosity, a desire tocontribute to scientific as well as social progress, anda strong need for recognition and independence. Oneof the rewards is the satisfaction of having made acontribution which one can consider one's own andwhich receives appropriate recognition from one's peers.Banting (7) clearly enunciated this when he said"Our religion, our moral fabric, our very basis of lifeare centered around the idea of reward. It is not ab-normal, therefore, that the research man should desirethe kudos of his own work or his own ideas." Whereelse but in an atmosphere of free inquiry can one besure that these drives are satisfied? Can either of thetwo centrally directed programs where bespectacledelders direct the activities of others have an effect otherthan to discourage and repel the young investigator?

In view of the unpredictability of science, there isno way of anticipating the future needs and organizing

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FIGURE 5 "Nearly all scientific research leads nowhere,or if it does lead somewhere, then not in the direction itstarted off with" (8).

the activities of scientists. If we agree with Medawarthat "nearly all scientific research leads to nowhere,or if it does lead somewhere, then not in the directionit started off with" (8) (Fig. 5), we must conclude thatthere is no alternative to free exploration by the maxi-mumnumber of inquisitive minds. It is often difficultto predict who will achieve success, since past per-formance allows one to choose among a group of provenproductivity, but is of little help in picking the youngscientist with the greatest potential. By leaving aplace for the nonconformist, by permitting explorationof currently less fashionable areas, and by allowingmaximum flexibility to follow up unexpected leads, weare much more likely to achieve major conceptualadvances than in a system that is rigidly confined byconcepts interpreted by the previous, generation.

Moreover, while the fruits of medical research donot readily lend themselves to the usual cost-benefitanalysis employable in many other areas of humanendeavor, there can be little doubt that the dollar costof "little science" is infinitely less and the efficiencymuch greater than that of "big science

Another point to consider is that either form of cen-trally directed science is likely to aggravate the currenttrend of removing many capable individuals from thelaboratory and sequestering them in offices in Washing-ton or the local centers as a self-perpetuating, unpro-ductive, scientific political elite. Would it not be wiserto redirect these talented individuals to the laboratory,where they can play an important role in their ownresearch, and guide and formulate the careers of youngerinvestigators ?

Lastly, by permitting maximal flexibility and allow-ing work to be done for true rather than contrivedreasons, we would encourage honesty of choice, preventprostitution of principles and ideas in a frantic searchfor financial support, and safeguard the intellectualdiversity which assures a proper climate for scientificinquiry.

What can we, as a scientific society and as individ-uals, do to prevent further inroads into a systemwhich has been so eminently successful and whichpromises greater achievements at less cost than anyother? How can we prevent this productive periodfrom becoming another dark age in the ever-changinghistory of science? The task of restoring the supremacyof the individual is enormous. It requires the activeparticipation of every member of the society and everyclinical investigator. It cannot be delegated to our busyofficers or the members of the National Public AffairsCommittee, all of whom are transients chosen for theirscientific and not their political expertise. That TheAmerican Society for Clinical Investigation is politi-cally powerless is clearly illustrated by its history. Itappears that the Society has only rarely expressed itselfofficially in a way that might be considered politically

1758 Edward C. Franklin

significant. On the first occasion, it took the momentousstep of offering President Woodrow Wilson its supportduring World War I. Shortly after, it passed a resolu-tion for the prohibition of the manufacture and im-portation of alcoholic beverages to this country for theduration of the war. Obviously, this altruistic act wasmotivated solely by patriotic reasons, since the un-availability of such beverages must have inflicted un-told suffering on the assembled members during theirmeeting in this glorious city. That things are not verydifferent now is illustrated by two of my own ex-periences as president, which emphasize our politicalineffectiveness. Earlier this year it was announced thatthe newly appointed Presidential Science Advisor hadmet with the officers of a number of scientific societiesto plan the future of science in the present administra-tion. My letter offering him the resources of TheAmerican Society for Clinical Investigation in planningfor the needs of biomedical research was not even ac-knowledged. Yet in a way this "no response" was moregratifying than my second venture into politics. In replyto a letter highly critical of impoundment of appro-priated funds and curtailment of training support, Ireceived a most ingratiating letter from the President'sDomestic Advisor thanking me for our support of theadministration's health policy.

Under these circumstances, what means are opento us to reverse the deleterious effects of the last fiveyears? The fate of medicine is at stake! In the firstplace, we must communicate clearly with every seg-ment of society if we wish to play a role in planningfor the future. Secondly, it is essential that we learnto make the best of our limited budget by directing thefunds into what we consider truly productive areas. Inaddition, we must strive to maintain an environmentwhich is so rewarding as to be irresistible to ouryounger colleagues.

I will not dwell on the need to interact with thelegislative and executive branches of the government,since the means open to us and the chances for successhave been proclaimed from this podium annually. Ourcase must be brought directly to the public. Mass edu-cation and modern information media have indeedraised the general public to a position which AlexanderMeiklejohn has referred to as "the fourth independentbranch of government". As pointed out by Ivan Ben-nett (9), "Science can no longer hope to exist amongother human enterprises through some mystique, with-out constraints or scrutiny in terms of national goals,and isolated from the competition for allocation of i

resources which are finite." Therefore it is incumbent i

upon us to give an account to society! This can no tlonger be done simply by the casual process of talking Ito our patients and nonmedical friends. The public ex- N

pects and demands more! Wemust enlist the help of the v

press and other communications media, which have c

recently demonstrated their powers to mold publicopinion. Techniques of instant communication and mod-ern methods of information gathering, storage, andtransmission have revolutionized the means availableto educate society. Scientific data, like political issuesor economic theorems, are not conveyed to the publicby specialty journals, but rather by the lay press, radio,and television. Reporters and editors require our helpto develop the public's insight into the workings ofscience and the value of research. By working withthem to set the hopes and expectations of the lay publicin the framework of the achievable, we will preventdisappointments engendered by false promises. Let itbe understood by everyone that in spite of our strivings,cancer and heart disease will not be cured overnight,and the urgently awaited practical applications mustawait the understanding of the basic laws of biology.Most importantly, society must be made to understandthat in our complex world, many of the intricate health-related problems which the medical profession is askedto solve are largely in the realm of social, political, andeconomic disciplines, and consequently far beyond oursphere of competence. We have to do our share intheir solution, but cannot be expected to shoulder thewhole burden.

Of equal or possibly even greater importance is theneed to communicate better with the remainder of themedical profession, the 350,000 physicians who takeour results from the Journal of Biological Chemistryand apply them to the patient. It is very disturbingthat last fall, more than 50% of the letters from physi-cians to Congress favored abrogation of training grants.The clinical staffs of our medical schools and associatedhospitals and especially physicians who are not affiliatedwith medical schools should be made to understand theimportance of clinical research if we are to succeed inour common goal of improving health care. By enlist-ing the resources of practicing physicians in clinicalresearch, we are likely to arouse their enthusiasm andinterest and to dispel the commonly believed myth thatthe clinical investigator is the oddball who has chosenthe easy life and who likes to sit sequestered in hisivory tower in search of abstract truth.

Above all, if we are convinced that clinical investi-gation is the major force in improving the qualityof medicine, we must make certain that there will beclinical investigators in the year 2000. From their firstday in Anatomy to the end of their residency, ourstudents and house staffs should be exposed to individ-uals engaged in research. By deed more than by word,we must make them aware that significant advances inthe scientific as well as the social arenas of medicinerequire complex programs by physicians, either togetherwith basic or with social and political scientists. Sincewe seem to have passed the temporary period of stu-dents' unfocused hostility to organized disciplines, our

Presidential Address 1759

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FIGURE 6 We must restore an intellectual climate which will bring our youth back out ofthe woods.

task should not prove difficult. There is no doubt thatour youth, now as always, is genuinely striving to im-prove the health of society. Unfortunately, the currentpolitical, social, and economic pressures are divertingmany of the most talented physicians from investiga-tive pursuits. If this trend is allowed to continue, thepractice of medicine will be arrested at its present stageof evolution. Yet we cannot hope to recapture 'the in-terest and enthusiasm of our brightest young people byappealing to their idealism alone. They will not returnto the fold until we can make a career in biomedicalresearch as challenging and attractive as it was in thelast two decades, when completion of training virtuallyassured the young investigator of an independent labor-atory, and above all, a chance to set his own goals.Perhaps, if we could restore this kind of climate, ouryouth would once again come back out of the woods(Fig. 6).

Though our national budget continues to increaseannually, it usually slights those programs we considermost important. Consequently, we must resign ourselvesto the fact that uncontrolled growth of science fundingis a thing of the past. In attempting to put to optimumuse the limited funds at our disposal and at the sametime create an intellectual environment that will makea scientific career attractive, we should heed the adviceof Gerard Piel (10) that "it is not the total amount ofsupport that counts but rather the terms on which itis given." If we include support of the individual asan essential term in our contract with society, sciencewill be enriched. By giving everyone the opportunity toevolve his own style, the final product will be greater

than the sum of its parts and the public will reap thebenefits.

ACKNOWLEDGMENTSI would like to express my sincere appreciation to mywife, Dr. Dorothea Zucker-Franklin, for the many hoursof self-sacrificing endeavor she devoted to make this talkreadable, and to Drs. Peter Elsbach and Saul Farberfor their helpful suggestions. Particular thanks are due toMs. Marlene Chavis for patiently typing the many pre-liminary drafts that went into making the final version ofthis talk. The illustrations by Dr. Mark Podwal speak forthemselves.

REFERENCES1. Merton, R. K. 1973. The Sociology of Science. Univer-

sity of Chicago Press, Chicago, Ill. 255.2. Monod, J. 1971. Chance and Necessity: an Essay on the

Natural Philosophy of Modern Biology. Alfred A.Knopf, Inc., New York. xiii.

3. Monod, J. 1971. Chance and Necessity: an Essay on theNatural Philosophy of Modern Biology. Alfred A.Knopf, Inc., NewYork. 29.

4. Peart, W. S. 1974. Medical research is too importantto be left to the researcher. The Glaxo Volume, 25thAnniversary Lectures. In press.

5. Weinberg, A. M. 1967. Reflections on Big Science. TheM.I.T. Press, Cambridge, Mass. 113.

6. Bronowsky, J. 1956. Science and Human Values. JuliusMessner, Div. of Simon & Schuster, Inc., New York. 88.

7. Banting, F. 1973. Quoted in Merton, The Sociology ofScience. University of Chicago Press, Chicago, IlL. 321.

8. Medawar, P. B. 1968. Induction and Intuition in Scien-tific Thought. Mem. Am. Philos. Soc. 75: 31.

9. Bennett, I. L. 1972. Quoted in D. Greenberg, Theaccountability of physicians and the scientists to so-ciety. Fed. Proc. 31: 1549.

10. Piel, G. 1961. Science in the Cause of Man. Alfred A.Knopf, Inc., New York. 35.

1760 Edward C. Franklin