As anyone who clicked through to this piece probably knows, yesterday saw the start of a Health Professionals Council of South Africa (HPCSA) hearing to assess whether Prof. Tim Noakes is guilty of unprofessional conduct. The charge against Prof. Noakes states:
That you are guilty of unprofessional conduct or conduct which, when regard is had to your profession, in that during the period between January 2014 and February 2014 you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet/s).
I attended all of yesterday’s session, and offer some thoughts on what transpired, below. I have not attempted to catalogue everything that happened – if you want a more detailed account, the News24 live-blog offers an accurate summary.
On futility – once more with the distinctions
It continues to exasperate that I can think of only
one person a handful of people who understand that there are (at least) two distinct issues at play in the general discussion around Noakes, LCHF and Banting. The first is the set of questions related to diet, and which is healthier for you.
In this set of questions, I’m bundling in long-term vs. short-term, treatment for obesity and diabetes, what proportion of population X are insulin-resistant and so forth. I do not, in general, comment on those issues. They are not a field of expertise for me. As I’ve repeatedly said, Noakes might well end up being a frontrunner in what eventually becomes scientific consensus.
The second set of questions relates to logic and philosophy of science, and to our responsibilities as educators, or journalists, or health professionals to discourage sloppy thinking on matters of significance (well, on all matters, but the stakes are sometimes higher than others).
So, I’ve consistently (with a few lapses, I’m sure) focused on the quality of argument that emerges from the Banting camp, rather than on the superiority of any particular conclusion. If you don’t care about those issues (you of course should), then you shouldn’t be reading my comments on them.
You certainly shouldn’t be asking me to present evidence that low-carb is bad, because that’s not what I’m claiming. You also shouldn’t be telling me that “there’s so much more bad science for the consensus” or somesuch, because maybe there is, and maybe there isn’t, but that’s not what I’m talking about. The fact that someone else (proponents of the consensus view) also does things wrong doesn’t give anyone else a free pass to be sloppy in their reasoning.
On futility II – the hearing that never happened
We spend the entire day hearing arguments about the constitution of the panel that was set to hear the case, and proceedings were eventually terminated at around 15:30 when it was agreed that the panel was improperly constituted. Proceedings will resume on November 23, assuming nothing else interferes with the process.
Should this hearing be happening at all?
I have mixed feelings about this. As with so many of our policies (and even heuristics related to social interaction), there’s a vast difference between what made sense in a pre-digital era and what makes sense now. Noakes is often to be found on Twitter – he’s written an ode to it, in fact, and his fans love him for how much he engages there.
The point of highlighting the pre/post-digital era is of course it would be irresponsible for a physician to encounter you in the street and tell you what your baby should eat, unless your advice is something rather generic and consensus-based. Even if the consensus is wrong, as Noakes thinks it is, it does sit with an advantage here – his job is to create a new consensus, after which he’ll get the same advantages.
But perhaps Twitter is different, in that it’s a broad discussion or sounding board for ideas, in which we shouldn’t expect people to view what Noakes tweets as prescriptions in the medical sense. That’s presumably what he thinks. I think he’s wrong in practice, because people do view them as prescriptions, and he should know that and act accordingly.
However, it’s possible that holding him to account for all possible consequences of his tweets does overstate the importance and role of Twitter, and also paternalise his Twitter following. For example, a non-prejudicial look at the tweet that started all the trouble is consistent with slowly weaning a child onto LCHF, perhaps in a manner that doesn’t run the risk of causing the complications the complainants in this case claim it would.
So, this case is raising very important background issues related to the appropriateness (or not) of how people with positions of influence engage on social media.It’s not going to be a waste of time, but is rather going to force everyone to resolve what I think are important issues.
It’s a great shame that many of Noakes’ supporters are struggling to see anything beyond a vendetta or bad faith here, and also that Noakes himself misses the point that it’s not about freedom of speech, but rather about the responsibilities of healthcare professionals to avoid causing harm.
He’d retort that it’s the Association for Dietetics in South Africa’s (ADSA) advice that causes the harm, but even if true (and even if he’s even representing what their advice is accurately), that’s something you demonstrate in journals, not with other people’s babies.
Is Noakes speaking “outside his field of expertise”?
One of the things that caused a fuss during the hearing was a statement made by the HPCSA’s lawyer that Noakes was operating or speaking as if he were a dietician, and that this is not his field of expertise. To briefly return to my futility theme, this was immediately leapt on by the Noakes-supporters as an attempt to suppress Noakes’ freedom to research and write on nutrition, while it was in fact nothing of the sort.
The argument was simply that because he’s operating outside of the “normal” General Practitioner (GP) set of ideas but rather as a dietician, it makes sense to include a dietician on the panel. Nevertheless, the motivated reasoning in response to this was quite something to behold, as it was immediately taken up as further evidence of the conspiracy against Noakes, who was now “not allowed” to talk about diet.
The clue as to what GPs do is in the name – they consult on a general set of health-related concerns, one of which is diet. But the claim made by the HPCSA lawyer was that Noakes was presenting himself as more than a generalist, but rather as a specialist in this area, and he should thus be assessed by a specialist also.
What was the problem with the panel composition?
The technical problem that (rightly) led to the cessation of the hearing was that the panel was lacking one particular member as per the regulations, where that member needed to be in Noakes’ profession, i.e. a GP. There was one GP on the panel, who was also a pediatrician, as well as a dietician (who I’ll return to in a moment), but there needed to be another Medical and Dental Board-registered GP present for a properly constituted panel.
What was interesting about the debate on the panel composition?
Both sides seemed intent on creating as favourable a panel as they could, which should of course be no surprise. The complainants argued strongly for the presence of a dietician, and Noakes’ lawyers argued strongly against. Noakes, of course, thinks that the dieticians exemplify bad science in this area, and he’d probably argue that they aren’t competent to assess the evidence he’ll present.
However, the problem with ruling them out is two-fold: one, it presents a circular argument, in that it assumes they are incompetent (or rather, cedes the argument regarding their competence) as reason to rule them out as assessors of the evidence; and two, if they are as incompetent as he thinks, surely it would be a simply matter to demonstrate this in the course of the hearing?
There’s the risk of a strategic blunder from the Noakes team here – the more intent they appear on trying to rule a dietician out as a panelist, the more people might wonder what they are so concerned about. If they are as scientifically backward as Noakes would have us believe, why not publicly expose that via the hearings?
The strange case of Prof. Blaauw
The dietician panelist, Prof. Blaauw, was initially considered a perfectly acceptable member of the panel, until we discovered two things about her (and the second, only rather late in the day). Over lunch, she informed the (superb) Chair of proceedings, Joan Adams, that she had once co-supervised an ethics thesis on the “media implications of Tim Noakes”. This was claimed to not impair her objectivity, and the Noakes legal team seemed happy with her, despite this knowledge.
Later on, though, we discovered that she was also a member of ADSA, whose President in fact laid the complaint against Prof. Noakes. This caused significant dissent around her suitability, as you’d expect it to given the conflict of interest.
Debate then ensued as to whether she was in fact legally part of the panel at all, as given that it had already been ruled that the panel was improperly constituted, she could not officially or automatically be considered part of a future, properly constituted panel either. Noakes’ lawyers went as far as to say that they might consider taking this issue to the High Court, if Prof. Blaauw ended up remaining on that future panel.
Bad faith and Tex bars
In an amusing turn of events, we reconvened after lunch to find that some prankster had placed Tex bars (a chocolate) on the desks in front of each panelist. Some of the Noakes supporters on Twitter immediately assumed that this was ADSA’s doing, which seemed to fit the generally uncharitable attitude on the #NoakesHearing hashtag, which also included some fat-shaming of various members of the complainant’s party.
Yes, these are emotive issues, and I can understand why people feel that someone they respect and admire for standing up to orthodoxy is being unfairly singled-out, but you don’t make an effective case for his virtue by demonstrating a lack of virtue yourselves. Even if “the other side” sometimes do the same, that does not make your doing so more appropriate either.
One of the Noakes supporters seems to have cottoned on to the reality that people like me don’t have a vendetta, but is rather simply interested in the arguments and ethics of how we debate them. But there’s still far too much ad hominem, and accusations of trolling put in terms that are themselves distinctly trollish. This is the problem of the filter bubble, as I’ve argued before, and I’ll again simply suggest that there is a conversation to be had here, and some of us are having it in good faith – whatever you might believe.
The Noakes legal team seem better prepared, and certainly appeared more effective in their rhetoric and argumentation. Now that the hearings have been extended to run for 7 days, I suspect that the complainants are going to have a difficult time competing. And, at the end of the day, Noakes will “win” on any permutation.
If he is (in the extreme scenario) struck off the roll and disallowed from practicing medicine, that’s of little consequence to his main interest, which is research and (mostly public) dissemination of findings related to diet. And, he and his supporters will have further “evidence” of his persecution.
And if he wins, that will of course serve as his – and the Banting diet’s – most significant tipping point towards public acceptance yet…
P.S.: The screenshot above is from Noakes’ Real Meal Revolution website, and you might find the last bullet-point of interest.