Theodore Dalrymple. False Positive: A Year of Error, Omission, and Political Correctness in the New England Journal of Medicine. New York: Encounter Books, 2019. 259 pp. Rs 2088, ISBN 9781641770460 (paper); Rs 1994, ISBN 9781641770477 (ebook)

Our generation read medical journals as we used to read telephone books or encyclopaedias: we extract whatever useful facts are in them as efficiently as possible, without considerable critical reflection. This tendency is exacerbated by the pressures of professional life: those who are in a position to adopt the new scientific information presented in medical journals are also often those with the least time to ruminate on the nature of it. This is unfortunate for, as Dalrymple points out, “there is more in a medical journal than straightforward scientific truth, if only because scientific truth is itself often less than straightforward.”

And so, for one year (2017), Dalrymple began an extended commentary of select articles in the New England Journal of Medicine (NEJM). The purpose of this undertaking is to underscore the difference between merely reading an article, and critically engaging with it to see whether the claims it presents are substantiated. Dalrymple engages in three interrelated modes of evaluation: the clarity of the writing (“One would not expect incisive prose to follow such a title, as indeed it does not”); the soundness of the reasoning; and the way in which the larger social and cultural sensibilities influence what is said, how it is said, and whether ideas are even deemed worthy of publication at all.

Readers familiar with the pseudonymous author’s works will recognise these themes. As the title of this book notes, the focus here is on excessive “political correctness”, and Dalrymple heartily dissects what he sees as the NEJM’s fulsome sensitivity. His critique of language is not only directed to turgid writing per se (“To make absolutely sure that the reader’s mind is numbed into submission, the article continues in this vein…”) but more pointedly to the way in which language is used to exonerate people from the responsibility of their actions. In the case of a clinical vignette featuring an infant, he argues, the Journal glosses over the point that an infant being left in the care of the mother’s boyfriend should be included as a possible flag for injuries potentially caused by abuse: “The delicacy of [the wording] and the desire not to cause unnecessary offense would be admirable in other contexts, but not in this.” Another article, he notes, replaces the term “heroin abuse” with “heroin use” in order “to avoid being seen as illiberal and censorious.”

A second theme of the book is to identify the ways in which faulty reasoning is woven into medical analysis and commentary. The identification of flawed inference and hyperbolic claims (selection bias, correlation misinterpreted as causation, proxy measures, absolute versus relative risk, numbers needed to treat versus numbers needed to harm, questionable extrapolation, and so on) is a skill generally covered in methodology textbooks, but applying these analytical methods to journal articles in real time is an intriguing exercise, and one that may be especially useful in shaking students’ uncritical deference to published sources. Dalrymple briefly comments on an article about prostate-specific antigen (PSA) screening to take issue with the failure to identify all-case death rates as well as the harms caused by treating prostate cancer. In a paper from another issue, he highlights the complexity of clinical trial design by explaining when one might choose a “per-protocol” analysis rather than an “intention-to-treat” design. Readers, on this account, should not just follow the text, but challenge the claims, be aware of what is not stated, and be able to set the articles’ content within the wider context of how lives are actually lived and medicine is practised (“those who spend their day poring over statistics are rarely thinking of individual human suffering”).

Again, however, his fundamental point is that it is important to interrogate the text in order to understand how the Journal is being used to further a particular political sensibility: “The NEJM seems to me a manifestation of a dangerous tendency in our society, that of self-enclosure in an ideological laager.” Those reading Dalrymple for the first time may become apoplectic. He is not subtle. Dalrymple writes of the “pieties of multiculturalism” and the “poison gas” of political correctness, and he states that hyperbole “is the stock-and-trade of identity politics.” He questions whether physicians should in fact aspire to being likeable (“Dr. Harold Shipman was generally well regarded by his patients, and he turned out to be the most prolific serial killer in British history”); he holds that physicians are themselves responsible for the opioid epidemic to the extent that they chose not to challenge sketchy requests for painkillers; and he argues that “it was not the desire to be more equal but the desire to be richer” that facilitated the decrease of rheumatic fever in countries such as India and China.

Within Dalrymple’s criticism of the fatuous championing of aspirational moral sentiments by the NEJM, the theme of individual agency (or its loss) is preeminent. A trigger warning: his arguments may cause readers considerable upset (although many of these points have been articulated in his previous books). The mortality rate of prisoners, he notes, is substantially less than the social class from which they are drawn: “a prisoner in England is just over half as likely to die in prison as he would be if he were at liberty to pursue his life as usual.” Heroin addicts cannot be discharged from all responsibility for their condition: “addiction to opioids is not instantaneous, nor does it imply an inexorable fate when it happens, or is achieved.” Everything wrong with this sensibility can perhaps be found in an article entitled “Breaking the Stigma – A Physician’s Perspective on Self-Care and Recovery,” which Dalrymple eviscerates with particular gusto. Our therapeutic culture assumes “that stigma must be harmful in itself” and that it cannot play a positive part in our social existence. On the contrary, argues Dalrymple, “fear, shame, and guilt are often justified; and an alcoholic who ruined his family’s life for years is rightly ashamed.” Here Dalrymple is at his most Kantian: we have a duty of self-examination, and capitulating to “emotional slush” is hardly conducive to a moral society.

The format of this book – chapters are around four to five pages, and there are 52 of them – can be frustrating where complex topics are raised briefly and provocatively (“A regime of proliferating ‘rights’ has the tendency to stultify the moral imagination”) and then set aside to consider another set of brief and provocative ideas. Many of these ideas deserve much more careful consideration, and the peremptory dismissal of positions without a fair hearing is unsatisfying. Nevertheless, it is an advantageous format for those with demanding jobs or small children (or both), where fifteen minutes of personal edification may be the daily limit.

Dalrymple’s epigrammatic style, if not his politics, would lend itself well to a Twitter presence. Intriguingly, while he is not himself active on Twitter, there are nonetheless several Twitter accounts dedicated to posting his bon mots. While entertaining to read, however, the easy articulation of snark can be tiresome. Dalrymple is at his best when he rails against simple-minded and self-indulgent writing, and he is at his worst when he begins to slide in that direction himself. In False Positive, Dalrymple underscores the complexity, uncertainty, and often transitory nature of scientific knowledge and its relationship to social norms: “Old Hippocrates was right after all: time is short, the art is long, the occasion fleeting and judgment difficult.”