Annual Oration 1969
By Franz J. Ingelfinger, M.D.
The title of the Annual Address delivered before the Massachusetts Medical Society in 1860 was "Currents and Counter-Currents in Medical Science." This sounds innocent enough. Yet some sensibilities must have been chafed, for within 24 hours the Fellows of the Society held an adjourned meeting and adopted, by a vote of 9 to 7, the following resolution:
"Resolved, that the Society disclaim all responsibility for the sentiments contained in the Annual Address."
A somewhat similar disclaimer appeared subsequently as a warning to the gullible at the head of many Annual Addresses, Discourses and Orations (as they were variously called) but especially those printed between 1915 and 1926. During this period, the Society disavowed responsibility for orators who declared themselves for subjects no less sacrosanct than good education and ethical medical practice.
"The truth," said the Orator of 1860, "is that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. Theoretically it ought to go on its own straight-forward inductive path, without regard to changes of government or to fluctuations of public opinion. But look a moment while I clash a few facts together, and see if some sparks do not reveal by their light a closer relation between the Medical Sciences and the conditions of Society and the general thought of the time, than would at first be suspected."
The general thought of his time, the Orator held, was a return to a belief in "Nature," supported by the "solemn scepticism of science." In the field of medicine, this "nature-trusting heresy" expressed itself as a challenge to polypharmacy, a confidence in "any investigations which tend to limit the application of troublesome, painful, uncertain or dangerous remedies."
"The community is still Overdosed," he proclaimed, and "Part of the blame of over-medication must, I fear, rest with the profession for yielding to the tendency to self-delusion, which seems inseparable from the practice of the art of healing . . . [but] another portion of the blame rests with the public itself which insists on being poisoned . . . The outside pressure, therefore, is immense upon the physician, tending to force him to active treatment of some kind." As for materia medica, "I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind, — and all the worse for the fishes."
This famous epigram will identify the speaker of 1860 to many. It was Oliver Wendell Holmes. I have cited him at length, for so many of his ideas have currency today. We are still debating, over a century later, the proper use of drugs, but the questions have become more momentous, because of the abundance of potent agents, both salubrious and toxic, that science has devised; because the makers of those agents have emerged as influential powers that affect the medical scene, and because the people and their government are no longer uninformed and passive recipients of what the doctor orders.
That one of the most famous of all Annual Addresses presented by one of the giants of American History should have occasioned censure by the then establishment is an irony that our society cannot ignore as it is confronted by revolutionary demands and ideas. Which will be rated, 100 years hence, as brilliant advances, which as disastrous regressions? Our judgment, the affaire Holmes should teach us, expresses unstable values. The events of 1860 also offer personal solace to every speaker privileged to stand on this podium. If his remarks draw approval, well and good. If the opposite is their lot — who would not be happy to sip bitter tea with the Autocrat of the Breakfast Table?
Accusations
The subject matter of today's Oration is also pharmacologic. Its focus is on some of the relations between those who make and those who prescribe drugs, and my particular topic is that pharmaceutical-medical interface which consists of drug advertisements in medical journals. You, the Massachusetts Medical Society, own what you and I believe is the finest medical journal in the world. It can claim to be the one in longest continuous existence and enjoys the largest number of voluntary paying subscribers. The practices of your Journal may thus be examined as reasonably representative of good medical publishing practices in general.
In 1968 the number of subscriptions to the Journal ranged between 106,000 and 112,000. The income from these subscriptions was roughly $750,000. If it were to cover the entire cost of producing and distributing the Journal, the income would have to be close to $3,000,000. What makes up the difference — 2.2 million, or 75 per cent of the total? Advertising revenue, and more than three fourths of this — or about $2,000,000 — comes from the promotion of drugs.
Do these facts compromise the purpose, value and integrity of the Journal? Hard-nosed business reasons exist why the Journal should not be so dependent on such soft support as advertising income provides, but the issues that burn today are fueled by arguments that are primarily moral and social. There is the fundamental charge that pharmaceutical firms exercise too much influence over medical education and hence over medical practice. To accomplish this, these firms are alleged to spend some $3,000 annually for every physician in the United States — or some 800 million dollars — on advertising: through detail men, free samples, independent mailings, sponsorship of educational and social functions, no-charge mass media and standard medical publications. Such advertising, the critics say, is detrimental to the public weal because it warps professional integrity, it raises the cost of drugs, it presents misleading information about the advantages and disadvantages of the agents advertised, it obscures the point that drugs should be evaluated on the basis of their cost-benefit, not merely their benefit, and it blemishes the dignity of medicine by using gaudy Madison Avenue gimmicks to promote agents created to sustain or comfort human life.
These general accusations have also have been directed, to a greater or lesser degree, at pharmaceutical advertising in the Journal. The first charge — namely, that editorial decisions and the words of the text will accommodate the desires of the advertiser — is the most serious and at the same time the most superficially obvious. It is also the most easily rejected. The larger the circulation of a journal, the more diverse and multiple its advertisers, and the more its traditions and record manifest probity —characteristics of which the Journal can boast — the less an advertiser will be able to affect an editor's decisions. For such reasons, or because of his own principles, the advertiser may not even try. In my brief two years as the Journal's editor, I am unaware of any attempts to influence, the Journal's contents. Not that the tentacles of promotion fail to probe. Several medical journals, both here and abroad, have recently been threatened with loss of some pharmaceutical advertising unless these journals were willing to interdigitate text with advertising pages. Such pressures, originating I would hope from the unconscionable competition of advertising agencies rather than from pharmaceutical houses themselves, warrant total condemnation. It may even be questioned if the advertiser would gain if the text of every journal, and the messages of the advertiser no less, were embedded in a matrix of panspectral copy extending solidly from the first to the last page.
When the Journal agonizes editorially about the role of pharmaceutical advertising, it is not, as a comment in a free mass-circulation publication would have it, because we are afraid that we shall be bribed. The problem is more subtle. In essence, it is this:
Does The New England Journal of Medicine, if it carries pharmaceutical advertising — and is in turn carried by such advertising — on the average help or harm the proper care of patients?
The abstract service that the Journal recently initiated on a trial basis illustrates one aspect of the dilemma concretely. Abstracts of the Journal's Original Articles, designed to serve retrieval and recall, are being mailed to all subscribers in a monthly booklet. The project is funded as a commercial venture by Eli Lilly and Company, whose products are advertised within the booklet, but not on the abstract cards themselves. So far, nearly 15,000 subscribers have used their own stamps and have returned — presumably without pressure from detail men — a questionnaire card to indicate reactions ranging from satisfaction to delight. Theoretically, the knowledge of, and hence the medical care provided by, these 15,000 should be improved. Some 5000 are unenthusiastic or noncommittal. There were also some unfavorable letters.
"I will not be educated by money extorted from the consumer by drug companies to be dispensed to the medical community," wrote one intern. A pediatrician was more vigorous: "This is another stupid attempt by the advertising media to make themselves available under the guise of being helpful. I am disappointed to find out that an outstanding journal such as The New England Journal of Medicine is willing to promote forced advertisements upon its customers. If I want abstracts of articles appearing in your journal, I can well afford to pay for them myself; and so can any other physician. I do not feel that my patients need to purchase them for me through the medium of higher drug prices.
Kindly put yourself to the trouble of being certain that I do not receive the proposed abstract cards. If you find it too troublesome or too expensive to prevent me from being placed on your mailing list for this 'service,' then I will facilitate your efforts by cancelling my subscription to The New England Journal of Medicine."
Although there were in all only five reactions of this type, we should not shrug off these negative comments for their lack of number. To a remarkable degree they stress the point that the moral and social problems of pharmaceutical advertising in the Journal are not matters of subornation; rather they are examples of the ancient philosophical conflict between ends and means.
Death-Wish Rejected
A pragmatic balancing of ends and means is particularly in order when demands are considered that the Journal accept no pharmaceutical advertising whatsoever. Such demands have been expressed by many individuals — physicians as well as planners — and also by groups of students. The Journal, for example, has received the following manifesto, "we believe that all medical journals such as The New England Journal of Medicine must not carry drug advertising," signed by 80 second-year students from Tufts University School of Medicine.
Within the context of a capitalistic and competitive economy, the business of advertising is well accepted. Western Society as a whole does not seriously challenge the concept that a continuous bombardment of man by one-sided, slanted statements is permissible — provided that such statements are identified as advertising. Nor do our most upright lay publications scorn to use the profits from advertising to offset the deficits incurred by other operations. Hence prohibition by law of advertising in general, or of advertising by one industry in particular, would seem inappropriate and, in fact, impossible. Under these circumstances, the elimination of pharmaceutical advertising by the Journal would perforce be a solitary action. What would happen? Would such a solitary perhaps idealistic gesture improve either the quality of patient care or the character of the Journal? The intensity of the "no" I hear exceeds that of a sonic boom.
If the Journal suddenly barred pharmaceutical advertising, the advertising budget of the pharmaceutical industry would have to reallocate some 2 million dollars in its advertising budget. Would Abbott give its share to Columbia Point? Or Wallace its fraction to Tufts, Harvard or Boston University proportionally? The p value of such a chance seems mighty slim. More likely, the advertising dollar would not desert its fellows, and less advertising of drugs in the Journal would merely mean more through other channels. Such a shift, depending on the nature of the new channels, might conceivably end up with a net loss for the quality of patient care.
The consequences for the Journal are equally predictable. Without pharmaceutical advertising, its subscription price would increase to about $25 per year. The suggestion that other advertising be sought lacks substance, for enterprises selling to a general market see no reason for placing advertisements in a medium read only by one restricted segment of that market. Similarly fanciful is the cry, "Price does not matter — doctors can pay!" Of course they can, but will they? What about the 80 Tufts second-year students and the 44,000 other medical trainees who now receive the Journal for $5 annually — will they pay? In spite of its exceptional qualities, the Journal would be threatened by an ominous prognosis. Circulation would drop, and the subscription price would correspondingly rise even more. In other words, the Journal might well achieve a moral but pyrrhic victory, for it would be as pure and free of taint as a corpse.
The Irresolute Censor
Since elimination of pharmaceutical advertising from the pages of either one or a few medical journals would seem to be a move devoid of any benefits, should not advertising of this type at least be subject to stringent control? Some indeed ask that the Journal evaluate, screen and edit advertisements with the same rigorous objectivity — some authors would call it nasty censorship — that it applies to reports of medical scientific endeavor. How can you, asks a letter writer, put side by side "erudite, scientific articles" and "pages of Kafkaesque, multicolored, super-overkill-diagrammed nature"? And others argue that the mere appearance of an advertisement in a respected medical journal should imply de facto endorsement by the editors of the safety and efficacy of the product advertised.
Opinions of this type are based on a strange conception of advertising. To advertise, in a business sense, is "to call public attention to, especially by emphasizing desirable qualities in order to arouse a desire to purchase or invest." It is, by definition, not a judicial weighing, a balanced approval or an educational effort listing all the pros and cons. To the contrary, most of us accept it as prejudiced and one-sided, purposely ignoring the possibility that a competitive product or method might be cheaper or better. Any biomedical manuscript submitted to the Journal that might warrant such adjectives — or even milder ones (such as uncontrolled, anecdotal or superficial) — would be rejected forthwith. The intrinsic character of advertising is such that if it were evaluated by the same criteria applied to medical manuscripts, the result would be exactly the same as if pharmaceutical advertising were prohibited outright.
A medical student to whom I tried to present this line of reasoning exclaimed, "Ha! — so you are using a double standard!" Of course we do! In fact the Journal applies a whole range of standards. In Special Articles and Editorials, opinion need not be documented as thoroughly as in Original Articles. In the Correspondence column, letter writers are allowed to say almost anything they want, provided their words are relevant, at least moderately interesting, not grossly inaccurate, not scurrilous, and briefly put. Were it not for such a range of standards, the Journal would be a dull publication indeed.
The fact that advertising is accepted by society as an intrinsically biased presentation is one of the principal reasons why its regulation is so inordinately difficult. At what point does the exaggerated and distorted become too exaggerated and too distorted? The Pharmaceutical Manufacturers Association has its own statement of principles of ethical drug promotion. The Federal Government, as is well known, is increasingly active in attempting to regulate what drug advertisements must and must not say. Most medical journals like The New England Journal of Medicine have, in addition, their own advertising committee to judge the acceptability of submitted copy. In spite of the best intentions, however, the results are not really satisfactory. The monitoring agencies themselves face a number of handicaps. To a varying degree, they lack authority, proceed in a fragmentary and unsystematic manner, and, for lack of competent manpower, are haphazard in applying their criteria. Voluntary self-regulation by members of a highly competitive industry is an exercise that elicits cynical smiles, particularly when not only the pharmaceutical but also the aggressive advertising industry is involved. The Federal Government has more authority but is encumbered by jurisdictional and operational restraints. A major difficulty is that it does not deal with pharmaceutical advertising in medical journals as a simple entity but defines three categories to which it applies values of varying stringency. It has its own triple standard.
One class of drugs comprises those sold over the counter — and hence known as OTC drugs. These agents are regarded as rather harmless, and the propriety of their advertising is not a charge of the Food and Drug Administration (FDA). Rather, the FTC — the Federal Trade Commission — handles these agents with the suede gloves of leniency in the apparent belief that the promotion of a relatively harmless drug requires relatively harmless control. Not even the ingredients are listed in some of the OTC advertisements appearing in medical journals. In one unhappy instance, a physician was pictured as recommending to an intern a well known antacid, but "First of all," the physician says, "he needs a unit of blood." As several indignant readers of the Journal pointed out, the premeditated administration of a single unit of blood is by all precepts poor medicine. It is regrettable that the regulation of OTC drug promotion has been in the hands of an agency that either could not or would not prevent the public from being hoodwinked by the kind of drug advertising that is seen in our mass media, especially T.V. At the moment, however, it looks as if the FTC were about to risk more aggressive control of OTC drug advertising.
The advertising of prescription drugs falls into the tougher domain of the FDA, but two classes of such advertising are recognized. In a so-called reminder advertisement, a manufacturer merely lists his name, the name of a product and the dose and form in which it is dispensed. No recommendations for the product's use, either directly or by implication, are permitted. A nice example of such an advertisement is the Panalba promotion that appeared in many medical journals some months ago. The product itself, of course, is now under a cloud, but the advertising was tasteful and unobjectionable. I wish there were more of these.
Unfortunately, pharmaceutical firms are convinced that their advertisements must not only name a product but also spell out its use. Such recommendations must then be made within the elaborate regulatory guidelines of the FDA. Essentially, the words of the advertisement must conform to the contents of the package insert, misleading or exaggerated claims must be avoided, and a list of indications must be balanced by a list of contraindications and untoward effects. Although the FDA has the legal power to see that such regulations are observed, it lacks the manpower necessary for their systematic and equitable application. It cannot afford, for example, to pre-screen advertisements on a routine basis.
The advertising committees appointed by many medical journals are beset with similar problems. Their expert, generally anonymous members are limited by their very expertise in the breadth of their competence, their time is subject to multiple demands, and like any human beings, they have their prejudices. Advertising committees, consequently, are apt to exercise uneven censorship.
There is, of course, no difficulty in detecting and agreeing on the gross breach, but the agencies that create colorful copy are usually far too clever to attempt the flagrantly offensive. Rather, they exploit the zone of indeterminateness that widely extends between what is clearly proper and clearly improper in advertising. Violations of this vague border are not easily identified, and it is all to easy to observe regulations in the letter but to disregard them in the spirit. Those who with limited facilities try to establish and maintain law and order in this area have an impossible task — somewhat like that of the UN patrols along the Suez Canal.
Many a three-page display provides an example with which we are all familiar. Striking scenes, agonized faces — including, in observance of current fashion, a sprinkling of those that are black —and succinct captions rivet the eye on the center spread where a drug is extolled by its catchy and most pronounceable trade name. If you bother to turn the page, you will find, in due conformity with the law, a mass of information, including a long list of precautions, contraindications and toxicities, all in such congested fine print as to discourage reading, and often enough with the untoward effects listed under a drug now identified by its jawbreaking generic name. This artificial compliance with a cumbersome regulation helps no one. Whatever the few major dangers and contraindications these should be clearly headlined; detailed listing of rare and minor reactions should be abolished as worse than useless. Subjects of a recent study found detailed descriptions of drug effects "frightening, confusing, or both"; whereas maximum comprehension and retention were promoted when statements were "brief and to the point." These observations, of course, are well known to advertisers, but the message has apparently not reached the FDA.
Another ploy is the claim that is truthful but more or less irrelevant. An advertisement for ampicillin showed a youngster with a set of teeth that in their perfection can be found only in the genre of the publicist. The caption announced "No teeth staining in children." True enough, was the reaction of our advertising committee, but unacceptable because no penicillin-like agent stains teeth, and antibiotics that do have this side effect have a spectrum of therapeutic usefulness that is not identical to that of ampicillin. This particular advertisement, however, was not challenged by the FDA.
In the instance of the antihypertensive agent "Ismelin," the roles were reversed. The FDA made the makers of the drug send out a "Dear Doctor" letter to retract any implication in the advertising that "Ismelin" might prevent organ damage. A member of our advertising committee, on the other hand, argued that if guanethidine (the generic name of Ismelin) is credited with reducing high blood pressure, why should it not also control to some extent the consequences of hypertension, such as cerebrovascular accidents?
Sometimes the advertising committee fails to obtain the support of the Editor. An expensive but effective antibiotic was advertised as unsurpassed in its therapeutic efficacy in pharyngitis caused by beta-hemolytic streptococcus. The committee demurred. It rated the claim as literally accurate but misleading in that penicillin G is equally effective for this type of pharyngitis but infinitely less expensive. Since advertising, in my opinion, is promotional not educational, the committee's point of view impressed me as somewhat unworldly. It would have to be some Al Cappian arctic nevernever land where advertisements, while extolling product A, simultaneously identified product B not only as just as good but also as quite a bit cheaper.
Although the functions of the FDA and a journal's own advertising committee overlap to a considerable extent, and although both are concerned with policing copy (that is, examining the words and pictures of an advertisement for misleading statements or implications), the two bodies also have special responsibilities. The FDA is increasingly concerned with the product itself, the approval of a drug for marketing and the specifications of its usefulness. The advertising committee, on the other hand, is at present the only guardian of taste. So far the Journal's committee has been no more than moderately unhappy with such eyetraps as Mercurys in union suits, but it has censored dubious captions (for example, "the tired mother's antibiotic"), or concepts so far-fetched as to parody the art of advertising.
The Journal's Obligation
If elimination of pharmaceutical advertising from the Journal is undesirable, and if precise control of copy is impossible, what can be done to maintain high standards of such advertising? Two methods deserve consideration. One is immediate, stopgap, and can be instituted by any journal. The other is long-term, potentially permanent in its effectiveness, and requires the collaboration of national forces now jealously self-contained.
A medical journal can engage in what might be called counter-advertising. A by-product of the Nelson hearings has been a publicizing, an advertising in a way, of the toxic effects of chloramphenicol; and the antismoking sequences shown on T.V. are apparently producing results. Although I cite these examples, let me hasten to add that not for a moment do I envision in the pharmaceutical area a counter-advertising campaign making use of equal space, splashy technics or blunt denunciations. Rather, medical journals might publish, to a far greater extent than is now true, objective appraisals of new drugs and their use. The New England Journal of Medicine, for example, could initiate a regular drug page to present conservative evaluations such as appear in the Medical Letter.
Certain members of the medical profession have recently made public statements to the effect that physicians are not dolts, that they are very well acquainted with the action of drugs, and that they are not misled by promotional activity. Such comments are fatuous, alarming and irrelevant. That we physicians are not dolts hardly requires certification by public testimony. That we know all about drugs in an ever changing scene of complicated and innovative pharmacology is an arrogation of knowledge that thwarts competent medical practice, and that we are not misled by advertisements is true to the extent that other information is available. This "other" information is what medical journals must emphasize. Opportunities for the continuing education of the physician must be expanded. The Journal must carry not only advertisements but also unbiased accounts of drugs. The physician reader may be titillated by the swinging copy, but he will be guided, I trust, by the sober science.
A scheme such as this should also prove acceptable to the pharmaceutical industry. Its words might be less subject to what it must regard as inordinately rigorous and yet erratic censorship. If its claim on advertising page 40 is blunted by the comments on text page 20, its position is essentially that of all who contribute words to theJournal. Nothing is immune from criticism or refutation, and peculiarly vulnerable are statements made either in the Correspondence column or in the advertising section, where publication does not in any sense imply editorial endorsement.
In the long run, more fundamental and far greater changes are necessary. New and better relations must be established among medicine, the pharmaceutical industry and government. The advertising of drugs and medical journals is but one band in a wide spectrum of abutments between the doctor and the drug maker. At some points, the boundaries and interactions they permit are laudably clean. The support of medical education and research by the industry, often under conditions that impose no obligations on the grantee, is admirable. The promotion of drugs, in all its manifestations, is controversial and warrants broad examination. Quite objectionable, however, are the practices whereby the doctor accepts unwarranted largess from a maker of drugs.
Poly- And Party-Pharmacy
In his 1860 oration, Holmes denounced polypharmacy. I hope it is not inappropriate to speak out, in the over-all context of my topic of pharmaceutical-medical relations, against what may be called "party pharmacy." Those who prescribe drugs, the medical profession, possess on the whole exceptional knowledge and skill in caring for the ill. For this work, often extremely arduous, the profession receives exceptional remuneration (both financially and —despite all the criticism — in public esteem). Pharmaceutical firms provide the physician with the wherewithal — a sophisticated array of potent and effective agents. For this, they too receive exceptional rewards. Why should these two constituencies, both eminently able and successful, exist in anything but an equal partnership for health? Why, except for mutual respect, should one group be beholden to the other? Why, specifically, should one group be offered and accept favors that are unnecessary and that distort the balance between the medical profession and the pharmaceutical business? Why should receptions, dinners, cocktail parties and happy hours be provided, free of charge, to medical groups and require — for the moment at least — naught but a sickly smile of gratitude. —"Sickly," because within many and perhaps most of us the congeners in the gin, bourbon or scotch we drink on such occasions include certain essences of impropriety and embarrassment. The reasons for these feelings are quite obvious. For if our prescribing habits are influenced by gratitude, those habits no longer are characterized by science and integrity; if we are merely free-loaders accepting a hospitality not based on us as persons, but on us as hands that fashion prescriptions, we are no better than cynical opportunists.
I speak as a sinner, not as a saint. But a few weeks ago, in a European country, I wined and dined, attended the opera and danced at a festive ball — all through the generosity of unknown and unhuman corporations. But sinners, when they see the light, feel with greater violence than do saints. It becomes all too clear that the chemistry of such unnatural relations erodes the outlines of dignity. The medical profession should renounce once and for all the acceptance of social and totally impersonal favors from the pharmaceutical industry.
The Balm of Moderation
Whereas the relation between the drug industry and medicine is in some respects too close, excessive friendship between the industry and government is hardly a problem. To the contrary, the inimical confrontations that characterize exchanges between these two bodies benefit no one — and certainly neither the doctor nor his patient. In this hostile atmosphere, extremist accents are vociferous and loud. One such voice is that of Dr. James L. Goddard, who mounted an attack in Esquire that indiscriminately lumped together drug manufacturers, doctors and many medical publications. And right in the middle of Goddard's line-up of bad men, what name should appear but that of The New England Journal of Medicine. The loud voices on the other side are no more conciliatory. On behalf of the Pharmaceutical Manufacturers Association, C. J. Stetler has issued pronunciamentos often richer in brickbats than building blocks. I am not too concerned, however, by the Goddard blast, for the cover of the Esquire issue in which it appeared seems to show pictures of Howard Hughes and his wife enjoying a swim in their pool. "We see you." boasts the caption, but according to Time, all we really see is models, a hoax to which Time granted the dubious achievement award. Articles, like men, may be judged by the company they keep.
The problem of drug advertising would no longer be a problem if the major parties concerned, government, industry and profession, would be willing to compromise and to join in a common and united effort. Under such tripartisan sponsorship, one and just one authority with one set of standards would have the task — and the teeth — to ensure drug advertising that would be reasonable and unobjectionable but yet would permit the advertiser to boost his product. Such a sponsorship might also assume responsibility for an authoritative and acceptable drug compendium.
The concept of medicine, pharmaceutical industry and government working together in harmony is probably as unpractically utopian as some of the plans suggested for managing advertising in the Journal. Yet there is no reason why the profession, the drug firms and government should not work together in a unit structured for debate and ultimate parliamentary action. Some orderly system must replace the piecemeal decisions, the public hassles and legal maneuvers that now appear to characterize the making, selling and using of drugs.
That the groups involved will have conflicting points of view is inevitable, but their resolution, not their aggravation, will have to be the goal. Extremists identify problems. Sometimes they clearly precipitate them. But solutions must be sought and achieved by moderates.
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Ingelfinger, Franz J. "Swinging Copy and Sober Science." New England Journal of Medicine 281, no. 10 (1969): 526-32.
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