Between medical paternalism and servility

Even today there are patients who leave diagnosis and treatment entirely to their doctors.  They make no effort to inform themselves about their illness or chart their own course; they do whatever their doctors advise.  Once the norm, this passive, willfully naive attitude has withered in the face of a multigenerational attitude shift, coupled with the wealth of medical information at hand today.  Direct-to-consumer drug ads on television, online peer support, medical websites and blogs of all stripes, "Dr. Google," PubMed — it almost takes dedicated effort to avoid learning about one's medical issue.   The complementary role of doctors as kindly but authoritarian caretakers feels outdated by decades, and to many nowadays, offensive.  "Paternalistic" has become the epithet of choice for doctors who fail to recognize, respect, and make room for patient autonomy and medical self-determination. Most doctors practicing today, even those of us decades into our careers, began medical training at a time when patient empowerment had already gained ground in the U.S.  Many of us supported it wholeheartedly.  In college I studied medical ethics and patient autonomy.  I volunteered at a community clinic called "Our Health Center" that aimed to empower patients.  My stated goal when applying to medical school was to help patients take responsibility for their own health.  Even today I tend to over-explain my reasoning to my patients, and to err — and sometimes it is an error — on the side of offering a smorgasbord of options along with their risks and benefits.

However, over the years the goalposts have moved.  For a growing subset of patients it is no longer enough that we doctors talk to them as fellow adults.  The one-time goal of shared decision-making has, in some circles, given way to a deep skepticism toward doctors and our expertise.  Some regard us as irksome gatekeepers who add little to medical decision making and serve mainly as roadblocks to obtaining the medical tests or treatments they already know they need.   In this jaundiced view, our role is reduced to rubber-stamping: ordering desired tests, signing requested prescriptions, drafting work excuses, and so forth.  For example, I've received many calls from would-be patients seeking a prescription stimulant for self-diagnosed "adult ADHD." The callers sound dismayed when I point out that my diagnosis may not agree with theirs.  Similarly, patients seek me out to provide documentation and advocacy on behalf of a psychiatric disability they swear they have, but I haven't yet evaluated.  I find myself wishing that such callers could face the consequences of their own decisions without involving the unwanted, apparently superfluous impediment of a doctor.

These examples from my practice could be dismissed as drug-seeking or "gaming the system."  But skepticism toward physicians and our expertise goes much further.  Patients insist on antibiotics for viral (or non-existent) infections.  Parents refuse to vaccinate their kids.  Online forums abound with horror stories of patients misdiagnosed and mistreated, who finally escape this nightmare only by taking matters into their own hands.  "Ask your doctor" drug ads imply that doctors will fail to consider the advertised treatment if not for patient self-advocacy (and the generous assistance of a multimillion dollar marketing campaign).  California has a voter initiative this fall that, among other provisions, would mandate random drug testing of physicians for the first time in the U.S.

There is a movement afoot to share medical records with primary-care patients, ostensibly for doctor-patient collaboration, but often justified on the basis of "transparency."  It is now deemed paternalistic for doctors to keep private notes of our own work, even though this is accepted in other professional and consultative fields.  Institutions no longer trust us to do high-quality work without oversight by non-physicians who track quality and patient satisfaction measures.  Some patients now balk when doctors ask personal questions, e.g., about religious practices or hobbies, that are not obviously related to a manifest disease process.  Learning about our patients as people, their strengths as well as weaknesses, is apparently also paternalistic.  Shouldn't the patient decide what areas of information to divulge?

Reducing doctors to servile technicians renders us safely powerless.  Never mind that we can no longer diagnose or treat illness as well, for example by drawing unanticipated connections between habits and disease.  For many patients, and apparently for society at large, it is more important not to feel a power differential.

This is an odd sentiment indeed.  Anyone offering a skilled service, professional or not, wields a degree of power — and at least a little paternalism — over clients or customers. The computer professionals and attorneys who come to my office expect their own clients to defer to their expertise.  My mechanic knows more about cars than I do, my barber about hair, my grocer about what produce is in season.  Somehow we don't find it threatening to put our faith in these authorities, especially when they welcome dialog and involve us in the decisions and recommendations that affect us personally.

People sometimes wonder when they may question a doctor's diagnosis or advice.  I say always.  I've spent a career encouraging patients to be curious, to ask questions, to understand their suffering and what may help.  This is the legacy of patient empowerment: all of us taking responsibility for our own well-being, and medical professionals respecting the right of patients to make their own well-informed health care decisions.

However — and it is a big however — this is not the same as physicians rubber-stamping everything patients believe or want.  Shared decision-making lies between "doctor's orders" and "patient's choice" and follows the ethical standard of acting in the patient's best interest (illustration courtesy of Practice Matters):

Nor should fear of sounding paternalistic silence us when detractors claim that everyone's opinion is equally valid.  It is falsely modest and politically naive to deny our own expertise.  When it comes to medical matters, we doctors, while admittedly fallible, are nonetheless right far more often than we are wrong, and far more often than even intelligent, well-read non-physicians are.  Like the attorney, computer professional, mechanic, barber, and grocer, we know things most other people do not.  There is no shame in that, nor is it a power trip to point it out.  A paternalism that demeans others is bad; a servility that demeans ourselves may be worse.

Top image courtesy of Ambro at FreeDigitalPhotos.net

OpenNotes: Good intentions gone awry

OpenNotes is "a national initiative working to give patients access to the visit notes written by their doctors, nurses, or other clinicians."  According to their website, three million patients now have such access, generally online.  Participating institutions include the MD Anderson Cancer Center in Texas, Beth Israel Deaconess in Boston, Penn State Hershey Medical Group, Kaiser Permanente Northwest, and several others.  Patients with a premium account in the My HealtheVet program at the VA have access to outpatient primary care and specialty visit notes, discharge summaries, and emergency department visit notes.  The New York Times recently ran a mostly celebratory piece on OpenNotes as applied to mental health visits at BI Deaconess ("What the Therapist Thinks About You"), garnering over 350 public comments.  Significantly, many of these comments expressed annoyance with any mental health professional who cited potential drawbacks — despite the fact that BI Deaconess doctors who actively participate in OpenNotes concede that such openness may be detrimental for those with "psychiatric or behavioral issues" (e.g., see this promotional video, starting at 2:15). The notion of sharing clinical notes with patients enjoys populist appeal.  On a self-report survey with no control or comparison condition, patients reported that OpenNotes helped them remember what was discussed during visits, feel more in control of their care, and improved their medication adherence.  Advocates also say it improves communication with patients and can correct factual errors in the record.  However, the strongest argument seems to be that patients like it.  Defenders repeatedly invoke "transparency," implying that the status quo is intentionally obscure and aims to hide something from patients.  Some of the rhetoric has a defiant, even self-righteous tone: one promotional video (at 3:16) features a patient who pointedly declares that she'll never be refused this access again.  And there's no clear endpoint: about 60% of the patients surveyed in the OpenNotes study believed they should be able to add comments to a doctor's note, and about a third believed they should be able to approve the notes' contents; the overwhelming majority of participating physicians disagreed with the latter.  If OpenNotes is widely accepted, it will be increasingly difficult to draw clear lines regarding the authorship and authority of clinical notes.

Fifty-five percent of eligible primary care doctors declined to participate in the OpenNotes study cited above.  Of those who did participate:

Several doctors struggled with the notion of a one-size-fits-all note, arguing that one document cannot address the needs of billing, other doctors, and patients.  A few changed their own use of the note; for example, eliminating personal reminders about sensitive patient issues, excluding alternate diagnoses to consider for the next visit, restricting note content, or avoiding communication with colleagues through the note.... A substantial minority reported [changing documentation, in particular when addressing potentially sensitive issues], including their reported change in “candor.” For example, some doctors reported using “body mass index” in place of “obesity,” fearing that patients would find the latter pejorative.

§  §  §

"Progress note," not "visit note," is the traditional term for a physician's written entry into a patient's medical record, documenting an outpatient or inpatient encounter.  (OpenNotes advocates may find "progress note" too quaintly optimistic to be publicly acceptable.)  Physicians write other notes for other purposes, including admission notes, procedure notes, transfer notes, discharge notes, and so forth.  Additionally, many notes are written by nurses and a wide variety of other clinical personnel, particularly in inpatient settings.

The traditional format of a progress note documents (1) symptoms and (2) physical examination, including lab test results, obtained by the physician, (3) his or her differential diagnosis, and (4) the next steps, such as further exams, tests, or treatments, that follow therefrom.  Medical students are taught to write SOAP notes as an acronym for these four components.  Such notes assist in performing and archiving medical work, much as a scientist's laboratory notebook records the design, data, and results of experiments.  Progress notes were not designed to be a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts for patients.  Yet these notes now serve many masters, resulting in excessively time-consuming documentation that squeezes out face-time with patients, and is increasingly cumbersome as a clinical tool.   Some of the additional trade-offs in adding yet another stakeholder, the patient reviewer, are cited in the quotation above, and cannot be casually dismissed as balderdash by defenders of OpenNotes.

OpenNotes presumably works best in primary care, and with an electronic medical record that expands abbreviations (and/or provides templates), corrects spelling, and produces legible output that patients can access online.  In contrast, notes with technical jargon by specialists such as ophthalmologists, anesthesiologists, radiation oncologists, and many others would be incomprehensible unless radically altered to be more patient-friendly.  Less "connected" practices would similarly be left out.  But even in the best-case scenario, progress notes are a poor tool for doctor-patient collaboration.  By nature they are shorthand, telegraphing complex medical reasoning in a few words.  Old-fashioned discussion is paradoxically superior for assuring that doctors and patients are "on the same page." Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.

The real thrust of the OpenNotes initiative is less pragmatic.  Many patients want to feel more in control of their care.  In addition, doctors aren't trusted as profoundly as we used to be.  If given the chance, many patients will gladly join the ranks of those who look over our shoulder.  And of course, if the traditional use of progress notes is framed as paternalistic or elitist, reforming these notes into something "democratic" seems like the only sensible thing to do.  The enthusiastic fervor to empower patients in this misdirected way (further) dulls a useful documentation tool which is no more inherently elitist or paternalistic than the work notes of a car mechanic or the recipe notes of a chef.  Everyone feels good about this newfound "transparency."  And that, apparently, is what really counts.

These considerations apply doubly in the case of mental health notes.  My colleague who writes the Psych Practice blog wrote a response to the New York Times piece on sharing therapy notes.  I agree with her completely.  I'd only underscore that psychotherapy based on psychoanalytic and psychodynamic principles depends crucially on gauged disclosure and the timing of verbal interventions.  These treatments anticipate and rely on the reality that the perspectives of therapists and patients inevitably differ, and that this discrepancy is not a simple error or miscommunication, but instead is the engine that drives psychological change.  Arguing for transparency in such treatment is tantamount to wishing that these therapies disappear (some critics will readily acknowledge this).

The relationship between doctors and patients should always be collaborative, but it is never equal.  One party is ill and needs help, the other offers expertise and resources the other doesn't have.  "Giving everyone a say" sounds democratic, but medicine isn't practiced democratically.  Try asking a car mechanic or a chef at a fine restaurant (or your child's schoolteacher, or an architect, or a police officer...) if you can share in their work-flow and decision making.  Most will initially appreciate your interest and offer you an overview.  A kind one may let you look under the hood.  However, very soon you will be told that you are in the way — that you can watch intently or enjoy a good result, but not both.  There is nothing paternalistic about this, it's how skilled workers do their jobs.  When reminded that this applies to physicians as well, and once the thrill of the "forbidden" behind-the-scenes look wanes, we will see that the remaining advantages of OpenNotes are better served by other means.

Military brain-chips to cure psychiatric disorders?

Sounding like something straight out of science fiction, DARPA recently announced grants to fund research and development of implantable brain-stimulation chips aimed to relieve, or even cure, mental disorders.  The Defense Advanced Research Projects Agency thinks big, and it has the money, i.e., our tax dollars, to back it up.  Decades ago, DARPA brought us the internet.  In comparison, revolutionizing psychiatry ought to be a walk in the park — right? Find a need and fill it: "Current approaches — surgery, medications, and psychotherapy — can often help to alleviate the worst effects of illnesses such as major depression and post-traumatic stress, but they are imprecise and not universally effective."  You can say that again.  So DARPA created a program called SUBNETS (Systems-Based Neurotechnology for Emerging Therapies) "to generate the knowledge and technology required to deliver relief to patients with otherwise intractable neuropsychological illness."   SUBNETS aims to create an "implanted, closed-loop diagnostic and therapeutic system for treating, and possibly even curing, neuropsychological illness."  In other words, computer chips in the brain.

SUBNETS will pursue the capability to record and model how these systems function in both normal and abnormal conditions, among volunteers seeking treatment for unrelated neurologic disorders and impaired clinical research participants. SUBNETS will then use these models to determine safe and effective therapeutic stimulation methodologies. These models will be adapted onto next-generation, closed-loop neural stimulators that exceed currently developed capacities for simultaneous stimulation and recording, with the goal of providing investigators and clinicians an unprecedented ability to record, analyze, and stimulate multiple brain regions for therapeutic purposes.

SUBNETS is hedging its bets.  With an overall budget of $70 million, it is funding both a diagnosis-based arm, in the manner of the DSM5 of the American Psychiatric Association (APA), as well as a “trans-diagnostic” approach, in the manner of the Research Domain Criteria (RDoC) of the National Institute for Mental Health (NIMH).   The ideological rift between the APA and NIMH last year was awkward and impolitic; fortunately,  SUBNETS has the resources to avoid choosing sides.  A research team at the University of California San Francisco (UCSF) will receive up to $26 million to study diagnostic groups, specifically post-traumatic stress, major depression, borderline personality, general anxiety, traumatic brain injury, substance abuse and addiction, and fibromyalgia/chronic pain.  Another team at Massachusetts General Hospital (MGH) will receive up to $30 million to tackle trans-diagnostic traits, such as increased anxiety, impaired recall, or inappropriate reactions to stimuli.  Both groups will include public and private partnerships, including with device manufacturers Medtronic, Draper Laboratory, and the start-up Cortera Neurotechnologies.

What to make of this?  Well, it's certainly ambitious.  As I read it, the effort relies on several unproven premises.  First, that psychiatric diagnoses, as currently construed, can be differentiated by monitoring activity in specific brain pathways.  This has been tried before without success, and it isn't clear that sensor technology was the reason.  An alternative model would suggest that mental states are an emergent property of widely integrated brain states.  If so, chips implanted in specific areas could no more capture this complexity than carefully listening to the trombone section could capture a symphony.

Another assumption is that carefully focused electrical stimulation can treat a variety of mental disorders.  The efficacy of transcranial magnetic stimulation (TMS) to treat depression provides some support for this idea.  In contrast, typical comparisons to deep brain stimulation to treat seizures and severe obsessive-compulsive symptoms only go so far.  Analogous stimulators may quell a panic state or chronic pain.  It is less clear how complex interpersonal patterns, such as those seen in borderline personality or substance abuse, could respond to this type of intervention.  Of course, we shall see.

A central tenet of SUBNETS is that implanted technology can promote healthy (or curative) neural plasticity.  Plasticity is a popular concept at the moment, highlighting the fact that brain wiring is not static, as was previously assumed.  "Neurons that fire together wire together" — that is, synaptic connections change dynamically in response to input, i.e., life experience.  This property underlies the hope that implanted stimulators may change the activity of neural pathways in a permanent way, "firing" the pathway together to make it "wire" together, and allowing the device eventually to be removed.  Again, we shall see.

Of course, there are many stumbling blocks ahead.  Implanting brain chips is no small matter, and this approach is unlikely to be used in the foreseeable future for anything short of the most severe, treatment-resistant disorders.  Initial public commentary immediately honed in on the "military mind control" aspect of the project, with visions of soldier drones being controlled on the battlefield via implanted chips.  The potential abuse of such technology is manifest and terrifying, and careful controls and standards are needed to assure freedom, not to mention safety.

At the most mundane level, the technology will only work if the science behind it is sound, and that remains to be seen.  Nonetheless, if even a portion of the SUBNETS agenda comes to pass, it would represent a monumental leap for psychiatric treatment.

Loss of privacy and the new psychic numbing

I grew up in the era of the nuclear arms standoff.  Thousands of warheads on land, at sea, and in planes stood ready to obliterate most of the human race if the Soviets, Americans, or a rogue third nation launched a nuclear "first strike."  Authors of that era wrote of the psychological effects of living under such a threat (not that it is gone now, but it certainly felt different back then).  Some said it rendered life fundamentally meaningless.  Why indulge personal hopes or dreams when we, our community, our entire culture could be gone in an instant?  Psychiatrist Robert Jay Lifton coined the term "psychic numbing" for the denial we employed, individually and collectively, to allow us to live our lives while faced with the real and ever-present risk that our world might end that very day. Psychic numbing was curious yet undeniable.  We all knew the danger was real.  But because the unimaginable horror of World War Three was coupled with an apparent inability to do anything about it, we told ourselves the likelihood was low and somehow pushed it aside.  Instead of being the top priority it arguably should have been, nuclear annihilation lurked like an ominous cloud at the periphery of consciousness.  We and our comedians made nervous jokes about it.  A few idealists joined peace and disarmament groups.  Meanwhile, the rest of us watched warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The dynamic of psychic numbing is repeating itself today.  This time it is not the existential risk of nuclear war, but the reality of losing our privacy.  Revelations that our own government monitors our private telephone conversations and tracks our vehicles, allegations that a few years ago would have been waved off as paranoid rantings, are now headline news.  We now know that our email is scrutinized for keywords (and possibly collected and stored in its entirety), and our cellphones are used to track our locations.  Like the nuclear threat of the 1970s, it feels as if we can't do anything about it.  Our discomfort lurks like an ominous cloud at the periphery of consciousness.  We and our comedians make nervous jokes about the NSA.  A few idealists join activist groups to oppose the scrutiny of innocent citizens.  Meanwhile, the rest of us watch warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The theft of privacy has been opportunistic and widespread.  The 9/11 terrorist attack justified not only "security theater" at airports, but also a trading away of everyday privacy in the name of national security.  Video cameras monitor public areas in major cities; license plates of highway traffic are scanned en masse and recorded by local and state police; the FBI can activate your laptop's webcam remotely and secretly (with a court order).  Meanwhile, quite apart from national security or law enforcement considerations, internet privacy has become an oxymoron.  The social web, an aspect of Web 2.0, promoted living one's life in full view of "friends" and others.  Facebook and Twitter distribute micro-doses of fame to monetize the formerly private lives of their users.  Younger people post photos of themselves in compromising situations while failing to appreciate the permanence of these images.  Older people use online health and mental health support sites, not realizing their "private" conversations are archived and publicly searchable.  A great many advertisers and others track web activity for commercial purposes, amassing huge databases without users' knowledge or consent.  Whether on actual highways or the quaintly-named information superhighway, the distinction between public and private is quickly eroding away.

Is privacy passé, a luxury we can no longer afford?  Psychic numbing tells us to shrug and bear the new reality.  As many thought 30 or 40 years ago about the nuclear arms race, loss of privacy appears to be the price of living in our modern world.

Don't believe it.  The forces that now seek to strip us of individuality and dignity have always been here.  New technologies present novel challenges, but human nature hasn't changed.  It took decades to realize we weren't forced to live with Mutual Assured Destruction hanging over our heads.  When we overcome our psychic numbing this time, we will re-discover that nervous humor, wary sidelong glances, and helpless fatalism are not effective ways to deal with a real problem.  We will re-discover the value and honor in self-respect.

Online commentary: marketplace of ideas or shouting match?

A central disruptive technology of our online world is the breaking down of unidirectional communication.  In years past, newspapers and other media published articles without immediate feedback from readers.  True, a few readers might telephone the editor's desk, and the paper might print a select handful of "letters to the editor" in the next issue.  But by and large: "Freedom of the press is guaranteed only to those who own one" (A.J. Liebling, The New Yorker, May 14, 1960).  The average person didn't own a printing press. Now, thanks to blogs, online forums, e-books and the like, anyone can publish.  There is freedom of the press for the masses, but not necessarily an audience.  The ubiquitous comments section in online media thus has a special place in the publishing ecosystem.  Eyeballs are attracted to the professional publication, meanwhile public commentary hangs on its coattails, gaining readership it would not otherwise enjoy.

My local newspaper, the San Francisco Chronicle, has a free online version.  The prolific public commentary is loosely moderated: some comments are deleted for personal attacks, obscenity, and the like.  Nonetheless, an air of bravado, vigilantism, and snap judgment weaves through page after page of commentary.  For example, an unfolding story about a fatal knifing following a baseball game attracts scores of comments with each new revelation.  Readers decide the young men are "thugs," argue over who likely started the fight, declare sports fans crazy and San Francisco as way too soft on crime.  Some proclaim with certainty that self-defense justifies wielding a knife, others just as adamantly that it never does.  There are 145 such comments today, adding to those from yesterday.

Does freedom to express an offhand opinion, and the privilege of having it seen by thousands of others, contribute to public discourse?  On the one hand, a freewheeling marketplace of ideas arguably allows the best to prevail.  Unfettered competition among different ideas, like competing products in a marketplace (or competing species in biological evolution) leads to survival of the fittest.  Neighbors discussing issues of mutual concern over the proverbial backyard fence — isn't this a cornerstone of democracy?

Popular Science takes a different view.  The 141 year old publication this week announced it is ending online comments on its articles.  They say a barrage of commentary that rejects well-established science, e.g., evolution and global climate change, creates controversy where none legitimately exists.  They claim this serves neither science nor the society that depends on it.  The announcement cites a Mother Jones piece that profiles and interviews a climate-change denying "troll"; notably, the 370 comments following that article run the gamut from thoughtful points about climate change to a heated debate about "mens' rights activists" and "femi-nazis" that has nothing to do with the original post.

Meanwhile, back at the San Francisco Chronicle website, a column appeared last week about a young man with apparent psychiatric issues who "is proof that something isn't working with the mental health care system."  He was picked up five times in recent months for bizarre, minor crimes — punching cars, climbing street signs, stripping naked in public, etc.  Each time he was detained on a 72-hour psychiatric hold, after which he was released.  Most recently he was atop a 40 foot ledge for nine hours, screaming and threatening passersby and police, all of which tied up dozens of first-responders, snarled traffic, and cost the city a lot of money.  As a result he is now in the County Jail medical ward, booked on an array of felony and misdemeanor charges.

The 97 comments that follow this column largely decry this man's repeated, rapid release from psychiatric custody.  Here are a few excerpts:

• We need to get the laws in this country changed to make it possible to put people like this in longer-term hospitalization. • Seriously what about some sanity, if your getting picked up repeatedly by the cops you need to be on long term hold. • So basically some lucky person has to be injured or killed by this guy before anything will be done. • Bring back psych hospitals. The pendulum has swung too far to an extreme in allowing the mentally ill to put themselves, and society, at risk on the streets. The social experiment has failed.

A few ideas quickly occurred to me.  We don't apply psychiatric holds based on how much "trouble" people stir up.  He's apparently not holdable — if he were, he would have been held.  Maybe he clears quickly, as would be the case with a medical cause of bizarre behavior, or drug intoxication.  He's detained on criminal charges now, so he won't be released in 72 hours this time unless he posts bail.  But the main thing that occurred to me is how this commentary so glaringly contrasts with that on the psychiatry blogs I read.  In these latter, narrow-focus forums, the predominant tone of the commentary is anti-psychiatric.  No one argues for longer-term hospitalization or says the pendulum has swung too far in favor of patients' rights.

Obviously, this is a matter of readership.  For better or worse, Chronicle readers feel safer with psychiatrists than they do with the man in the news story, and they aren't terribly sensitive about protecting the latter's liberty.  Anti-psychiatrists, in contrast, are a small but vocal minority who disproportionately flock to psychiatry blogs, just as those who reject science flock to the comment boards at Popular Science.  Some of the blogs at Psychology Today also attract devoted critics, some of whom hotly object to the tone with which a sensitive topic has been discussed.  (My blog is apparently not controversial enough to attract such vitriol.)  Should psychiatrist bloggers and those at Psychology Today follow the lead of Popular Science?  Should we disallow commentary, claiming that it creates controversy where none legitimately exists, and that this false controversy serves neither our professional work nor the society that depends on it?

In my view, the answer is captured by a variation of the Yerkes-Dodson law.  That is, too little agreement is just as bad as too much.  An echo chamber of unanimity brings conversation to a halt, as does a cage fight where everything offered is criticized in a hostile way.  Discourse proceeds best when all parties and views are treated with respect, and when a substantial shared basis for discussion exists.  In my opinion, commentary should be permitted on online forums.  However, comments that reject the basic tenets of the discussion — the legitimacy of science in a science forum, mental health treatment in a psychiatry or psychology forum — should be disallowed.  Speakers have a right to express such views, of course, just not by usurping the forums and readership of their opponents.  Likewise, off-topic comments, whether commercial spam, political diatribes, or pet peeves, do not add to thoughtful discourse.  Nor does overt contempt or name-calling.  This means comment moderation is needed, which adds effort and expense to operating an online media outlet.  But the situation as it is now does not serve public discourse very well.  Freedom of speech is not the freedom to grab the microphone from the speaker's hand and use it to shout to a crowd who came to hear someone else.