Letter to the Editor. Restraint is not the better part of valor

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  • Barrow Neurological Institute, St. Joseph’s Hospital, Phoenix, AZ
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TO THE EDITOR: The helpful work of Linzey et al.1 serves as a starting point for many of us in the neurosurgical community venturing into the social media world (Linzey JR, Graffeo CS, Wang JZ, et al. Neurosurgery and the rise of academic social media: what neurosurgeons should know. J Neurosurg. 2018;129[4]:1093–1097). In the section A Cautionary Word, the authors describe pitfalls to avoid for the prudent neurosurgeon engaging in social media, one of which is posting politically or socially divisive content. Although generally good advice, the framing of this warning is suspect. What could be interpreted as politically or socially divisive content may also be seen as the civic engagement on which our society’s institutions depend.

Echo chambers are not theoretical. They affect the communities that we and our patients live in. Disease outbreaks related to vaccine avoidance promoted by online misinformation campaigns have demonstrable public health costs.2 Misinformation arises when the voices of scientists and the medical community are diminished or self-censored in the interest of appearing “neutral” or rooted in a preference for avoiding contentious discussion. The effects of misinformation in online and broadcast media have been clearly documented in the current coronavirus pandemic,3 a public health crisis of which the neurosurgical community is now very aware.

There is no reversing the trend of our civic lives moving increasingly online, and so too should the diverse ideas of the neurosurgical community. Many of us can offer salient and thoughtful perspectives on topics not directly related to neurosurgery. Ensuring that our public discourse is tethered to reality is a responsibility we all share. If a surgeon is willing to field the consequences, there need not be self-censorship on topics that may be difficult, yet important, to discuss.

Two American congressmen, Dr. Ami Bera and Gerald E. Connolly, wrote a letter in 2018 regarding a decision to disband the Global Health Security Agenda (GHSA) within the National Security Council (NSC).4 They note:

At this crucial juncture, forcing out some of our nation’s most respected leaders on global health security and scaling back our investment in countering pandemic threats sends a dangerous message to our GHSA partner countries that the U.S. no longer considers global health security a priority. Given the fragmented organization of global health security responsibilities throughout the federal government, having a designated official at the White House coordinating the response is critical to an effective operation…. Saving lives from the next global pandemic starts with investing in preparedness before it strikes.

The prescience of this statement is striking. While we can only guess at alternative outcomes of a global pandemic, it would be hard to imagine a scenario where less engagement of physicians and surgeons in the civic arena, online or otherwise, would have led to a better outcome.

Dr. Sanjay Gupta’s documentary One Nation Under Stress is an impactful example of what can be accomplished when neurosurgeons choose to engage and participate in media beyond the narrow scope of professional neurosurgical practice. Dr. Gupta addresses very politically and socially divisive topics, including ones that affect our mutual home state of Michigan, as he pries into the root causes of the falling American life expectancy, now shorter than all other major developed countries.

The neurosurgeon should contemplate the consequences of wading into controversial topics and should not be compelled to. Still, it is not a pitfall to participate in civic discourse. The idea that “restraint is the better part of valor” was originally used in jest by the vain, boastful, and cowardly knight Falstaff in Shakespeare’s Henry IV, Part 1 (Fig. 1). His declaration stemmed from self-preservation and was primarily a justification for inaction. And while Falstaff was a likeable character, Shakespeare did not intend for him to be an example. Remaining inert can at times be considered a virtue, but as Voltaire observed in the 18th century, “what most persons consider as virtue, after the age of 40 is simply a loss of energy.”

FIG. 1.
FIG. 1.

A picture of the knight Falstaff, with his page. “Falstaff und sein Page,” 1841, by Adolf Schrödter. Public domain. Downloaded from Wikipedia (https://en.wikipedia.org/wiki/Falstaff#/media/File:Adolf_Schr%C3%B6dter_Falstaff_und_sein_Page.jpg). Figure is available in color online only.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Linzey JR, Graffeo CS, Wang JZ, et al. Neurosurgery and the rise of academic social media: what neurosurgeons should know. J Neurosurg. 2018;129(4):10931097.

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  • 2

    Johnson NF, Velásquez N, Restrepo NJ, et al. The online competition between pro- and anti-vaccination views. Nature. 2020;582(7811):230233.

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  • 3

    Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18:89.

  • 4

    Connolly GE, Bera A. Letter to John Bolton, Assistant to the President for National Security Affairs. May 15, 2018. Accessed July 9, 2020. https://connolly.house.gov/uploadedfiles/connolly_bera_letter_to_nsa_john_bolton_on_global_health_security.pdf

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  • 1 Mayo Clinic, Rochester, MN
  • | 2 University of Michigan, Ann Arbor, MI
  • | 3 Massachusetts General Hospital, Boston, MA

Response

A witty quote proves nothing.

— Voltaire

If we shadows have offended,

Think but this, and all is mended,

That you have but slumbered here

While these visions did appear.

— William Shakespeare, A Midsummer Night’s Dream

We were honored to learn that our recently published primer on social media for the practicing neurosurgeon has sparked debate among our most respected colleagues, and we are grateful to Dr. Cole and Dr. Spetzler for their thoughtful interpretation of the article. Indeed, we concur with their core message. As leaders in an ever-changing medical and civil landscape that extends not just online but far beyond the reaches of clinical practice, neurosurgeons should not excessively self-censor—even in public discussions of weighty topics that are beyond the scope of our professional expertise. Notwithstanding, we would also emphasize that our recommendation was neither “self-preservation” nor “inaction” but rather prudence and sound judgment, and that our cautionary tone was shaped to be mindful of an intended readership that is potentially unfamiliar with the inherent vulnerabilities of social media.

Expressed in the more playful, erudite, literary mood preferred by the authors, while we appreciate the good-natured equivocation between our attitudes and those of the baffoonish Falstaff, we would suggest that our recommendations more closely approximate those of Friedrich Nietzsche’s Zarathustra, who spake, “I love the valiant; but it is not enough to wield a broadsword, one must also know against whom. And often there is more valor when one refrains and passes by, in order to save oneself for the worthier enemy.”1,2

Candidly, no neurosurgeon should ever fear speaking up when confronted with unambiguous wrongdoing; and yet, in reality, many more conflicts inhabit gray spaces than ones that are black or white. If our primary calling is indeed to the service of neurosurgical patients, and if “The needs of the patient come first,” to borrow from Dr. William Mayo, then we are obligated to consider the potential for adverse outcomes that may be associated with alienating patients, family members, colleagues, or other members of the healthcare team.3 This possibility is particularly emphasized, given the relatively degenerate nature of most online discourse surrounding politically contentious issues in the contemporary moment. Although in spirit, we of course agree that “Many of us can offer salient and thoughtful perspectives on topics not directly related to neurosurgery,” we also note that even the most reasonable voice breaking through the echo chamber is unlikely to disabuse the trolls of their ignorance. In such circumstances, the most resonant advice for the level-headed neurosurgeon comes from George Bernard Shaw: “Never wrestle with pigs. You both get dirty and the pig likes it.”

These nuances notwithstanding, we are ultimately reassured by the fundamental compatibility of our views with those expressed by Dr. Cole and Dr. Spetzler. Taken together, they provide a valuable set of core principles for public life as a neurosurgeon, online or elsewhere, guided by the archetypal traits of our specialty: clarity and independence in our thoughts, steadfastness in our morals, and poise in our judgments.

References

Artist’s rendering showing the trajectories for the ipsilateral supracerebellar infratentorial (iSCIT), contralateral supracerebellar infratentorial (cSCIT), ipsilateral occipital transtentorial (iOCTT), and contralateral occipital transtentorial/falcine (cOCTF) approaches to the pulvinar. Also shown is a cadaveric view of the pulvinar via the cSCIT approach (inset). Artist: K. Larson. Used with permission from Barrow Neurological Institute, Phoenix, Arizona. See the article by Sun et al. (pp. 1172–1181).

Contributor Notes

Correspondence Tyler S. Cole: tyler.cole@barrowbrainandspine.com.

INCLUDE WHEN CITING Published online July 31, 2020; DOI: 10.3171/2020.5.JNS201819.

Disclosures The authors report no conflict of interest.

  • 1

    Linzey JR, Graffeo CS, Wang JZ, et al. Neurosurgery and the rise of academic social media: what neurosurgeons should know. J Neurosurg. 2018;129(4):10931097.

    • Search Google Scholar
    • Export Citation
  • 2

    Johnson NF, Velásquez N, Restrepo NJ, et al. The online competition between pro- and anti-vaccination views. Nature. 2020;582(7811):230233.

    • Search Google Scholar
    • Export Citation
  • 3

    Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18:89.

  • 4

    Connolly GE, Bera A. Letter to John Bolton, Assistant to the President for National Security Affairs. May 15, 2018. Accessed July 9, 2020. https://connolly.house.gov/uploadedfiles/connolly_bera_letter_to_nsa_john_bolton_on_global_health_security.pdf

    • Search Google Scholar
    • Export Citation
  • 1

    Idrobo C. He who is leaving…. Nietzsche-Studien. 2012;41(1):78103.

  • 2

    Nietzsche F, Kaufmann W. The Portable Nietzsche. Penguin Publishing Group; 1977.

  • 3

    Clapesattle H. The Doctors Mayo. Mayo Clinic; 1941.

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