Democratising the scientific method
Authors: Shivaram Prasad Singh, Prajna Anirvan
Journal: Journal of Hepatology (2024)

Democracy in ScienceJournal of HepatologyVol. 80Issue 5PreviewIt is not standard practice for the Editor-in-Chief to reply to a Letter to the Editor with a dedicated Editorial, but such a response is warranted in the case of the letter from Lonardo A. et al.,1 given its nature and the relevance of its content, which call into question the editorial strategy of the Journal of Hepatology regarding the new nomenclature of "metabolic fatty liver syndromes" endorsed by ALEH, AASLD and EASL after a long and difficult consensus process.2 Full-Text PDF Reply to: "Democratising the scientific method"Journal of HepatologyPreviewDon't let a letter divide us Full-Text PDF "I disapprove of what you say, but I will defend to the death your right to say it."- Evelyn Beatrice Hall ("The Friends of Voltaire") To the Editor: We read with much interest the editorial so wonderfully penned by Prof. Paolo Angeli concerning the raging debate surrounding the change of nomenclature of non-alcoholic fatty liver disease (NAFLD).1Angeli P. Democracy in science.J Hepatol. 2024 Feb 14; (S0168-8278(24)00055-2)https://doi.org/10.1016/j.jhep.2024.01.013Abstract Full Text Full Text PDF Scopus (0) Google Scholar While we are effusive in our praise for its high intellectual standard, we would like to highlight our points of concern too. Nothing epitomises the guiding principles of democratic process more than this oft-quoted and eulogised statement by Evelyn Hall that upholds the Voltairean principles of freedom of thought. And it is indeed on the edifice of opposing and diametrically contradictory streams of thought that the monumental achievements of modern civilisation – encompassing progresses made in the natural sciences, technology and humanities – have been accomplished. And therefore, reducing our understanding of democracy to a mere 'voting' process would rob democracy of its very essence, its 'soul', and make it a mere consensus-building forum of the polity. And this seems to be the case today across nations over the world where democracy has been reduced to the mere opinion of the majority, which is but a blatant denial of the unity of opposing ideas, thoughts and forces that has shaped the ideals of democracy. The idea of 'unio oppositorum' is one of the cornerstones of modern dialectical philosophy,2McGill V.J. Parry W.T. The unity of opposites: a dialectical principle.Sci Soc. 1948; 12: 418-444Google Scholar thus denying this fundamental fact would be a total misinterpretation of the principles of science upon which democratic processes have been built. As regards consensus, the history of medical science is replete with instances where consensus has been used to erase the contribution of individuals from the collective memory of society! Servetus, the discoverer of the pulmonary circulation, was literally baked alive from the feet upward and suffered the heat of the flames for 30 min before finally succumbing to one of the most painful and brutal methods of execution conceived. Ignaz Semmelweis who advocated for handwashing as a way to prevent the spread of infections in hospitals was condemned to the asylum by consensus simply because physicians were insulted that he had dared to question and criticize their professional practices, working habits and standards of hygiene. Thomas Kuhn famously suggested that consensus among scientific communities operates within certain "paradigms" – established sets of theories and underlying assumptions that guide research in a particular field.3Matthews M.R. Thomas Kuhn and Science education.Sci Educ. 2022 Dec 13; ([cited 2024 Apr 2]; Available from:)https://doi.org/10.1007/s11191-022-00408-1Crossref Scopus (5) Google Scholar According to Kuhn, these paradigms remain dominant until accumulating "significant" anomalies lead to a period of crisis. A crisis leads scientists to seek new theories, eventually resulting in a paradigm shift where a new paradigm replaces the old one. This process represents a series of shifts rather than a straightforward march towards truth. To Professor Angeli's question as to what could compromise the clear and simple communication to society more than the use of different nomenclature for the same disease, we have a straightforward answer: nothing, but in the same breath, we feel constrained to say that we ourselves are to blame for confusing the poor patient with semantic whataboutery while failing to offer an effective therapy! It is good that a consensus has been reached by different liver societies with regard to the change of terminology of NAFLD after a rigorous process. But, this in no way means that the old terminology should be condemned to the purgatory of hepatology! Did we reach a point of crisis with NAFLD? Prof. Angeli does agree that the new nomenclature is not perfect and has potential biases and that there is enough scope for debate and discussion. If that is so, it is self-contradictory to provide 'clear guidance' to authors to shun the term 'NAFLD'! Moreover, the very reasons that led to the entire name change exercise have been nullified by the findings that the change of nomenclature is going to have no bearing whatsoever on the natural history, pathophysiological characteristics, and management of the entity.4Hagström H. Vessby J. Ekstedt M. et al.99% of patients with NAFLD meet MASLD criteria and natural history is therefore identical.J Hepatol. 2024 Feb; 80: e76-e77https://doi.org/10.1016/j.jhep.2023.08.026Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Perazzo H Pacheco AG Griep RH et al.Changing from NAFLD through MAFLD to MASLD: similar prevalence and risk factors in a large Brazilian cohort.J Hepatol. 2024; 80: e72-e74https://doi.org/10.1016/j.jhep.2023.08.025Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 6Chen L. Tao X. Zeng M. et al.Clinical and histological features under different nomenclatures of fatty liver disease: NAFLD, MAFLD, MASLD and MetALD.J Hepatol. 2024; 80: e64-e66https://doi.org/10.1016/j.jhep.2023.08.021.80Crossref PubMed Scopus (0) Google Scholar, 7Song SJ Lai JC Wong GL et al.Can we use old NAFLD data under the new MASLD definition?.J Hepatol. 2024; 80: e54-e56https://doi.org/10.1016/j.jhep.2023.07.021Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 8Ratziu V. Boursier J. AFEF Group for the Study of Liver FibrosisConfirmatory biomarker diagnostic studies are not needed when transitioning from NAFLD to MASLD.J Hepatol. 2024; 80: e51-e52https://doi.org/10.1016/j.jhep.2023.07.017Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar And is it a consensus? We are afraid it may not be so: the "supermajority (67%) vote" is in no way a consensus.9Rinella M.E. Lazarus J.V. Ratziu V. et al.A multi-society Delphi consensus statement on new fatty liver disease nomenclature.Hepatology. 2023 Dec 1; 78 (Epub 2023 Jun 24): 1966-1986https://doi.org/10.1097/HEP.0000000000000520Crossref PubMed Scopus (314) Google Scholar Moreover, the other opposing group has been continuously and relentlessly using the term 'metabolic dysfunction-associated fatty liver disease (MAFLD)' and has developed a consortium to further research in this regard.10George J. Lau G. Kawaguchi T. et al.Furthering research on MAFLD: the APASL Metabolic fAtty lIver DiseasE coNsortium (MAIDEN).Hepatol Int. 2023; 17: 546-549Crossref PubMed Scopus (2) Google Scholar Needless to say, there has been an overlap of hepatologists from both camps who have swung pendulously between camps! If indeed we are to move forward along a common path, we should allow 'a hundred flowers to bloom and a hundred schools of thought to contend.' Guidance – simple or complex – forcing authors and readers to adhere to one particular terminology is certainly not the way forward. The authors did not receive any financial support to produce this manuscript. The authors of this study declare that they do not have any conflict of interest. Please refer to the accompanying ICMJE disclosure forms for further details. Both authors contributed equally to the writing of the manuscript. The following are the supplementary data to this article: Download .pdf (.34 MB) Help with pdf files Multimedia component 1