Doctor Munchausen and Sense About Science

Editorial Note: This is the fifth in a series of Doctor Munchausen posts that include:

• Dr Munchausen, I presume
• Dying for a Cure
• Dear Luise
• Father Munchausen

They followed a Sense about Science series of posts that included:

• Sense about Science: Follow the Rhetoric
• Sense about Science: First Admit no Harm
• Sense about Science: Follow the Lawsuit
• Sense about Science: Follow the Patient

The AllData campaign

The Sense about Science posts centered on how a campaign which many thought was about trying to get access to clinical trial data – AllData – appears to have been co-opted by Sense about Science, an operation more closely linked to efforts to hide the adverse effects of treatment than to reveal them.

For many colleagues taking issue with AllTrials in the Sense about Science posts appeared an unhelpful thing to do, just as taking issue with doctors might also seem unhelpful – what about all the good doctors you are impugning. There is not the same concern for priests on whom it’s open season, and even making movies like Calvary about killing them is seen as acceptable and perhaps even therapeutic.

Most of the AllTrials coalition see themselves as good and unimpeachable just as most doctors and most priests see themselves – and indeed as they are. Some of the AllTrialers might wonder about Sense about Science but their general sense is that their own “goodness” and purity of motivation will overcome any problems there may be with Sense about Science.

They have no sense that the dram of eale always wins out:

“Their virtues else be they as pure as grace, as infinite as man may undergo, shall in the general censure take corruption from the particular fault”.

The idea of linking AllTrials to abuse will seem ridiculous to some, horrific to others. The link lies in the difference between AllTrials and AllData.

Crash

In 1974, J G Ballard’s novel Crash was published. This wreckage of automobiles, broken bodies and lurid sex became a success de scandale. Ridiculous to some, horrifying to others. There had been nothing quite like this twisted tangle of sex and car crashes before. All many could see was pornography.

Around the time he began killing but long before anyone had heard of Harold Shipman, Ballard anticipated the original Doctor Munchausen – medicine was the place which gave a serial killer the greatest opportunity he said. (For anyone who has bothered to flick through the contents of this blog there is also a further surprise – Crusoe makes a fleeting appearance).

Twenty years later Ballard spelled out just exactly what Crash was all about.

The key to crash

The balance between fiction and reality has changed in the past decades. Their roles are reversed. We live in a world ruled by fictions of every kind – mass-merchandizing, advertising, politics conducted as a brand of advertising, the pre-empting of any original response to experience by the television screen. We live inside an enormous novel. It is now less and less necessary for the writer to invent fictional content. The fiction is already there. The writer’s task is to invent reality.

In the past we have always assumed that the external world represented reality, however confusing or uncertain, and that the inner world of our minds, its dreams, hopes, ambitions, represented the realm of fantasy and the imagination. These roles have been reversed. The most prudent and effective way of dealing with the world around us is to assume that it is a complete fiction – conversely, the one small node of reality left to us is inside our heads.

The outside world is now the dream. If we are to understand what is going on, we now need to apply Freud’s classic distinctions between the latent and the manifest content of dreams to the external world of so-called reality.

Given these transformations, can the writer any longer make use of the techniques and perspectives of the traditional nineteenth century novel, with its linear narrative, its measured chronology, its consular characters grandly inhabiting their domains within an ample time and space? Is the subject matter, the sources of character and personality sunk deep in the past, the unhurried inspection of roots, the examination of the most subtle nuances of social behavior and personal relationships? Has the writer still got the moral authority to invent a self-sufficient and self-enclosed world, to preside over his characters like an examiner, knowing all the questions in advance? Can he leave out anything he prefers not to understand, including his own motives, prejudices and psychopathology?

The writer’s role, authority and license to act have changed radically. He knows nothing any longer. He has no moral stance. He can offer the reader the contents of his own head, a set of options and imaginative alternatives. His role is that of the scientist on safari or in the laboratory faced with an unknown terrain or substance. All he can do is devise various hypotheses and test them against the facts.

Crash into medicine

In June this year the BMJ published an article supposedly about how the Black Box Warning that antidepressants cause suicide had led to a drop in the use of the same antidepressants and an increase in suicides. The message was widely trumpeted in daily newspapers and other news outlets as well as the press office of Harvard University and the American Foundation for Suicide Prevention.

In fact there had been no drop in the use of antidepressants and no increase in suicide rates or suicide act rates. The letters sent to the BMJ in response to the article wondering how such a shoddy piece of work could possibly have been published are worth reading – rarely is academic contempt so scathing.

The only serious question is how something like this could have slipped through the BMJ review process. Perhaps it was because at the time the editorial staff of the BMJ were consumed with the issue of branding – should they switch from being the BMJ to being the The BMJ. A rather good symbol of the kind of transformation from substance to perception that Ballard notes has happened all over the modern world.

In this newly branded world pointing out the fatal flaws in an article make no difference. This is a world in which calls to retract Study 329, a trial of paroxetine in children, which lies at the heart of a Fraud action and a $3 Billion fine against GSK fall on deaf ears. A world without shame. It’s not even clear that a jail term for a Professor found guilty of inventing patients that didn’t exist would spell the end of an academic career.

This world makes no sense anymore. Evidence Based Medicine has become a Study 329 world writ large – where claims made for the efficacy of a treatment and its safety cannot be trusted. This is a world where the citizens of Hamelin can be co-opted to support campaigns to have AllTrials registered in lieu of campaigning for access to AllData from studies like 329.

If you want to survive as a patient in this world, there is little option but to become a scientist on safari or in the laboratory faced with an unknown terrain or substance. You have to devise hypotheses and test them against the facts.

The key hypotheses that need to be tested concern your doctor. Is this person safe? You might not be faced with Dr Munchausen but it is no longer clear even on the balance of probabilities that your doctor is likely to be safe. One test to run is to see whether your doctor is an AllData or AllTrials doctor.