A century ago Freud and Jung made us aware of the biases underpinning what patients say. Not everything should be accepted at face value. In particular claims of abuse may not be based on reality. We needed experts – analysts – they claimed to tease out what is real from what is not.
The Catholic Church was once intensely hostile to Freud, but when it came to child abuse adopting a Freudian approach was very convenient. But while Freud essentially denied that real abuse was taking place and got away with it in his life-time, the Catholic Church has learnt to its cost that many claims of abuse are real.
This intensely dramatic picture shows a former Pope convening the US cardinals in Rome. They were ostensibly there to put the problem of child abuse in the Church to right but it now seems that the meeting was about managing the consequences for the Church rather than for any of its victims.
There is no pope in medicine. The Presidents of National Associations perhaps once came close. Now someone like Andrew Witty comes closest to fitting the bill.
Whatever about a Pope, there are lots of Cardinals. These usually come with the title professor. Just as with the analysts, these professors have had a training that stresses that you cannot believe everything you are faced with. In this case it’s more a matter of not believing the evidence of our own eyes as it is doubt about what someone says. We see patients balloon in weight in front of us or voice suicidal thoughts that clear when the treatment is stopped but the Cardinals are the people who on behalf of the Pope tell us this is not happening.
How often eagerness to see a positive response can mislead
The primary training these Cardinals now get is in evidence based medicine (EBM). Psychoanalysis was once a significant advance, as was EBM. Both made us keenly aware of the biases that both doctors and patients bring to therapy – how often their eagerness to see a positive response to a treatment can mislead them as to what is going on.
Psychoanalysis made us more aware of the importance of fetishes – especially sexual fetishes. A fetish is a part that substitutes for a whole. Adherence to psychoanalysis ultimately itself became a fetish that impaired many doctors’ abilities to engage with the real complaints of their patients.
EBM has fetished RCTs in a way that endangers our ability to handle many of the real problems our patients have and our ability to tackle the abuse to which they are subject.
If the skepticism that underpins controlled trials were applied primarily to the claimed benefits of treatments – the original purpose of these trials – there would be little problem. But instead these trials have become a means to deny the harms that drugs cause. Your observation that your patient has been injured by treatment is an anecdote, we are told. There is no evidence here.
Our Cardinals feel sympathetic for your problems but advise you in the interests of the Church at large to keep quiet. You will be doing the Devil’s work if you speak out about things you know nothing about.
Remaining quiet for how long?
We have reached a critical juncture. On the one hand we have evidence from company run trials, up to half of which remain unpublished and over 80% of which are ghostwritten, and close to 100% of which the data are unavailable for independent scrutiny. On the other hand we often have evidence of a problem appearing on a drug, that clears when the drug is stopped and reappears when it is restarted.
This kind of evidence until recently was thought to be the strongest causal evidence there was in clinical practice. In over 80% of cases evidence like this turns out retrospectively to have been right. So which is the more dependable when treatments go wrong, the evidence from company trials or the evidence from doctors and patients own eyes?
When they hear Evidence Based Medicine most people think they are hearing Data Based Medicine. It is an irony that trials are used to drown out good observations from individual case studies when such case studies are often the one group of studies in modern medicine where we actually have the data – the person who was injured and their clinical record.
It seems, if only for rhetorical purposes, we need a way to demonstrate how unreasonable it is not to take such reports seriously. If the Church is to survive, we need some Cardinals to take up this cause.
Meanwhile back in the church of GSKology…
In the Church of GSKology, the striking parallels between the way the Catholic Church is handling abuse cases in the Archdiocese of Minneapolis and GSK are handling access to clinical trial data were pointed out.
The legal system in Minneapolis though seems to be sorting the Catholic Church out. Judge van de North has just ordered the Archdiocese of St Paul and Minneapolis and the Diocese of Winona to release the names of 58 priests “credibly linked to episodes of child abuse”. (Although the story seems to have vanished from the Star Tribune site – http://www.startribune.com/lifestyle/234042431.html).
The legal system is not getting to grips with the Church of GSKology or with Astra-Zeneca in Minneapolis in anything like the same way.
In the case of Study 329, GSK got patients to sign consent forms saying they would not receive treatment that differed from standard clinical practice, when in fact the plan was to force titrate these children up to imipramine 300 mg per day.
At the end of the study there was a statistically significant increase in the rates of suicidality on Paxil compared to placebo.
Children have been abused. Whose duty is it to inform these now grown children. Pope Andrew?
Or the doctor involved in the trial or their institutions?
- Marty Keller, or if not him, Brown University?
- Barbara Geller from St Louis?
- Rachel Klein from New York?
- Neal Ryan from Pittsburgh?
- George Papatheodorou or CAMH where he was working then?
- Stan Kutcher from Dalhousie?
- Gabrielle Carlsson from Stony Brook?
- Graham Emslie from Dallas?
- Karen Wagner from Dallas?
- Michael Strober from UCLA?
- Greg Clarke from Portland?
- Elizabeth Weller from Columbus?
There were lots of others pulled in to the exercise, pleased perhaps to get their name on a paper. Boris Birmaher for instance.
Rumor has it there are a bunch of bioethicists and lawyers who have got greatly exercised about things going wrong in a St Paul and Minneapolis Astra-Zeneca clinical trial. Perhaps some of them could weigh in on the issue of what should happen next in the case of 329. GSK and A-Z are both British companies – perhaps this is a British thing.
What are the duties of companies, doctors, universities and clinical institutions in a situation like this?