Saturday, February 02, 2013

A Condemnation of Suppression of Medical Research... by Ben Goldacre in the New York Times

Amazingly, this topic now seems to be in the mainstream.

The Goldacre Version in the New York Times in 2013

In his op-ed, Ben Goldacre introduced it thus:

the entire evidence base for medicine has been undermined by a casual lack of transparency. Sometimes this is through a failure to report concerns raised by doctors and internal analyses, as was the case with Johnson & Johnson. More commonly, it involves the suppression of clinical trial results, especially when they show a drug is no good.

He noted that this problems was supposed to be fixed by the registration of clinical trials, and by changes in editorial policies at medical journals:

many in the industry now claim it has been fixed. But every intervention has been full of loopholes, none has been competently implemented and, lastly, with no routine public audit, flaws have taken years to emerge.

 The Food and Drug Administration Amendments Act of 2007 is the most widely cited fix. It required that new clinical trials conducted in the United States post summaries of their results at within a year of completion, or face a fine of $10,000 a day.  But in 2012, the British Medical Journal published the first open audit of the process, which found that four out of five trials covered by the legislation had ignored the reporting requirements. Amazingly, no fine has yet been levied. 

An earlier fake fix dates from 2005, when the International Committee of Medical Journal Editors made an announcement: their members would never again publish any clinical trial unless its existence had been declared on a publicly accessible registry before the trial began. The reasoning was simple: if everyone registered their trials at the beginning, we could easily spot which results were withheld; and since everyone wants to publish in prominent academic journals, these editors had the perfect carrot. Once again, everyone assumed the problem had been fixed. 

But four years later we discovered, in a paper from The Journal of the American Medical Association, that the editors had broken their promise: more than half of all trials published in leading journals still weren’t properly registered, and a quarter weren’t registered at all. 

Goldacre's conclusions were:

Withholding data not only misleads doctors and patients; it’s an insult to the patients who have participated in clinical trials, believing that they were helping to improve medical knowledge. 

Medicine routinely overcomes enormous technical challenges, and there is nothing complicated about the changes needed to prevent Johnson & Johnson, or Roche — or anybody — from withholding information.

Hear, hear!

Our Version, Starting in 2003

Note that 10 years ago, in 2003, in my article on American health care dysfunction that could have been only published in Europe, (Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Intern Med 2003 Mar;14(2):123-130.  Link here)  I noted that an important cause of this dysfunction is that:

the scientific basis of medicine is increasingly under attack.

The integrity of medical research has been violated by the deliberate suppression of its results.

At that time, I suggested one solution would be:

Medical schools and universities must re-affirm their support of scholarly work in the spirit of free enquiry,...

Furthermore, in one of our first posts on Health Care Renewal in December, 2004, in the context of the discovery of internal company documents (in this case, from Eli Lilly) that showed that information about the adverse effects of a drug (in this case, increased aggression associated with fluoxetine, that is, Prozac), we wrote,

The increasingly complex story of suppression of SSRI research seems to be part of a growing epidemic of suppression of medical research.
Let's say it again. Withholding data from clinical research is unethical because:
1. it breaks the promise to research subjects that their voluntary participation has scientific or social value, but undisseminated research has no value; (See Emanuel EJ et al. What makes clinical research ethical? JAMA 2000; 283: 2701-2711.)
2. it impedes scientific progress;
3. it prevents patients from receiving the best possible medical care.
But until this unethical behavior starts having negative consequences for its perpetrators, the epidemic of research suppression is likely to continue. 

Note the similarity to what Goldacre published in the Times yesterday.  You heard it here first.

To date we have published 102 posts with the label "suppression of medical research."  Obviously, Ben Goldacre's NY Times op-ed shows that suppression of research still rarely leads to negative consequences for its perpetrators.  Obviously, by making drugs, devices, and other health care interventions appear safer and more effective than they really are, suppression of medical research has lead to huge revenues for health care corporations, and has made many health care executives exceedingly rich, and many of the health care professionals and academic leaders who have enabled or implemented research suppression somewhat rich.  In the face of such perverse incentives, until we end the impunity of those who suppress medical research (and by the way, those who authorize, direct, or implement all sorts of other unethical, criminal and corrupt behavior we discuss on Health Care Renewal) things will not get better.  I can only hope that having this subject appear in a New York Times op-ed may lead to some real progress.

ADDENDUM (2 February, 2013) - see also comments on 1BoringOldMan blog. 


Mickey Nardo said...

We did hear it here first, for sure! And I hope we haven't heard the last of it. The chorus is growing...

Trevor3130 said...

Then there are earnest types who shill "Antibiotics cost about £550 million to get from concept to production via trials", as in New antibiotics are a matter of life or death.
Richard Smith reports "we have no idea how many people in the NHS are having chemotherapy and what the outcomes are" in A paperless NHS by 2018?
Knowledge is dangerous.

Marilyn Mann said...

There was also an op-ed by Peter Doshi and Tom Jefferson last April on a similar theme:

Also, Ben Goldacre's book Bad Pharma goes into more detail:

Anonymous said...

There has been suppression of the truth about HIT.
There has been suppression of the deaths from HIT.
Hospitals punish those who go public and disclose the internal malfunctions caused by HIT that create the patient injuring mayhem.

Afraid said...

Wow, from 2003 until now is ten years. While I applaud your efforts, the results must dissapoint you.

Keep up the good work!

Anonymous said...

Dr. Poses,

As Dr. Dorio said in an earlier guest post: "Health Care Renewal defines the problem, but not always the solution. Even when there might be solutions, they must be broadcast and directed at a higher level to ignite public opinion."

It is true that Dr. Goldacre's message has been shouted by many before him, and you are one of the more notable examples. Though he is not saying this first, it is possible he is being more effective at being heard.

While that would not have been, and will not be, possible without individuals such as you, I would welcome a Health Care Renewal post dissecting why Dr. Goldacre is managing to possibly achieve a more echoic message. There may be things about such an analysis that could be instructive in carrying forward your struggle.

Perhaps the book "Bad IT" lurks in the future. I doubt it. However, I still believe that a post on discussing strategies, and what can be learned, would be interesting.

As was said in this review of the new book (

"Goldacre’s work, then, is a lightning conductor for much that has come before. But more than that, Big Pharma is a campaigning work, designed to catalyse a movement and leverage access to the corridors of power. Goldacre has also taken to social media to reinforce the message of his book, keeping the momentum building.

So far this strategy has worked spectacularly well. The Emperor’s New Drugs was every bit as damning as Big Pharma, but it might as well have been published in Antarctica to an audience of penguins for the impact it had on the general public. Big Pharma, on the other hand, has been unanimously endorsed and promoted by the British broadsheet newspapers."

I think that Goldacre is trying to build a coalition that will outlast the media's short attention span. I think he is trying to generate enough publicity that pharma will be afraid to not engage in the debate for fear of losing control of it.

I also believe that Goldacre's arguments and/or motivations may hold up better to scrutiny than some of Kirsch's, but that is not my central point.

Thank you for your sustained efforts at Health Care Renewal. I hope that Dr. Goldacre is planning to emulate that persistence.