Doctor Munchausen: Hear no, See no – What?

Being Irish makes it possible to tackle certain things – or, now possible. The question of the Catholic Church, for instance, and its handling of children – whether their abuse at the hands of pedophile priests, or the appalling treatment of unwed mothers in Magdalene laundries, or the shipping of children born outside marriage out of Ireland for adoption.

There have been two Irish movies on these themes in the last year – Philomena and Calvary. From a distance of several decades it seems it has become possible to look at certain events and see what was wrong.  Similar stories have come from countries from North America to Australia.

These stories have tended to play down the complicity between doctors and the Church. In some Canadian and American settings, it was worth more to the Church to have orphans designated as psychiatric patients – the Church got paid more. In other settings, in Ireland perhaps, it looks possible that orphans were entered into vaccine trials by nuns liaising with doctors, when not being sold to wealthy foreigners.

The Pedophile Priest seems to incarnate the problem of evil in our day. Until recently it seemed like an evil that could be handled in that these priests appeared to be relatively rare. It was the past. We had learnt lessons. It was very disturbing but not deeply threatening. Until Jorge Bergoglio suggested that one in fifty priests might be problematic and Britain exploded with reports of mass sexual exploitation of young girls by predatory men in close to every city in the land it seemed. Maybe it wasn’t priests who had led to so many unwed young mothers in Ireland.

Doctors and the Church

Intersecting with this story was a disturbing interaction between the Church and medicine. Doctors it seemed could be found to make psychiatric diagnoses on orphaned children that led to treatment with antipsychotic drugs in the 1950s and 1960s, and one of the drivers of this seemed to be that the Church got more money from the State as a result. The doctors, of course, also got paid. This feels like a seriously corrupt nexus operating with near impunity on the basis that no one is going to be bothered to investigate the fate of some orphans.

Could doctors have really colluded in this way? One of the striking features of medicine in Ireland until recently is that in most official pronouncements on ethical or moral issues, medicine has been to the right of, more conservative than, the Catholic Church. Whatever about individual doctors and individual priests, medicine as a body has seemed at least as likely if not more likely to be inhumane and unresponsive to the needs of people than the Church. Talk of doctors and nuns or priests colluding doesn’t seem so far-fetched against this background.

But it’s all in the past. We have of course learnt lessons.

Doctors and Pharma

So who is now entering children into clinical trials like Study 329 – GlaxoSmithKline’s (GSK) famous trial of Paxil (Seroxat – paroxetine) compared to imipramine and placebo in adolescents who were supposedly depressed? Is the pharmaceutical industry wonderfully more ethical and concerned about children than the Catholic Church was? Does industry profit from this? Are the doctors reimbursed for each child entered? (Likely around $5000 per child).

Unlike the 1960s, there is of course informed consent now. In Study 329 you were informed that participation in the trial would not lead to any different treatment from standard clinical care. Well, standard clinical care for the use of imipramine in adults at that time would have been to use doses of around 150 mg or less. In their adult trials running at the same time, GSK were using a 150 mg dose. But in Study 329, the protocol from the get-go mandated pushing every child who got imipramine up to 300 mg if possible. It’s difficult to see any rationale for this other than by making imipramine look so toxic, Paxil might look good by contrast.

Who is Responsible?

When the trial was finished there was clearly a very marked increase in suicidal acts in the children taking Paxil. In normal clinical practice if someone becomes suicidal on an SSRI like Paxil, I would try to make sure afterwards that they understood that this was an effect of the drug rather than something inherent to them. This is important for their perception of themselves afterwards. I would also indicate that the same might happen on many other antidepressants, some of which also act on serotonin without being labeled SSRIs. It might also happen on painkillers like Tramadol, which is a serotonin reuptake inhibitor.

So whose responsibility was it to ensure good clinical practice was adhered to? GSK deny all responsibility – this is a treatment issue and it’s not our job to treat patients. This should be done by the doctors who know the patient best. The doctors can’t easily do it because GSK haven’t told them there is a issue and have ghostwritten a paper with their names on it saying that Paxil is wonderfully effective and safe for young people.

Driver on the Train to Auschwitz

In terms of responsibility, we don’t hold the train driver responsible for Auschwitz. Are doctors little more than drivers operating the train to Auschwitz?

Back in the 1950s or 1960s doctors were little gods. It would have been inconceivable to cast them in the role of train drivers. The men responsible for the medicating of orphans and giving them vaccines were closer to Doctor Munchausen figures or perhaps even had something in common with Dr Mengele – although this is a judgement made easier by the benefit of hindsight.

But today even Professors from Brown, Harvard or Oxford have so little real say that it is in some respects difficult to see them as any more than glorified train drivers.

We live in an era when AllTrials, the BMJ, and GSK can all appear part of a cosy alliance.

It’s also an era when children in orphanages, foster care and in care generally, are getting vastly more psychotropic drugs given to them than ever before.

Thirty years from now if doctors escape judgement because it is deemed they were just train-drivers, it is as likely they will be a vanishing breed as priests are now, as much use as salt that has lost its bite.

Footnote

The Dr Munchausen series is here:

• First  Dr Munchausen I Presume
• Second  Dr Munchausen: Dying for a Cure
• Third  Dr Munchausen: Dear Luise
• Fourth   Fr Munchausen I Presume
• Fifth  Dr Munchausen Sense about Science
• Sixth  Dr Munchausen Judge and Jury
• Seventh   Dr Munchause Pharmacophile

For the record, I personally see the problem of evil primarily as an absence of good – a system problem. It’s rarely if ever a case of evil people, although since Cesare Lombroso’s work a century ago the world has had to live with the problem that there are people who are morally deficient.

How this might apply to pharma and doctors was laid out in a series of posts:

• First  Brand Fascism
• Second  Witty A: Report to the President
• Third  Marilyn’s Curse
• Fourth   When does Yes Mean No

The antidote was We have a Dream.