Who is in Charge of Modern Medicine?
Vitality September 2002 issue

By Helke Ferrie

The International Conference of Medical Regulators took place in Toronto June 15-18, and those charged with maintaining medical standards throughout the world attended in large numbers. While most of the participants appeared to be stereotypical administrators – low-key, burdened, mildly bored - their presentations were shocking to the point of making my pulse race. This was a post mortem on medicine and a collective funeral dirge for what was once known as values: ethics, trust, professional honor, integrity, altruism - all that upon which the science and practice of medicine depend. I was the fly on the wall hearing what none of them want shouted from the rooftops.

My request for a media pass came with the comment that this was the first time the press would be allowed in. As it turned out, I was the only media person. No press releases had been sent out. This crowd (about whose Canadian members’ crimes against patients and doctors I have written frequently) does not like publicity. I suppose, they didn’t want to get caught saying no to a journalist who asked for a pass, but they sure weren’t about to invite them all in! Since none of the presenters knew a reporter was present, they held their dismal wake without restraint and let it all hang out.

The themes of th'l of the public interest; Continuing Medical Education, the lack thereof as doctors go on automatic pilot when leaving medical school; Corruption through conflicts of interest with the corporate sector and government interests, also bound to corporate priorities; Research Misconduct such as ignoring human rights of patients and fudging data; and finally: Who Regulates the Regulators? Apparently nobody, which is why everybody complained that nobody trusts the regulatory system anymore. These were the actual session headings and are not my nasty interpretation of them. The last speaker, MPP Thomas Mulcair from Quebec urged the regulators to deal with all of the above with integrity “before the TV cameras of W5 and the microphone of investigative journalists are in your faces”.

We ought to be thankful regulators admit, when they are amongst themselves, that they have made a royal mess. By contrast, their publications are insufferable spin. The College of Physicians and Surgeon of Ontario (the conference’s host), for example, publish their bi-monthly glossy “Members’ Dialogue” referred to by many members as “Member’s Monologue” and “Members’ Pravda”, because of its similarity to the former Soviet Union’s national newspaper.

The first day’s presentations were “Regional Reports on Current Issues and Trends in Medical Regulation” and constituted a survey of Canada, USA, Europe, Africa, Asia/Pacific and the Middle East. However, when I arrived, I was informed that these were “closed educational sessions” and was sent home again. The revelations of the next three days, which I was permitted to attend, were such that I sincerely hope the first day’s educational session did them a world of good.

History

The attempt to regulate medical practice goes back to the earliest known laws, the Code of Hammurabi, written on stone tablets in cuneiform script some 4,000 years ago in ancient Mesopotamia, now Iraq. It prescribes nasty penalties for doctors whose patients had bad outcomes – not very encouraging for research, so unsurprisingly the Middle East remained a medical backwater for thousands of years. On the other hand, in ancient Egypt and Greece, were medicine had divine status and doctors were bound by religious ideals, medical science made the greatest strides from which we are still learning today. The same is true for China. In the west, legislative regulation and administration became serious in 1511 when England’s parliament passed the first regulatory laws and founded the Royal College of Physicians in 1518. In our hemisphere, the College of Physicians of Upper Canada came about in the 1850’s, and Texas was the first in the US to have a medical regulatory body in 1873. The US Supreme Court in 1888 ruled that doctors had to have uniform, specified qualifications before they could be let loose on people. Today, self-regulation of the medical profession is legally a privilege granted by the government but also anchored in law.

The need for verifiable, standardized qualifications became necessary as scientific medicine and surgery were emerging alongside superstition of the most deadly kind as well as ancient medicine with a proven track record of millennia. However, when order is imposed, power politics takes over as well. For example, in Canada, medical regulation has always been associated with a policy of “restricted entry”, as Canadian historian Hamowy observes. In Ontario Jews and Eastern Europeans were unable to join the CPSO until the 1960’s. (Today doctors risk excommunicated by disciplinary trial if they “fail to meet the standard” because they cure people without drugs.) By the late 1960’s the drug companies joined the regulatory process - first with genuine wonder drugs like antibiotics, then with the toxic brew designed to control symptoms as well as a huge slice of the world economy. Dr. Philip Hebert of the Clinical Ethics Center at Toronto’s Sunnybrook Hospital put it bluntly in his conference presentation by sadly pointing out that now we have a “new ethos” for which “altruism is a thing of the past” and “medicine has become just another money-making enterprise” as business and politics “de-professionalises” them.

The Current Mess

There are three main areas in which medical regulation has failed to live up to its mandate: 1. Protecting bad apples, i.e. doctors who are important to insurance and drug companies or are just plain incompetent and get away literally with murder. 2. Witch hunts against innovative doctors or those who don’t get their information from drug company reps, but through primary biological research, and who have developed replicable and biochemically based cures, not management strategies, for cancer, asthma, and chronic diseases. 3. Turning a blind eye to rotten science and conflicts of interests. The difference between the first area mentioned and this third one is, that the first one is active participation in corruption, while the third one is just ordinary neglect. All three areas surfaced at the conference as topics of discussion in excellent presentations by Drs. Richard and Sylvia Cruess of McGill University, the UK’s Dr. Kerry Breen of Australia.

Medical regulators all over the world are reeling from the impact of huge disasters. One UK speaker wondered how one could start preventing “medical Enrons”. What profoundly disturbed me was that though these facts were acknowledged, they were discussed in the dispassionate manner of meteorologists enumerating the tornadoes of the last thirty years. These were not “acts of god”, as the insurance industry calls natural disasters. These are acts of people, quite ungodly and wholly preventable. I worry, though, that for most attendees it was going to be business as usual. I hope I am wrong.

The UK’s Dr. Shipman, now confirmed to have murdered 215 of his patients (after having most of them rewrite their wills in his favor) nearly escaped unnoticed because he was a member in good standing – in spite of the disproportionate number of death certificates this one country doc was signing. Canada’s Dr. Nealey did his worst in British Columbia, then in Ontario, went on to the UK and was finally caught – by a patient’s relative. All those dead babies in Bristol and Winnipeg wound up being victims of a system that focuses on paper and no longer relates to flesh and blood reality.

Other international scandals involve doctors aiding totalitarian regimes in torture, their unchecked commerce in poor countries with “donor” kidneys and eyes, and in affluent countries (including Canada) involving their patients in drug trials without their knowledge – all of which the regulatory bodies seem not to confront. In some places regulation has become virtually incapacitated. In India, patients’ relatives were reported recently to have vented their rage against this rampant corruption in a New Delhi hospital such that a slug fest ensued and everybody wound up as patients in the emergency department, doctors included. For the details on the Canadian regulatory failure, the best sources are the Toronto Star series, “Medical Secrets” available on their web site, and the harrowing accounts collected by Susan B. McIver, a BC coroner, in her recently published “Medical Nightmares – The Human Face of Errors”. For the Canadian Colleges see www.collegeofphysicianswatchdog.com. Its “Glasnost Report”, was prepared by 3 medical associations and 6 patient advocacy groups.

In the area of patient relations, the problems range from the lackluster support of the World Health Organization’s effort to stop female genital mutilation to actively blocking patients’ treatment choice. In Ontario, the CPSO fought to the last moment to stop the December 2000 health freedom legislation, the Kwinter Bill. Inadvertant comic relief was provided by the French. A senior French medical regulator (not present at the conference) was asked by an American medical journalist, how French regulators handle sexual misconduct. The French official asked, “What do you mean?” The reporter said, “Sex with patients.” The reply, “For us that’s a private matter between the doctor and the patient.”

The world’s most prestigious science journal, Nature (March 28), ran an article entitled “Can you believe what you read?” showing how the editors of the most respected medical journals have had to engage in some fundamental housecleaning because research data too often reflect corporate interests instead of reporting observed facts. It announced two international conferences held this year on conflicts of interest in medicine (Atlanta and Warsaw). On June 27th Nature reported that even medical bioethicists are now “being offered stock board positions, consulting contracts, research grants, and even stock options” by pharmaceutical companies - and they accept these goodies! The former editor of the New England Journal of Medicine, Marcia Angell, justly famous for her fearless scrutiny of conflicts of interest in medicine, now works closely with the Center for Science in the Public Interest (www.csip.org)

An example of the third area of concern happened here in the 1990’s. When Health Canada’s scientists, led by Dr. Shiv Chopra, asked for input from the Canadian Colleges on what they thought about the impact of bovine growth hormone on human health, they responded, it was fine. Their response was based on no scientific data whatsoever, and when Dr. Chopra and colleagues, following a Senate inquiry, succeeded in banning BGH, the Colleges remained unconcerned at having rubber stamped a carcinogen and endocrine disrupter, now also forbidden in Europe.

Why would regulators suppress good medicine? Perhaps because their council’s non-elected members not only represent the pharmaceutical and insurance industries as “stake holders”, but also sit the discipline committee where they can select their perceived enemies? Or because even the elected members and the executive are, through their university jobs and research grants, may serve agendas other than patients’ needs? More than 80% of all Canadian doctors have financial ties to the industry. Such interests are not served by doctors whose diagnoses implicate that industry’s products as causes (e.g. cancer-causing pesticides are made by pharmaceutical companies). The treatments of these doctors, scientifically based on biochemistry, are bad for business, being a direct attack on the merely symptom-controlling and mostly toxic pharmaceutical products which they render obsolete.

The zeal with which North American medical regulators prosecute good doctors has inspired Canadian and US lawyers to specialize in protecting them. In Texas, a whole law firm is dedicated to this field: Brown & Fortunato works throughout the US. Its Health Care Group chairman recently told me that some of their lawyers are especially well qualified because they hold degrees in law as well as in those offered now by universities in legal medicine focused exclusively protecting medical innovation against medical regulators. Thankfully, if Truth and Justice are forsaken in one area, they have a way of finding instruments elsewhere in society.

Just how bad things have become can be measured by the fact that on February 5 of this year the prestigious journal, Annals of Internal Medicine (vol. 136, no. 3) published simultaneously with the UK’s famous Lancet (same date) the “Physicians Charter” (www.professionalism.org). The charter asserts that it is time doctors get back to the basics and reads like the Hippocratic Oath of 2,500 years ago in modern English. The message is simple: don’t screw your patients financially or sexually, don’t hurt them, let them chose among available treatments, and treat them properly even if they are black, Jews, poor, retarded, dying, just plain old, or don’t have any money, and don’t blab about them to others without their consent. (Canada’s Privacy Commissioner, George Radwanski spoke at the conference and handed out the government’s fat report on this last issue: www.privcom.gc.ca .) Most of all, don’t lie when you do research because somebody offers to pay you for it. Wow! Hippocrates is groaning in his grave. This document, prepared by an international team of medical ethicists for the “Medical Professionalism Project” was handed out to all conference participants. It states at the outset: “We share the view that medicine’s commitment to the patient is being challenged by external forces of change” which “the tempt physicians to forsake their traditional commitment to the primacy of patients’ interests.”

The best presentation was that by Dr. Solomon Benatar of South African, currently teaching bioethics at U of T (http://dante.med.utoronto.ca/ethics, and http://icarus.med.utoronto.ca/ethics). His was a breath taking tour through the suffering of humanity and the profit that can be made from it: 86% of annual global expenditure on health care goes to 16% of the world’s population, and 90% of all health care research goes to 10% of the actual disease burden of the world, focusing on impotence, hair loss and blood pressure control, because the really sick people are “superfluous to the market as they cannot produce or consume.” Medical regulators should stop this trend of “erosion of professionalism” he said. He concluded that doctors, researchers, regulators, governments and patients must “move away from a military and market metaphor and embrace an ecological metaphor” and focus on “population health as well as individual health”.

Most immediately, though, what can you do to protect yourself while medicine sheds its old skin and struggles to be reborn? Read the books suggested below, especially Susan McIver’s excellent book – tough to read, but great on advice on how to empower yourself as patient, how to avoid getting killed inadvertently, and how to get decent medical care, how to learn when to trust and when to be defensive. McIver’s book might save your life. Remember, only informed patients will transform rotten regulatory systems and help create good medicine.

K. Ausubel, When Healing Becomes a Crime, Healing Arts Press, 2000

J.S. Cohen, Overdose: The Case Against the Drug Companies, Tarcher-Putnam, 2001

M. L. Culbert, Medical Armageddon, rev. edition, , C & C Communications, 1997

R. Hamowy, Canadian Medicine: A Study in Restricted Entry, Fraser Institute, 1984

S.B. McIver, Medical Nightmares, S.B. McIver, Chestnut Publishing Inc., 2001

Jeffrey Robinson, Prescription Games, McClelland & Stewart, 2001

The Olivieri Report, Canadian Association of University Teachers, James Lorimer & Co.2001