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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Decent LifeA Delicate BalanceA Fragile LifeA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Mirror Is for ReflectionA Mirror Is for ReflectionA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst MarriageAgainst 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It may be constitutive of our enduring appetite for tragedies that bitter truths are best metabolized by witnessing them being feigned -- demonstrated in some sort of ceremonial form. Take the canonical example of Hamlet, where the revelatory vehicle is twice theatrical -- it is the play-within-a-play which shatters Claudius's mask. An episode which is tellingly prefaced by a 'dumb show', a hyperbolic pantomime:
Anon comes in a fellow, takes off [the King's] crown, kisses it, and pours poison in the King's ears, and exit. The Queen returns; finds the King dead, and makes passionate action. The Poisoner, with some two or three Mutes, comes in again, seeming to lament with her. The dead body is carried away. The Poisoner wooes the Queen with gifts: she seems loath and unwilling awhile, but in the end accepts his love.
This unambiguous display exposes not only the exceptional pretense of the perpetrator, but also, and perhaps more importantly, the unexceptional complicities and weaknesses that constitute the deeper moral substance of the tragedy. That 'normal' human frailties can spiral into ethical disaster is not only a lesson in history, but also one in the natural history of our species. And if this is part of what we are, perhaps constant dramatizations are needed.
David Healy's Pharmageddon is such a reminder; it provides, in clear prose, a stage and adequate lighting so that we may come face to face with those who, quite literally, poison us while claiming our admiration. The book exposes the domination of current medicine by pharmaceutical corporations, and the derailment of a scientific enterprise which allowed itself be captured by marketing imperatives. These are not novel worries, but, in unmasking the usual villains, Healy also illuminates the countless seemingly reasonable compromises which continue to render medicine vulnerable to disfigurement and hijacking. They are the more ominous presence in this play -- the self-indulgence of too many doctors, the naivety of some patient groups, the carelessness of numerous regulators, the irresponsibility of most ghost writers, the numbness of the general public.
That Healy manages to anatomize the progressing undoing of medical care -- and of the 'art' of medicine -- as the result, in part, of a hellish aggregate of 'normal' intentions and actions is perhaps the main merit of his book. It is, in any case, one of the more subtle threads of a volume in which subtlety isn't otherwise a priority. Pharmageddon is fundamentally a diatribe. It belongs, more specifically, with a number of other recent books aimed at convincing a lay audience that the colonization of all areas of life (healthcare and medical science in this case) by corporate interests and their ideological vehicles has appalling effects.( Other examples: Marcia Angell – The Truth about Drug Companies, Jerome Kassirer – On the Take, Edward Shorter – How everyone became depressed, Jeremy Greene – Prescribing by Numbers.) Like all such diatribes, Healy's assumes a tint of theatricality (beginning with its title), but this is not to say that this plea is not legitimate or, indeed, timely. It is to say, simply, that its dramatic overtone, even if pragmatically understandable, adds little to the overall argumentative solidity of the book. On the contrary, it might erode the feeling of urgency that Healy wants to instill, especially in a skeptical reader. It is as if Healy, like Hamlet, feels that truth needs to be staged for it to produce effects.
A somewhat more worrying imbalance in Pharmageddon is that it proposes to make a point about the current state of affairs in medical care in general, while it remains significantly dependent on a discussion of psychopharmacology. This is only natural, given Healy's previous work in that field, and the fact that this area of healthcare and medical science is particularly fragile. The tension remains, however, since arguably psychiatry does not provide the best metric for the medical universe. There certainly are regions of medicine of greater scientific and professional solidity. The cost of its wide scope is that Pharmageddon lacks the steady traction Healy's writing had in, say, The Creation of Psychopharmacology (2002). This does not invalidate the claims made in the current book, but the more ambitious of them (those that refer to the state of all medicine) would require further evidence to be clearly adjudicated.
With these weaknesses noted -- they are to a certain extent inherent in the decision to write a militant volume targeting a non-expert readership -- Pharmageddon succeeds in presenting a very powerful argument for rethinking the medical world and its pharmaceutical shadow. Healy's agenda is well set and comprehensive; he is not content to expose the exuberant and lucrative administration of poorly tested toxins to ever larger segments of the population, but dwells also on the toxic social and cultural context which has made this collective moral failure possible. The cultural critic is an important and welcome voice in this book.
Pharmageddon is divided into nine sections built on specific focus rather than separate themes. The core thematic threads are introduced from the very beginning and they run throughout the book, so, to avoid redundancy, it is best to refer in the following to these fundamental ideas as they take center stage in the text. The initial emphasis (Introduction, chapters 1 and 2) is on the history and impact of importing the logic of marketing into the medical world; the focus then moves (chapters 3 - 6) on the idea that the science of medicine itself faces bankruptcy -- concepts such as evidence and knowledge are brought into question by the practice of privately producing medical research at an industrial scale; finally (chapters 7 and 8), Healy highlights the larger implications and the moral scandal of doing away with the ethos of caring.
This thematic repertoire suggests a reading of Pharmageddon as an effort at recovery -- a perspective abundantly vindicated as one goes through the book. Medicine faces not only a dubious transformation; it faces loss in the form of induced amnesia. If only the medical world remembered the better moments of its own ongoing self-reflection. Revealingly, early in the book, Healy refers to past warnings of which his own are the echo. The reader is introduced to characters such as Dr. Alfred Worcester, an eminent early geriatrician who saw it intellectually acceptable to wonder whether the primacy of diagnosis and its technicalities would erode doctors' 'traditional knowledge of human nature' (Worcester quoted by Healy, p.3). Few in the profession today will find such worries respectable, and it makes sense to ask, with Healy, why. Are we simply past such childish scruples?
Another distant voice invoked by Healy belongs to Philippe Pinel, the man who, in the wake of the French Revolution, liberated the mad from their chains and gave a decisive impulse to what would be later called 'moral treatment'. Discussing, in the first pages of his 1800 treaty (Traité médico-philosophique sur l’aliénation mentale ou la manie – dated year IX of the French Republican calendar (http://gallica.bnf.fr/ark:/12148/bpt6k432033/f6.image.r=art.langEN).), 'the favorable circumstances of [his] study of mania' at the hospice of Bicêtre, Pinel noted that the turmoil of the revolutionary years had been conducive to mental breakdowns (therefore to numerous admissions), and that this had been somewhat compensated by the contribution of an experienced concierge who had helped maintain an orderly life in the asylum. Pinel claimed that such observations had more weight than 'frivolous attempts to use novel cures' (‘le frivole essay qu’on peut faire de nouveaux remèdes’ (Pinel 1800, p.9)), and he emphasized that in the case of 'mania', as with other illnesses, '[i]t is an art of no little importance to administer medicines properly: but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.' (Translators’ Preface to the second edition of Pinel’s treatise, p. xiii. In the original : ‘car dans la manie, comme dans beaucoup d’autres maladies, s’il y a un art de bien administrer les médicaments, il y a un art encore plus grand de savoir quelque fois s’en passer.’ (Pinel 1800, p.10)). Above all, a doctor should not harm by being overconfident in the power of his tools; reflective refrain, mustering the strength to do nothing when nothing useful can be done, is a prime medical virtue. This view of medicine informs Healy's book too (In 2008, Healy, together with Louis Charland and Gordon Hickish, translated the second, 1809, edition of Pinel’s treatise. The translators begin their Preface to that volume by suggesting that the (inexact) quote from Pinel’s 1800 treatise referred to above was the impetus for making the book available to English-speaking audiences.), and it is characteristic of the commitments from which his attack on the current state of affairs in medical care stems.
The first and main target of this offensive is pharmaceutical marketing. As elsewhere in our culture, it is easy in medicine to rationalize what one does according to a narrative of progress. Surely we have come far from the medical world of, say, the 19th century, when many made fortunes by selling false hope and often poison in the form of proprietary drugs advertised as miracle cures. (See for example the ad sections of late 19th – early 20th century US newspapers archived at http://chroniclingamerica.loc.gov/ ) Healy argues that our own technologically superior and bureaucratized medical reality stands in far more ambiguous relations to the mistakes of past times than one might have hoped. The emergence of marketing was associated with the commercial zeal of the proprietary cures manufacturers; now marketing, reaching an aggressive maturity, has come back to haunt medicine. The most dramatic effect is the transformation of the self-conception of medicine -- from an art of healing familiar with human suffering and even 'human helplessness' (p.16) to a service industry clothed in a rhetoric of science and technical expertise.
This contrast should not be read as absolute or as recommending a rejection of science in favor of some mythical, unspoiled past. It is lucidity that has been lost, not romantic innocence. The culprit is not primarily medical science, but it being hijacked for profit. The pharmaceutical marketers of today, as those in the past, have been able to capitalize on the very means society has designed to protect itself against frauds. For example, intellectual property rights -- say, patents on new drugs -- should stimulate genuine innovation, and the fact that we collectively recognize brands should help screening for fakes and inferior products. More to the point, the fact that we filter the consumption of some drugs via prescriptions issued by qualified doctors should reduce the risk of poisoning large numbers of people with 'miracles cures'. In reality, Healy argues, these arrangements have been captured and used by pharmaceutical marketers as vehicles for generating disproportionate profits and undeserved prestige.
Instead of promoting innovation, patents have often oriented pharmaceutical research towards producing derivative drugs -- versions of existing compounds with minor chemical changes. The cost is a fraction of what research for a novel compound would involve, but patents (therefore monopolies, therefore profits) can be thus extended indefinitely. The novelty resides in the way such compounds are sold, not in the science behind them. According to Healy, often enough nowadays disease concepts are introduced, popularized, or semantically redesigned essentially as marketing instruments -- in order to boost the sales of a specific drug or class of drugs, even when those compounds do not signal any change in our understanding of pathology. What gets branded and sold is essentially an illness; the branded drug fits naturally in the manufactured profile of the disease entity -- it usually promises a rosy lifestyle with that disease, not its eradication.
Take the example of Depakote, introduced by Abbott Laboratories as a 'mood stabilizer' and not as just another sedative. 'The beauty of the term mood stabilizer -- Healy notes -- is that it had no precise meaning.' (p.36) But this is precisely why it worked commercially. Who wouldn't be in need of some 'mood stabilization'? To be less fluctuating emotionally becomes a lifestyle choice, and, according to Healy, medicine is increasingly dragged in the direction of representing itself as a provider of such services. As a consequence, the category of the patient is in the process of losing its medical meaning, designating in its stead an ever expanding pool of consumers encouraged to manage health risks and enhance their biological and psychological functioning by ingesting branded chemicals. To be ill becomes synonymous with not being 'on' a certain medicine. This explains the inflation of certain, often subclinical, diagnoses (e.g. moderately-high cholesterol, osteopenia, mild depression (On this example, see also Edward Shorter’s How Everyone Became Depressed.)) beyond reasonable epidemiological proportions.
Doctors are supposed to act as gatekeepers between the ambitions of pharmaceutical marketing and public consumption of drugs, but Healy thinks this does not help, even if the introduction of prescriptions was a reaction to irresponsible marketing of medicines directly to consumers. In this case too we have arrived at what Healy calls 'a conspiracy of goodwill' (p.95) -- admirable intentions turned upside down by systemic forces inherent in the way our societies have come to work. The prescription-only status of many drugs has made doctors the target of pharmaceutical marketing, a situation, Healy claims, they are not vaccinated against by their professional upbringing. Some resist, but many, out of naivety, arrogance, or cynicism, have begun to act as sales agents. Individual cases and motives range from corruption and unambiguous conflict of interest (paid-for professional events in exotic locations, conference tours, speaking fees and stock options etc.) to falling victim to marketing dressed as science (partial or falsified data published as solid research often in authoritative venues, sometimes by medical celebrities etc.). The most aggravating situations are those in which medical academics -- people who clearly should know better -- sell out to those who mock medical science.
Healy traces the symptomatic phenomenon of the blockbuster drug -- those medicines that bring in at least $ 1 billion per year -- in part to the success of marketers in transforming the uses of patents and prescription status. While his argument is strong, especially in those cases where enormous profits are associated with minor benefits for patients and even proven adverse effects (as with the likes of Paxil), it is less clear what could be done to solve these problems. Doing away with patents and prescriptions, as Healy seems to advise at points, would be of little help in a context in which direct-to-consumer marketing and the manipulation of consumer groups are at least as damaging as recruiting doctors to act as a sales force. What measures one could take to restore medicine to its original mission of being life-saving truly is a discouraging question. Healy does not ignore its larger implications, but his agenda for change is not always convincing or consistent. To return to the example of prescriptions, even if this barrier does not function as intended, a playing field with no barriers of this kind will probably be even less leveled than it currently is. Doctors still have some bargaining power in their dealings with the marketers and hopefully some will use that for the benefit of their patients. Perhaps we should do our best to reinforce legitimate scientific and medical authority wherever we can find it, instead of institutionalizing distrust of all authority. Isn't one, in recommending that attention should be paid to Healy's case, doing precisely the former?
The rejection of a medicine rebuilt on marketing priorities and newspeak does not amount simply to a de-humanization argument of the sort that rapidly degenerates into antiscientific ramble. Medicine faces disfiguration precisely because pharmaceutical marketing has become adept at manufacturing the appearance of science. Scientific authority -- the prestige of the white coat -- is an asset to be captured and reenrolled as money-making rhetorical machinery. 'From the point of marketing, -- Healy observes -- the advantage of the medical sciences is not that they might lead to better drugs but rather that they provide concepts and languages for marketers to use.' (p.58) Medical concepts selectively repackaged as selling propositions have the advantage of emanating, at least for a while, an aura of objective respectability. Have people talk about their serotonin and cholesterol levels -- as they used to talk about their childhood traumas not so long ago -- and they will be likely to buy the associated product. Profit via what Healy aptly calls 'capturing understanding' (p.60).
This erosion of medical science goes, however, beyond losing control over its proprietary language. We arrive at the second important direction of attack developed in Pharmageddon. Healy thinks that medical research itself is undergoing a disquieting transformation. This is driven both by internal forces -- ideas about what science amounts to -- and by the already mentioned influence of the market. Internally, medicine has been (re)modeling itself on a certain ideal of scientific objectivity. Evidence should be the ultimate basis of all decisions a doctor makes. Vocation, experience, intuition, empathy, wisdom may matter, and historically they have been treasured, but for the modern doctor solely evidence should be decisive. Indeed, increasingly this doctor will be forced to follow the evidence, as it gets institutionalized in treatment guidelines. Ideally, this limits the errors stemming from individual hunches, biases, inattention, or ignorance. That it also transforms doctors into medical apparatchiks focused on procedures may be an acceptable cost. Healy, predictably, disagrees.
This procedural model of medicine is flawed, Healy claims, since it rests on a flawed conception of what evidence is, and of how it is produced and managed. The core chapters of Pharmageddon present a case for skepticism about the fundamental elements of evidence-based medicine: the idea that statistical significance is decisive in adjudicating claims, and that corresponding experimental tools, essentially the randomized controlled trial, are the best one could do to determine which treatments work and which do not; the idea that data thus produced are adequately scrutinized in the peer review process, and that professional peer-reviewed publications deliver unbiased, authoritative information; the idea that all scientific data, published and unpublished, are in principle accessible, and that authors are intellectually committed to what gets published under their names; the idea that good science -- convincing evidence -- speaks for itself and cannot be curbed by external forces (say, political or commercial). Since such tenets seem basic for any scientific enterprise, it is important to understand the substance and limits of Healy's doubts.
For one thing, Healy does not dispute medicine's footing in scientific findings, but what counts as medical knowledge. What comes into question, specifically, is a certain cult of numbers. Stats and measurements sometimes 'hypnotize doctors' (p.75) due to the glimpse of 'seductive possibilities of control' (p.168); they achieved such a prestige as to trump both common sense and clinical judgment. Moreover, it is often the case that doctors do not pay attention or simply do not understand the math behind many statistical proofs that a drug works, or that it works better than other, older and cheaper, compounds. To complicate clinical decisions even further, statistical tests often aim at deciding ambiguous cases -- when it is not immediately clear whether a treatment works, or worse, when biological mechanisms are not understood and one is blindly testing for correlations. After all, no sophisticated math is needed to prove that aspirin, insulin, and penicillin are effective. One forgets that quantification is an instrument of research, not a replacement for scientific reasoning.
None of these difficulties should suggest that medical research can proceed without rigorous testing. Perhaps Healy should stress this more clearly. The difficulty is to determine the proper role of results that often hover on the border of statistical significance. Rigor in determining these numbers should not be seen as a ground for being confident about their interpretation. Healy's point that good numbers by themselves are not synonymous with good science stands.
It is not clear, however, how one should manage the skeptical element in Healy's argument. No one should expect that all treatments will be 'unambiguously effective' (p.78). And Healy abuses the suggestion that often older treatments are more effective than recent ones backed by ambiguous results. Problematic ambiguities are in medicine to stay, and marginal benefits might be all the benefits available to some patients. It makes sense to explore them, and large scale experiments resulting in statistical observations seem the only way to do it. Mentioning clinical judgment and doctors' discretion, as Healy does, changes the subject and obscures the fact that there are no easy answers for the all too human tendency to do away with doubt and to act under an 'illusory certainty' (p.77). Both the controlled trial and the doctor's wisdom can be fetishized.
What seems more helpful in Healy's observations is the point that with drug testing too we face a strange reversal. Tests, e.g. randomized controlled trials, Healy notes, 'began as means to control therapeutic enthusiasm' (p.81). They were put in place to counter the tendency to overmedicate -- to throw at a disease the chemicals at one's disposal with insufficient discernment. In testing, one started by assuming that a treatment does not work, and one raised a statistical bar so as to select truly effective compounds. While the exoskeleton of this rationale survives, Healy argues that its substance has melted away. The reversal consists in running tests in order to prove that a drug has some therapeutic effect. Now, it matters if what one tries to find is success rather than failure, especially since nowadays drug manufactures -- those who stand to gain from proving success -- are also those who pay for, and manage the testing process. No wonder then that controlled trials, which ideally should limit action (i.e. medication) à la Pinel, have become 'technologies that mandate action' (p.90).
At this point the focus moves from doctors playing the sorcerer's apprentice under the cover of fragile scientific rationales, to the issue of being deliberately misled by elaborate simulacra that pass as science. The question of what counts as science turns out to be related to the paradoxical one of who owns science. As suggested above, Healy insists on the toxic effects of most testing of new medicines now being run by the companies that manufacture those drugs, a situation which erodes public control over the data thus produced. This is an arrangement that should have saved public resources while freeing innovation from the chains of bureaucracy. Instead, according to Healy, it has resulted in systemic corruption.
The problems start with data gathering and extend to the publication of results and the elaboration of guidelines. Healy documents situations in which patients have been excluded from trials or had their symptoms misclassified to make a drug look good; situations in which results of 'unsuccessful' tests have been hidden; situations in which only part of the data has been published or the raw data have been buried under legal barriers. And the problems extend to what gets published. A significant proportion of articles describing test findings, Healy claims, are now ghost-written, indeed there are companies specialized in ghost-writing 'research' papers. These are not research companies, but public relation firms, and the writing process has little resemblance with true science -- papers are sometimes written before tests are concluded, then delivered to those, sometimes medical celebrities, who sign them, finally rushed through the review process and published in (friendly) prestigious journals.
What remains, in such conditions, of the hard-won epistemic authority of science? In Healy's words, mere 'statistical decoration' (p.117) for what in fact is a 'new anecdotalism' (p.94). If one cannot distinguish between the academic paper and the advertising copy, between the salesperson and the professor of medicine, then perhaps suspension of judgment is the best one can do. But this is obviously to push one's case to absurd limits. The point is that we are confronted with possibly dangerous fakes, cases like that of study 329 (data were doctored by SmithKline to show that the antidepressant Paxil was safe for children), not that all distinction between science and simulacrum has been lost. We face a harder task of discernment than before because of how we designed our peculiar modernity, confounding goals and means: science with quantification, effective social action with standardization and privatization, good medicine with client-friendly service provision.
This misshapen horizon affects all areas of public life. One dramatic example that almost suggests itself, and which Healy does not miss, is education (pp. 191, 237). But the impact on the medical world is probably the most disturbing, since it has injected a poisonous fog in our ability to deal with illness and death -- our own and others'. In one of the best passages of his book, Healy reminds his reader that
[R]eal disease is not something we consume. Like death, albeit slower, it consumes us. [...] We make our accommodations with disease as best we can, and since the time of Philippe Pinel that accommodation has involved a medical realization that sometimes the greatest wisdom is do nothing other than have the medical team and patient endure together. (pp. 190-91)
This latter idea -- that there is a medical duty of enduring together, of care in a demanding sense of the word -- is at the root of the third and last core criticism put forward by Healy. The accusation is that care is a duty actively ignored in modern medicine. Doctors are encouraged to act like technical personnel maintaining biological machinery by pumping chemicals into it according to guidelines they themselves do not control. Patients should be smiled at during this process, but what they say beyond checklist symptom registration should not concern a doctor. This is, of course, a negative ideal rather than a description of clinical reality, which continues to be a mixed story. But the tendency to marginalize cost-ineffective, time-consuming, emotionally-taxing care is hard to dispute.
In a recent piece in the NY Review of Books (On Breaking One’s Neck (http://www.nybooks.com/articles/archives/2014/feb/06/on-breaking-ones-neck/).), doctor Arnold Relman, who is in his 90s, describes the life-saving treatment he received at the Massachusetts General Hospital after falling and fracturing three vertebrae in his neck in June 2013. The doctors at MGH did wonders, but, Relman observes, this did not seem to be about the person being saved:
Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside. [...] Reading the physicians' notes in the MGH and Spaulding records, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices.
Should it matter, since Relman's life was saved? The real issue here is not the somewhat trivial-because-permanent threat of us becoming 'new barbarians' (Healy p. 264). As Relman confesses, he as a doctor had missed what he as a patient painfully discovered: the enormous difference made by being heard. It is not only that relating to a patient can be healing or at least comforting; patients can voice clinically relevant information, and that information can be missed if the only person actually seeing and speaking to them is, if they are lucky, a nurse. The problem of dismantling the traditional relation between doctor and patient concerns then not only the ethical standing of a human being, but also, more narrowly, medical deontology.
Traditionally, medicine crisscrossed the classical distinction between scientific knowledge and craft or art. The latter element, fundamental for the doctors' ability to care for their patients, gave medicine its character and balance --science and art, universal and intimate. No worthwhile notion of medicine would survive the loss of this ambiguity; the idea that it could is poison poured into our ears, and whatever his overstatements Healy is right about that. We should not be wooed.
Pharmageddon might not be the most cerebral manner of describing what lays ahead, but, if there is a suitable meaning to the term, it consists in contemplating the possibility of 'calming' such fundamental worries as those related to being vulnerable and eventually dying -- abandoning oneself to the care and kindness of strangers -- by taking a pill. Drugs, Healy notes, 'are chemicals used for a social purpose -- to treat conditions that we define as diseases' (p. 240). The nightmarish thought is that we might end up, if 'disease mongering' (p. 113) is not tempered, by curing ourselves not of illness or death, but of what makes our existence characteristically human.
© 2014 George Tudorie
George Tudorie is a PhD student in philosophy, Central European University, Budapest; and teaching assistant, College of Communication and PR, Bucharest.