Stop witch-hunting Wakefield
Dr Michael Fitzpatrick has been a staunch critic of Dr Andrew Wakefield, who kickstarted the MMR-autism scare. So why is he defending him against the General Medical Council?
Dr Michael Fitzpatrick
Reports of measles outbreaks around England coincide with the announcement that Dr Andrew Wakefield, who advanced the now-discredited theory of a link between the MMR vaccine and autism in 1998, is to face disciplinary charges before the General Medical Council. There has been speculation that he may be struck off the medical register. I believe that it would be better for the medical establishment to learn some lessons from the MMR fiasco and allow Dr Wakefield to sink into obscurity.
My position on Dr Wakefield’s role in the campaign against MMR is a matter of public record – it is well known to readers of spiked. He is a scientist in whom self-belief turned into self-delusion. When he could not substantiate his hypotheses to the satisfaction of his peers he found a responsive audience among scientifically naive journalists, lawyers and parents, who found his theories congenial to their own agendas.
The result has been a campaign that I have characterised as ‘increasingly irrational and irresponsible’, causing unwarranted distress to parents of autistic children and anxieties for parents facing decisions about immunisation – and contributing to a decline in MMR uptake, resulting inevitably in renewed outbreaks of measles. Having turned his back on the world of science, Dr Wakefield now associates with anti-vaccination zealots and quacks who offer unproven biomedical treatments for autism (he now works at a private clinic in Texas).
Though I have no great sympathy for Dr Wakefield in his current predicament, I still do not think he should be struck off the medical register and I am sceptical that any benefits will result from his appearance before the GMC. Though his work was crucial to the notion of an MMR-autism link, he cannot take all the blame for the scare, for which many others share responsibility. The charges against Dr Wakefield, amounting to ‘serious professional misconduct’, arise from three aspects of the study published in the UK Lancet in 1998 that suggested a link between MMR and autism: the quality of this research, its ethical conduct and its funding (1).
Dr Wakefield is accused of publishing ‘inadequately founded’ research. As I have argued elsewhere, I believe that the Lancet study was flawed by a biased selection of cases and on several other (now widely acknowledged) grounds. As I have also argued, this insubstantial and speculative paper should never have been published in a reputable journal. Dr Wakefield’s superiors at the Royal Free hospital, where his study was conducted, and the peer reviewers and editors of the Lancet, were all at fault in not identifying these flaws.
But poor quality research is regularly produced in eminent scientific and medical institutions and published every week in journals such as the Lancet. These are matters that should be taken up in open debate among scientists. Producing ‘inadequately founded’ research does not amount to professional misconduct and should not be considered a matter for disciplinary sanctions. Indeed, resorting to disciplinary measures in response to bad science is likely to discourage good science, which often advances through exposing error. If every doctor who publishes a second-rate paper is to be hauled before the GMC, its bureaucracy will soon be overwhelmed.
Dr Wakefield is further accused of ‘subjecting children to unnecessary and invasive investigations’ and of failing to obtain proper ethical committee approval for his study. Again, I have made clear my view that it was not justified to submit autistic children to lumbar punctures (to obtain cerebrospinal fluid) and ileo-colonoscopy (to examine the bowels and obtain biopsy specimens). It seems doubtful that these investigations were clinically indicated in all, indeed in any, of the children and that they were carried out for the purposes of research (or in some cases in the – forlorn – hope that they might advance litigation claims).
However, Dr Wakefield can claim that the children’s parents were keen for them to undergo these investigations and that, in some cases, they identified bowel inflammation that responded to treatment. Documents obtained by the intrepid investigative journalist Brian Deer, and published on his website, certainly raise questions about whether Dr Wakefield and his colleagues complied fully with ethical procedures (2). Though Dr Wakefield has a case to answer here, even if he were found guilty on these charges, this would seem to justify a stern reprimand and strict conditions on any future studies, rather than major disciplinary sanctions.
The third charge against Dr Wakefield is that of obtaining funding ‘improperly’. This is presumably a reference to the exposure by Brian Deer that he failed to disclose the receipt of £55,000 from the Legal Aid Board in relation to some of the 12 children in the Lancet study, whose parents were then attempting to claim compensation from the vaccine manufacturers. Should Dr Wakefield have declared this income and the conflict of interest that it created? I agree with the judgement of Dr Richard Horton, editor of the Lancet, that he should and that his failure to do so meant that the paper was ‘fatally flawed’ on these grounds, as well as the methodological grounds indicated above (3).
However, I do not accept the now widespread notion that this episode reveals that Dr Wakefield was primarily motivated by greed and that his behaviour was fraudulent. For a rogue scientist, the conviction that you are Galileo generally has a much greater influence than mere money – but, if it turns out that your theories are not only heretical but also plain wrong, the consequences, as in this case, may be more damaging than if you were a simple fraudster. In any event, though Dr Wakefield was mistaken in not being candid about his funding, this should not be considered a hanging offence and does not justify him being struck off. (If disciplinary measures are being taken against Dr Wakefield in this area, perhaps the Law Society might consider the conduct of the lawyers, whose ignominious role in the MMR-autism affair wasted £15 million of public money and left more than 1,000 parents with nothing, while enriching the lawyers and their expert witnesses.)
There is a danger that the prosecution of Dr Wakefield, which is not expected to start until next year, nearly a decade after the launch of the scare, will turn into a witch-hunt. This would play into the hands of Dr Wakefield in his self-indulgent posture of victimhood and encourage his supporters to move even further down the road towards canonising him as a martyr. It also reflects a degree of bad faith in the medical establishment as it attempts to compensate for its failure to respond effectively to the anti-MMR campaign at an earlier stage. The GMC charges fail to identify Dr Wakefield’s most important offence: this was not that he produced poor-quality science, but that instead of substantiating his improbable hypothesis, he embarked on a public campaign against MMR that could not be justified scientifically. But this campaign demanded a prompt and forceful challenge in scientific and political terms, not disciplinary measures 10 years later.
One of the most important factors in the evolution of the MMR controversy was the fact that it took so long for the negative judgements on Dr Wakefield’s work that were shared virtually unanimously by his peers to get across into the public realm. The result was the persistence of parallel, but largely non-communicating, universes. In the private world of medical science, authorities in the spheres of infectious disease and microbiology, paediatric gastroenterology and autism were united in regarding the link between MMR and autism as a hypothesis that was both wildly implausible and lacking in support from scientific evidence. Meanwhile, in the world of public opinion, there appeared to be a substantial scientific case in favour of the MMR-autism theory, one that derived legitimacy from the facts that it had been advanced by a team of researchers at a major London teaching hospital and published in a journal of international repute.
With a handful of distinguished exceptions, the scientists and doctors who dismissed the MMR-autism theory either remained silent or confined their discussions within medical circles. Meanwhile, the campaign against MMR promoted its claims in the public realm with great panache. Advised by a leading PR company, Dr Wakefield briefed compliant journalists, and his campaign derived substantial support from solicitors pursuing legal-aided litigation, parent groups and proprietors of separate vaccine clinics. The result was an extraordinary divergence between the expert medical consensus that the MMR-autism theory was a non-starter and the perception among sections of the public that there were doubts about the safety of the triple vaccine.
The lesson that emerges from the failures of leadership in the medical profession over MMR is that it is not enough to challenge junk science in exclusive conferences and in specialist journals (though that is an indispensable start). When public health is threatened by a researcher who promotes his theories in the mass media before they have been substantiated scientifically, it is vital that these theories are challenged in public as well as in private. It is also important that the invidious character of these methods of evading scientific scrutiny is exposed and the potential dangers pointed out.
In short, instead of vindictively pursuing Dr Wakefield, the medical establishment should put its own house in order. While Dr Wakefield has now left the scene, it is only a matter of time before another self-deluded scientist on a mission comes along.
One final point. After a week in which an increase in measles cases has provoked newspapers that have supported Dr Wakefield’s campaign to renew their calls for the government to provide separate vaccines as an alternative to MMR, it is worth emphasising that the refusal of the UK Department of Health to concede to such demands in 2002 was one of the few successful official responses to the anti-MMR campaign.
It was widely reported that Sir Liam Donaldson, the UK’s chief medical officer, threatened to resign if the government, under strong political pressure, acquiesced to the demand for separate vaccines. Prime minister Tony Blair’s earlier equivocation over whether his son Leo had received MMR had revealed the strength of tendencies towards vacillation on this matter at the heart of government, causing a serious blow to public confidence in the vaccine. The medical authorities’ stand had a strong scientific basis: there was good evidence for the efficacy and safety of MMR and none whatever for the proposed alternative. It was also sound politics. Any concession to the demand for separate vaccines could only have undermined confidence in the triple jab, resulting in a further, and perhaps even wider, loss of confidence in the child immunisation programme.
At this critical moment the intransigence of the immunisation authorities helped to bolster the confidence of health professionals, which had been battered by the persistent adverse publicity for MMR and its impact on parents. The lesson of the MMR debacle is clear: whereas indecisive leadership increases public anxiety and confusion, a robust, scientifically-founded stand is likely to allay fears and sustain public confidence.
(1) Jeremy Laurance, ‘In the dock: the man who caused the great MMR scare’, Independent, 12 June 2006
(2) See Brian Deer’s website www.briandeer.com
(3) Richard Horton, ‘MMR: Science and Fiction’, Granta, 2004