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Applying common sense to medical ethics

October 16, 2008
Adirondack Daily Enterprise

In a recent article, I noted that one of the authors owned a patent suspiciously related to the conclusions reached in his article. Am I being overly cautious or am I justified in pointing out such coincidences when reviewing the apparent validity of published research?

Someone once said, "Everyone has his price." Is this just as true for medical researchers as it is for the "everyone" in that observation? Is medical ethics today merely a persistent reminiscence of a bygone era, which is maintained from an ivory tower by a bunch of "old fogies" trying to exert their diminishing influence on an uncaring profession willing to sell its soul to the highest bidder?

Is Dr. Steven Nissen of the Cleveland Clinic one of those old fogies when he concludes, "Our colleagues and patients can only trust in evidence-based medicine if they trust in the evidence. To the extent that problems undermine trust, they undermine the entire scientific process?" Could he have had in mind the recent embarrassment suffered by the New England Journal of Medicine when the editors of that prestigious journal became aware of the failure of several researchers to disclose the existence of patents they held on related technology, as well as the significant funding of their research by a tobacco company, in spite of the fact that their article was about CT screening for early-stage lung cancer.

Then again, maybe he was thinking about those articles on arthritis, cancer and migraine published within a two-month time span in JAMA, the Journal of the American Medical Society. It seems that each author involved opted to avoid disclosing a funding and consulting relationship, with companies selling drugs for these very conditions until sometime afterward.

When a politician is discovered to have suspicious or even flagrant association with entities or individuals that stand to benefit unfairly from that relationship the fur begins to fly. Similar discoveries made with respect to the scientific community tend to be far less evident and far more subtle. The similarity deviates sharply, therefore, when a scientific publication is inspected with regard to its validity as a source of future relevance, appropriateness and permanent value. Usually this sort of peer review, due to the intricacies involved, is undertaken by others in the community possessing the knowledge and equipment required to comprehend and test those intricacies. Unfortunately, there is a "catch 22" involved in this sort of peer review; will such closely involved reviewers possess personal interests leading to unsubstantiated bias that is contrary to the conclusions presented in the publication, whereas undetached reviewers might possess insufficient specific knowledge about the subject matter? In other words, on one side of the "catch" we could have a reviewer whose interests deviate enough to produce a negative evaluation, but on the other side we probably have a reviewer who might find it difficult to arrive at an appropriate evaluation.

Thus, we are left with the possibility of endless dispute among those scientists having the closest intellectual relationship with the intricacies of the presentation under review. If we must suspect ulterior motives by those having superior knowledge, we must, on the other hand, also suspect any potential for benefit from an evaluation undertaken by someone with only a basic knowledge of the arguments involved.

Given these and other pitfalls inherent in a medical review, the best solution to the dilemma might be to apply two main criteria: nitpicking of the methods utilized to obtain validity, and evaluation of future relevance, appropriatenesss and permanent value as interpreted by the reviewer.

This approach provides the reviewer with an escape mechanism that can then be presented to those reading the review as an impression open to discussion rather than as a critical finality. For example, suppose I point out to you the likelihood that a research project, undertaken on only ten patients having a specific disease, may well provide insufficient statistical evidence with which to reach anything more than a reason for future research. Unless the authors of that publication declare their results to be merely preliminary evidence for further research, there is good reason for both of us to doubt the value of the presentation in general.

For those of you trying to grasp the significance of this discussion with respect to your own personal interests, think of it in light of what happens when you receive different opinions from different physicians. When this occurs, you become the one who should do the nitpicking as well as the application of common sense when evaluating the relevance, appropriateness and permanent value of medical advice.

In similar fashion, common sense should be applied when considering all the medical hype appearing in today's news and advertising. Medical ethics can no longer be counted on to always provide us with a security blanket. We must take responsibility for our own medical decisions or suffer the consequences.

Marvin Ackerman is a retired physician living in Queensbury.



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