"Patient Safety" Gravy Train

"Patient Safety" Gravy Train

We hear so much about "whistleblowers" losing so much during the process of trying to bring their concerns forward, but closer examination shows that many prominent "whistleblowers" have actually done quite well out of their activities. Julie Bailey set up a limited company, and tours the country giving talks. She particularly frequents trusts with a history of problems - and those who pay her for an appearance seem immune to her brand of vitriol. Many also buy multiple copies of her dreadful book for their staff to read. Gary Walker and Jenny Fecitt both have companies. Another whistleblower was offered a post with the Department of Health created specifically for her - doing what we don't know. I imagine many nurses reflecting on their lack of a pay raise will be surprised that there is enough to create these lucrative posts on a whim. 

Bill Cash paid someone a round £4,000 for a "report" on Mid Staffs. Who received this money? We don't know (despite this being paid out of parlimentary expenses). Nice work if you can get it. Julie Bailey and Deb Hazeldine certainly produced a report for Bill Cash. Were they the recipient of this £4,000? Cure the NHS have been silent on where their funding has come from. 

The content and value of the right to freedom of speech

The content and value of the right to freedom of speech

The recent furore surrounding "trolling" of the McCanns and the death of a woman from Leicestershire "doorstepped" by Sky News has produced a variety of reactions, some of which support dramatic state intervention to prevent free speech.  Banning speech because it is "offensive" makes the right to free speech an empty one - after all, why would anyone want to ban speech which wasn't offensive to anyone? 

This is not to defend all comments as a legitimate expression of free speech. It would be wrong to fetishize free speech to the extent that libellous comments or incitement to violence were protected. However, the objections of the McCanns include that their twins will be exposed to these comments if they go on the internet unsupervised (the wisdom of letting any minors on the internet unsupervised is debatable). It is noticeable that many of the reports failed to distinguish sufficiently between Tweets to the McCanns, and Tweets about the McCanns. This is a very important distinction. The McCanns have "no significant social media presence" apparently. Perhaps this lack of presence is a reaction to the widespread criticism of them on social media from some quarters, and I don't think this is necessarily a reason to dismiss the trolling. If the McCanns were being targetted in a campaign of harrassment, that is a different matter from comments being made about them. Plain libel is a civil matter, for good reason. The wrong is recognized by the courts, but it is not considered a criminal matter. They have already demonstrated that they have the means and will to pursue defamation suits (unlike the vast majority of the population). So the comments of Jim Gamble are quite surprising, given that a former senior police officer might be expected to know the law - or at least have the sense to check the law prior to expressing an opinion.

Many who have been genuine victims of harassment on the internet would note a sharp contrast to their own treatment by the police, who in certain areas are frankly dismissive. So Jim Gamble's comment that everyone who had similar experiences to the McCanns should go to the police just seems to show that he's divorced from reality. In many areas of the country, the police will not get involved, simply advising people to close their accounts on social media. There is a perception that these issues are only dealt with where the victims are celebrities or notables. This would erode the notion of justice for all, and reek of privilege in the old-fashioned sense of "private law". 

"Self-radicalisation" - a object lesson in confused thinking

"Self-radicalisation" - a object lesson in confused thinking

I read today about a fifteen year old girl who is believed to have run away to join ISIL who was widely described in the media as "self-radicalised". 

The term "radicalisation" is often used to describe a process that denies responsibility for extreme views, on the basis of "brainwashing" or something similar. The responsibility is shifted from the "radicalised" to the radicaliser". Or the authorities for allowing this to happen. The idea that someone can be "brainwashed" is no longer tenable. But even if it were, how could you brainwash yourself? When the radicaliser and the radicalised are the same person, then it is no longer possible to shift responsibility to an external source. 

The simple fact is that people choose to adopt ideologies. Some are more malleable and suggestible than others, but ultimately we can and should hold people responsible for the beliefs they adopt. 

Gender Neutral Toilets - Why?

Gender Neutral Toilets - Why?

If gender neutral toilets are the answer, what is the question? The justification appears to be persons who do not identify themselves according to binary genders. How common is that? Are gender neutral toilets needed for them? Do they desire to use them? Do gender neutral toilets make them feel safer?

Apparently, it is incorrect to state that gender neutral toilets are for transgender people, or for a "third sex". Which just leaves me confused.

I genuinely don't know why gender neutral toilets are necessary. I do wonder if the provision of gender neutral toilets is an attempt to challenge the widely accepted notion of gender binarity. Social engineering, in other words. 

The tricky distinction between innovative practice and quackery.

The tricky distinction between innovative practice and quackery.

The evidence-based medicine (EBM) movement has heralded increased emphasis on basing medical practise on the best available clinical evidence, although as Greenhalgh stated recently, there are problems with the implementation of EBM. It would be a false dichotomy to divide medical practice into evidence-based and non-evidence based; the principles of EBM recognize that there are different levels of evidence. 
There are some treatments that are acknowledged as being unproven. All treatments must be unproven at one time, just as all adults were once children. Penicillin and heart transplants were radical new treatments once. It can be argued that in modern medicine, a great deal of work goes into discovering new modalities of treatment, so compounds are not found by the process of trial and error of previous eras. This is not strictly true - although drugs are designed on the basis of known receptors (beta blockers being the first example), new compounds are screened using a number of techniques to assess them for particular effects. Antibiotics are still found by sampling bacteria in various places. So there are still treatments developed where it is not known exactly how they work. Where there is a known mechanism of action, there may be as yet unexplained actions that actually explain the therapeutic effect. For example, statins have an anti-inflammatory effect.
Even where there are logical reasons why a treatment might work, there is still a requirement to demonstrate empirically that it does in fact work. So prior to the completion of definitive trials, all unproven treatment are on an unequal footing.
So how do we distinguish innovative practice from quackery? In some cases, the brand of alternative medicine in question has been investigated extensively and been found to be ineffective. There may be good reasons to suspect that on the basis of the assumptions inherent to the modality or the known science that it will not work. But in the absence of empirical evidence, this cannot be definitive. Although the principles of homeopathy are absurd, nonetheless without good evidence we could not dismiss the possibility that it works. There is good evidence that it doesn't. 
However, where the treatment proposed is new, how can we distinguish quackery from bona fide responsible innovation? Really only on the basis of biological plausibility, with all the problems noted above. Only empirical evidence of lack of effect can really divide quackery from medicine. It cannot divide quackery from innovative practice.

Medical Expert Witnesses and the GMC

Medical Expert Witnesses and the GMC

The thorny issue of shaken baby syndrome has been contested in the courts many times. It is part of the scientific process that there needs to be robust debate over facts and theories. Although police forces and prosecutors may prefer to have settled science to support their prosecutions, often the science involved is not unequivocal. There is a range of legitimate opinion on the subjects of shaken baby syndrome and forensic sleep disorders, among many other bio-medical matters. Nevertheless, sincerely held scientific opinions have resulted in referrals to the GMC - an area which is arguably outside its remit (and certainly outside its field of expertise).
So Waney Squier is before the GMC on the basis of her testimony on shaken baby syndrome. Complaints against her have been made by the National Police Improvement Agency. This followed a report that a British police officer suggested that dissenting expert witnesses should be investigated. (http://www.telegraph.co.uk/health/healthnews/11094379/Shaken-baby-expert-faces-witch-hunt.html)

According to the Medical Practitioner Tribunal Service (who run fitness to practise hearings), the allegations are:

that during these proceedings Dr Squier provided an expert opinion evidence by way of written report and/or oral evidence outside her field of expertise. It is also alleged that Dr Squier failed to discharge her duties as an expert in that she failed to work within the limits of her competence, to be objective and unbiased and to pay due regard to the views of other experts.

It is alleged that Dr Squier’s actions were misleading, deliberately misleading, dishonest and brought the reputation of the medical profession into disrepute.

http://www.mpts-uk.org/calendar/event_details.aspx?ID=29076af4-7fce-44b2-81c3-914d078f1acc

It is regrettable that the decision of Judge Collins in the High Court in Meadow  was overturned. He ruled that the GMC should not invoke disciplinary proceedings unless a trial judge commented on the quality of expert evidence given. The Court of Appeal overturned this ruling, stating that the GMC was able to adjudicate where such issues impacted on fitness to practice. It is unclear when, if ever, a doctor’s expert witness work would impact on their fitness to practice. 

The courts set the standards for expert testimony, and it is the courts that should adjudicate on these matters. If they are concerned, then a GMC referral may be appropriate. Having a party to court proceedings refer expert witnesses to professional bodies is not conducive to the fact finding process.

Ideological Opposition to the Saatchi Bill

Ideological Opposition to the Saatchi Bill

My presentation about the ideological opposition to the Saatchi Bill was received well at the Postgraduate Bioethics Conference. Although there are concerns about the effect of the Saatchi Bill on patient safety, there are some groups whose objections are not related to patient welfare at all. 

The two groups of ideologues opposed to the very principle of permitting wider use of innovative treatments are 1) the evidence-based medicine fanatics and 2) so-called “skeptics”.  The self-described “skeptics” appear to be a group of humanists/atheists committed to fighting alternative medicine, most of whom have no scientific qualifications whatsoever, having graduated in history, IT or other non-scientific fields. Both these groups have articulated their concerns that the bill is a “quack’s charter”.

Both these groups suffer from ethical blindness. They fail to appreciate that bad science can be good ethics. Similarly good science can be bad ethics, as the medical experiments of Nazi Germany demonstrate all too well (experiments which have driven the current framework for research governance). 

It would be blinkered thinking to consider that lack of research evidence prohibits the use of a treatment. The pioneer of the PRCT, Austin Bradford Hill, stated

‘All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. This does not confer on us a freedom to ignore the knowledge we already have, or to postpone the action it appears to demand at a given time.’

He also stated that

‘Any belief that the controlled trial is the only way (to study therapeutic efficacy) would mean that not only that the pendulum had swung too far but that it has swung right off the hook.'

Ethical illiteracy is worse than scientific illiteracy in this context. Ironically, the humanists seem to have lost sight of their humanity.