4th October 2013Blog
If you are working in pharma and are not aware of Dr Ben Goldacre you should be and it is remiss of you not to be. Dr Goldacre has established himself as a critic of dodgy science and in that mantle has laid about the reputation of the pharma industry, such as it is, in no uncertain terms in his latest book Bad Pharma. Now there is a very important yet subtle difference between the title of his first book Bad Science and that of his most recent effort. ‘Science’ is a subject, a concept, a non-human thing and when described as bad this is simply a statement of opinion about its merit that can be made on very factual grounds. ‘Pharma’ on the other hand is an industry led by people and full of people; ‘bad’ in this context is a moral judgement on those people and the argument Dr Goldacre puts forward must be analysed as such.
Badness of course, as a judgement on a person or group of people, cannot be demonstrated in a trial or proven in the scientific sense, but it can be argued for provided some rules are followed. A good argument will make clear the point at issue, state the case both for and against, and avoid hypocrisy and generalisation, before reaching a transparently reasoned conclusion. The reader, whether or not they agree with that conclusion should feel better informed and more sure of their own moral view. Dr Goldacre makes a moral judgement about pharma and the people working in it (and I’ve no objection to that), but fails to justify the position he takes with a reasoned case. It is to coin a phrase, a bad argument, not morally bad but technically mediocre. It lacks definition, it cherry-picks, it makes broad generalisations from isolated examples, it fails to recognise what is good, and lacks the required integrity (in the sense of consistency) a good argument should possess; let me explain.
Defining the issue
In any debate it is very important to define the question under discussion as words are open to interpretation. I’ve made clear that I interpret the word ‘bad’ in the context of the word ‘pharma’ as a moral judgement on the people in the industry. Dr Goldacre may argue that is not what he meant, but this is irrelevant as it should be clear what he did mean rather than leaving it to the random interpretation of the reader. In what sense is the word ‘bad’ being used, is it every company or just some, is it as true today as 10 years ago, who is responsible for being bad – if it isn’t everyone in pharma who is it? [He does state in his intro to the book that ‘I suspect that most people who work in industry are fundamentally good-hearted…’ but this seems disingenuous in the face of a book subtitled ‘How drug companies mislead doctors and harm patients’ and which features scant mention of any good-hearted behaviour by anyone in pharma. In any case, personally I’d rather be labeled bad than a good-hearted person too stupid to see any wrong-doing around them.]
Let’s face it we all cherry-pick to some extent, it’s a natural human habit to form a view, sometimes lazily, and then look around for evidence to support that view. We have a natural tendency to see patterns that agree with our view of the world order as is well explained in Bad Science. In medicine and science we have to be more exacting than that and Dr Goldacre is right to out flagrant examples of the art by pharma and by others. It is therefore with a wry grimace that I observe Dr Goldacre cherry-picking for England in his denigration of the pharma industry.
‘You may think big pharma is evil; I agree with that premise,’ he states in Bad Science and proceeds to identify examples which support the claim. This motif continues in Bad Pharma. The problem with this approach is that it does not itself prove that pharma is evil. Most people and organisations do dodgy stuff at one time or another. It is highly likely that working on a premise that Dr Goldacre is evil and, with full access to all aspects of his life and thoughts, I could support my premise with a series of anecdotes. It would, however, not prove my premise to be correct because I would be ignoring all the good stuff he’s done and to judge someone or something evil in total I need to demonstrate that I’ve considered the balance of good and bad
For every story of evil in Bad Pharma, I could write an equivalent story in a book called Bad NHS; I wouldn’t write that book because I understand its premise to be flawed. Bad stuff goes on in the NHS as it goes on in pharma but on balance I would say that the world is a better place for the existence of both though both can undoubtedly improve.
There is a variation on finding the evidence to suit the premise which starts with the cherry and works backwards to a wide and ill-founded conclusion and Bad Pharma uses what is essentially a semantic trick, extensively. It works like this:
- Cherry: ‘Some pharma companies have hidden trial data such as in this example…’
- Conclusion: ‘Pharma companies hide trial data’
The cherry is undoubtedly true, factually correct and morally reprehensible. The conclusion generalises the example to all industry and makes the accusation current rather than historical suggesting in the process this activity is condoned. This broad conclusion cannot be assumed from one or more historical facts and this flaw in reasoning should be at least recognised in the argument. Let’s take an alternative example:
- Cherry: ‘Some doctors have murdered their patients such as in this example…’
- Conclusion: ‘Doctors murder patients’
Again the cherry is undoubtedly true, but the conclusion whilst in one sense correct is patently nonsense as a generalisation on the behaviour of doctors. Dr Goldacre is relying on the prejudice of his audience to make the first example sound reasonable when in fact it is as unjust as the second. [I’ve written before on the power of prejudice to see all bad pharma behaviour as typical and all bad healthcare behaviour as exceptional.]
A very reasonable complaint about the argument I have expressed above is that it makes it impossible to accuse pharma of being bad if the response is always going to be that any examples of bad behaviour are an exception, particularly in a situation where there is no method for quantitatively measuring badness.
Paradoxically, the best way of establishing an argument that pharma is bad is by recognition of the good bits. If the good work done by pharma is recognised, the criticisms have more bite as the author has plainly considered both good and bad in his subject and has come to his conclusions having considered and weighed both.
When I read Bad Pharma I get no sense of any proper acknowledgement of the phenomenal achievements of the pharma industry, aside from a few begrudging sentences here and there. There is no clear recognition that the profit motive, for all that it can lead people to do wrong, also leads to some things that are powerfully good for humanity. A good Bad Pharma would have featured whole chapters on the successes and achievements of pharma. It would have made the conclusions of the book stronger, not weaker, because as it is the book is so lopsided that the author cannot have considered the subject matter fully in the round.
Part of the tragedy of this is that Dr Goldacre’s plea to the industry itself (with some very good points) is likely to fall on deaf ears because he does not describe in his book anything I or others who work in pharma recognise as an accurate impression of the whole business. If someone is accusing you of being evil or morally bad and fails to recognise anything good about you then at a very human level it is very difficult to listen to them quite apart from the fact you conclude that they simply don’t know much about what you do in reality.
Let’s be clear I’m not here questioning the integrity of Dr Goldacre – I have no reason to doubt it and frankly I consider his bullish approach to science malpractice to be a good thing. It is after all an approach which stimulates debate such as this.
What I’m questioning here is the integrity, in its non-loaded sense, of the many accusations he levels against pharma. He rails against marketing of medicines, and pricing of drugs and lack of attention to third world diseases and pharma malpractice without truly addressing why the pharma industry should be treated differently to other areas of life or business. The argument relies for completion on the prejudice of the audience not to question, for instance, why the pricing and selling of Dr Goldacre’s book ignores many of the principles he would have pharma adopt. It may be there is a case for pharma being different to every other sort of business in the world, but it must be explained and not assumed. This is a subject to which I will return in my next outing.
The word count is against me and looking back I’ve only been able to touch upon elements of Bad Pharma that leave me disquieted without delving in detail into examples. I’ll leave you to do that and occasionally feel the rage at some of the more overt misrepresentation what is currently the moral state of play in pharma.
Agreed, a part of my disquiet concerns some of the accusations which I recognise as reasonable. Missing data for instance remains an issue both in pharma and academia and as a member of the Faculty of Pharmaceutical Medicine I was pleased to see the Faculty named as the sole medical organisation clearly stating this is unethical
Most of my disquiet however is about an opportunity squandered. This could have been a profound argument considering the moral position of the pharmaceutical industry in the 21st century, recognising the achievements and challenging the flaws. Instead it is a mediocre caricature designed mainly to illicit the boo-hiss of an audience whose mind is already made up on the moral standing of the industry. Tragically for those of us who live and work ethically in pharma, his audience is extensive.