[back] Wakefield GMC Hearing 2007
Monday 11 August - Friday 15 August
by Martin Walker MA for http://www.cryshame.co.uk
Humbug: deceptive misrepresentation, short of lying, especially by pretentious word or deed of somebody's own thoughts, feelings or attitudes.
Max Black, The Prevalence of Humbug ,
cited in On Bullshit by Harry G. Frankfurt,
Princeton University Press, 2005, Princeton.
Last week Miss Smith continued to go through each case of the children cited in the Lancet paper. Rather than reduce the cases to bullet points, this week I decided to write up one child in some detail to give readers a good idea of how the prosecution case is being presented. I then look at the prosecution case in greater detail in the next two sections.
Before beginning her analysis of each child's case, Miss Smith outlines the charges relating to the case. The case I have chosen to report is Child 5. Professor Walker Smith is charged on a number of counts in relation to this child, the two main charges relating first to the reasons for referral and admission and second to the use of procedures which the prosecution claim were not clinically indicated.
Child 5 had been referred to the Royal Free Hospital after his parents found out about the work of Dr Wakefield and asked their GP to refer him. Miss Smith went through the letter from the General Practitioner. It's main feature was that the child had been diagnosed as autistic and had serious behavioural problems. The GP had referred the child to three consultants. The parents were concerned about the link between their child's condition and the MMR vaccination.
Miss Smith's first point of attack, as it has been in a number of other cases, was the fact that the GP, in his letter of referral, appeared to make no mention of gastrointestinal symptoms. Miss Smith relies on this point as if the GP's letter to the Royal Free is meant to consist of a complete and thorough account of all the child's symptoms, when it is actually a note giving the receiving doctor a very general account of the child's presentation.
When this is put to Professor Walker-Smith, he makes a number of quite clear points. He first says that Miss Smith is wrong and points to two places in the letter where the GP mentions gastrointestinal symptoms. He then makes the point that he did have children referred to him who had no evident gastrointestinal symptoms and that he considered it his job to decide on the relevance of the various symptoms the child had. But Walker-Smith's most serious point is that the GP who had written the letter had decided to focus on the child's autism and having done this had spent little time on any concomitant symptoms.
Miss Smith then made much of the fact that the GP had said that the parents were aware that a 'study' was going on and they wanted to be involved in that 'study'. The loose use of language has bedevilled this hearing from the beginning, allowing Miss Smith to make mountains out of molehills. Of course it is not practical for either the GP or Walker-Smith to remember or understand completely, after so many years, what was meant and understood by the word 'study'. Miss Smith is of course convinced that the GP and the parents are fully conversant with 172/96 and it is this to which they refer. Professor Walker-Smith is more catholic in his interpretation and puts forward the sensible view that 'the study' could mean anything to do with seeing this group of children.
Miss Smith cannot resist pursuing Walker-Smith on the matter of 'the study' she is insistent that Walker-Smith clearly agreed to see this child so that it could be part of 172/96.
Professor Walker-Smith's clinical notes make clearer the gastrointestinal problems that child 5 has. Aged two, he began holding his abdomen, rigid with pain, and had bouts of diarrhoea once a month, while producing one soft stool a day.
Miss Smith of course makes out that Professor Walker-Smith is enhancing his diagnosis so that he can whip the child into the Royal Free to have a colonoscopy performed. She queries Walker-Smith's decision to prescribe a colonoscopy and wants to know why inflammatory markers were not obtained from blood samples first.
Professor Walker Smith argues with Miss Smith, pointing out that this particular boy had very serious behavioural problems and it was not possible to take blood samples. Miss Smith counters with non-sequiturs which follow her own distorted internal logic but do not make the slightest sense in the context of Walker-Smith's cross examination. She says, 'You skipped the inflammatory markers because his symptoms were slight', implying that Walker-Smith knew full well that the child did not have gastrointestinal problems.
Walker-Smith comes back with a good piece of empirical observation. He tells the panel that the parents of child 5 were 'wonderful' and he got a very clear picture from them of the boy's pain and how difficult it must have been for the parents dealing with this pain.
He added information gained from the experience of studying this group of children at the Royal Free. He tells Miss Smith that it was necessary for the children with bowel problems to have a colonoscopy, that the team knew that most of these children had to have further investigation.
Miss Smith bludgeons on about the blood tests. Professor Walker-Smith simply corrects her, ' You haven't taken account of what I said, when he came to see me, he was extremely hyperactive'. Miss Smith refuses to listen, almost as if she puts her hands to her ears and screws up her face, then she returns to her pre-determined flight path. 'Isn't it the truth, that regardless of the child's actual behaviour you were determined that he was going to have a colonoscopy regardless?
Professor Walker-Smith bridles at this and raises his voice slightly. 'This is so unfair, why should I at this stage in my career embark upon a research study outside of the child's interest?'
Of course Miss Smith is the last person capable of giving even a vaguely sensible answer to such a heartfelt question and the truth is that she hasn't got an answer to this particular one.
Miss Smith, gives Professor Walker-Smith a few brief lessons in medicine, telling him that he wasn't justified in going straight to a colonoscopy without assessing inflammatory markers.
Walker-Smith comes back at her with a lifetime's experience in gastroenterology. 'As a doctor, you learn by experience and my experience suggested that inflammatory markers were not essential in this case'.
Miss Smith apparently does a quick side step with a question which asks whether it is not the case that many autistic children have bowel problems. Professor Walker-Smith is not fooled by the side-step and forges ahead in a straight line, bringing Miss Smith up short with a powerful straight statement. 'We seem to be going round in circles Miss Smith'.
Miss Smith makes her final assertion about colonoscopy, which is more or less the same as that which she has made in other cases. 'I am suggesting that you suggested the colonoscopy because the child was entered in a research study'.
The cross-examination on child 5 ends with Miss Smith, summarising the histological conclusion of the various procedures carried out on the child. She makes it appear that these results are minimal and didn't necessitate the colonoscopy. Professor Walker-Smith gives a final answer saying that it is not up to the histopathologist to come to clinical conclusions. The independent observer must be left with the feeling that even the minimal information achieved from the colonoscopy, such as the inflammation in the large bowel, would inevitably have helped the doctors move forward with this case ... and of course, as always, that Miss Smith is some files short of a brief.
* * *
Everything became clearer during last week's hearing, the prosecution case was revealed in all its rusty and corrupt glory. Finally it became clear why only three out of the twelve authors of the Lancet paper are on trial at the GMC; something that I have previously been unable to fathom.
I have said on a number of occasions that with the intervention of Medico-Legal Investigations (MLI), the private enquiry agency that helped Dear Brian put his case together, this fitness to practice hearing changed into one about scientific misconduct aimed at aiding the pharmaceutical company vaccine campaign. The basic theme in all the pre-trial propaganda was that Dr Wakefield's research had been discredited. Of course it never has been. This, however, was the task that the prosecution set themselves when the hearing began; to show clearly not that Wakefield et al, had failed to prove any link between MMR, bowel disease and regressive autism but to show that Dr Wakefield and those with whom he had worked, had experimented upon vulnerable children who suffered from genetically determined classic autism.
When one considers the ramifications of this central charge, both its formulation and its effect are frightening. In detail, the prosecution is saying that the three doctors in the dock inveigled young children, often with the help of their ‘neurotic' parents, to the Royal Free Hospital, where, without fully forewarning the parents or seeking research ethical committee approval, they carried out dangerous colonoscopies and other risky procedures upon them.
I say colonoscopies, not just 'procedures' because it is this particular diagnostic procedure upon which the prosecution has placed most emphasis. There has been talk about other procedures, such as lumbar puncture and barium meal; however, these other procedures have not ranked as high in the prosecution evidence as colonoscopy.
In discussing the danger and suitability of colonoscopy in these cases, the prosecution have depended up the evidence of Professor Booth. Despite his ability to prevaricate and obscure issues, despite his undoubted 'quackbuster' approach to environmental hazards and despite even his skilled and apparently practiced ability to filibuster any question that might have hinted at his ignorance, Booth was a remarkably good witness for the prosecution. The case he put forward went as follows; any child with suspected inflammatory bowel disease should first be given blood tests for inflammatory markers. Their case history notes should be scrutinised to find any reference to gastrointestinal symptoms and only as a very last resort should colonoscopy be used to look for abnormalities in the bowel.
Since Booth's evidence, the idea of blood tests and inflammatory markers has haunted the defendants, particularly Professor Walker-Smith, and despite the fact that their lack of use has been frequently and coherently explained, Miss Smith has come to use the event of colonoscopy, together with the lack of evidence of inflammatory markers, as the main foundation for the prosecution.
If we cast even the most superficial glance over the defence arguments for using colonoscopy without evidence of inflammatory markers, we can see they are solid and reliable. Professor Walker-Smith is not against the use of blood tests for inflammatory markers, actually describing himself as one of the pioneers of such tests. However, he maintains that blood tests do not guarantee the disclosure of bowel inflammation. In fact, he argues, there are a number of conditions that do not respond at all to these tests. What is more, such tests give no real idea of the type or degree of inflammation suffered by the patient. But perhaps even stronger than this scientific argument, according to the defence, is the fact that many of the children who presented at the Royal Free Hospital had serious behavioural problems brought on by their regressive autism, that were so serious that the taking of blood was extremely difficult.
Professor 'obscurantist' Booth presented the prosecution with very unclear arguments with which Miss Smith might contradict the defence approach. He did not suggest that some conditions were not manifest with blood tests, and he refused to agree that many children suffering from autism were too difficult to handle while taking bloods. It might appear odd however, that the prosecution should rely so heavily on the one witness who was perhaps their weakest expert. They have had to do this however, because as is now apparent, the matter of colonoscopy, as the ‘risky' procedure described by Booth, is at the very centre of their prosecution.
We might have seen all this coming when Miss Smith intoned in all seriousness that Dr Wakefield was guilty of 'causing colonoscopies to happen'. While it is difficult to imagine a more ludicrous charge than this, the logic of it within the prosecution case is quite clear. If the colonoscopies were to be central to the prosecution case, if Professor Walker-Smith can be accused of 'ordering them' and if Professor Simon Murch can be accused of carrying them out, Dr Wakefield had to be accused of something in relation to them.
Of course, everything falls down, if not initially with the basic stupidity of the charge, then later when we come to look at the question of motivation. I have said before that the prosecution has not once even suggested a motive for these three doctors embarking upon illegal, illegitimate and sinister experiments on child subjects. This lack of one of the central features of any prosecution is now gathering increasing negative moss as the marble of Miss Smith's case rolls slowly downhill.
In the words of Professor Walker-Smith last week, 'Why would I?' carry out unsanctioned experiments on children. It is indeed a question that needs answering. Why would a long standing and professional paediatrician with 30 years experience in the field, a few years from retirement, suddenly embark upon a series of 'dangerous' experiments on young children. Nothing is clear from Miss Smith's case. If we were to be flattering to her cause, we might say that it seemed initially to be her case that the whole point of this exercise was that Dr Wakefield and his colleagues were intent on gaining evidence helpful in disrupting government vaccine policy and aiding claimants in breaking three of the world's biggest pharmaceutical companies. However, although Miss Smith's cross examination of both Dr Wakefield and Professor Walker-Smith, have slid under the table basic questions of the law suit against these companies, the prosecution have yet to prove that the investigation into inflammatory bowel disease and regressive autism, or even the adverse reactions provoked my MMR, were in any way illegitimate or unworthy areas of clinical diagnostic investigation.
Because the prosecution, muddled from the beginning, is unable to point to cogent motive , , they have inevitably left a whole host of speculative thoughts in the minds of the Panel. If these ‘risky' investigations were not carried out on the basis of clinical need, it would take no great imagination for people to conclude that Miss Smith is accusing the defendants of acts relating to sadism or torture. If she is willing to accuse them of failure to seek 'rational' parental consent, of avoiding approval from a research ethics committee, of carrying out procedures for the very sake of it when other, non-dangerous, approaches are just as viable, what is there to stop her from going the whole hog and suggesting 'satanic abuse'.
The implicit level of Miss Smith's unreasoned approach, can be seen in the bizarre exchange that took place on Thursday August 14. Miss Smith had suggested that Professor Walker-Smith had not got research ethical committee approval, because he simply wanted to research the children without it. And after having suggested that the children were inducted into the Royal Free under a research protocol and not on the basis of clinical need, Miss Smith put the following to him:
'The truth is, isn't it, that you were looking for an excuse to do a colonoscopy'.
In fact, this one sentence could be used on the grave-stone of the prosecution case, the whole mad farrago of the evidence, comes down in the end only to this, that the three defendants have ruined their professional lives by committing the gravest immoral crimes against children for no reason other than the fact that they wanted to do them.
Professor Walker-Smith has dealt magnificently with 'Mad' Miss Smith, and although he wavered a little on Monday and Tuesday, by Wednesday and Thursday, he was repeatedly repelling her. His answers became forceful and sometimes provocative. He frequently forced Miss Smith back onto the ropes, and left her stumbling around using last years tactics when dealing with uncomfortable witnesses; the 'Yes well, lets pass on to the next subject' tactic which Miss Smith uses whenever the witness defeats her with clear and believable answers to inane questions.
But perhaps the signs that Professor Walker-Smith had really got Miss Smith's measure began to appear on Thursday and Friday. Whether by design or accident (the latter is not quite believable) the professor began frequently to answer Miss Smith's rickety, long winded and propagandist questions, before she had finished voicing them. This led time and again to Miss Smith expressing her real tetchy self ; 'You really have to let me finish the question' and 'Would you please let me finish'. During one particularly long diatribe that might or might not have been leading to a question, Professor Walker-Smith interrupted her, and she bit back at him in an extremely up-tight tone, 'I haven't asked the question yet, can you just wait'. The hilarious thing is that Miss Smith seriously thinks that she is occupying a moral high-ground from which she has the right to be rude to the defendant.
Of course, Miss Smith's attitude is that of prosecutors since time immemorial; an attitude that assumes the moral high ground long before the jury have voiced their verdict and treats defendants as if they are inevitably guilty simply by dint of appearing before them. In this case, if the truth be known, the moral polarity of the defence and prosecution is completely reversed, while the prosecution is perpetrating the greatest moral outrage, the defence is acting completely without guile and with obvious innocence.
It's difficult to know whether Professor Walker-Smith is being impish or just gauche, consistently interrupting Miss Smith, asking her questions ('I'm the one asking the questions!; she replied), pushing her back aggressively with his own strong statements of outrage. In my notes on Friday morning, I wrote:
Walker-Smith is sharp as a tack this morning, absolutely a match for Miss Smith. In fact running rings round her. Walker-Smith is absolutely brilliant, it's as if he's 'on something'. He's clear, strong, combative and arguing in a clear voice; really kicking ass.
Oddly, Walker-Smith has taken to apologising profusely when he is ticked-off for interrupting Miss Smith, but it is difficult to find a note of sincerity in these quite abject apologies as they come studded with irreverent chuckles. The rabid intelligence of Bertold Brecht's approach to answering questions before the House of Unamerican Activities Committee comes to mind when listening to Professor Walker Smith's insincere sounding apologies. Brecht answered nearly all the questions put to him using double negatives, in an attempt to confuse his interrogators.
In one of his answers to Miss Smith, Professor Walker-Smith, despite his age, stature and seemingly small 'c' conservatism, introduces the only note of politics so far broached by the defendants or their counsel. Answering Miss Smith's attempts to tell him what test he should and should not have carried out, he said ' This (your criticism) is really a challenge to my clinical freedom'.
The fact is , Miss Smith is quite insufferable when she acts as if she's a doctor rather than a lawyer. Personally, I am not at all interested in listening to her 'play doctors', especially when she is involved in exchanges with one of Europe's best recognised paediatric gastroenterologists or even more so when I know that she is parroting the words of her prevaricating mentor Professor Booth.
* * *
It is clearly the case that a good counsel needs the same breadth of education and information as a good interpreter. At any time they could be called-upon to present a case relating to a particular occupation or area of knowledge. Miss Smith comes from a chambers that specialise in medical cases. Throughout this case she has, however, shown scant understanding of the culture of medicine and the context of working doctors. This was brought home to me last week, when she cross-examined Professor Walker-Smith on why he had changed a decision that had first been recorded in a letter. Miss Smith has consistently argued that all that is written down is a record of the truth. In this case, Professor Walker-Smith maintained that the doctors talked amongst themselves very often and he could have changed his mind after a short conversation over the case notes anywhere.
There is a considerable difference between the craft of being a lawyer and that of a doctor working in a crisis situation, trying to find a diagnosis. Only the very best lawyers can think on their feet. In the main, being a good barrister depends upon knowing and understanding the law, developing a style that will communicate that knowledge to a judge, a jury - or in this case a panel - and being familiar with all the facts and arguments to carry through well structured evidence-in-chief and cross examination. Perhaps an exceptional barrister is one who can force the form of the opposition into such a mould as can establish and articulate the barristers own agenda.
The practice of medicine, and particularly the art of diagnosis, is completely different from the rational tasks the barrister faces. Doctors in a crisis, trying to find a diagnostic solution, must behave in a creative way, trying to understand the hidden rules that have developed and guided an illness. A doctor in this situation needs creative perception and an ability to think on his feet.
There is however, another fundamental and basic difference between a lawyer and a doctor; the venue for the lawyer is the court, a completely formal situation, which now often bars anyone from laughing, even at jokes, during proceedings, a situation where, in the main, silence prevails and extraneous discussion or language in any form is frowned upon; passing and reading notes is the closest that the barrister in court gets to a collective working situation. For doctors, all this is different; it is almost impossible for doctors to act individually, answerable as they are on all sides to colleagues, patients and the hospital administration. The working environment of the doctor in a hospital is co-operative and collegiate. This point came home forcibly when Miss Smith insisted at one point last week, that in relation to one particular decision, Professor Walker-Smith was ‘the chief'. Walker Smith was insistent 'things don't work like that in the NHS', 'There are no chiefs, there is a collegiate approach to problems', he said
While lawyers work primarily alone, most doctors in the setting of an inner city hospital work collectively. The importance of this is that were you to ask a barrister why she changed her argument at a certain point, she would, if she remembered it, be able to tell you the specific thought processes behind it. If on the other hand you ask a doctor, twelve or thirteen years after a decision was made in the treatment of a patient, or the analysis of a diagnosis, it could be that the decision was made in the lift during a conversation with another doctor, or it might have been made an hour after a meeting of interested students and specialists who were going through histology slides and it might even have been made during an argument with another four specialists that developed in the morning in the canteen and carried on during a meeting in the afternoon.
Both Dr Wakefield and Professor Walker-Smith have stressed that this medical culture, especially in cases where a diagnosis is being searched for, is germane to any outcome. Dr Wakefield, during his evidence, presented the ongoing search for a diagnosis of the 12 Lancet Children, as a creative process. This is especially true in cases of undiagnosed illnesses - those whose treatment has not been previously written down or formalised.
Professor Walker-Smith, during his cross examination, has told Miss Smith that she should remember that everyone talked to everyone else about these cases. Decisions were made all the time in telephone conversations, and, of course, not a word of these decisions was written down.
It is extremely worrying that Miss Smith pays no heed to the fact that this 'culture' exists in a large hospital and that doctors work in a collective manner. It took decades through the nineteen-seventies, eighties and nineties, for sociologists and journalists to realise that while many of the decisions made by police officers were recorded in a variety of ways, many of the underlying processes that led to people being questioned, charged or convicted, began in the canteen where 'canteen culture' guided many of the attitudinal responses of police officers.
Miss Smith, however, appears not to be up with her reading of sociology as far as doctors are concerned and she insists that an adequate description of reality can be deduced from general practitioners letters, and passing references to things in a variety of notes. The fact is these 'records' are often nothing more than the musings of the doctor concerned; an aide memoire .
As well as this, Miss Smith appears to have no ear for history, believing as she does that the most important decisions are faithfully recorded in some manner and that medicine is such an inorganic process that once things have been written down they cannot be changed or altered for the better.
It took historians, and teachers, decades to get away from the idea that history entails listing the names and dates of Kings and Queens. What we now understand as history includes that almost invisible and somewhat ethereal culture that can be read between the lines in the official record. Miss Smith's case is failing in a number of ways, but in this lack of insight into the culture of a big hospital faced with a public health crisis it is failing spectacularly.
* * *
Miss Smith's performance last week made me realise for the first time in some years how keenly I miss Dennis Potter's (1906 - 1975) brilliant musical dramas ( en.wikipedia.org/wiki/Dennis_Potter ). For those of you who don't know Potter's work, he wrote a number of series for television, the most popular of which was Pennies from Heaven . All his dramas had musical interludes, during which the play's character sang and danced.
Miss Smith's performance last week brought back to me the immense joy that I got from Potters musical drama 'Cruising for a Colonoscopy.' (Well, I'm sure he would have written it had he not died). In this play three doctors driving to a nightclub on New Year's Eve, after a difficult years work, are pulled over by two pharmapolice . They are arrested for ‘going equipped to perform a colonoscopy' and then taken before the magistrate, who although she looks like Miss Smith, has a great yellow beak.
In the short time that I had to write this piece for the Cry Shame site, I couldn't find a copy of the play itself and only managed to get hold of bits of the libretto; however, I have typed out these bits below, with some notes from memory about how the characters appeared. I'm sorry that I can't offer you any music and you will all have to do the best you can. All the action takes place in the year 2025.
In one of the earliest scenes the two pharmapolice officers swagger over to the doctors' car and getting to the front of it, burst into song. They are both baritones and they nose around the car as they sing, their thumbs stuck in their belts:
The law works in mysterious ways,
Doesn't it just,
Yet a few years a-go,
We would have been-looking for men
breaking and entering,
Going equipped with jemmy's and masks.
But what have we here,
In these post modern times,
Medical men, so we've been told,
real Burke and Hare, just like of old.
Sinister men, looking for healthy young things.
The two pharmapolice officers then stand together to sing a duet.
We've caught you this time,
We can see from your medical garb
And the equipment you carry,
You were just looking
for any excuse
to carry out another colonoscopy
As the police officers finish this song, the three doctors step from the car and walk round it to link arms facing the two police officers. They are dressed in white surgeon's robes with face masks.
We don't understand
How can you say these things about us.
Where is your proof,
Of our 'going equipped'.
Why would we want to do such a thing?
Our careers are unblemished,
Our research is unfinished.
You pharmapolice are determined to stop
Our careers. The slightest thing, the smallest op,
And you force us to stop.
Well, we're going to a party,
And you can't stop us now.
We've finished work for today,
And we don't want a row.
We're not going to stay
And be insulted by you.
We've worked hard all year,
In the name of the people,
And we're going to a party now.
The next scene is in a magistrates court. The three doctors are in the dock, the two pharmapolice are standing at ease with their backs to the defendants facing the judge. The judge is Miss Smith (as she was known then as Sally 'Starlet' Smith) she is dressed in the black costume of a huge vulture. Her wings flap occasionally and she rises slightly over her bench. When she first played this part, the theatre critic for the Evening Standard wrote 'Starlet Smith is very forceful, her voice, many screeches higher than that of Celine Dion, is unnerving and some people leaving the theatre complained of regressive deafness.
I put it to you,
And you must agree,
That it is the case,
I'm sure you can see,
You were caught bang to rights,
Cruising for a colonoscopy.
You must understand,
That we don't believe
A word that you say,
There was never any clinical need,
On young children you feed.
You will have to admit
That you were just looking
for any excuse,
To carry out a colonoscopy.
If you were honest,
You would be bound
To agree, that you have no defence,
That you have created offence,
While it's all very well,
For you to pretend that you were trying to find
A diagnosis for an unknown disease.
It's clearer than clear to me that you were,
Just cruising for a colonoscopy