Observations

medicine and the media Cervarix: not the new MMR The UK press may have learnt lessons from the MMR furore, though this hasn’t stopped some papers from sensationalist stories about the HPV vaccines, writes Rebecca Coombes

We have known for more than a week that the without clearing any inferences that the injection Sunday Times coverage of Natalie Morton’s death Cervarix vaccine did not kill 14 year old Natalie was the cause of her death, which we now know is Morton (BMJ 2009;339:b4032). But the sad death clearly not the case.” sexual activity for teenage girls is all right,” said of the Coventry schoolgirl shortly after receiving Although Harper has reservations about the Richard Millard. the human papillomavirus (HPV) vaccine on 28 delivery of the mass HPV vaccination campaign, she The GP, writer, and broadcaster Phil Hammond September presented a difficult test to the press in is satisfied with the safety record of both vaccines. is not surprised at some of the more over the top the United Kingdom. “The evidence base is quite adequate for both coverage but questions why the government wasn’t The story had some of the hallmarks of the vaccines. The evidence for Gardasil does show a quicker off the mark. furore over the measles, mumps, and rubella very small risk of adverse events. Both vaccines are “The only way to counter scare stories is to have (MMR) vaccine—a health scare also concerning a in general safe for most women.” charismatic communicators to shoot them down vaccine with a previously excellent safety record. If the Sunday Express story was simply out and quickly. Andy Burnham should have led the charge Journalists had their fingers burnt over MMR, when out inaccurate, minor errors elsewhere were also with the HPV vaccine but has been slow out of the they gave credence to the maverick doctor Andrew creating problems. These included reports directly blocks.” Wakefield and his later retracted evidence that the after Natalie Morton’s death that the whole HPV Hammond also questioned why the government MMR vaccine might trigger autism. Perhaps wary vaccination campaign had been suspended in the didn’t quash any conspiracy theories and publish of charges of gullibility, initial reports of Natalie UK. This was not true; instead there was a delay in the assessments it made of the two HPV vaccines. Morton’s death were restrained. “Don’t panic” ran getting replacement supplies of Cervarix after the “If you don’t publish in full why you made a the Daily Mirror headline. Science friendly media batch that included the vaccine used on the 14 year particular decision at the time, it smells as if you’re agencies, such as the Science Media Centre, old was quarantined as a precaution. trying to conceal something. The Tories have made successfully fielded questions from the press and However, Tom Sheldon, of the Science Media some capital out of this, as well as the press.” provided expert quotations. Centre, writing in the Guardian, defended the right No evidence exists that Gardasil is any safer The story moved quickly: on 1 October of journalists to ask questions. “Local radio stations than Cervarix. An article in JAMA in August preliminary reports showed that Natalie had a have been inundated with emails from worried (2009;302:781-6) reported the results of safety large malignant tumour in her chest, which had parents, some questioning whether to allow their surveillance in the first two and a half years since caused her death. But some news desks were daughters to have the vaccine. And it was natural Gardasil hit the market and found 32 unconfirmed unable to shake the scent of a different story. On to wonder whether the vaccine had anything to do deaths. Two further deaths have occurred in 4 October, in headline letters several inches high, with Natalie’s death. Who wouldn’t ask questions? Europe, one in Germany and in Austria. The main the Sunday Express declared the “Jab ‘as deadly as That is the job of journalists, and to address the difference between the two vaccines is that Gardasil the cancer.’” These words were attributed to Diane possibility of a link was legitimate.” also protects against most forms of genital warts. It Harper, who has been involved in clinical trials of But this was never going to be the next MMR, is also more expensive. GlaxoSmithKline’s Cervarix and Merck’s Gardasil. says Sheldon. “[Anti-vaccination] campaigners But some press stories suggested that cheaper Speaking to the BMJ, Harper, professor of got barely a sniff of the action. We have learnt too also meant less safe, in the case of Cervarix. obstetrics and gynaecology, community and family many lessons from last time. Responsible, cautious Amanda Platell wrote in the Daily Mail: “The tragedy medicine, and bioinformatics and personalised scientists were everywhere this week, offering of [Morton’s] death highlights the scandal that this medicine at University measured, evidence based information.” government went for [the] cheapest option.” It was “The only way of Missouri-Kansas This measured tone didn’t filter through to the a line the Daily Mail had been peddling all week. to counter scare City School of review section in the Sunday Times of 4 October, in Two days after Natalie Morton’s death, the paper’s Medicine, said Rosie Millard’s 1000 word feature entitled “What columnist Allison Pearson stormed: “Why were we stories is to that she was has this jab done to our girls?” The former arts not told a deluxe version was available?” have charismatic extremely unhappy correspondent spoke to families involved in a class But amid the more hot headed comments, communicators to at the “horrible action suit against GlaxoSmithKline. The parents Tom Sheldon is keen to emphasis how far health shoot them down misconstruction” of claim that their children had an adverse reaction journalists have come since the MMR scare. In fact, quickly. Andy her statements. to the HPV vaccine. The feature began ominously: he says, the “most frightening pieces of [anti- “I was not “A year ago Rebecca Ramagge was a happy, sporty vaccination] rhetoric” he’d come across was from a Burnham should accurately quoted in teenager. Today she’s a 13 year old crippled with doctor, Richard Halvorsen, in the Daily Mail, and not have led the charge either the Daily Mail or chronic fatigue syndrome who has been laid up in a journalist. . . . but has been the Sunday Express,” bed for seven months.” Says Sheldon: “I know of one health journalist slow out of the she said. “I never said Although Natalie Morton died from a tumour, who argued vociferously on Wednesday to stop blocks” that the ‘jab was as not the vaccine, said Millard’s article, “privately her editors splashing with ‘Ban this killer vaccine.’ deadly as the cancer,’ some NHS doctors are of the view that the injection Google this headline and see who won.” nor was the interview exclusive [as was claimed]. might well have been a catalyst.” A sceptical GP Rebecca Coombes is an associate editor, BMJ The journalists did not reveal the autopsy results of quoted in the article was not a vaccination expert [email protected] Natalie Morton at the time of the interview, leaving but the journalist’s brother. “A giant vaccination Cite this as: BMJ 2009;339:b4124 the statement that she died after her injection— programme is the sort of tacit agreement that See NEWS, p 824

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Legal Tender Sheila A M McLean Live and let die The case of Kerrie Wooltorton rests solely on whether or not her decision to refuse lifesaving treatment was legally competent

The inquest into the death in on admission to the hospital, her off the ventilator. It seems plausible that 2007 of Kerrie Wooltorton (BMJ doctors were legally unable to provide Ms B could well have been depressed 2009;339:b4070) has focused media treatment, and the existence or not of by her situation, yet the court ultimately attention on advance decisions a binding advance directive was legally upheld her right to refuse ventilation and (directives) or “living wills.” It has irrelevant. This, of course, depends on even levied a small fine on the doctors provoked some commentators to argue the presumption that she was legally involved for failing to comply with her that giving legal standing to competently competent at the time of the refusal. wishes. executed advance directives, as the The fact that she apparently had some Assuming that Ms Wooltorton was Mental Capacity Act 2005 does, is a form of personality disorder is not in indeed legally competent, the existence step too far onto a potentially slippery itself persuasive evidence that she was of the advance directive was, as we slope. (It is worth noting that this act not competent. It is well established in have seen, irrelevant and is needlessly does not apply to Scotland.) Although law that even the presence of mental confusing in this case, which in essence it is undoubtedly a tragic case, it is illness is not a bar to the presumption is only about a straightforward refusal worthwhile to unpick what we can learn of competence (Re C (adult: refusal of of consent by an adult person who is from it and what the main issues at medical treatment) [1994] 1 All ER 819). However dreadful deemed legally competent. Simply put, stake are. The Mental Capacity Act 2005 clarifies it must be for a doctor who imposes treatment in the Ms Wooltorton had apparently that a person is legally incompetent if “ face of a competent refusal would be ingested antifreeze on up to nine he or she is unable to understand the healthcare guilty of assaulting the patient. previous occasions but had nonetheless information relevant to the decision, to professionals to However dreadful it must be for accepted lifesaving treatment after retain that information, to use or weigh watch a person healthcare professionals to watch these incidents. To complicate matters, that information as part of the process of who could be a person who could be saved die she was also said to have had an making the decision, or to communicate saved die because because they have declined available “untreatable” emotionally unstable his or her decision (whether by talking, treatment, they have no alternative but personality disorder. The final twist sign language, or any other means). The they have to do so in these circumstances. The in this complex story was that a few conclusion of Ms Wooltorton’s treating declined available recent legislation does not change this days before her death she had drafted physician, which he apparently took treatment, position. Of course, had Ms Wooltorton an advance statement indicating that some pains to have verified, was that Ms they have no arrived at hospital in an unconscious she did not wish to be treated should Wooltorton did not fail the competence alternative but state and with no advance directive, the the same circumstances arise in the test outlined in the Act and was chances are that doctors would have future, even if she called an ambulance. steadfast in her wish to reject treatment. to do so in these done everything in their power to save Rather than being treated, she wanted Of course, it also seems that she circumstances her, and this would have been justified to die in a situation where she was may have been depressed, and this by the legal doctrine of necessity. Had not alone and where comfort care was possibility has also raised some she arrived unconscious but with an available. A document containing a concerns. Should a person who is applicable advance directive, equally no rejection of treatment was presented depressed have his or her decisions attempt at treatment would have been by Ms Wooltorton on admission to respected, especially when the ” lawful. hospital when she was still conscious. consequences of so doing are as grave However, neither of these situations Presumably this document had been as they were in this case? This is a arose. Ms Wooltorton was adult and executed in line with the legislative difficult question to answer, but some apparently competent and able at requirements, and it was apparently implications may be derived from other the relevant time to reject treatment. accepted as valid. examples. Take the case of a person The question, therefore, is not about What can be drawn from this case? who rejects life sustaining treatment, advance directives but about whether Firstly, even though Ms Wooltorton albeit in different circumstances. One or not her decision was in fact legally had previously accepted lifesaving such situation arose in the case of Ms competent. If she was, then refusal treatment after ingesting antifreeze, no B (Ms B v NHS Hospital Trust [2002] was her right and, as such, had to be legal inference can necessarily be drawn 2 All ER 449). Here, a woman had respected. from this that she would—had she become tetraplegic and depended on Sheila A M McLean is director of been thinking clearly—have accepted a ventilator. Her mental competence the Institute of Law and Ethics in treatment on the final occasion. In other had previously been in doubt, but it Medicine, University of Glasgow words, even if she had “changed her appeared that she was competent at the [email protected] mind” in the past, objectively she had time she requested the removal of the Cite this as: BMJ 2009;339:b4112 the right to make a different decision on ventilator. Her treating doctors declined This article appeared in an earlier version this occasion. to agree to this and attempted to as a BMJ blog (http://blogs.bmj.com/ bmj/2009/10/01/sheila-mclean-on-advance- Secondly, as she was able to make a encourage her to agree to an alternative directives-and-the-case-of-kerrie-wooltorton) contemporaneous refusal of treatment regimen that would involve weaning her See News, p 824

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Doctors and Human Rights John S Yudkin The Israeli Medical Association and doctors’ complicity in torture The IMA needs to take well documented allegations more seriously than it has done so far A recent BMJ news report outlined the chairman of the IMA’s ethics board ethics committee, and its members—is reasons behind the call by 725 doctors reported in March 2009, having contacted whether the security risks facing Israel from 43 countries for the former chairman and spoken to “most of those listed,” all can be allowed to over-ride human of the Israeli Medical Association (IMA), of whom denied either any connection rights. Furthermore, Dr Blachar, as Yoram Blachar, to step down as president with the prison services or, in the case the president of the WMA, had an of the World Medical Association (WMA).1 of the three who were so employed, any unparalleled opportunity to re-examine, The doctors’ petition, addressed to involvement in interrogations, torture, or from a neutral standpoint, the role Edward Hill, chairman of the WMA Council, medical approval for this.6 of the Israeli medical profession in documented a series of reports, going Responding to this open letter the defending human rights. Failure to back to 1996,2 of cases in which Israeli directors of Physicians for Human investigate to the level of accepted doctors have been accused of complicity Rights-Israel and of Public Committee international norms could imply an in torture and where the IMA had failed Against Torture in Israel posed a series anxiety that the claims have veracity. either to respond to or fully to investigate of questions to the chairman of the Furthermore, the BMA should demand the charges. Although Dr Blachar is no ethics committee, outlining why they from the Israeli Medical Association a longer the IMA president and concludes believed that the investigation had The question more vigorous response in investigating his term as WMA president this month, the not been “a professional, detailed and these testimonies. The BMA has put on petition still raises important questions thorough examination of serious and “that needs record its serious concerns regarding concerning the IMA’s commitment to specific claims raised in the Report” considering—by the reports of medical complicity in torture investigate and tackle possible complicity (see Web Extra material on bmj.com). IMA president, its at Guantanamo Bay and so would not be of Israeli doctors in the torture of prisoners They requested confirmation that ethics committee, singling out Israel for censure.7 and detainees. investigations had included “inquiries and its members— A common response to criticism of In March this year I contrasted the beyond the telephone conversations Israeli policies or practice is that it is a powerful position statement on torture mentioned in the letter,” such as is whether the consequence of antisemitism. Any such posted on the IMA’s website with conversations with doctors working at security risks comments coming from Jewish critics the failure of that body to respond to the hospitals where the prisoners had facing Israel can be warrants the label of “self hating Jews.”8 allegations in a report, published in May been treated, reviews of medical files, allowed to The roots of such interpretations are easy 2007, by the Public Committee Against and documentation of examinations over-ride human to understand, but, as with the response Torture in Israel.3‑5 The report comprised and treatment from the time of arrest. to the Goldstone report on the Gaza detailed testimonies of nine torture They pointed out that such inquiries rights conflict,9 10 this may merely be an attempt victims and included names of medical would circumvent the inability of many to silence critics. Dr Blachar has written to personnel involved in their management of those providing testimony to name doctors who are members of Physicians in prison or referral hospitals, several of the individual doctors involved and that for Human Rights-Israel to say that, the personnel being IMA members.6 The even the awareness of those doctors that because criticism of the IMA expressed reasons for medical involvement varied, torture had taken place should have led to ” in international forums or “slinging mud but the report included an account by a 29 their reporting the fact to the authorities. at the doctors of Israel” provides “fertile year old man with a sacral ulcer. During his They also challenged the ethics ground for anti-Israeli and anti-Zionist interrogation, he was intermittently tied committee chairman’s implication that it anti-Semitism,” the IMA has decided to over a four day period with all of his limbs would be easier to check such allegations sever all ties with Physicians for Human arched back over a chair with a sharp edge were there “some shred of evidence other Rights-Israel, an action that could have to the seat. His testimony recounted visits than the word of the prisoners,” pointing dire consequences for the provision of to a hospital where he was examined, out that the denial of an allegation of care to some of Israel’s most vulnerable and after the intervention of his guards rape or sexual harassment would not groups.11‑13 the doctors prescribed analgesics and be sufficient grounds for refusing to The WMA’s Tokyo declaration provides returned him to prison. Six weeks later investigate it. The letter concluded a powerful statement on the need to end he was referred to a different hospital for by calling for a comprehensive and all medical complicity with torture.14 The investigation of the permanent foot drop exhaustive investigation of the events new president of the WMA should work that had subsequently developed. described in the report, specifically with member associations to develop The IMA, which fulfils not only the regarding physicians’ conduct, and for guidelines on their role in investigating functions of a union and a guild, like the the IMA to act to instil the rules of medical and censoring doctors who contravene British Medical Association, but also the ethics among physicians in public this declaration. role of ethical overseer similar to that of hospitals and in detention facilities. To John S Yudkin is emeritus professor the UK General Medical Council, had, date the IMA has not responded to this of medicine, University College by early this year, failed to investigate letter. London [email protected] the allegations in the report.3 However, The question that needs Cite this as: BMJ 2009;339:b4078 in response to concerted pressure, the considering—by the IMA president, its References are in the version on bmj.com

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