Monday 4th August - Friday 8th August

And Your Conscience Miss Smith?

There are none so deaf as those who do not want to hear.

An alibi, is a claim 'to be in another place'; it is often the centre piece of the defence in a criminal trial. Of course, criminals invent and produce alibis that dispute the charges brought against them. And not just alibis. Defendants who might be guilty concoct and manipulate whole stories, which not only place them at other locations but also create for them new identities and forge whole new universes in which they live their lives. This is in the nature of the defence, especially where the defendant is guilty. It is imperative for the rightly accused defendant to maintain the maximum distance between himself and the persona and culture of the person described by the prosecution.

This resort to the description of a dual world is, of course, less commonly used by the prosecution. In prosecuting on behalf of the victim, the prosecutor has rarely the need to invent personae to tell detailed but untruthful stories about the victim's habitat and culture. Such things are unnecessary because on the whole most prosecutions are founded on real and noteworthy events; the victims of crime and their relatives are really damaged and concerned to make public their circumstances in full.

The prosecution has need of false scenarios mainly in political trials or in those which by accident or sometimes intent, are brought against wrongly accused defendants. So it was that in 1916 the state produced diaries that incriminated Roger Casement, the British civil servant with strong Irish republican loyalties, containing homosexual fantasies that perhaps did more to get him convicted than the factual evidence brought against him. In cases of wrongful conviction, the defendant is portrayed in a fashion that best fits the prosecution case and which the defendant's   closest friends would fail to recognise. In all such cases, the defendant in question is imbued with characteristics they simply do not posses; an ability with and recourse to the use of firearms, bomb making equipment, an amorality, a hardness of spirit or a streak of psychopathy that in reality are not part of their world.

The portrayal of Dr Wakefield as a dishonest, cruel and amoral chancer, began long before the GMC hearings.   Since the publication of the Lancet paper, the pharmaceutical companies, with their hand-maidens in the science lobby groups, have presented a cartoon picture of Dr Wakefield as a lone maverick. Since the hearing began, the prosecution has manipulated evidence and constructed a scenario, which is a long way from describing the defendants or the good work they have done on behalf of sick children and their parents. In order to build a case against the doctors, the prosecution has had to fabricate not only a story, but new identities for the three defendants.  

The prosecution has used facts like clay in order to mould a case. They first avoided bringing evidence from the parents about the children and then they painted a picture of work in a hospital that has more in common with the story board to Apocalypse Now than it does with a well run hospital department. Before we look at Miss Smith's cross examination of Professor Walker-Smith, it is worth looking more closely at the main pillars of the prosecution case to see what they establish.

The prosecution case is that the defendants experimented on children in order to construct a fantastic case that MMR caused adverse reactions in children, and so make claims against the drug companies. The three defendants, presumably together with others in the Royal Free Hospital, in pursuit of this experimentation, conducted very risky procedures upon children with behavioural difficulties. Last week Miss Smith revealed a so far unexplored part of this diabolical scenario when she accused Professor Walker-Smith of having treated the children he had seen prior to the ethics committee approval of 172/96, as 'guinea pigs'; people used as subjects of experimentation.

Another plank of the prosecution is that the children who ended up at the Royal Free Hospital were never seriously ill. Although some of them might have been 'naturally' autistic, none of them had anything wrong with them that could not have been dealt with by local medics. They were, Miss Smith says, cajoled, corralled, pressed and manipulated into the Royal Free Hospital by Dr Andrew Wakefield against the better advice of their general practitioners and consultants.

In order to construct this case, the prosecution has had to describe the children ultimately as victims of both their own parents and the defendants. This part of the prosecution scenario is perhaps the most corrupt and dishonest and the facts around it need the most massaging to turn it into a courtroom reality. Last week, Miss Smith further embellished her case, by implying that the parents had psychologically unbalanced motives for sacrificing their children to the experiments conducted by the defendants. In a long and badly constructed question - as are many of Miss Smith's - taken straight from the Roy Meadow's Parenting Manual, Miss Smith suggested that in their eagerness to see their children made better - from what condition she didn't elucidate, but most probably 'natural' autism - the parents egged on the doctors to experiment upon their children.

To stand up their case, the prosecution has had to present the three doctors as some kind of cabal working in counter distinction to all the other hospital staff. Only in this way could the defendants be joined as a small Active Service Unit of Evil (ASUE). How their criminal intentions and their experiments were kept secret from the rest of the Department and even the rest of the Royal Free Hospital remains a mystery. To the frequently asked question, 'Why are not all the other authors of the Lancet paper in the dock?' the answer is simple. According to the prosecution case, most other people in the Royal Free Hospital, even those who authored the paper, were antagonistic to Wakefield and a number of them were brought as professional witnesses by the prosecution. Of course had all the authors and those who happily worked with Dr Wakefield, been prosecuted by the GMC, the hearing room might have looked like the Libyan courtroom during the trial of Bulgarian nurses charged with purposefully giving patients HIV - oddly enough following the many abuses of process by the prosecution, their is already a resemblance between the cases.

Miss Smith has remained determined throughout her cross examination of both Dr Wakefield and now Professor Walker-Smith, that the three defendants were not acting as doctors normally do within the regime of a hospital. Interestingly, of course, they weren't. Perhaps for the first time in British medical history, a whole department of an NHS hospital was given over to the examination of children suffering from a serious adverse reaction caused by the routine prescription of a childhood vaccination. One only has to contemplate this for a matter of seconds before the meaning of the GMC case becomes abundantly clear.

Apart from those occasions that hospitals and doctors make mistakes, the routine of allopathic medicine is straightforward. At the best of times, it goes like this; the patient feeling unwell attends their primary care giver, the general practitioner; the GP summons his native intelligence, runs through contemporary government sponsored scare stories and other more sensible references and arrives at a general conclusion about the patient's condition. If curing the illness is apparently within the GP's gift, they prescribe a likely potion, but if the condition eludes them and seems to warrant investigation by a higher medical authority, the patient is given an appointment to be seen by a consultant at a local hospital. At the appointment, the consultant will read the patient's notes, agree, amend or disagree with the GP's assessment and on the basis of a definite diagnosis the patient will be given a hospital appointment for tests or an operation, or perhaps a prescription with a regime to follow.

This however, is the 'boring story of medicine', medicine stripped of culture and social relations. In the more dramatic post-modern version of the detection of illness, the complaint suffered by the patient is always an undiagnosed illness. And because of this, the imaginative doctor, equipped with glass panels to scribble on with a wax crayon, or a window in some cases, is intuitively led to a deep understanding of the whole nature of illness, society and the universe, entirely by argument and the reading of social, religious and sexual signs. Although such stories of medical detection are mainly fictional, this exciting style is inevitably based upon modern realities.

These realities occur, though rarely in the NHS, when there is a sudden outbreak of a novel disease, or when a number of people report a previously undiagnosed illness. This was how the children who found their way to the Royal Free were treated and their cases researched; with an urgent sense of crisis and without any diagnostic guidelines. The doctors working on these cases believed that they were up against a major crisis in public health involving the lives of innocent young children. The prosecution in this case, however, have been unable to give the doctors credit for uncovering the truth of the illness, because it would have meant conceding that MMR was implicated in bowel disease and regressive autism.

In the prosecution's presentation of the 12 Lancet children, a number of things stand out. First, none of the children have been presented to the hearing and only one of the parents was called to give evidence. This one parent, called by the prosecution, was convinced by GMC lawyers that they were appearing for the defence, and like a number of other prosecution witnesses tried her best to give evidence for the defence.

Second, Miss Smith has consistently presented these cases as if they could have been either adequately dealt with by general practitioners, or involving mothers in cahoots with Dr Wakefield, forcing GPs to refer their children to the Royal Free. However the children got to the hospital, the prosecution has portrayed them as healthy children with minimal if any gastrointestinal problems. Everything has been done to make the children invisible and to reduce the reality of their illness. It could be said that the children, together with their illnesses, have been painted out and the blame for the sidetracking of their cases placed upon neurotic mothers and amoral experimenting doctors.

The truth is that what got these 12 children to the Royal Free by different routes and what got them examined and treated when there, was the fact that they were all, initially, victims of undiagnosed illnesses. It was because of this that in a number of cases, the GPs involved were unhappy about, or unable to come to conclusions about any diagnosis and even some consultants were more than happy to refer the children to a hospital miles away from where they lived. The children arrived at the Royal Free not because Dr Wakefield inveigled them there or conspired with the parents to get them referred there, but because within a short time of being approached by the first parent, more referrals had arrived, more phone calls had been made, more parents had spoken to Dr Wakefield and more children had been seriously damaged by MMR.

When Miss Smith argues that the children admitted to the Royal Free, or seen by Professor Walker-Smith at his outpatient consultations, became the subjects of experimental research, she is distorting the creative medical work that began with the arrival of these clinically undiagnosed children. It has to be stressed that the path to determining a diagnosis in any outbreak of a 'new' and previously undiagnosed illness is utterly different from the process followed in previously diagnosed cases and illnesses with a recorded history.

During her cross examination last week, it finally seemed to filter through the barren wastes of Miss Smith's mind, that the 'clinical protocol' consistently referred to by Dr Wakefield and Professor Walker-Smith, was a diagnostic tool and not a research protocol tendered to the research ethics committee. Understanding how doctors who are good at their jobs go about finding links, and causal factors, in undiagnosed illnesses isn't rocket science, but Miss Smith even with enlightenment was having none of it, 'So this was an unwritten protocol' she mocked, 'An informal and unwritten protocol', she seemed on the verge of saying, 'I should coco' but stopped herself. To   Miss Smith's uncreative mind, 'a protocol' would always be a set of rules guiding a research project, and so every time the word 'protocol' was mentioned a neon light attached to Miss Smith's hair band spelled out G U I L T.

Miss Smith's inability to understand the clinical protocol was indicative of her apparent lack of understanding about what doctors or epidemiologists do when they try, often fighting against time, to describe a new illness. In these circumstances, lacking a diagnosis and sometimes, even the labels to describe the symptoms of the illness, individual doctors have to work under a common protocol. It is not written because it changes from day to day as elements are added to it or taken away from it. Miss Smith has made much of this fast moving discourse over a symptomatic picture. She has railed against the fact that some tests, such as the lumbar puncture have drifted in and then out of the frame of the clinical diagnostic work. She has objected to their use but then when they are withdrawn suspected subterfuge. As Walker-Smith has repeated to her over and again, as they saw more patients some tests were dropped because they were providing little or no information; aha! so these were research tests exclaims Miss Smith.

The truth is that had Miss Smith seen this keenly post-modern diagnostic investigation into a new syndrome in some television series, had it been about a mathematician or a portrayal of Sherlock Holmes by Jeremy Brett in full flight, she would no doubt have been carried away by the intuitive and spectacular workings of the human mind. It would appear however, certainly in Miss Smith's view, that there is no place for creative cutting edge medicine in the NHS.

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