Princess Health and Northwestern Upholds its "Brand," Never Mind Free Speech and Academic Freedom. Princessiccia

Princess Health and Northwestern Upholds its "Brand," Never Mind Free Speech and Academic Freedom. Princessiccia

academic freedom anechoic effect bioethics censorship free speech mission-hostile management Northwestern University

Gusty 11:35 Add Comment

Threats to free speech and academic freedom in health care were a major concern when we started Health Care Renewal.  Such threats may now be less anechoic, but do not seem to have diminished.

Censorship and the Resignation of Alice Dreger

The latest example was at Northwestern University. The basics of the case appeared in the Chronicle of Higher Education. Alice Dreger just resigned her position of 10 years as "a clinical professor of medical humanities and bioethics."

What prompted her departure was the fallout over an article by William Peace, who at the time was a visiting professor in the humanities at Syracuse University. Mr. Peace wrote an essay for an issue of the journal, Atrium, that Ms. Dreger guest-edited. The essay is a frank account of a nurse who helped Mr. Peace regain his sexual function after he was paralyzed.

According to Ms. Dreger, Eric G. Neilson, vice president for medical affairs and dean of the university�s school of medicine, tried to censor the essay. The essay is straightforward in its description of sex, and includes multiple mentions of 'the dick police,' but the purpose is to illuminate what went on in the era prior to disability rights and studies.

As Mr. Peace writes, the unconventional approach of the unnamed nurse 'injected a compassionate eroticism that made me a better man.'

In her letter, Ms. Dreger writes that the university allowed the essay to be published online only after she and Mr. Peace threatened to talk publicly about what they saw as censorship. She writes that she was 'disgusted that the fear of bad publicity was apparently the only thing that could move this institution to stop censorship.'

Now the essay is out there, for all to see, 'dick police' and all. So what does Ms. Dreger want?

She asked the university to acknowledge that attempting to remove portions of the essay was a mistake and to promise not to do so in the future. 'They never acknowledged that the censorship was real,' Ms. Dreger said in an interview. 'I wanted a concrete acknowledgment and assurance that my work would not be subject to monitoring.' That, she said, would have been enough for her to remain.

The idea that institutions must acknowledge wrongdoing is central to Ms. Dreger's academic work.

More details about university managers' alleged attempts to control the content of an academic journal emerged in an article in the local newspaper, that is, the Chicago Tribune.  The managers wanted to appoint their own oversight committee to control journal content.

The journal Atrium stopped publication after faculty objected to the new oversight committee, which [University spokesman Alan] Cubbage has described as 'an editorial board of faculty members and others, as is customary for academic journals.'

Note, however,  that editorial boards are usually appointed by journal editors, not managers or executives.

Also, as noted in an article in Inside Higher Ed,

Dreger, who guest-edited the 'Bad Girls' issue [in which the controversial article first appeared], said that soon after publication, medical school administrators asked Atrium�s editors to remove the essay from the web, because the content was considered inflammatory and too damaging to the new Northwestern Medicine 'brand.' (Northwestern Memorial Health Care recently acquired Northwestern�s Feinberg School of Medicine faculty practice and merged with Cadence Health to operate under the Northwestern Medicine banner.) The editor, another faculty member, refused to single out one article for censorship and took down the journal�s web archive instead.

Furthermore, the university administration's reaction to the publication of the article prompted another resignation,

The controversy prompted the resignation of Kristi Kirschner, a former clinical professor humanities and bioethics at Feinberg, in 2014. Kirschner, now an adjunct professor of disability and human development at the University of Illinois at Chicago, told Inside Higher Ed earlier this summer that the alleged censorship had a 'chilling effect, antithetical to the idea of the university.'

As for that "chilling effect,"

A university spokesman declined to comment on Dreger�s case on Tuesday, saying it was a personnel issue. He also declined to answer general questions about censorship or the status of Atrium, which recently had its funding reduced, causing the journal to be canceled.

Atrium�s editor, Katie Watson, an assistant professor of bioethics and medical humanities, declined an interview but said the funding cut was not related to the 'Bad Girls' issue or censorship.

She referred additional questions to a post she wrote for Peace�s blog, Bad Cripple, in June, in which she said that she was disappointed with Peace for taking certain details of the case public, and in which she confirmed that a university content oversight committee meeting had been 'disheartening.'

"[T]he medical school required me to allow a vetting committee to review my editorial choices and veto them if they were perceived to conflict with other institutional interests," Watson wrote.

So note that the allegations of censorship have come from at least three separate faculty members at Northwestern, and from the author of the censored article, a faculty member at another institution.  Furthermore, on university spokesperson has contradicted these charges.  

Previous Mysterious Events at Northwestern

Of further concern is that this case may be part of a pattern.

Two years ago we wrote (here and here) about another case, albeit mysterious and convoluted, at Northwestern in which a faculty member, Dr Charles Bennett, resigned after being accused of mismanaging the finances of a government grant.  However, although he was responsible for the scientific management of the project, university managers, nor Dr Bennet, were responsible for its finances.  While the university settled allegations of financial mismanagement, and a university staffer pleaded guilty to related charges, a university statement implied that it was mainly Dr Bennett's fault, per the Cancer Letter

'As the settlement makes clear, the covered conduct in the settlement involved allegations focused on Dr. Charles Bennett, and grants for which Dr. Bennett was the principal investigator,' Northwestern officials said in a statement.

In addition,

The statement was signed by Northwestern President Morton Schapiro, Provost Daniel Linzer, and Vice President for Medical Affairs and Dean of the Feinberg School of Medicine Eric Neilson.

Note that the Vice President and Dean Neilsen above was the same Dean who Prof Dreger accused of trying to censor her journal.

Suspicions were raised at that time that the treatment of Dr Bennett might have been somehow related to how he made himself unpopular by authoring research that suggested Aranesp, a blockbuster Amgen epoetin drug, was much more dangerous than it seemed.  The Cancer Letter had interviewed one of Dr Bennett's collaborators,

[Michael]  Henke confesses to wondering whether the many powerful enemies Bennett made in the pharmaceutical and biotechnology industries have struck back.

'We shouldn�t feed paranoia,' Henke said. 'However, given the exclusively positive experience when collaborating with his group, makes me wonder whether this litigation might follow some very particular other issues.'

And recently the editor of the Cancer Letter, and the author of the above article, has been fighting subpeonas from Amgen intended to make him reveal his sources of negative information about Aranesp, (look here and here).

As far as I can tell, the questions I raised about the case of Dr Bennett (look here and here) have never been answered.

Nonetheless, the case of Prof Dreger has also been rather anechoic.  It was also covered by the Times of London Higher Education Supplement, and inspired comment from FIRE, but has otherwise not gotten national media attention, or any apparent coverage in medical or health care journals.  

Sometimes you may be paranoid, and sometimes someone may be out to get you.
Summary and Comments

So, to summarize, multiple sources suggested that top Northwestern Medicine leadership attempted to censor an academic publication edited and led by university faculty.  After publication of an article apparently controversial for its sexual content, but which likely also brought up valid issues about compassionate treatment of disabled patients versus traditional ethical concerns about boundary issues for health professionals, university leaders imposed an oversight committee which apparently was more concerned about the instiution's "brand" and other "institutional interests" than about free discussion of important health care issues.  The chilling effects of this attempt at censorship seemed to include resignations by two faculty members, and the demise of the journal.

Thus it appears that the managers were putting public relations and revenue concerns ahead of the fundamental academic values of free speech and academic freedom, thereby threatening these values.  In a post on Bioethics.net, Craig Klugman reminded us,

 According to the American Association of University Professors (1940):
'Academic freedom is essential to these purposes [the search for truth and its free exposition] and applies to both teaching and research. Freedom in research is fundamental to the advancement of truth.'

Cary Nelson, president of the AAUP and an English professor says that academic freedom:
'Gives both students and faculty the right to express their views � in speech, writing, and through electronic communication, both on and off campus � without fear of sanction, unless the manner of expression substantially impairs the rights of others or, in the case of faculty members, those views demonstrate that they are professionally ignorant, incompetent, or dishonest with regard to their discipline or fields of expertise.'

Even the American Society for Bioethics & Humanities, which is known for not taking positions on 'substantive moral and policy issues,' does take positions to support academic freedom and has done so in the past.

Since 1940, the notion of academic freedom has been a core tenet of university and faculty life. The idea was born in response to centralized governments telling researchers what they could and could not study and what they should and should not teach.

So free expression and academic freedom remain under threat in academic health care institutions. These threats seem in part to stem from managers' continuing inclinations to put commercial concerns ahead of the academic mission, perhaps fueled by prodigious amounts of money waved around by health care corporations looking to make their marketing appear more scientifically based.  These threats may be partially enabled by the anechoic effect, a sort of second order self censorship, so that cases of censorship are another kind of recent unpleasantness that get little public attention.

Students, health care professsionals, and faculty members who care about medical education and research ought to be asking some hard questions about the leadership of their organizations.  It looks like Northwestern students, trainees, and faculty members could have lots of questions to ask.

As we have said until blue in the face, true health care reform would enable leadership of health care organizations that upholds and is willing to be accountable for putting patients' and the public's health first, and leadership of health care academic organizations that also puts honest, transparent research and education ahead of commercial interests.   

Princess Health and How the Anechoic Effect Persists: The Case of the Continued Punishment of Dr Elliott . Princessiccia

Princess Health and How the Anechoic Effect Persists: The Case of the Continued Punishment of Dr Elliott . Princessiccia

academic freedom adverse effects anechoic effect free speech intimidation manipulating clinical research mission-hostile management University of Minnesota

Gusty 13:02 Add Comment

We have frequently discussed the anechoic effect, how evidence and opinions that challenge the dysfunctional status quo in health care, and that might discomfit those in power in benefit from it, have few echoes.  One major reason for the anechoic effect is that people are afraid to speak up because thus disturbing the powers that be may have bad consequences for the speakers.   

A December 21, 2014 article in the Minneapolis Star-Tribune updated an ongoing example of how the leaders of health care may seek to silence their critics.  The article updated the career trajectory of Dr Carl Elliott, a psychiatrist physician and bioethicist at the University of Minnesota who dared challenge the university's handling of the untimely death of a patient in a university run clinical trial.

Background - the Dan Markingson Case

We first blogged about this case in 2011.  The case itself dates from 2003, and first got media attention in 2008.  A good quick summary appeared in the Center for Law and Bioscience blog out of the Stanford Law School. 

Dan Markingson � a vulnerable, psychotic young man � was forced to choose between enrolling in a Pharma-funded drug study or being involuntarily committed (in other words, locked up).  A UMN [University of Minnesota]  doctor enrolled him in the study despite having just determined that Dan 'lack[ed] the capacity to make decisions regarding [his] treatment,' rendering it highly unlikely that Dan could have given valid informed consent to participate.  As Dan's mother, Mary Weiss, observed his mental condition deteriorating, she repeatedly tried to have Dan removed from the trial � at one point asking  'Do we have to wait until he kills himself or someone else before anyone does anything?'  But the UMN co-investigators in the drug study refused to terminate his participation.  Shortly after Ms. Weiss made her desperate plea, Dan Markingson killed himself by cutting his own throat.

Dr Elliott, an expert in bioethics who had concentrated on issues such as the effect of conflicts of interest and commercial influences on clinical research, started probing the death of Mr Markingson after the 2008 media reports.

Some of what Dr Elliott found appeared in a May 23, 2014 article in Science. He concluded that previous efforts to investigate the death of Mr Markingson were flawed.

 Elliott came to believe that every investigation�not only by FDA but also by the Minnesota Board of Medical Practice, the university's IRB, and its general counsel's office�had been flawed or incomplete. FDA did not seek Weiss's perspective, the views of Markingson's caseworker, or interview staff at the halfway house who had interacted with Markingson, for instance. (FDA would not comment on the Markingson case for this story.) Nor did the agency examine conflicts of interest. Weiss's lawsuit was dismissed not on its merits, but because the university's IRB and Board of Regents were deemed immune from liability thanks their role as state employees. (The judge did argue that informed consent was obtained appropriately, because Markingson had signed the consent form and had not been declared mentally incompetent by a court.)

Furthermore, he found reasons to think that the problems with the trial in which Mr Markingson died were not unique.  He and a colleague

heard from other individuals who insisted that they had been harmed in UMN psychiatric drug trials or had witnessed others' mistreatment. One man said he had worked in the psychiatric units of the hospital where Markingson was treated. Another identified herself as a counselor for teenagers. Elliott heard from parents, who said their son or daughter had enrolled in a study under pressure.

Thus, Dr Elliott and others concluded that the university should do a thorough investigation of the case,

In November 2010, eight faculty members, including Elliott and [McGill University bioethicist Leigh] Turner, wrote a letter to the university's Board of Regents, requesting an independent, university-commissioned investigation into the Markingson case.

The Punishment of a Dissident

As the Science article noted, former Minnesota Governor Arne Carlson said that the

university hired Elliott because it 'found him to be one of America's most outstanding bioethicists. The moment he comes up with something that is sensitive to them, he becomes the village idiot.'

In fact, as we noted in 2013, in a 2012 post in the Center for Law and Bioscience blog, not only did university officials rebuff the call for a new, thorough investigation of the untimely death of Mr Markingson, but the university general counsel, who had been operating at the heart of this case, appeared to threaten the leading bioethicist dissident, Dr Carl Elliott:

 After Carl Elliott, the University of Minnesota bioethicist, refused to drop the matter, [university chief counsel] Rotenberg asked the university�s Academic Freedom and Tenure Committee to take up the question of '[w]hat is the faculty[�s] collective role in addressing factually incorrect attacks on particular university faculty research activities?' � a question that appeared both to accuse Elliott of 'factually incorrect attacks' and to call for some unspecified action to 'address' them.  Other faculty, including the president of the Minnesota chapter of the American Association of University Professors, viewed this as an attempt to intimidate Elliott into silence.  If so, it backfired.  The story ended up in the press, putting the Markingson case back in the public eye and once again making the University of Minnesota look really bad.

The December 21, 2014 Star-Tribune article reported that university administrators seem to be out to get Dr Elliott once again. First, it interviewed the university's chair of psychiatry,

[Dr S Charles] Schulz, the department chair, says he can�t even bear to read Elliott�s published accounts anymore. 'It�s too painful,' he said.

Both he and Olson say that Elliott gives only one side of the story and that he ignores the facts that don�t support his case.

'I think [people] believe that because Carl Elliott is a professor of bioethics and a member of the Center for Bioethics, that he must be telling the truth,' said Olson. But 'he�s not pursuing this in an academic way. I don�t think it�s conduct that becomes a faculty member and a peer.'

What is not academic or unbecoming about investigating the death of a vulnerable psychiatric patient during a clinical trial is not clear. Then,

University officials have not been amused. They accuse Elliott of whipping up hysteria with 'false and unfounded' allegations, and undermining research efforts in the process. And while the university hasn�t tried to fire him, it has reprimanded him for 'unprofessional conduct,' a move that he�s now challenging under the tenure code.

Again, rather than investigating the death of Mr Markingson, or at least responding to specific allegations, university administrators have set about to punish their own distinguished faculty member who wondered why a vulnerable patient died during a university run clinical trial. 

Finally,

So far, academic freedom has protected Elliott�s job. But last winter, the university claims, he crossed a line. It accused him of using a 'fabricated letter' in a speech about the Markingson case at Hamline University and demanded that he issue a retraction.

The 2004 letter, addressed to Weiss, Markingson�s mother, appears to be from a university lawyer disputing her right to her son�s medical records. The U says it�s a forgery; Elliott says he doesn�t believe it, and he refused to issue a retraction. He called it an attempt to discredit Weiss, adding: 'I won�t be part of it.'

Elliott received a letter of reprimand in August from Dr. Brooks Jackson, the current dean of the Medical School, citing him for 'significant acts of unprofessional conduct.' The reprimand is on appeal.

The evidence that the letter was a forgery was not apparent.  Yet while they pursue their own faculty member for his investigation of Mr Markingson's death, university managers still apparently have not addressed the many problems in the university's version of the story of Mr Markingson's death, from the fragmentary nature of previous investigations to the problems just revealed in a Scientific American blog with the knowledge of an expert witness for the university in the lawsuit brought by Mr Markingson's mother against it.  

Summary

Dr Carl Elliott is a respected physician bioethicist who has uncovered problems with commercial contract research organizations doing human research (see our blog posts here and here), and has written a critically acclaimed book, White Coat, Black Hat (reviewed here by Dr Howard Brody on his blog.)  Yet his previous work counted for naught when he dared look into possibly unethical clinical research done at his own university.  As noted in the Star-Tribune article,

Within the U�s Center for Bioethics, where he has worked since 1997, he says the tension is so palpable that he dreads setting foot in his office. He does most of his work from coffee shops.

In my humble opinion, it appears that top university managers have put their personal interests ahead of the mission of their university, the role of their faculty members in upholding that mission, and even the welfare of patients who put their trust in the university's academic medical center.  The hard life that Dr Elliott has lead since he started to challenge his own university's administrators show how the anechoic effect is generated.  As long as leaders of academic medical institutions, and other health care organizations can put their own interests ahead of the mission, health care professionals and other academics who object are likely to have their lives made miserable, possibly lose their jobs, or worse.  How many will have both the courage, and the resources to stand up for what is right under such a threat.

True health care reform would turn leadership of health care organizations over the people who understand and are willing to uphold the mission of health care, and particularly willing to put patients' and the public's health, and the integrity of medical education and research when applicable, ahead of the leaders' personal interests and financial gain.

ADDENDUM (30 December, 2014) - Post corrected.  Dr Elliott trained as a physician but is not a psychiatrist.

ADDENDUM (30 December, 2014) - also see comments on the 1BoringOldMan blog. 

Princess Health and Allegations That Merck Threatened Researchers Who Expressed Doubts About Vioxx. Princessiccia

Princess Health and Allegations That Merck Threatened Researchers Who Expressed Doubts About Vioxx. Princessiccia

academic freedom free speech intimidation Merck Vioxx

Gusty 08:29 Add Comment

The Philadelphia Inquirer reported a series of allegations that a top Merck executive threatened and intimidated physicians who questioned the safety of its Cox-2 inhibitor drug Vioxx, now off the market.
Louis M. Sherwood, who retired as a Senior Vice President of Medical and Scientific Affairs for Merck, had been known as "the epitome of an upstanding guy, smart and well-respected." The Inquirer reported that "Sherwood earned accolades from both worlds [academia and industry]. At retirement in March 2002, he was given two lifetime achievement awards, one from industry physicians and one from medical-schol professors."
Nonetheless, evidence discovered in one of the cases against Merck revealed:

• Lee Simon, a former Harvard faculty member, after lecturing about the risks of Vioxx, said he was threatened by Sherwood: "he would hurt my career if I continued to lecture." Sherwood also charged that Simon was biased against Vioxx. However, the Inquirer reported that Simon's "boss at Harvard, Steven Weinberger, now a Vice-President at the American College of Physicians in Philadelphia, confirmed getting Sherwood's call but said it had 'nothing to do' with Simon's promotion." Weinberger stated, "Lou Sherwood was not at all threatening me." Yet, John Yates, Sherwood's successor at Merck, contacted Simon, and said, according to him, that Sherwood's behavior "would never happen again, that it was unnecessary, that it was not the behavior of Merck." [Note that Dr. Weinberger has appeared in Health Care Renewal posts in the past, here, here, and here, on the subject of declining interest in primary care, which he has suggested is due more to shortcomings in how medical schools promote the field to students and due to inadequate current "chronic care models" than to pressures faced by practicing physicians, including external threats to their core values.]
• M. Thomas Stillman, from the University of Minnesota Medical School, also questioned the safety of Vioxx. A Merck "sales executive" described him as a "vocal adversary of Merck and Vioxx" in an email. A memo documented that Sherwood had "complained to Stillman's boss." Yates also called Stillman to apologize.
• Gurkirpal Singh, from Stanford University, questioned whether data about Vioxx was being hidden. A memo by Sherwood described Singh as "perceived as an advocate for Searle," which was then the manufacturer of the competing drug, Celebrex. The Inquirer reported that Sherwood called Singh's supervisor, Professor James F. Fries, at home, labeled Singh "anti-Vioxx," suggested Singh would "flame out," and threatened Fries with "consequences for myself and for Stanford," according to Fries. Fries wrote Merck to complain, noting all the above cases and those of two other researchers. Fries then got a call from David Anstice, President of the Human Health-Americas division of Merck, saying that Sherwood's behavior was "not the norm," and promising to take action.

These are serious allegations, involving apparent efforts by a pharmaceutical company to stifle free speech and academic freedom to suppress unfavorable comments about the company's products. Such behaviors threaten core academic and scientific values. If physicians and researchers cannot openly discuss scientific findings, science will not advance. If they cannot openly discuss possible harms to patients, patients may be harmed.
Unfortunately, if these allegations are true, they will become just another entry in the sorry catalog of threats to free speech and academic freedom in medicine, (which may relate to the many threats to free speech and academic freedom in colleges and universities, such as those that have been documented by FIRE.)
Physicians and scientists must learn how to defend themselves against such threats, or science, and worse, patients will suffer.

Princess Health and Allegations That Merck Threatened Researchers Who Expressed Doubts About Vioxx.Princessiccia

Princess Health and Allegations That Merck Threatened Researchers Who Expressed Doubts About Vioxx.Princessiccia

academic freedom free speech intimidation Merck Vioxx

Gusty 08:29 Add Comment

The Philadelphia Inquirer reported a series of allegations that a top Merck executive threatened and intimidated physicians who questioned the safety of its Cox-2 inhibitor drug Vioxx, now off the market.
Louis M. Sherwood, who retired as a Senior Vice President of Medical and Scientific Affairs for Merck, had been known as "the epitome of an upstanding guy, smart and well-respected." The Inquirer reported that "Sherwood earned accolades from both worlds [academia and industry]. At retirement in March 2002, he was given two lifetime achievement awards, one from industry physicians and one from medical-schol professors."
Nonetheless, evidence discovered in one of the cases against Merck revealed:

• Lee Simon, a former Harvard faculty member, after lecturing about the risks of Vioxx, said he was threatened by Sherwood: "he would hurt my career if I continued to lecture." Sherwood also charged that Simon was biased against Vioxx. However, the Inquirer reported that Simon's "boss at Harvard, Steven Weinberger, now a Vice-President at the American College of Physicians in Philadelphia, confirmed getting Sherwood's call but said it had 'nothing to do' with Simon's promotion." Weinberger stated, "Lou Sherwood was not at all threatening me." Yet, John Yates, Sherwood's successor at Merck, contacted Simon, and said, according to him, that Sherwood's behavior "would never happen again, that it was unnecessary, that it was not the behavior of Merck." [Note that Dr. Weinberger has appeared in Health Care Renewal posts in the past, here, here, and here, on the subject of declining interest in primary care, which he has suggested is due more to shortcomings in how medical schools promote the field to students and due to inadequate current "chronic care models" than to pressures faced by practicing physicians, including external threats to their core values.]
• M. Thomas Stillman, from the University of Minnesota Medical School, also questioned the safety of Vioxx. A Merck "sales executive" described him as a "vocal adversary of Merck and Vioxx" in an email. A memo documented that Sherwood had "complained to Stillman's boss." Yates also called Stillman to apologize.
• Gurkirpal Singh, from Stanford University, questioned whether data about Vioxx was being hidden. A memo by Sherwood described Singh as "perceived as an advocate for Searle," which was then the manufacturer of the competing drug, Celebrex. The Inquirer reported that Sherwood called Singh's supervisor, Professor James F. Fries, at home, labeled Singh "anti-Vioxx," suggested Singh would "flame out," and threatened Fries with "consequences for myself and for Stanford," according to Fries. Fries wrote Merck to complain, noting all the above cases and those of two other researchers. Fries then got a call from David Anstice, President of the Human Health-Americas division of Merck, saying that Sherwood's behavior was "not the norm," and promising to take action.

These are serious allegations, involving apparent efforts by a pharmaceutical company to stifle free speech and academic freedom to suppress unfavorable comments about the company's products. Such behaviors threaten core academic and scientific values. If physicians and researchers cannot openly discuss scientific findings, science will not advance. If they cannot openly discuss possible harms to patients, patients may be harmed.
Unfortunately, if these allegations are true, they will become just another entry in the sorry catalog of threats to free speech and academic freedom in medicine, (which may relate to the many threats to free speech and academic freedom in colleges and universities, such as those that have been documented by FIRE.)
Physicians and scientists must learn how to defend themselves against such threats, or science, and worse, patients will suffer.