Bad Pharma

How medicine is broken, and how we can fix it

Ben Goldacre
revised and updated edition 2013

reviewed by Mira de Vries

"The most expensive doctors in the world can only make decisions about your care on the basis of the evidence publicly available to them" states Goldacre in the introduction. The rest of the book details the various ways in which that evidence is skewed or missing. If you are only now beginning to follow the debate about the pharmaceutical industry, this book is a good choice due to its thoroughness.

By the time I finished reading it -- it's not the kind of book you can't put down -- hundreds of reviews of it have appeared on the Internet, including a fine one on Wikipedia. There's no point in my repeating what others have said, so I'll concentrate on the aspect that other reviewers seem to overlook, namely illogic.

To be fair, there is a lot of good logic in the book. The author displays healthy skepticism, so in that sense he is way ahead of most other physicians. One wonders how with all this insight, he can continue in his profession. That is contradiction number one. More follow.

"The regulators and professional bodies we would reasonably expect to stamp out such practices have failed us," and "These [voluntary] policies don't [work]," he writes. What, then, is the point of advocating for more regulations and policies?

"[R]umours, oversimplifications and wishful thinking can spread through the academic literature, just as easily as they do through any internet discussion forum." Why then, doesn't he oppose the power accorded to the academically educated medical profession? Same question, different quote: "It would be wrong to imagine that patients are unique in being manipulated by the way figures on risk and benefit are presented. In fact, exactly the same result has been found repeatedly in experiments looking at doctors' prescribing decisions, and even the purchasing decisions of health authorities, where you would expect to find numerate doctors and managers, capable of calculating risk and benefit."

In the same vein: "I ... wish that this book could teach you everything you need to know [to make decisions about which treatment is best for you entirely by yourself], but the reality is that medical decision making requires a lot of specialist knowledge and skills, which take time and practice to acquire at a safe level of competence, and there's a serious risk of [you] making very bad decisions." You'd never guess that a mere 5 pages before this outrageously arrogant argument, he writes, "If doctors were forced to admit to the uncertainties in our day-to-day management of patients, it might make us a little more humble." He lists ten samples of illegitimate prescription considerations which I omit for the sake of brevity. Elsewhere he writes, "[I]t would take six hundred hours a month to read the thousands of academic articles relevant to being a GP alone," and "The most expensive doctors in the world don't know any better than anyone else." So where is all this competence that justifies physician's power over other people?

Goldacre proposes embedding trials in clinical practice, thereby pooling statistics on "real-world" patients from "routinely collected electronic health records." But such records rarely tell a complete story. Doctors generally do not follow up on their prescriptions. <<Hello Mrs. Smith. Are you still taking those pink pills I prescribed last week (or: last year)? Are you feeling better now? Or worse?>> Unless Mrs. Smith is incarcerated or being compulsorily drugged, her physician doesn't know whether she took the pills as prescribed, claims to have taken them but didn't, started taking them but stopped, never picked them up from the pharmacy, or gave them away to her neighbor's mother-in-law who was completely cured by them. This is the same kind of methodological sloppiness that he rightly criticizes when drug researchers do it.

Another: "Direct-to-consumer drug advertising ... distort doctor's prescribing behaviour [because patients demand the drugs in the ads]," yet "Clopidogrel came to market in 1999 with no advertising, and was used widely, with no advertising, until 2001. Then the drug company introduced television advertising, spending $350 million in total. Oddly, this had no impact on the number of people taking the drug..." Why is that odd? And even if an increase were measured in the number of people taking the drug, who's to say that not the physicians are influenced by these same ads on TV?

Tantalizingly, Goldacre makes sweeping, slandering statements about "conspiracy theorists" and denies being one. Google defines conspiracy as "a secret plan by a group to do something unlawful or harmful." This is precisely how Goldacre characterizes the pharmaceutical industry. Why doesn't he proudly assume the role of conspiracy theorist like Robert S. Mendelsohn called himself a "Medical Heretic"?

But Goldacre's most glaring inconsistency is in lashing out at the pharmaceutical industry while not questioning modern medicine's reliance on pills. He opposes testing drugs against placebos in spite of the fact that placebos regularly outperform active drugs. What better indication can there be that it is time to overthrow the pill-for-ill paradigm? He accuses us: "[A] lot of patients have been persuaded ... that pills fix things." Haven't physicians been persuaded of the same? A person who is sick, disabled, elderly, or dying is more likely to realize that what he needs is hands-on care than the physician, for the simple reason that the physician's profession is prescribing pills, not providing hands-on care.

To illustrate how naive even an insightful physician can be, I close with the following quote from the book: "Each person with schizophrenia ... may find that serious relapses damage their lives, costing them their home, job or friendships, and so they might choose to tolerate some side effects..." Since when are people with the presumed condition of schizophrenia free to make their own drug choices? What are their "relapses" other than withdrawal from drugs they never should have been prescribed? What can damage their lives more than the disabling and disfiguring consequences of psychiatric drugs? Did ever a grosser medical understatement make it into print than calling the consequences of this poisoning "some side effects"? And how many people drugged for "schizophrenia" have "homes, jobs, or friendships"? Really now, Benny, get a life -- but not mine.

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