| by Carlo Fonseka
( December 23, 2012, Colombo, Sri Lanka Guardian) I believe that it was
in the practice of scientific medicine that humanity perfected the technique of
avoiding personal bias and prejudice in the conduct of human affairs. In these
days of intense legal controversy I found it mentally stabilizing to rehearse
the stages I passed through in reaching the aforesaid conclusion.
Pre-medical
As a preliminary to medical studies we had to learn the elements of
physics, chemistry and biology. In retrospect our pre-medical education in
science consisted largely of cramming our heads with as many facts as could be
squeezed in. Nobody taught us that the scientific approach to the world is
essentially the process of looking for cause and effect relationships by
careful observation, logical reasoning and practical testing in real life. We entered
medical school without a clear conception of scientific methodology.
Pre-clinical
In medical school we were first taught the structure (anatomy) of the
human body, how it works (physiology) and its chemistry (biochemistry). I well
remember being taught that the human body is a machine in the strictest sense
of the term (i.e. a contrivance for transforming one form of energy into
others) and that it obeys the physical laws of thermodynamics to the letter.
The behavior of a machine such as a bus is entirely predictable. For example,
if it uses petrol as fuel, it will run on petrol irrespective of the size,
shape, personality, mood, attitudes and beliefs of the guy who pumps petrol
into it. The logic of treating the human body as nothing but a machine became
irresistible to me when I was a medical student. I still remember a limerick
which I found very convincing:
There was a young man who said: "Damn!
It grieves me to think that I am
Predestined to move
In a circumscribed groove:
In fact, not a bus, but a tram"
At the end of our period of preclinical studies the acceptance of
biological determinism in the practice of medicine seemed inevitable to me.
Pharmacology
When we came to study pharmacology, i.e. the way drugs work, at first I
couldn’t quite believe what we were taught. After all, if the body is a machine
like a bus then it must react to a drug (a medicine) introduced into it in the
predictable way that a bus will treat petrol that is supplied to it. In fact,
however, nothing could be further from the truth. We learnt that the response
of a patient to a drug is the resultant of at least 10 different factors
including such things as:
* the doctor’s personality, mood, attitude and
beliefs;
* the patient’s personality, mood, attitude and
beliefs;
* what the doctor has told the patient;
* the patient’s past experience of doctors;
* the patient’s estimate of what has been received and
of what ought to happen as result; and
* the social environment eg. whether supportive or dispiriting
[ See Clinical Pharmacology by Bennett & Brown,
9th Edition p.4 ]
Randomisation & blinding
The realization that both doctors and patients (like lawyers and
clients) are subject to bias and prejudice due to their beliefs and feelings
made it necessary to device a technique to prevent bias from influencing the
outcome when a drug is given to a patient. The technique rejoices under the
name of "RANDOMIZED, PLACEBO-CONTROLLED, DOUBLE-BLIND CLINICAL
TRIAL". A full description of this technique is not necessary to establish
the point of this article. Suffice it to say that even in the entirely material
business of judging the efficacy of a drug, it is necessary to avoid rigorously
the inevitable influence of bias and prejudice. The two most important aspects
of this technique are "randomization" and "blinding".
Randomization, introduces a deliberate element of chance into the process of
evaluating the action of a drug (The equivalent in legal cases would be to
allocate cases to different judges on a randomized basis.) Given that both
doctors and patients are subject to bias, and the fact that this will inevitably
influence the outcome, steps must be taken to avoid bias by
"blinding" both the patient who takes the drug (first blind man) and
the doctor who gives it (second blind man). This is done by the use of a
"dummy" tablet (placebo) which is exactly like the drug. By this
technique the patient does not know what he is receiving and the doctor does
not know what he is giving. It is by such an elaborate procedure that the bias
of doctors and patients is eliminated in judging the efficacy of a drug.
Conclusion
The equivalent of this procedure in judging a case in court would be for
the judge not to know whose case he is judging and the client not knowing by
whom he is being judged. Quite clearly the application of such a procedure is
virtually impossible in regard to cases. Therefore, in order to maximize the
probability that the outcome of a given case is not influenced by the bias on
the part of a judge who is in a position to influence the outcome, would be for
the judge whose bias might influence the outcome in the case to vanish from the
scene. That is why I urged my friend Dr. Shirani Bandaranayake to apply for a
leave of absence from her exalted office during the period that her spouse’s
case is being investigated. For her to continue in that incredibly powerful and
influential position at a time when her spouse’s case is being investigated
would, in my judgment, constitute a serious case of screaming conflict of
interest.
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