Editorial writer heard 'round medical world Angell speaks loudest on ethics in research

October 26, 1997|By Jonathan Bor | Jonathan Bor,SUN NATIONAL STAFF

In the 10 years since she rose to the New England Journal of Medicine's second highest post, Dr. Marcia Angell has won admirers and critics for her uncompromising editorials on issues that are important to the nation's doctors.

She opposed laws against physician-assisted suicide and criticized doctors for denying pain-relieving narcotics to dying patients. She endorsed a Canadian-style health care system and took on lawyers and journalists for scaring women about silicone breast implants.

Surely nothing, however, has attracted more attention than her Sept. 18 editorial, "The Ethics of Clinical Research in the Third World," in which she challenged the morality of U.S.-sponsored AIDS studies in Africa.

In an act of editorial chutzpah -- some would say arrogance -- she compared the trials to the notorious Tuskegee experiments.

The reactions were intense.

"I'm quite honestly appalled by these people," said Dr. Alfred Sommer, dean of the Johns Hopkins University School of Hygiene and Public Health, where researchers are planning several of the overseas experiments.

But Angell is sure of her position and willing to take on those who oppose her.

"I've been appalled by the heat without light," said Angell, 58, a petite woman who speaks in soft, measured phrases that carry surprising wallop.

"First of all, people who should know better are putting out arguments that are absurd and disingenuous. Second, I am appalled by the shift in focus from the merits of the discussion to the personalities.

"These arguments are fallacious and almost caricatures of themselves. Yes, the New England Journal of Medicine likes to see scientifically rigorous work. But when it comes to choosing scientific purity over ethical purity, I'll choose the second."

Problem with placebo

The trials might seem innocent enough: an effort to find inexpensive ways to curb the horrifying spread of AIDS from pregnant women to their babies. But she doesn't see it that way. Her problem came when researchers, displaying what she called "a slavish adherence to the tenets of clinical trials," decided to evaluate experimental therapies by giving women in "control groups" pills that do nothing.

Researchers insisted that they were doing the scientifically appropriate thing -- comparing a therapy to the absence of therapy in places where people generally go untreated. But Angell, expanding upon a critique first raised by consumer health advocates, said they were willfully denying treatments that could save hundreds of children from dying of AIDS.

"The justifications are reminiscent of those for the Tuskegee study: Women in the Third World would not receive anti-retroviral treatment anyway, so the investigators are simply observing what would happen to the subjects' infants if there were no study," she wrote.

The Tuskegee experiments were the four-decade trials, halted in the 1970s, in which government scientists watched Southern black men deteriorate with syphilis, withholding penicillin even after the drug was accepted as a cure.

In medicine, there is no accusation more likely to incense.

Two members of the journal's editorial board resigned in protest. David Ho, a world-renowned AIDS expert, and Dr. Catherine Wilbert, a pediatrician from Duke University, said they were offended by the comparison to Tuskegee and should have been consulted before the editorial ran.

Sommer said the critics "are Americans who have absolutely zero experience, have never been involved in changing scientific paradigms or changing policies. They are getting involved in an issue about which they know nothing."

Dr. Sidney Wolfe, a consumer health advocate who first raised the Tuskegee comparison with colleague Peter Lurie, hasn't always agreed with Angell. The two are on "completely opposite sides" of the breast-implant issue, said Wolfe, who campaigned vigorously against the devices.

"She's very smart, very articulate and she speaks English very clearly and plainly," said Wolfe, director of Public Citizen Health Research Group. "We are very pleased she wrote a strong editorial on the issue."

Last week, the controversy took a new turn. Hopkins indicated that it would drop the placebo part of its Ethiopia study, scheduled to begin in 1998, if other trials indicate that the experimental therapy -- a short course of AZT -- is effective. Scientists insisted that they were merely adapting to new evidence, and rejected Wolfe's claims that they had seen the "error of their ways."

Smart and unafraid

Angell grew up in Arlington, Va., part of a huge family that considered medicine the province of men. Her father was a civil engineer with the Army Corps, her mother a homemaker. They saw college in her future and possibly a health-related job. Maybe a medical technologist, certainly not a doctor.

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