What is the moral collapse in the Cochrane Collaboration about?
Peter C GøtzscheDOI: 10.20529/IJME.2019.064
AbstractOn September 13, 2018, one of the founders of the Cochrane Collaboration was expelled from the organisation, by a narrow vote of 6 to 5. Many see this as a moral collapse in what was once a magnificent grassroots organisation, guided by ethical principles and helping people make better decisions about healthcare interventions.
I am that excommunicated person. I review here the essential issues leading to my expulsion, which occurred primarily because, in my capacity as a board member, I had challenged the CEO’s virtually total control over the board, his mismanagement of Cochrane, and the direction in which he was taking the organisation. My criticism of psychiatric drugs and the highly prestigious Cochrane review of HPV vaccines also played a role. Freedom of Information requests revealed that the CEO went well beyond his brief to demand my removal from the Nordic Cochrane Centre, resulting in my sacking.
Cochrane has become too close to industry and has introduced scientific censorship, which is detrimental for a scientific organisation. The board has announced a “zero tolerance” policy for repeated, serious bad behaviour. It would be beneficial if its CEO and board members applied this principle to themselves.
I also discuss a recent paper by Trisha Greenhalgh et al that purported to have analysed the current Cochrane crisis in a disinterested fashion, which it did not. Instead of discussing the undeniable facts and the horrific abuses of power, TG consistently used positive terms about Cochrane and negative ones about me and my supporters.
Key words: Cochrane Collaboration, industry bias, evidence-based medicine, censorship, drug industry
On September 13, 2018, one of the founders of the Cochrane Collaboration was expelled from the organisation. This took place at the Cochrane Colloquium in Edinburgh, and it was the first time that anyone had been expelled. Many see this as a moral collapse in what was once a magnificent grassroots organisation, guided by ethical principles such as transparency, openness, democracy, collaboration, avoiding conflicts of interest, minimising bias and helping people make better decisions about healthcare interventions.
I am that excommunicated person and I have described the events in a book (1). In this commentary, I review the essential issues and discuss a recent paper that purports to analyse the Cochrane crisis in a disinterested fashion, which it does not.
Non-issues made big issuesThe affair started with two petty complaints related to psychiatry levelled against me by Cochrane’s CEO, Mark Wilson, about my use of the letterhead of the Nordic Cochrane Centre, of which I was the Director (1, 2). Both cases involved deaths likely caused by psychiatric drugs. Ryan Horath, a lawyer unbeknownst to me, described one of them this way: “JESUS CHRIST, WHAT IS WRONG WITH YOU PEOPLE. A researcher is making inquiries about the suppression of information regarding children who died in a clinical trial and everyone is worried about what letterhead it is written on?”(1).
As I disagreed with Wilson that I had violated his Spokesperson Policy, I appealed his decision to the Cochrane Governing Board, which it was my right to do according to the agreement my centre had with him. The whole affair should have ended with the board’s arbitration, but a decision was never made. Instead, Wilson and his close ally, Martin Burton, co-chair of the board and Director of the UK Cochrane Centre, launched a full-scale assault on me (1).
Cochrane hired a law firm, and Counsel was asked to investigate my actions going back 15 years and based on a 330-page binder produced by Burton with inputs from Wilson, but not from me. The board called the investigation “independent” although Counsel was paid for by Cochrane. I rejected Cochrane’s allegations in a 66-page report (1, 2). Counsel found it inappropriate to go back even three years and did not find that I had broken the Spokesperson Policy (1, 3). In a morally intact organisation, the affair would have ended there.
Principles of Natural Justice not followed by CochraneAt the September 13 Cochrane board meeting, I was a board member, but I was allotted only five minutes to defend myself, after which the board used six hours to conjure up a spurious excuse to expel me, for so-called bad behaviour (1). This process had all the hallmarks of a secretive show trial with a pre-planned outcome, although Wilson is not supposed to wield any power over the board. I was outside the room when this discussion took place and did not get an opportunity to reject the many false statements that were made during the meeting (1).
I had insisted that the meeting be recorded, which the co-chairs had tried to avoid (1). After it ended, I learned that I had been expelled by a narrow margin, 6 to 5. When four of the remaining 12 board members resigned the next day in protest over my expulsion, the board realised that no traces should be left of the meeting; these four members were asked to hand over their recordings on a memory stick and to delete them from their computers. However, the recordings were leaked, and they reveal that what was said at the meeting contrasts sharply with the board’s official announcements (1).
The two co-chairs, Martin Burton and Marguerite Koster from Kaiser Permanente, broke all essential rules applicable to charities and to Cochrane in the course of the meeting (1). During the secretive proceedings, Burton mentioned that I could say what I wanted “within the bounds of decency, defamation and hate speech.”(1). Four days after the board meeting, Burton delivered a formidable hate speech about me at Cochrane’s Annual General Meeting, which was identical to a defamatory board statement issued the same day (4). Cochrane headquarters also ensured that the more than 10,000 Cochrane contributors wouldn’t miss the statement, sending it out via their group email lists. Later, they put up another defamatory statement on the home page of the Nordic Cochrane Centre’s website, without informing us and stripping the Centre of our administrative rights (1).
Actions motivated by hatred and spite, rather than truth and honestyBurton’s hate speech is worth listening to. It is on YouTube (5) (starts after 36 minutes and lasts 10 minutes). It was inspired by inappropriate insinuations during the secretive board meeting about the “Me Too” movement by three board members, Burton included (1). Burton shocked the audience, making many people believe that I had sexually harassed women or committed serious crimes, even though they could not reconcile this with their knowledge of me. But Burton was smart. He said that, for “confidentiality” reasons, he could not give any details, which added fuel to the defamatory rumours his speech created, because some people thought he protected the “victims” when in fact the only victim was me. The insinuations were so horrible that the eight remaining members of the board sheepishly needed to state, at a webinar on October 4 where they tried to explain why I had been expelled, that there were “NO allegations of sexual or physical misconduct, or any other criminal activity.”(6)*
No examples of my alleged harassment of colleagues or bad behaviour were provided, even though questions about this were raised during the Annual General Meeting. On the other hand, I have documented numerous examples of Wilson’s continued harassment of me and other centre directors over the years (1, 2). During the secretive board meeting, several board members mentioned his harassment. At a March 2018 board meeting in Lisboa, the capital of Portugal, a board member burst into tears when she said that Burton was afraid of Wilson. This is the only time I have seen a board member cry. In Lisboa, Wilson shouted and called me a liar although I had spoken the truth (1, 7), and he assaulted another board member when he agreed with me (1). Both these board members resigned in protest.
Burton’s hate speech and the unjustified and my basically illegal expulsion led to turmoil, and Cochrane went into damage control. The board spent the next few weeks trying to justify its actions, issuing mendacious and defamatory statements against me during carefully staged public events.(1, 4, 6, 8) Their tactics did not work and instead set off a chain reaction of protests by scientists and members of the public.
Via Freedom of Information requests, my lawyer found out that Wilson, in contacts with the Danish Ministry of Health and my hospital, had insisted that I no longer work at the Nordic Cochrane Centre, which is funded by the Danish Government, and this resulted in my sacking (1). In fact, Wilson overstepped his mandate and should not have been allowed to exert any influence on internal affairs in another country. A letter with over 10,000 signatures sent to the Danish Minister of Health requesting that my sacking be prevented had no effect (1).
Cochrane reacted the way any business with a dishonest leadership would react. The Cochrane Governing Board hid behind confidentiality clauses and continued to defame me, misleading millions of people, including its own members, about what really happened on September 13 in Edinburgh.
Independent inquiry deniedThe 31 Centre Directors in Spain and Latin America called for an independent investigation of the process that led to my expulsion (1, 9). However, the board refused, likely because it would expose them and the truth would come out. The investigation is no longer needed, as my book, with its numerous verbatim accounts of what was said at the secretive board meeting, says it all (1).
As an elected board member ─ with the most votes of all 11 candidates although I was the only one that criticised the Cochrane Executive Team in my election statement ─ it was my duty to point out any irregularities in the governance of Cochrane. I established that the CEO and the co-chairs of the board tampered with meeting minutes (1). On October 9, I filed a complaint with the Charity Commission about serious mismanagement. One year later, this complaint is still pending (6).
Dissent and honesty suppressed to appease pharma industryThe real reason for my expulsion was that I, in my capacity as a board member, had challenged the CEO’s virtually total control over the board, his mismanagement of Cochrane, and the direction in which he was taking the organisation, focusing on brand, product and business, rather than on getting the science right and having open debates about what it shows. “It’s about having a unified voice,” as one board member expressed it (1). Many have interpreted this as scientific censorship. It was also relevant that I had criticised psychiatric drugs and the highly prestigious Cochrane review of the HPV vaccines published in May 2018 (1).
The board has fiercely denied that my expulsion has anything to do with the HPV review, but the leaked recordings show that this is not true (1). “HPV” appears 48 times in the transcript of the board meeting. Furthermore, it is extremely likely that Burton orchestrated the remarkably similar letters of complaint that all called for my expulsion from the board because I had criticised the Cochrane HPV vaccine review; these letters arrived immediately after I had submitted my report to Counsel (1).
The Cochrane leadership were also unhappy that, soon after I was elected to the board, I criticised the fact that up to half of Cochrane authors are allowed to receive financial support from the company whose product is being reviewed (10). Cochrane’s motto is “trusted evidence,” and if we don’t trust guidelines authored by people with financial conflicts of interest, why would we then trust Cochrane reviews authored by such people? BMJ’s Editor-in-Chief wrote that my expulsion reflects “a deep seated difference of opinion about how close to industry is too close.”(11)
The other board members supported my proposal that people with financial conflicts of interest should not be allowed to be authors of Cochrane reviews. I rewrote the commercial sponsorship policy in an afternoon and sent it to the board; but after a year, the proposal had not progressed at all, and after two years, we have still not seen a renewed policy (1). As one board member who resigned said, there is increasingly strong resistance in Cochrane to say anything that could affect pharmaceutical industry interests (1).
After my expulsion, there were many articles in medical journals such as Science, Nature, BMJ, BMJ Evidence-Based Medicine, and Lancet, and elsewhere (7, 11, 12, 13, 14, 15, 16). Most of them were critical of Cochrane. Lancet noted that no examples were given in Edinburgh of my alleged bad behaviour and that, “There was a total lack of transparency at the annual general meeting; no one knew what was going on … Cochrane declined The Lancet’s repeated requests for an interview.”(7) Richard Smith, previous Editor-in-Chief of the BMJ, wrote that, “Most of us either cannot see that the emperor is naked or will not announce it when we see his nakedness, which is why we badly need people like Peter.”(17, 18)
The “disinterested” analysis by Trisha Greenhalgh et alIn a paper published on March 18, 2019, a Professor from Oxford, Trisha Greenhalgh, and three colleagues (whom I will call “TG” for the rest of this paper) purport to have analysed the Cochrane crisis in a disinterested fashion (19). They say that more than one version of the truth may exist and that mutually exclusive narratives about what is good science or good governance can be usefully combined using higher‐order theory.
However, they fail to address the crucial issues, even though all the essential facts, including Counsel’s report, have been on my website, www.deadlymedicines.dk, since fall of 2018. They quote a Lancet article that alludes to these documents (7), but ignore the documents themselves. Furthermore, while the BMJ pointed out that the board ignored the report from its own Counsel (15) (which, in my view, exonerated me of all charges raised, in contrast to the board’s official announcements), TG cite the board’s announcements as if they were true, but do not cite any of my statements demonstrating that some were mendacious (1, 4, 8). They also completely ignore Counsel’s report.
Instead of discussing the undeniable facts and describing the horrific abuses of power (1, 6) which have caused some Cochrane volunteers to worry that they might be next in line to be expelled, TG construct two mutually exclusive narratives in which they consistently use positive terms about Cochrane and negative ones about me and my supporters. Our views on conflicts of interest and academic freedom are called “monastic” and “fundamentalist”, respectively. We are “moral entrepreneurs” who “may occasionally fall short on critical self‐reflection”. Those 10,000 people who signed the letter to the minister to prevent my sacking display “intellectual rigidity” and suffer from “moral and philosophical immaturity”. I think it will amuse the world’s most cited medical researcher, Professor John Ioannidis from Stanford University, who wrote to the Danish Minister of Health to prevent my sacking (1, 20), that TG call him morally and philosophically immature. TG lead their readers astray by saying that, “recent events in Cochrane can be framed as an epic struggle for the organization’s scientific, philosophical, and moral soul … the schism between a procedural and expert‐centred approach to best evidence and an alternative approach that is more ‘socially distributed, application‐oriented, trans‐disciplinary and subject to multiple accountabilities.’” They beat about the bush; use empty words favouring Cochrane; and repeatedly ascribe views to us that we don’t have (see below).
The art of always being rightTG use many of the tricks described in philosopher Arthur Schopenhauer’s booklet, The art of always being right: (21) “False premises;” “Postulate what has to be proven;” “Use seemingly absurd propositions;” “Choose metaphors favourable to your position;” and “Put his thesis into some odious category” (also known as name calling). In addition, their essay is pompous. For example, my “considerable scientific authority” is said to be the product of historical and cultural forces. In my humble opinion, it is simply the deserved result of producing good science (1). TG postulate much that simply isn’t true. My supporters never said I was fully entitled to speak for the Nordic Cochrane Centre because I “was such an exceptionally good scientist,” and the reference TG quote provides no support for this claim (19). According to Cochrane rules, I was entitled to speak for the centre because I was its director (1). Plain and simple.
We have never argued that a “systematic review is essentially a technical task rather than a broader analytical and critical process”; or that “content experts may not be required on systematic review teams since assessing methodological quality is an almost exclusively technical task.” TG quote a paper by Ioannidis and me as having said this, but we said nothing to that effect (22). We are well aware that content experts can be helpful and that highly skilled researchers can reach different results even when using the same meta-analysis protocol and rigorous methods. My co-workers and I have demonstrated this empirically: Ten researchers performed the same ten meta-analyses independently of each other, and disagreements were common and often larger than the effect of commonly used treatments (23).
It is pure fabrication and libellous when TG state: “In a further strand in the ’bad behaviour’ narrative, Gøtzsche was suspended in October 2018 from his position at the Rigshospitalet and University of Copenhagen, allegedly for mixing his private expenses with those of the Nordic Cochrane Centre and failing to comply with independent financial audits.”(19). They give a reference that says absolutely nothing to this effect and they also got one of the authors wrong (24).
Collusion with the journal, fabrication of “facts,” and editorial misconductThe facts are these: A Danish journalist and editor, Kristian Lund, who publishes drug industry-supported journals on the web, got access to my financial records three years back in time. When he and his team did not find anything of value for their benefactors, they lied about it (1). In the drafts for the first five of their more than 15 articles, I counted 63 untruthful statements. I therefore explained that, according to §267 of the Danish Criminal Code, the articles “are libellous and express slander. They are affected by so many untruths, speculations, and distortions that it would make no sense to comment specifically on them. They are basically not source-based. On this background, I do not wish to contribute with concrete comments.” My response was published in one of their articles (25). The lies continued unabated even after my hospital had declared that they had not found any confusion of private money, government grants and other funds, which statement they also printed in one of their articles (26).
I informed Mathew Mercuri, the editor of Journal of Evaluation in Clinical Practice where TG published their paper (19), that they had lied about the reason for my sacking and that this was very serious and libellous. The journal wanted to react by publishing a corrigendum that only said that TG’s paper “was edited to remove a statement that was not directly supported by its stated source.” After my protest, that the word “directly” indicated that what TG had written might be true after all, they removed this word (27). However, despite my protests and despite it being contrary to international guidelines for medical publishing, they said they would remove the original paper and upload a version without the libellous statement. International guidelines are clear that once an article is published, no correction can be made in the text without indicating what exactly was changed and why.*
Since the editors did not say what was removed and why, TG’s defamation of me can continue unabated. They published a Corrigendum in October, which stated that, “The article Greenhalgh et al,1 was edited to remove a paragraph that was not supported by its stated source.” However, this is not true. The mendacious statement still appears in the revised version from October, and there is no hint anywhere in the article that it is mendacious.
Hilda Bastian, a non-leading scholarTG allege that I presented a distorted version of the truth in my books and lectures and reacted in a hostile way towards both academic and financial oversight of my work. This is also untrue, and the two references TG offer say absolutely nothing about what they claim (24, 28). One is to a blog (28) by Hilda Bastian whom they consider “a leading scholar,” which trick Schopenhauer calls “Appeal to authority rather than reason.”(21) Ryan Horath, the lawyer mentioned above, has commented on Bastian’s blog (28). “Given the personal history you have with Dr Gøtzsche … particularly over mammography, I think you could have disclosed that to readers … Hate distorts the personality of the hater …” The blog by Bastian is about our critique of the Cochrane review of the HPV vaccines (28). She calls our research group “anti-vaxxers,” which one would not expect from “a leading scholar.” We acknowledge that vaccines have saved millions of lives, and I have just repeated this in an evidence-based book about vaccines (29).
Horath commented on another of Bastian’s blogs (30). To her opinion that I should refrain from harassing staff, he asked why she trusted the board’s clearly slanderous language and noted that Counsel’s report did not describe any harassment although he was “bending over backwards to please the board.”(1, 30)
Confusing honest science with “extreme positions”According to TG, I have been accused of scientific bias and am an intellectual maverick who has taken extreme positions on mammography screening programmes, depression pills, and the HPV vaccines. The truth is that what I have concluded is based on the science I have studied carefully. This is not about being extreme but about being honest and telling people what I found. TG say I have been criticised for having “allegedly ignored or dismissed evidence that did not support his chosen position,” and I have “put pressure on the Danish government to change policy in line with his views.” I would put it this way: If you speak truth to power, you will be criticised; people come up with all kinds of flawed research and complain that you did not cite it. And lobbying governments for introducing evidence-based policies is a good thing.
TG say that I and my supporters define good systematic reviews in terms of methodological rigour and elimination of bias whereas most of the Cochrane Board and their sympathisers incorporate factors such as attention to relationships among reviewers and reflexivity and dialogue around scientific and other judgements. However, science is not a consensus exercise or about feeling good together. Furthermore, everyone in Cochrane aspires to methodological rigour and elimination of bias, which is why there is a Cochrane Handbook of over 600 pages telling people what to do. What “relationships”, “reflexivity” and “dialogue” really mean is scientific censorship, the “unified voice.”(1) The board meeting recordings clearly reveal that it is more important not to upset colleagues who did a poor job with the HPV vaccine review than to get the science right (1). This clubbiness is detrimental for a scientific organisation.
Poor Cochrane HPV vaccine review, scientific censorship and “eminence-based medicine”The selective and sloppy way TG use the literature is also apparent when they discuss the HPV vaccines. They provide a reference to our second criticism of the Cochrane review of the vaccine, but the title is wrong, they wrongly list Peter Doshi as a co-author of the article, the link to the article does not work, and the publication date is wrong (19, 31). What is worse, they do not tell their readers what our paper was about (31). They give Cochrane’s Editor‐in‐Chief, David Tovey, and his deputy, Karla Soares-Weiser, the last word, even though we had documented that the Cochrane review should have included at least 35% (over 25,000) additional eligible females in its meta-analyses; that there was incomplete reporting of serious adverse events; that deaths were misreported; that they used the word “placebo” throughout the review and in all its meta-analyses, although no included trial used a placebo comparator; and that the editors had incompletely assessed the authors’ conflicts of interest and ignored additional ones (31). As our paper was a reply to the Cochrane editors’ article, this is yet another example of “Appeal to authority rather than reason,” or “eminence-based medicine.” The Cochrane editors “ruled that what had been described as ‘omissions’ were actually the result of defensible judgements that took account of clinical, scientific, and policy realities.” This is plain wrong.
TG assert that the board had no objection that I published my views as an independent scientist. The truth is that they spent much of the secretive board meeting condemning this (1).
Double standards in the Cochrane CollaborationTG say that I resisted the Collaboration’s governance mechanisms and could not effectively govern my own Centre. This is not true (1). Counsel misunderstood what centres are free to do, as he thought they are only allowed to do Cochrane work. They do other things, including non-Cochrane related research, and if they didn’t, few of them would survive (1).
TG say I have “accused” the board (and the CEO, Mark Wilson) of discrimination. It is more than an accusation. I have proved it, with numerous examples, and other board members testified about this at the board meeting (1). Worst of all, Wilson exonerated a member of his own staff for having done exactly what he had accused me of doing for years — presenting his own views without a disclaimer that these are not official Cochrane views —and Burton prevented me from presenting this incriminating evidence to the board (1).
All of a sudden, by the end of their paper, TG abandon their philosophical mumbo jumbo that includes a discussion of “postnormal science” and become highly pragmatic: “Systematic reviews are expensive. Furthermore, only a tiny fraction of senior researchers can boast no industry connections at all.”(19). Ethics is a branch of philosophy, but TG do not seem to worry about the ethical problem – or its consequences for patients ‒ in having authors of Cochrane reviews with close ties to the drug industry.
Sticking the head in the sand and the double-tongued approachSo, how do TG propose to resolve the Cochrane crisis? By sticking their heads in the sand: “We suggest that one way out of Cochrane’s current crisis is to stop trying to resolve it … Articulating Cochrane’s challenge in terms of an incommensurable tension between two philosophical perspectives allows us productively to harness the conflicts that gave rise to it, since both versions may provide insights when making complex judgements … we believe that the crisis in Cochrane is epistemic.” (19). I wonder what they are trying to say here.
Greenhalgh seems to be double-tongued. She wrote to me on September 15, 2018, the day after I had explained on my website that Cochrane had expelled me two days earlier:(32) “I am interested in this story NOT because I take the line ‘Peter is right, the CC [Cochrane Collaboration] is wrong’, but because the CC seems to be taking the view that they have a monopoly on the truth … By throwing you out, CC are saying they no longer want dissent, disagreement, debate.”. The same day she tweeted: “Does Cochrane need help from its many friends? If so, just ask.”
In a letter to the journal in which TG published their paper, TG’s paper is described as “highly problematic. The authors claim that their analysis is neutral; instead, it appears to privilege one perspective over the other and to support the inclusion of pharmaceutical and device industries in the production of scientific knowledge and in science policy.”(33)
I was invited to submit a comment on TG’s paper, but the editors did not like my manuscript. People who wish to read a truly disinterested analysis of the Cochrane crisis are better served by reading the BMJ paper, “Has Cochrane lost its way?”(34)
ConclusionThe board announced last fall that they will have a “zero tolerance” policy for repeated, seriously bad behaviour (4). It would benefit the Cochrane Collaboration if its CEO and board members applied this principle to themselves. They have harmed the collaboration substantially by their concerted, undemocratic actions. I am just the symbol of how wrong it currently is.
Conflict of interestI have dedicated my book about Cochrane’s moral collapse to the thousands of unpaid Cochrane volunteers who create Cochrane’s wealth and I have cited it in this paper.
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