Issue 8 / 5 March 2012

MEDICAL practitioners are very familiar with the concept of accountability. Whether we work in private practice, community practice or hospitals, we are subject to a structured regulatory system.

Formal complaints are assessed and acted upon, resulting in sanctions where appropriate. In NSW, a separately administered Health Care Complaints Commission (HCCC) is involved in a coregulatory model with the NSW board of the Medical Board of Australia.

The HCCC was in the NSW Supreme Court late last month supporting the principle of accountability — not the accountability of doctors or nurses this time, but of an anti-vaccination organisation.

In July 2010, following investigation of a complaint, the HCCC issued a warning against an anti-vaccination group calling itself the Australian Vaccination Network. The HCCC found that the AVN “misleads readers by using reliable and peer-reviewed research, but quoting selectively from it, often in contradiction to the conclusions or findings of the studies themselves”.

When the AVN failed to comply with the HCCC’s recommendation to post a warning on its website, the HCCC issued the following warning against the AVN: “The AVN’s failure to include a notice on its website of the nature recommended by the Commission may result in members of the public making improperly informed decisions about whether or not to vaccinate, and therefore poses a risk to public health and safety”.

The AVN’s action in the Supreme Court questioned the HCCC’s jurisdiction over it. According to Section 7 of the Health Care Complaints Act 1993, the requirement for a complaint to be made about a health service includes “(b) a health service which affects the clinical management or care of an individual client”.

The Supreme Court judge found that the AVN did supply a “health service”, but that had not been shown to affect the clinical management or care of an individual client. It was therefore found that the HCCC had no right to issue a warning against the AVN.

The finding of the Supreme Court says nothing, however, about the quality of information provided by the AVN. As noted by research scientist and commentator Dr Rachael Dunlop, “There is no suggestion that the AVN’s information can now be declared scientifically valid and accurate”.

What mechanisms are left, then, to hold the AVN to account? How can unregistered providers of “health care information” be held accountable for the information they disseminate?

Since August 2008, the HCCC’s powers in relation to unregistered health practitioners have been broadened under the Health Legislation Amendment (Unregistered Health Practitioners) Act 2006. These powers now extend to previously registered practitioners, as well as other providers such as naturopaths, acupuncturists, psychotherapists, therapeutic masseurs, social workers, occupational therapists and homeopaths.

An associated code of conduct “requires that practitioners must provide services in a safe and ethical manner”.

Providers of “health care information” should be included under these powers and this code of conduct.

Health misinformation can cause both direct and indirect harm. Perhaps it is time to end the polite tolerance of this harm and hold these providers to account.

Dr Sue Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

Posted 5 March 2012

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11 thoughts on “Sue Ieraci: Anti-vaccine accountability

  1. Debbie Slater says:

    I agree entirely that health information should be evidence-based and without bias. However, it is not only ‘health information services’ that do not always adhere to this principle. As a health consumer advocate I have come across health professionals – including doctors – who quote selectively from out-of date or discredited evidence to reinforce a particular point of view, present opinion as fact and use highly-emotive language when presenting health information. In such circumstances it is difficult to say how a health consumer is able to make a truly informed choice. To quote the NHMRC Guidance on Collaborative Maternity Care: “Informed choice occurs when a woman has the autonomy and control to make decisions about her care after a process of information exchange that involves providing her with sufficient, evidence-based information about all the options for her care, in the absence of coercion or withholding any options by any party.” Such a definition of informed choice should be the basis for all health professionals and health information providers when providing health information to health consumers.

  2. Rhianna Miles says:

    Well said, Sue. It is very important that suppliers of health information (whether registered practitioners or not) are held accountable for their advice.
    With the advent of a move away from medical paternalism, and an increased preference for patient autonomy, we must ensure that information that patients are using to exert their own autonomy and health decision making is accurate, up to date and representative of the current state of medical literature.
    Widespread misinformation regarding particularly vaccination is rampant. I fail to see how an individual patient can make a truly informed medical decision, when they are bombarded with emotive and incorrect information from these unregulated health care providers.

  3. daman langguth says:

    When ex-presidents of the AMA make statements in the media supporting the integration of non-evidence based care in to actual medicine, this totally undermines the message we are sending to the public. If something works (and all that might entail), show it does and thus it should be used.

    I don’t want my children in a school with unvaccinated kids, if you are against vaccination you are probably against gravity: there is more evidence for vaccination.

  4. John Cunningham says:

    Well said Sue!

  5. Mia says:

    There is a reason why the public mistrusts the information from the ‘official’ sources. Bias, pseudo science, self-interest, fraud, are all part of medical practice.

    Healthcare is still plagued by statistical deception and bad science that distort policy and put patients at risk, the Radical Statistics group’s annual conference heard on 24 February.

    Senior academics said flawed and fraudulent use of data was having a malign effect and many parties were to blame, including the government, economists, drug companies, regulators, medical publishers, and researchers.

    Aubrey Blumsohn, a senior lecturer in metabolic bone disease at the University of Sheffield, said scientific fraud was often misrepresented as the work of aberrant individuals.
    But, he told the conference, “It is not rare, it is a group activity.” He said it could involve collusion between drug companies, researchers, journal editors, ghost writers, and regulators.
    He said the mechanism for fraud was usually more nuanced than direct fabrication of scientific findings and involved techniques and behaviour that could “disturb the scientific record.”
    He said the details of fraud often only emerged during litigation but that this “should not be the most important part of the process.”

    http://www.bmj.com/content/344/bmj.e1526?etoc=

  6. Dr Ken Harvey says:

    Adamson J said:

    http://www.caselaw.nsw.gov.au/action/pjudg?jgmtid=157076

    45 In my view, the use of the words “the clinical management or care of an individual client” evince an intention that only a complaint concerning a health service that has a concrete (even if indirect) effect on a particular person or persons is within jurisdiction. Complaints about health services that have a tendency to affect a person or group, but which cannot be shown to have had an effect, would appear to be excluded.

    46 If Parliament wishes to describe conduct that has a particular tendency, rather than having an actual effect, it can do so. Examples include the prohibition in the former s 52 of the Trade Practice Act 1974 (Cth) (now s 18 of the Australian Consumer Law) which proscribed “conduct that is misleading or deceptive or is likely to mislead or deceive” in respect of which it is well established that the actual effect of such conduct need not be established.

    In short, the NSW Parliament should fix the defects in the legislation to allow the HCCC to compel bodies like the AVN to correct dangerous mis-information.

  7. Alex Wood says:

    The article suggests that information to HCCC may have been not sufficiently prepared or that Supreme Court was not given sufficient material.
    As I understand “justice”, Courts need to be supplied evidence that they can consider in the judgement.
    Is it the case that more careful presentation with evidence of harm to one or some may have been successful against anti vaccination network?

  8. GP says:

    Who do I beleive? Your evidence based medicine which has been repeatedly shown to hide lies, cover-ups and lackj of the truth? Or my personal experience? My daughter almost died following her second triple antigen injection. If I follow your advice and give my daughter another one of your “safe” vaccines and she dies or worse still develops brain damage, will you pay for her life maintenance? I bet that you won’t.

  9. Dr Ken Harvey says:

    After reading the court judgment I believe Alex Wood is right; a better prepared case citing individual harm may well have got up. Equally, I believe the legislation needs to be changed as Adamson J suggested.

    With regard to GP; I agree that very occasionally common vaccines can cause severe harm. However, the benefits to the majority clearly outweigh the rare risk. I am old enough to remember wards in the Fairfield Infectious Diseases Hospital that were full of patients in iron lungs paralysed by polio; now entirely prevented by vaccines.

    Having said that, I support no-fault medical compensation for those rare people injured by immunisation. Immunisation both protects the individual and also society through herd immunity; society therefore has an obligation to compensate those rare people injured by immunisation.

    See: https://www.mja.com.au/journal/2011/195/1/no-fault-compensation-scheme-s

  10. Kerwyn Foo says:

    @ Debbie and @Mia:
    Whilst I agree that there is much also to be desired in applying evidence to decision making in ‘establishment’ healthcare, it does not change the fact that the AVN is, in fact, lying to the public. And one cannot defend lying by pointing fingers and saying “everyone else is doing it”. It’s still wrong.

  11. JD says:

    Unfortunately, the medical profession doesn’t seem to understand the psychology of risk: when faced with doing something active which is potentially harmful and doing nothing for which the blame is less obvious or attributable to something else, many people will choose the latter. This is even enshrined in our saying: “First do no harm”.
    As doctors, we balance risks daily – be active or passive; it can be hard. For those not trained to make these sorts of decisions, it can feel safer to do nothing, especially when most vaccines have “minor” side-effects. The recent fiasco with the flu vaccine hasn’t helped.

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