By Carlo Fonseka –

Prof. Carlo Fonseka

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 and 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.

Conclution

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.