6 Everyone's interests
So far we have seen that the MMR debate has been far from neutral, with collective and individual values playing a part in decision making – by scientists, policy makers and parents. One angle of the debate has been a preoccupation with conflicts of interest. With researchers increasingly reliant on funding from sources that have clear interests in the outcome, openness and transparency about who funds what research is deemed essential so that reviewers can take this into account when assessing whether a paper is suitably objective.
Events in the MMR debate took an important turn on 22 February 2004 when the Sunday Times reported that Wakefield had secured £55 000 from the Legal Aid Board in 1996, two months before the study reported in the 1998 Lancet paper commenced. The funding was to investigate the link between the MMR vaccine and autism in the cases of ten children with a view to establishing whether the parents would be able to sue for compensation. ‘Four, maybe five’ of the children were involved in the study reported in The Lancet. Although Wakefield continues to insist that this did not represent a conflict of interest, most of his co-authors and the editors of The Lancet thought otherwise. On 6 March 2004, a ‘partial retraction’ of the original paper was issued by ten of the thirteen authors. Whereas the findings on gastrointestinal problems associated with autism were allowed to stand, the interpretation of a possible link between autism and the MMR vaccine – although this was never made explicit in the paper – was deemed to have had ‘major implications for public health’ and the interpretation was formally retracted.
The Lancet requires authors to declare financial arrangements or personal relationships that could bias their work. The failure to declare the Legal Aid Board funding was the final straw for Lancet editor Richard Horton. Having spent six years defending his own and the journal's reputation from recriminations for publishing in the first place, the incident provided an opportunity for The Lancet to distance itself from what had become one of the most controversial papers ever published.
In a commentary accompanying the partial retraction of the 1998 paper, Richard Horton sets out the difficulties that accompany research of this type, and the problems with decisions about publication. Click to view: Horton, R. ‘The lessons of MMR’, The Lancet, 363, pp. 747–49. Horton emphasises that there are ‘lessons to be learned’. List the lessons Horton outlines in this article, and compare it with your own list of what lessons you think should be learned from the MMR controversy. What is your position on the view that Horton was being opportunistic in using the conflict-of-interest issue to deflect criticism of his handling of the matter?
Peer review is often held up to be the criterion which distinguishes research that stands up to ‘scientific scrutiny’. It is a validation gateway through which scientific research must pass before it is admitted to the canon of reliable knowledge. Yet the process of peer review is highly subjective, relying on editors' and reviewers' judgements on the influence of funding sources on interpretation of results. It is widely recognised that few scientists are entirely disinterested in the results of their research, although these interests do not necessarily bias the outcome. However, by not declaring potential conflicts of interest, researchers leave themselves open to accusations of lack of integrity.
A second potential conflict of interest plays an important role in the MMR debate, and that is the funding general practitioners receive for reaching immunisation targets – in the region of £3000 per annum if 90% of the infants on their patient register complete the immunisation programme. This may have a negative effect on the perceived impartiality of the advice given to patients by GPs. Some practices were found to be removing unimmunised children from their registers in order to boost their percentage uptake.
Issues surrounding conflicts of interest serve to highlight the importance of trust. Parenting is largely a matter of instinct. Subjecting a child to a painful, invasive intervention, such as a vaccine, goes against instinct and relies on trust that the procedure is in the child's best interests. No matter how unproven the risk of contracting autism from MMR is, the decision to vaccinate remains a very real dilemma.