A shortage of expert witnessess
The fall-out from these decisions are very serious indeed. Although an expert may genuinely believe that he/she is expressing an opinion based on knowledge and experience, has been properly instructed and has been accepted as an expert by the court, a lay disciplinary tribunal can still override this. Despite the fact that the members of the tribunal themselves lack expertise, they have nevertheless concluded that a physician is providing evidence that is outside her area of competence. Not only that, they have decided that Dr. Squier should be struck off the medical register. Although this was reversed by the High Court, she was banned from acting as an expert witness for a period of three years.
Clearly this experience has been extremely difficult and probably traumatic for Dr. Squier. Even more important is the message it sends out to other people who are could act as expert witnesses in other cases involving SBS. In view of the risks to a person’s reputation and career who can blame anyone for declining an invitation to be an expert witness in a case where the determination of the cause of SBS is critical. This is confirmed by the fact that two other SBS sceptics Dr Irene Scheimberg and Dr Marta Cohen have stopped giving evidence. A similar stance has been taken by two supporters of the diagnosis including Professors Tony Risdon and Colin Smith, both of whom gave evidence against Dr Squier at her panel. So we really are in a mess because the courts are likely to have difficulty in obtaining the necessary input to assist in reaching a verdict on a complex issue.
Support for Dr. Squier
Despite the establishment view on SBS there is actually considerable support for the position taken by Dr. Squier. Several other specialists have travelled along a similar path as a letter to the Tribunal pointed out:
“Dr. A. Norman Guthkelch, the first physician to propose in print that shaking can cause subdural hematoma (in the British Medical Journal in 1971), has also defended caretakers accused of infant shaking. He told one of our members in 2012 that he is “horrified” at how his initial proposition is being misrepresented in court, saying, “I am frankly quite disturbed that what I intended as a friendly suggestion for avoiding injury to children has become an excuse for imprisoning innocent parents.” Dr. Squier has received the support of not only Dr. Guthkelch but also a number of other prominent physicians, including Dr. Patrick Barnes at the Louise Packard Children’s Hospital Stanford; Dr. Roland Auer at the University of Saskatchewan College of Medicine, author of Forensic Neuropathology and Associated Neurology (Springer 2005); and Dr. Jan Leestma, author of Forensic Neuropathology (CRC Press, third edition 2014)—all three of whom once accepted the prevailing model of shaken baby syndrome but have since changed their minds”(1).
Perhaps the most significant development has been a health technology assessment conducted in Sweden (2).
The basis for diagnosing SBS (or traumatic shaking) is referred to as the triad, namely: subdural haematoma (bleeding between the dura mater and the brain), retinal haemorrhages, and various forms of brain symptoms (encephalopathy). The presenting history is often that of lethargy, seizures and apnea. The purpose of this Swedish evaluation was to determine how reliably the triad or its components can be explained by traumatic shaking of children up to one year of age. The most important finding is the paucity of good quality evidence available to provide insight into the condition. Although 1065 full scientific papers were available, 1035 were excluded because they did meet the basic criteria. This left 30, of which 28 were ruled out because they were poor quality, leaving two that were moderate quality. There was not a single paper, which was assessed as high quality. The main reason for this was that the published papers failed to provide information on whether traumatic shaking was confessed to by the perpetrator or had been witnessed. The deficiencies included inadequate presentation of data and circular reasoning. So it is not in the least surprising that the conclusions of this investigation were that:
- There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low quality evidence).
- There is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking (low quality evidence).
The first study conducted by Vinchon et al (3) was based on 412 cases, of which 124 were classified as Inflicted Head Injury (IHI) and 288 as Accidental Trauma (AT).
The reality is that this is an issue, where it is very difficult to establish what has happened based on an examination of the individual involved. Hence there needs to direct evidence to reach a sound decision on the cause. Under these circumstances, many of the specialists cannot do anything more than offer an opinion, which is based on their experience that they claim is expertise. Unfortunately anyone who disagrees is regarded as a threat to the establishment. At this point, all the powers and authority that can be mustered are wheeled out to protect the status quo. This then becomes the overriding objective. The critical importance of providing accurate advice so that the courts can dispense reliable judgments is conveniently forgotten. The lack of genuine knowledge is ignored and there is no attempt by the “great and the good” in the UK to face up to the issues as has been done in Sweden.
There are distinct parallels between this case and that of Professor Tim Noakes in South Africa (4). In fact it is highly significant that both initially accepted the establishment position but changed their minds because of genuine doubts. The status quo should be regarded as a “working hypothesis” not an article of faith, which so often proves to be the case. Any genuine challenge should be welcomed but subject to critical evaluation.
It is time to get back to basics. Scientists, especially in disciplines related to medicine and health, must appreciate the fundamental principles of the scientific method. In particular, they have to appreciate the established order is not the last word and may have to be changed radically if progress is to be made. Furthermore, the culture and organisation of those working in research must be geared up to accommodate this.
Finally it is totally unacceptable that those with the ability, drive and courage to make these crucial contributions have been castigated. A very sad commentary on the professional approach to scientific investigations.