My conclusions

The conflict that erupted into public in September 2018 fanned the flames of many longstanding arguments about the Cochrane Collaboration. But I don’t think the Cochrane/Gøtzsche blowout happened because of differences over principles, opinions about industry conflicts of interests, or scientific methods. Plenty of people in the Cochrane world hold the same views as Gøtzsche, and just as strongly, yet thrive or at least co-exist within it.

I also don’t think it was because of his criticism of the Cochrane HPV vaccine review. I think the conflict that became public in September was already at the irreconcilable differences stage in June when a lawyer was commissioned. That was before Gøtzsche’s criticism of that review was published. The way he went about that critique, including refusing to provide a list of the trials claimed to be missing from the review, doubled down on conflict with the CC and suggests he had no interest in de-escalation. It certainly inflamed the situation, but it wasn’t the cause.

I don’t think it was because of a dispute over Cochrane’s move to being very commerce-oriented either. That wasn’t new by a long way. The NCC had been a long-term major beneficiary of its proceeds: his campaign protesting Cochrane’s strategic direction began just months after Cochrane stopped providing a significant portion of its commerce-derived funds to the NCC annually, not when the direction was set and its negative consequences became obvious many years earlier.

I think it was because since 2014, two developments were propelling the parties to a high-speed collision. One was Cochrane’s organizational development eroding both Gøtzsche’s autonomy as a Cochrane Centre director and the Centre’s finances, and that was his power base. The other was Gøtzsche ramping up the extremism, scope, and volume of public campaigning that could harm people’s health, often explicitly in Cochrane’s name, always with his mantle of Cochrane credibility, and entwined with selling books for personal profit. That not only resulted in further erosion of his autonomy specifically as a prominent Cochrane leader: it increased scrutiny in Denmark of his local public funding and raised demands for accountability there for the funding and for his actions, thus jeopardizing the rest of his NCC financial and power base. Gøtzsche was, I think, vigorously painting himself into a corner that he wouldn’t be able to fight his way out of.

Gøtzsche has written: “The [2014] letter from Cochrane’s leadership”, that disowned his views about psychiatry and psychiatric drugs, “was a threat to what I had built up over 30 years, including my centre, which is on government funding”. Apparently, even public concern expressed by the Minister of Health a couple of months before that was not enough for Gøtzsche to consider that it was his rhetoric in the media that posed the threat.

In my opinion, he badly over-estimated the cards he held, and failed to read the room. In December 2018, in his Politiken op-ed, he wrote that he had argued the Ministry should change the NCC’s name and dump Cochrane, in favor of funding him to continue on the path he had been on – when it was precisely that path that appears to me to have become politically radioactive in Denmark.

The Cochrane name enabled Gøtzsche to rise to prominence. Withdrawing the Cochrane mantle from his battles has damaged the Collaboration’s credibility with some people, but it will preserve (or restore) Cochrane’s credibility for others in the medical and public health communities he has targeted. Far more importantly, stopping Gøtzsche using Cochrane’s credibility was critical to limiting how many people could be harmed after acting on his claims when they were dangerous ones not based on Cochrane reviews.

It was common, when the part of this that occurred in the English-speaking world became very public, for people to argue Cochrane should have done more to resolve the conflict with Gøtzsche. That would certainly have affected how some people reacted to the split. However, I don’t believe anything could have resolved the conflict. Cochrane’s basic request was, I believe, reasonable. I was very publicly outspoken under that same kind of expectation in the years I worked for the NIH, for example: it’s common outside universities. I could find nothing to indicate that Gøtzsche would consider changing course under any circumstances. Indeed, that refusal to ever budge is one of the reasons many admire and applaud him.

The barrage of controversy and conflict Gøtzsche generates impresses and excites some people, too, or it's considered just a nuisance, worth putting up with. But for others, it’s at best an exhausting drain of energy away from more constructive effort, and at worst personally traumatizing. The more targets Gøtzsche picked, the more he was criticized or attacked – and the more he attacked back and attacked others. Gøtzsche has been the subject of major attacks, for sure, including ones that were unfair or included misinformation. I don’t believe, though, that this justifies his own behavior. Most people would find it difficult to be at the receiving end of the kind of rhetoric and accusations that Gøtzsche uses about colleagues, other individuals, or whole clinician communities – especially in the cases where he is more powerful than the people he is attacking, and/or they cannot avoid or ignore him because of their job or Cochrane position.

Warrior culture is inimical to collaboration, I wrote in 2002 in response to the mammography battle. But warriors are praised for bravery, and the term iconoclasts ­– who historically were destructive and at times violent – is used admiringly. I think warrior behavior is inimical to properly debating scientific findings, too. Yet people cheer warriors on, and they can accrue vocal adherents and powerful enablers, thanks to common interests/ideologies, and camaraderie from shared past battles. It’s a common problem in activist communities.

Neither an affinity for conflict nor wanting to be at the cutting edge of challenging the establishment are inherently in the public interest or the interests of science. They can be twin drivers, though, to extremism. As I’ve said before: “I think the main thing I learned – very painfully – in 20 years as a health consumer advocate, is that zealots always, always end up hurting patients. Because whatever it is that they are against, is not the same as being for patients, and it will, inevitably, betray us”.

Rigorous science was key to whether the positions Gøtzsche advocated so fiercely were beneficial or harmful to the public. The rigor he has been applying, though, varies greatly to say the least, especially in the books that underpin his campaigning, and his rhetoric is often not calibrated to the strength of evidence for the causes he champions. So the circle of support and tolerance for what he was doing started to waver and reduce in his academic and mainstream media worlds. His self-belief and resolve appeared, though, to be strengthened, if anything, by widening circles of opposition.

It seems to me from reading what he has written, that he would never see a boundary between his non-Cochrane and his Cochrane work, or between himself and “his” Centre. It’s no wonder, then, if he feels betrayed by the Cochrane Collaboration not stepping up to defend his activism. If it wasn’t about Cochrane reviews, though, there was no reason the Collaboration should have defended it, and several reasons why it shouldn’t. Even had the CC backed him to the hilt, I doubt that that would have protected him in the long term in his battle with the medical community locally: it seems to me more likely that the Danish government would have stepped away from Cochrane, with the Copenhagen ship going down with its captain.

In 2018, Gøtzsche increasingly turned the force of his social power explicitly against the Cochrane Collaboration, urging others to take up the battle, too. He gives the impression he wants to ensure its downfall. But the organization can thrive without Gøtzsche. And it has been weathering his public attacks for years. However, had the Cochrane Collaboration continued to provide a high-profile platform for campaigning on an expanding raft of controversial health positions not based on its reviews, then it ran the risk of being an organization doing more harm than good to public health (and deservedly losing credibility, too). The Collaboration isn't a university, and it isn't a broad health lobby: it's an organization with a specific remit about its own systematic reviews, and has been from the start. I haven't detected an appetite for changing that fundamental purpose, even amongst people who have argued for other change in response to this episode.

To me, this sad story is a signal lesson in the importance of accountability, especially for those funded with the public’s money. Gøtzsche worked hard to create a comfortable cocoon of grant-application-free long-term public funding of a team to be able to study what he wanted, how he wanted to, and to communicate it in the mass media. It was possible in that constellation because of trust for the Cochrane name. Walking away from co-authors and medical journal peer review for analyses for his advocacy freed him from even more constraints. Gøtzsche seems keen to replicate the model in his Institute for Scientific Freedom. He said this at the symposium launching it:

“I would suggest we have a very small advisory board, because the idea is just that we have some people we can ask for advice when we need advice. It’s not about having meetings, and –– I hate bureaucracy. I want to get things done! So the less bureaucracy we can have in this Institute the better. And I can tell you, then you have the right Head, because I hate bureaucracy. So there will be very little bureaucracy. Now, the overall purpose is very simple: to preserve honesty and integrity in science….”

Too much bureaucracy is bad, for sure. But for a research institute, so is too little. Transparency and accountability, even when you don’t think you need advice, safeguard honesty and integrity in public life. Skirting around anyone who could slow you down and make you consider and justify things more carefully, and demonizing people who criticize your ideas or your tactics, is not a path to integrity, good science, or policy in the public interest.

Gøtzsche has said: “My view is that a hero is someone who has other genes than non-heroes…There are a few odd people like me who have something different in our genes….” It’s a biological trait that constitutes him for leadership, and communities turn to people like him with these “special genes” in a crisis, he said. I think that belief and self-image explains a lot. I am glad the Cochrane Collaboration is no longer tethered to every issue he might take up.

Hilda Bastian

8 February 2020

Note: I continue to call the organization the Cochrane Collaboration, even though it now brands itself as “Cochrane” instead. I do so, not just because I feel strongly about the “collaboration” part of the name, but because the name of the charity has not actually been changed.