I haven't been talking about the Merck-Vioxx trial, but people are asking me how I think the it's is going. Unfortunately, I have no idea. And, I'd think that most of the people commenting on it in the press have no idea, either, when you get right down to it. All I know about the testimony is what I read in the media, and I'm not willing to accept that data as good enough to use.
The daily reports coming out of Texas are probably about as misleading as a round-by-round commentary of a boxing match. Anyone reporting this story is looking for exciting news, a big quote, a damaging revelation or slip-up. That's what will get the most play, and if there wasn't anything in those categories on a given day, the next best thing will do. A trial is a natural fit for the narrative instincts of most reporters, and that's what the readers expect to see, too.
The similarities to the reporting of an electoral campaign or confirmation hearing should be kept in mind, and a political scandal is the perfect example of the form. Punch! Counterpunch! Attack from the right! Feint from the left! A steady delivery of reasonably sized news chunks keeps the story moving along, the viewers tuned in, and the readers buying papers. Never ignore narrative bias; you're soaking in it.
But, unlike a boxing match, we don't know who's ahead on points so far in the Merck trial. The jury will be influenced by the facts presented to them, but also how they were presented and by whom. All of this will be layered on top of what they already know and the opinions that they already have. I don't presume to know what's going through their minds, because even if I were sitting there in the courtroom with them, I'd surely have a different perspective on the whole matter. If I had to guess, I'd say that Merck has a reasonable chance of getting out of this one. But I'm not putting any money down on that opinion. Merck's got enough on the table for everyone.
Well, fine, you say - but who should win? Grudgingly, I have to admit that I don't know the answer to that one, either. The details of the death in this case aren't all out yet, and I'm not a pathologist. And the details of Merck's internal knowledge and subsequent marketing decisions aren't all out yet, either. I think that their problem was believing what they wanted to believe (a tendency never to be underestimated), but it could end up looking worse (or better) than that.
However, it does seem clear that COX-2 inhibitors have caused, or at least contributed to, some deaths. Balancing those against the benefits they may have had for a much larger group of people is a very difficult calculation, but it's one that you'd have to make before coming to a final judgment on the whole class. The FDA has, of course, decided to leave the drugs on the market, so you know where they finally came down.
But the overmarketing of the drugs (by everyone, not just Merck) is, in the end, how we got into this situation. If COX-2 inhibitors had been prescribed mostly to people who had demonstrated an intolerance to the existing drugs, I doubt if any excess deaths would have been noticeable even had they occurred. (But if that had been the expected market, how many companies would have entered the field at all?)
Things have come to the point where many companies have made the decision not to get involved in huge marketing battles over blockbuster drugs. They're trying to put together a business out of more specialized drugs in less competitive areas, or where there's less direct-to-consumer marketing (which is quite expensive.) The pendulum, perhaps, is swinging back.