Australian Physician Disciplined for Misrepresenting Mannatech Products to Patients

Health Practitioners Tribunal/September 8, 2000

Citation:

Medical Board of Queensland v Raddatz

Parties:

Medical Board of Queensland, Applicant
v. Ian Geoffrey Raddatz, Registrant; and
Dr.. Evan Jones, Dr.. Jane Turner, Patient C,
and Patient Mac, Complainants

D. 2392 of 2000

Health Practitioners Tribunal:

Originating Court: Brisbane

Delivered on: 8 September 2000

Delivered at: Brisbane

Hearing Dates: 4 September to 8 September 2000

Tribunal: Judge Pratt QC, Dr. J. Golder, Dr. F. New, Mr.s R. Kerr

Order:

Cancellation of registrant's registration for two years -- Condition not reapply for registration until demonstrated his resolution to abide by all current ethical standards, policies and practices provided by the board.

Medical practitioner offering substances (Mannatech products) to patients which were not proven or accepted treatments for:- Haemochromatosis; cancer; infertility; brain damage ­ attempting to recruit cancer patient's daughter as "downline" sales person in the direct marketing of Mannatech products.

Recommending Mannatech products when he had a direct interest in and stood to gain financially from sales

imposed by the Medical Board of Queensland in recommending Mannatech products and failing to make patients aware of the true status of such products and providing information which lacked the appropriate balance against presently accepted medical standards. Health Practitioners (Professional Standards) Act 1999 ss. 123; 124(91)(a)(b); 240(2)(b); 241(2)J(i) and (ii) "Unsatisfactory professional conduct" Childs v Walton (unreported) Court of Appeal NSW 40252/1990 per Samuels, Priestley and Meagher JJA. In Re Dr. Steeper New Zealand Medical Journal 25.4.1990.

Counsel: Mr.. R Devlin for the applicant; Mr. D Tait for the registrant

Solicitors: Minter Ellison for the applicant; Griffiths Parry for the registrant

JUDGMENT

HIS HONOUR: By section 124(1) of the Health Practitioners (Professional Standards) Act 1999 (the Act) each of the following is a ground for disciplinary action against the registrant:

(a) The registrant has behaved in a way that constitutes unsatisfactory professional conduct;
(b) The registrant has failed to comply with the condition of practice imposed under this Act or the Health Practitioner Registration Act under which the registrant is registered; ... By definition "unsatisfactory professional conduct" for a registrant includes the following:
(a) Professional conduct that is of a lesser standard than that which might reasonably be expected of the registrant by the public or the registrant's professional peers;
(b) Professional conduct that demonstrates incompetence, or a lack of adequate knowledge, skill, judgment or care, in the practise of the registrant's profession.

On 14 June 2000 the Medical Board of Queensland (the Board) referred this matter or matters relating to the registrant, Ian Geoffrey Raddatz (the registrant), arising out of the complaints of Dr. Evan Jones, Dr. Jan Turner, Patient C and Patient Mac suggesting a pattern of conduct or practice, and being of the belief that the matter or matters may provide a ground for suspending or cancelling the registrant's registration. The grounds for disciplinary action alleged pursuant to section 124(1)(a) of the Act were that the registrant behaved in a way that constitutes unsatisfactory professional conduct in that he engaged in:

(a) professional conduct that is of a lesser standard than that which might reasonably be expected of the registrant by the public or the registrant's professional peers; and/or
(b) professional conduct that demonstrates incompetence in the practise of the registrant's profession; and/or
(c) professional conduct that demonstrates a lack of adequate judgment in the practise of the registrant's profession; and/or
(d) professional conduct that demonstrates a lack of adequate care in the practise of the registrant's profession; and/or
(e) improper conduct; and/or
(f) unethical conduct; and pursuant to section 124(1)(b) in that he has failed to comply with a condition of practice imposed under the Act or the Medical Act 1939.

The grounds alleged by the Board were:

1. In relation to the complaint of Patient Mac in the course of treatment of Patient Mac between 1 March 1999 and 5 June 1999, the registrant offered Mannatech to the patient as a treatment for haemochromatosis when Mannatech is not a proven or accepted treatment for haemochromatosis.
2. In relation to the complaint of Dr. Jane Turner, in the course of treatment of Patient T between 1 November 1999 and 26 November 1999, the registrant advised the patient and/or one Dr. that Mannatech would assist the treatment of Patient T following her diagnosis with cancer when there was no reliable evidence upon which to give such advice.
3. In relation to the complaint of Dr. Jane Turner, in the course of treatment of Patient T between 1 November 1999 and 26 November 1999, the registrant used his position as Patient's T general practitioner to present Mannatech as a business opportunity to Patient Ts daughter, Dr..
4. In relation to the complaint of Patient C in the course of treatment of Patient C on 15 December 1999, the registrant offered Mannatech to the patient as a treatment for her infertility when Mannatech is not a proven or accepted treatment for infertility.
5. In relation to the complaint of Dr. Evan Jones, in the course of treatment of Patient M between 1 February 2000 and 28 February 2000, the registrant advised the patient to cease taking Epilim, Valium and Temazepam and to take Mannatech in circumstances where there was: (a) A significant risk of deterioration in the behaviour of the patient; (b) A high risk of serious and potentially life threatening epileptic seizures; and (c) A high risk of harm to the persons associated with the patient, if the patient followed the advice of the registrant.
6. Conditions were placed on the registration of the registrant by the Medical Board of Queensland pursuant to section 30K(2) of the Medical Act 1939 on 23 November 1999. Dr. Raddatz has breached these conditions in that he has failed to comply with the Board's policy on complementary, alternative and unconventional medicine in that he: (a) Failed to act ethically and in his patients' best interests according to the fundamental values of the profession by recommending Mannatech products to patients in quantities of up to $250 per month in value; and/or (b) Misrepresented information or opinion by failing to make patients aware of the likely effectiveness of a given therapy according to published and accepted information, notwithstanding his individual beliefs by providing promotional material from Mannatech to patients, which lacked an appropriate balance against presently accepted medical standards.
7. At all material times, the registrant was in a position whereby he stood to gain financially, either directly or indirectly: (a) From the purchase of Mannatech by any of the patients referred to in paragraphs 1, 2, 4 and 5 above; and (b) From the recruitment of additional distributors of Mannatech, as in the circumstances referred to in paragraph 3 above.

The registrant has practised for many years on the North Coast. Until 1998 his practice has been successful and, in a relevant sense, uneventful. It was then that he was introduced to Mannatech products and as a result his conduct and attitude changed.

What then are Mannatech products? For our purposes they are four in number called Ambrotose, Phyt-Aloe, Plus and Sport.

Dr. Lindsay Brown, senior lecturer in the Pharmacology, Department of Physiology and Pharmacology at the University of Queensland, was called by the Board and among other things had this to say:

The Australian community expects that medicines and medical devices in the marketplace are safe and of high quality, to a standard at least equal to that of comparable countries. The objective of the Therapeutic Goods Act 1989, which came into effect on 15 February 1991, is to provide a national framework for the regulation of therapeutic goods in Australia and ensure their quality, safety and efficacy. The regulatory framework is based on a risk management approach designed to ensure public health and safety, while at the same time freeing industry from any unnecessary regulatory burden. Essentially, any product for which therapeutic claims are made must be entered in the Australian Register of Therapeutic Goods (ARTG) before the product can be supplied in Australia. The ARTG is a computer database of information about therapeutic goods for human use approved for supply in, or exported from, Australia. The Therapeutic Goods Act, Regulations and Orders set out the requirements for inclusion of therapeutic goods in the ARTG, including advertising, labelling, product appearance and appeal guidelines. Some provisions such as the scheduling of substances and the safe storage of therapeutic goods, are covered by the relevant State or Territory legislation.

Products assessed as having a higher level of risk (prescription medicines, some non-prescription medicines and medical devices) are evaluated for quality, safety and efficacy. Once approved for marketing in Australia these products are included in the ARTG as 'registered' products and are identified by an AUST R number. Products assessed as being lower risk (many non-prescription medicines including most complementary medicines and low risk medical devices) are assessed for quality and safety. Once approved for marketing in Australia, these products are included in the ARTG as 'listed' products and are identified by an AUST L number. In assessing the level of risk, factors such as the strength of a product, side effects, potential harm through prolonged use, toxicity and the seriousness of the medical condition for which the product is intended to be used, are all taken into account.

Licensing of manufacturers. Australian manufacturers of therapeutic goods must be licensed. Their manufacturing processes must comply with principles of good manufacturing practice (GMP). The aim of licensing and standards is to protect public health by ensuring that medicines and medical devices meet definable standards of quality assurance and are manufactured in conditions that are clean and free of contaminants.

The evaluation for quality, safety and efficacy of new medicines is exhaustive, relying on controlled clinical trials. Clinical trials have been the standard method to assess new medicines since the thalidomide disaster in the late 1950s. A clinical trial will compare responses in two groups of patients: those receiving the test compound and those acting as a control group receiving an existing, standard treatment or, if this is inappropriate, a placebo treatment with an inert substance. Control patients are crucial since many diseases are self-limiting; further, there may be a high "placebo" effect where the provision of treatment by itself causes a positive response. The avoidance of bias in collecting data is a further crucial issue. To minimise this, most trials are carried out as a double-blind exercise, where neither the investigator nor the patient is told whether the patient has received the active or placebo preparation. Many trials will also use a cross-over technique where the patient receives both active and placebo preparations separated by enough time for the compound to be removed from the body. Further, studies are usually performed in large cohorts of patients to adequately define both the therapeutic and any toxic effects. The organisation of clinical trials is complicated, time-consuming and expensive but is considered essential to protect patients.

No evidence has been provided to me, nor could I find any evidence by a search of the medical literature using the NIH-based PubMed database that any of the Mannatech products have been subjected to controlled clinical trials for any possible therapeutic role.

Dr. Brown then went on to discuss advertised ingredients of some Mannatech products and continued:

Thus, under the definitions provided by the Therapeutic Goods Administration, it is my opinion that these products marketed by Mannatech do not contain any therapeutic good which could help in preventing, diagnosing, curing or alleviating a disease, ailment, defect or injury. These products are likely to be defined as complementary medicines by the Therapeutic Goods Administration. No safety data on these products was accessible, but the limited information on their composition suggests that these products are unlikely to produce significant adverse effects. However, there is also no reliable scientific evidence that these products produce any worthwhile therapeutic response.

It is my opinion that these Mannatech products are not proven or accepted treatments for these serious medical conditions. I have not been able to find any reliable evidence that suggests that these products have any usefulness in these conditions.

As to whether there is any reliable evidence that suggests that Mannatech could assist with the treatment of cancer, or as a supplement to be taken whilst undergoing chemotherapy, it is also my opinion that there is no reliable evidence that these Mannatech products could assist with the treatment of cancer. While these products may be taken as a supplement to chemotherapy, there is no evidence either for a positive or negative effect for these patients.

As to whether the printed material about Mannatech (which the registrant had given to patients) accurately represents the likely effectiveness of Mannatech and is based on accepted scientific studies, and represents the results of those studies in an accurate and balanced way, it is my opinion that the printed material on these products does not reflect the likely effectiveness of the products nor is it based on accepted scientific studies nor are the two published studies reported in an accurate way. It is my opinion that these products have minimal, if any, therapeutic usefulness based on currently available information.

The Tribunal accepts Dr. Brown's several opinions. Simply put, Mannatech products are not conventional medicines. Whatever their adherents might claim, they are simply complementary, alternative, unconventional.

The question of the registrant's interest in and attitude to Mannatech products had come to the attention of the Board in mid-1999 when it was complained that the registrant had substituted a Mannatech product for insulin in the treatment of a diabetic patient. A committee of assessors was appointed by the Board on 27 July 1999 to inquire into the eligibility of the registrant to remain registered as a medical practitioner.

The committee inquired and interviewed the registrant in August 1999. In due course it submitted its report. At a meeting of the Board on 23 November 1999 it was resolved that:-"(i) the Board receive the report and accept the recommendation of the Committee of Assessors that Dr. Ian Geoffrey Raddatz is fit to practise medicine, subject to conditions; (ii) pursuant to Section 30K(2) of the Medical Act 1939, the following conditions be imposed on Dr. Raddatz's registration;

(a) Dr. Raddatz must abide by the Medical Board's policy on complementary, alternative and unconventional medicine;
(b) he must record all treatment, including but not limited to, complementary, alternative and unconventional treatments, in the patients' clinical notes;
(c) he must submit to a practice audit by the Board or auditors appointed by the Board in three months time;
(d) he must attend for treatment by a psychiatrist experienced in psychotherapy and approved by the Board, at a frequency to be determined by the treating psychiatrist;
(e) he must authorise his treating psychiatrist to inform the Board of termination of treatment or if there is a significant change in health status;
(f) he must submit to the medical supervision of an experienced general practitioner who is not associated with his practice;

In fact, those resolutions were put into effect by letter to the registrant dated 26 November 1999. It is a matter of grave concern that at least two of the matters placed before us - that is to say, the matters of patients C and M - took place after the registrant had been well and truly put on notice that his attitudes to the treatment of patients with Mannatech products were not shared by his peers and were inconsistent with accepted practice. Indeed, his constant references to Mannatech products to the mother of patient M were in clear breach of the first condition which the Board imposed on his continuing to practise. That is to say, that he must abide by the Board's policy on complementary alternative and unconventional medicine.

The relevant portion of the policy reads:

2. In treating patients: ... (b) act ethically and in their patients' best interests according to the fundamental values of the profession; ... (d) ... Patients must be made aware of the likely effectiveness of a given therapy according to published and accepted information, notwithstanding the medical practitioner's individual beliefs.

On 8 March 2000, the Board resolved to suspend the registrant's registration. Indeed the evidence shows that the Board, from the beginning, acted in a measured and responsible fashion. On 31 August 1999, the Board asked an experienced and highly regarded psychiatrist, Dr. Nigel L Prior, to examine the registrant. Dr. Prior interviewed the registrant on two occasions, 10 September 1999 and 25 May 2000. He provided written reports soon after each occasion. These reports were put in evidence and Dr. Prior was called and cross-examined.

As to the first report dated 22 September 1999, the Tribunal accepts that at that time the registrant showed evidence of an adjustment disorder with depressed mood (mild) and personality dysfunction - obsessive and narcissistic traits. We think Dr. Prior's recommendation that the registrant seeks referral to a psychiatrist for individual psychotherapy an appropriate one.

Dr. Prior also strongly suggested that the registrant be counselled by the Board and that he be directed to desist from unethical behaviour in the promoting and selling of substances which are not scientifically validated and which he endorses.

In his second report dated 31 May 2000, Dr. Prior noted, correctly we find, statements made by the registrant about his most recent behaviour, said to have breached the conditions to his practising imposed on 23 November 1999.

The registrant continued to deny fault in that regard and stated his intention to continue to recommend Mannatech products to his patients and that his wife will continue to sell them. We accept that that is what he told Dr. Prior.

Dr. Prior's view is that the registrant holds the unwavering belief that he is in the right and has no conflict of interest. Dr. Prior thought that the registrant cannot be shaken in his belief that Mannatech products are a viable alternative to conventional medicine in the treatment of many conditions.

Dr. Prior found no evidence of major mental illness but described his obsessional personality characterised by marked inflexibility on the subject issue.

Dr. Prior noted that the registrant continues to lack understanding of the nature of the doctor/patient relationship and the significant influence which doctors can have on their patients. The Tribunal accepts those observations by Dr. Prior. Indeed they were strongly supported by much of the evidence placed before us. In fact, the Tribunal also noted the registrant's apparent inability to empathise with the patient's perspective and likely perception in the event that the doctor suggests unconventional treatment without properly informing the patient of its true status.

Furthermore, it was evident to the Tribunal as the evidence unfolded that the registrant did not understand the distinction between substances classified with an AUST R number by the ARTG, that is to say, evaluated for quality, safety and efficacy and those merely classified with an AUST L number, that is to say, not yet evaluated as efficacious because they have not been subjected to proper testing and thus shown to work.

In short, to the end he was, by his several acts and representations to his patients and/or their representatives, passing off or attempting to pass off the AUST L for the AUST R, to adopt the terminology of the hearing. That, on any view of it, is "unsatisfactory professional conduct", especially when one considers the extremely high likelihood that the patient will be deceived into believing that the doctor is suggesting properly tested efficacious medications.

Before dealing with the several patient/doctor situations litigated before us, the Tribunal wishes to comment upon the concept of conflict of interest and how the present fact situation should be approached.

Soon after his involvement with the Mannatech Group, the registrant arranged an association between the Group and his family through a family trust, the chilDr.en (3) being the beneficiaries. The relationship was a direct marketing association which meant that the products which could only come from the Mannatech Group, could be sold by the trustees for the benefit of the cestuis qui trust. Thus, a profit could be made from direct sales.

The next avenue for profit lay in the recruitment of associations who would rank as "downliners", viz a vie, the family trust. Downliners, it emerged, are required to hand up, notionally at least, a portion of their profits so that the family trust stood to benefit from subsequent sales engineered by downliners. Hence the registrant's attempt to recruit new associates as revealed in the evidence.

Although the registrant's wife was extremely coy, with great respect to her, about how many downliners were contributing to the registrant's family trust by this means, we were left with the impression that the numbers are substantial.

As to direct trust sales, the registrant's wife was openly selling Mannatech products. Trust money was being spent on the registrant's chilDr.en.

This was, of course, an obvious actual conflict of interest situation. It is desirable to state what this means in the view of the Tribunal. In such a situation, there is a strong risk that the registrant will consciously or unconsciously recommend a product in which he has a financial interest direct or indirect in favour of a better product in which he has no such interest. A better product in the sense that it would be more beneficial in the treatment of the patient.

It is the potentiality of this sort of interest based preference that is also to be avoided. There is no validity in the argument that an interest of this kind is permissible and that one only offends ethical standards if one actually prefers one's own product against the patient's best interests. Interests of this kind which open the way for potential adverse preference are and should be frowned upon as unethical. In that regard, the Tribunal believes it expresses the views of the vast majority of registrants.

On numerous occasions the registrant acted unethically and thus engaged in unprofessional conduct by recommending Mannatech products to patients and/or their representatives when he stood to gain directly or indirectly from their taking up the recommendation, as against substances of proven efficacy in which the registrant had no financial interest.

On any view of the registrant's behaviour ground 7 for disciplinary action has been established.

We turn now to deal with grounds 1 to 6 as particularised. In fulfilling our statutory duty to consider any relevant previous decisions by a disciplinary body or the Medical Assessment Tribunal of which we are aware (section 240(2)(b)), we have come across several relevant statements of principle provided by Courts and other tribunals with which we respectfully agree and adopt. The first is from our New Zealand counterpart in Re Dr. Steeper, who was found to be acting unconventionally with a Vega machine. See New Zealand Medical Journal, 25 April 1990.

The committee recognised and acknowledged that there is a demand for alternative therapy from patients as well as practitioners who find that a proportion of patients do not have their expectations fulfilled through orthodox medicine. Nevertheless medical practitioners who practise alternative medicine should be conscious of the need for ensuring that their patients are fully informed as to the nature of the practices being undertaken. Where those practices depart too radically from orthodox medicine, the practitioner should question whether his role is in fact one of a medical practitioner or some other type of practitioner. If the latter should be the case then the doctor should not operate under the guise of orthodox medicine. The fact of medical registration and holding oneself out as a medical practitioner does lead to patients accepting the treatment however radical given by the doctor as having authenticity or credence. The patients in this case were misled into initially accepting the reliability and authenticity of the manner in which Dr. Steeper used his machine. The committee believed that this practice under the guise of orthodox medicine misled his patients and amounted to professional misconduct ...

Unorthodox or alternative medicine was not on trial. Specific allegations were made against Dr. Steeper in the methods and manner in which he treated three patients together with statements and advice he gave to them. They were frightened, distressed and misled whilst all somewhat vulnerable as mothers of young chilDr.en who consulted a medical practitioner who practised homoeopathy. In the committee's view the standing of a doctor as a registered medical practitioner enabled Dr. Steeper to give credence or status to the use to which he put his machine, the predictions and diagnosis that he made. The committee had no doubt that in each of the respective cases alleged the behaviour of Dr. Steeper fell substantially below the standard required of a registered medical practitioner and individually and cumulatively his actions comprised professional misconduct.

In Childs v. Walton, Court of Appeal, 40252/1990 (Unreported) the New South Wales Court of Appeal considered another alternative medicine case. In the unanimous judgment their Honours, Samuels, Priestley and Meagher JJA had this to say:

A departure from a generally accepted procedure does not necessarily constitute professional misconduct. There may be different schools of medicine and disputes between them. Adherence to the practice of a minority group does not alone entail professional misconduct. 'Every innovation has to be performed for a first time. That something has not been done is not proof that it ought not to be done.' But a new departure in professional practice or technique must conform to the accepted ethical standards of the profession. It will be a question of fact in each case whether criticism proved amounts to no more than professional dissent or conservative distaste for novelty, or, on the other hand, to the professional reprobation which founds professional misconduct.

Armed with these guidelines, which are obviously sound, we consider the facts of each case. Patient Mac was suffering from haemochromatosis. She was receiving regular venesections. Her husband suffered from high blood pressure. Patient Mac knew a lot about her condition. She had joined a haemochromatosis support group in Brisbane. She got regular newsletters. In late May 1990 the registrant, who was her GP, called Patient Mac's home and told her about Mannatech products. He said, "I believe it can help you with your haemochromatosis." He said words to the effect, "It's wonderful stuff. You'll be able to cut down on your venesections and you may also be able to stop having them altogether."

He went on to say that, "This new treatment could help with Rob's blood pressure", referring to the patient's husband. "I would like to talk to both of you. Would you make an appointment and come in and see me?" Later they did, and the registrant repeated his comments about the Mannatech products. He said, "You will not have to have venesections as often and may not have to have them at all." And to her husband, who asked, "Can I stop taking my blood pressure pills?" he replies, "Yes."

The Tribunal accepts the opinion of Dr. Christopher Brown that:

The statement to Patient Mac that Mannatech would cut down the venesections and may permit them to be stopped altogether, is specious and most improper in the absence of any published and accepted information. Similarly, the assertion that her husband could stop his blood pressure tablets is also specious and quite improper in the absence of any published and accepted information.

And finally the Tribunal accepts Dr. Brown's comment: "There is no indication that the registrant properly informed Patient Mac that Mannatech was a substance that had not received appropriate independent assessment and validation." This amounts to obvious unsatisfactory professional conduct in the opinion of the Tribunal. The registrant allowed his enthusiasm for the Mannatech products to cloud his judgment. If he'd considered patient Mac, her feelings and best interests instead of himself, his desire to cure all and sunDr.y with these products, his dedication to the cause and his desire for gain clouded his judgment. Had it not been so he would have realised that Mannatech products could not possibly be used to treat haemochromatosis wholly or in part.

Patient T and her husband attended the registrant from time to time. They'd been doing so for years. The registrant mentioned Mannatech products to the husband for his arthritis early in 1999. About April 1999 Patient T began having bouts of diarrhoea, which was later diagnosed as ovarian cancer by Dr. Michael Gregora. And we note, in passing, that that was at the instance of the registrant's own examination of Patient T.

Before and after that diagnosis the registrant consistently promoted Mannatech products to Patient T and her daughter, Dr.. He even at one stage suggested to Patient T that another daughter, not the registrant's patient, would be assisted by Mannatech products with her cervical cancer! In any event, in regard to her diarrhoea the registrant said, "This stuff will help you with your problem."

Patient T did start taking Mannatech pills but soon afterwards got quite sick. She couldn't keep the pills down. After Patient T underwent surgery and chemotherapy in late 1999 her daughter, Dr., liaised with the registrant about future care for both parents. The registrant tried to recruit Dr. as a Mannatech associate (the inference is open that it would have been as a down-liner) and repeatedly told Dr. that Mannatech products would do wonders for Patient T and her husband: "These wonderful pills will help your father's illness and work wonders on your mother's cancer."

The Tribunal accepts the evidence of Dr. Christopher Brown that: "The recommendation that Mannatech would help the diarrhoea is without foundation and is improper. The registrant's claim that Mannatech will work wonders for your mother's cancer is not supported by any published and accepted information and discreditable under the circumstances. There is no indication that the registrant properly informed either Patient T or Dr. that Mannatech was a substance that had not received appropriate independent assessment and validation." In these cases the particulars alleged to constitute grounds for disciplinary action two and three were clearly made out. The registrant demonstrated a clear lack of adequate judgment and behaved quite unethically. To try to recruit Dr. in these circumstances is quite unacceptable.

The next case of Patient C is significant for several reasons. Patient C was a medical nurse of some 22 years standing. She had suffered scarred fallopian tubes and wanted to have chilDr.en. Before this period, 1998/1999, when the registrant became enchanted with the virtues of Mannatech products, he had referred Patient C to a gynaecologist to try for a baby through IVF. This did not prove successful.

In 1998 Patient C went to the registrant about a rash on her back. The registrant suggested she try Mannatech to help her condition. He gave her a video to watch. About six months later, after the registrant's episode with the complaint about switching Mannatech products for insulin with the diabetic patient had come to light, Patient C went to see the registrant about an injury to her foot.

On that occasion the registrant said to her words to the effect,"There is new evidence Mannatech is successful with infertility." She recalled that he went on to say words to the effect, "It works well on the cells." She understood, quite clearly, that the registrant was advising her that Mannatech was a treatment for her condition of infertility. She told us that she knew that she had told the registrant that her difficulty conceiving was caused by scar tissue in the fallopian tubes.

On the assurances provided by the registrant, she was joyful for an hour or two until she thought the matter through, and then she became depressed. She said the registrant's treatment of her caused a real setback in her emotional state with respect to her infertility. She said that it's made it difficult for her to have a positive attitude to treatment suggested by other medical practitioners. The Tribunal sees this treatment of patient C as very hurtful and serious.

In pursuing his fixation for Mannatech products and their benefits, real or otherwise, the registrant became insufficiently sensitive to the feelings and well being of this patient. It concerns the Tribunal that he does not seem to have grasped the effects of his words on this patient. The Tribunal accepts Dr. Stephen Brown's comments that: "The statement that new medicines supports Mannatech as being successful in infertility, particularly in the context of the established scarring of the fallopian tubes in this patient is not supported by recognised medical opinion. It is clearly improper and potentially disturbing to the patient to make such an unbalanced claim." Doctor Brown went on: "There is no indication that the registrant properly informed patient C that Mannatech was a substance that had not received appropriate independent assessment and validation." Ground 4 is made out. The registrant's professional conduct demonstrated a clear lack of adequate judgment and also amounted to unethical conduct.

We turn now to patient M. Patient M was a lad who had a disturbed background of Dr.ug taking and serious violent offending. He had been a patient of the registrant's before recent serious head injuries in respect of which he had been hospitalised. He presented with his mother to the registrant's surgery with scant information from the discharging hospital.

It became apparent to the registrant that he was under a regime of heavy sedation apparently for his propensity to violence, even sexual violence, whilst in hospital. However, the board's case in respect to patient M has caused the Tribunal difficulty for several reasons. Upon a careful review of the evidence we find we can't be satisfied that the registrant's advice in respect of the taking of epilim, valium and temazepam was sufficiently clear to warrant the Tribunal finding that the registrant was (a) wrong in seeking to reduce the Dr.ug intake in the circumstances; and (b) intending that Mannatech products should be used as a replacement in any real sense.

That doubt coupled with the conflict which built up between the registrant and patient M's mother and the unfortunate failure of the Princess AlexanDr.a Hospital to provide the registrant with more information has led us to the view that we should find in favour of the registrant in respect to ground 5. No ground for disciplinary action as alleged has been made out. But that is not the end of the patient M matter.

There is still the question of whether the registrant's several acts, omissions and representations made to patient M and his mother constituted breaches of the board's policy on complementary, alternative and unconventional medicine. In any community such as our own, doctors must jealously guard their right to prescribe and the patient to receive any new treatment, the demonstrated safety and efficacy of which offer hope of saving life, restoring health or alleviating suffering.

In all such cases, doctors must fully inform the patient about the treatment, including the new or unorthodox nature of the treatment where applicable. In any event, new or unorthodox treatments notwithstanding, doctors have a duty to help patients decide on treatments they prefer by informing and advising them about the nature of their illness and its possible consequences, the probable cause of their illness and the available treatments, together with the likely benefits and risks.

When we look at the statements made to patient M and his mother, we see that the registrant's pattern of behaviour remained the same as it had before he was put on the condition that he must abide by the board's policy on complementary, alternative and unconventional medicine. He provided patient M and his mother with written promotional material put out by Mannatech and he frequently tried to induce them to try Mannatech products. Dr. Christopher Brown was correct, in the view of the Tribunal, when he said that there is no indication that the registrant properly informed patient T or T's mother that Mannatech was a substance that had not received appropriate independent assessment and validation.

We find that the same can be said of the registrant's advice to patient C in December 1999. It is almost as though the registrant was prepared to ignore that particular condition.

The Tribunal is of the view that the registrant remains in a similar frame of mind to this day. The Tribunal accepts the intimation from his counsel, Mr. Tait, that the registrant proposes seeking treatment from Dr. Jill Reddan, an eminent psychiatrist. However, with all due regard for Dr. Reddan's skills in psychiatry, it does not seem to us that much progress will ever be made in achieving the registrant's reversion to acceptable attitudes until the registrant himself decides that such a reversion should take place. To the Tribunal that happy day seems far off.

For completeness, the Tribunal adds that it accepts that on at least three occasions after 23 November 1999, the registrant handed out Mannatech promotional material to patients. Ground 6 has been made out. The registrant has displayed again a lack of adequate judgment and behaved unethically.

In a moment we will invite submissions as to which of the courses set out in section 241(2) should be followed in these matters. We must say, however, that the Tribunal wishes to emphasise that it has had and will continue to have the provisions of section 123 of the Act firmly in mind. The purposes of disciplinary proceedings and disciplinary action against a registrant are: (a) To protect the public; (b) To uphold standards of practice; (c) To maintain public confidence in the profession.

HIS HONOUR: There is no point in our retiring and coming back again. What has got to be done has to be done. The reality is that in every other sense this registrant has shown himself to be perfectly conventional, effective, caring and valuable. When I say "in every other sense" I am talking about in every way other than his obsession with Mannatech and its products. Anyone who cares to read it can see what we said before about his treatment by Dr. Jill Reddan. We meant what we said when we expressed doubt as to whether or not even her expertise will achieve a preparedness to return to the mainstream of medicine and comply with the ethical standards which the mainstream pursues until his mind is ready for that reversion.

It is the decision of the Tribunal that the registrant's registration be cancelled for two years from today 8 September 2000. One condition will be imposed under section 241(2)(J)(i). The registrant may reapply for registration when the term of two years has expired only after he has truly resolved, and demonstrated such resolution, to return to the views of his erstwhile peers and to abide by all current ethical standards, policies and practices provided by the Board. The tribunal is not inclined to impose any conditions under section 241(2)(J)(ii) in this case. Responsible public bodies such as the Board need no intimation from the tribunal as to how it should act in two years time except in exceptional cases. This is not such a case.

The parties have liberty to apply in respect to costs not agreed.


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