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How not to run a drug study: The University of Minnesota puts on a clinic

At Scientific American, Dr. Judy Stone is using a notorious case of research misconduct at the University of Minnesota (where I studied bioethics) to walk through the requirements of ethical research on human subjects and the many ways they can be violated.  It can be difficult to keep up with the research scandals at Minnesota’s Psychiatry Department over the years, so for the sake of clarity: this is the one involving Dan Markingson, a young man who killed himself while participating in an industry-funded clinical trial of Seroquel (the “CAFE” study).

The problems with the CAFE study and the way Markingson was treated would fill a book.  Carl Elliott, a bioethicist (and my former academic advisor) at the University of Minnesota, has been relentless in seeking to keep Markingson’s story in the public eye and to hold his own university accountable for its conduct.  You can read Elliott’s account here, but here are some of the lowlights:

In 2003, 26 year-old Dan Markingson was suffering from psychosis and was threatening to kill people, including his own mother.  A judge ordered Markingson involuntarily committed on the recommendation of a UMN doctor named Stephen Olson.  Dr. Olson then persuaded the judge to release Markingson, but only on the condition that he followed Olson’s treatment program.

But rather than simply caring for Markingson, Olson’s “treatment program” consisted of enrolling him in a clinical trial in which Olson was serving as an investigator.  In other words, Markingson was given a choice between participating in the study or being involuntarily committed.  Moreover, Markingson clearly lacked the capacity to consent to participate in the study – just days before Markingson was enrolled in the trial, Dr. Olson himself had attested that Markingson “lack[ed] the capacity to make decisions regarding [his] treatment.”

Needless to say, this is a novel and outrageous way to “recruit” study participants (and one that is now prohibited by Minnesota law).  But Olson had enormous incentives to get subjects enrolled and keep them in the study.  Under the university’s arrangement with AstraZeneca (Seroquel’s manufacturer and the study’s sponsor), the psychiatry department earned more than $15,000 for each subject who completed the CAFE study.  In addition, the Minnesota study site had previously been placed on probation for failing to recruit an adequate number of participants.

In his conduct of the drug trial, Dr. Olson delegated important responsibilities to a social worker named Jeanne Kenney:

“despite the fact that Kenney had no formal medical training, she apparently administered prescription drugs to research subjects and made formal judgments of the side-effects. She frequently assessed the severity of potentially dangerous adverse events such as akathisia [disturbing feeling of inner restlessness and inability to be still], and sometimes she even assigned the job to a social work intern she was supervising. According to the [Minnesota Board of Social Work], her record-keeping was “devoid of any clearly articulated, consistent set of treatment goals” and she omitted crucial information relevant to suicide prevention. When Markingson’s mother, Mary Weiss, left “alarming voicemail messages” about her son’s condition, Kenney did not respond adequately.  Kenney also made significant mistakes about medication dosage and a medical diagnosis, and these mistakes remained in the chart until well after Markingson’s suicide, when Kenney went back and changed them. To top it all off, Kenney often signed the chart with the initials of a physician.”

Dan’s mother, Mary Weiss, wanted Markingson to be treated for his illness, not enrolled in a drug study.  As time went by she observed her son’s mental condition deteriorating and went to great lengths to try to get Dan removed from the study.  But Olson and Dr. Charles Shultz (a co-investigator in the study and chairman of the university’s psychiatry department) declined.  Finally, Ms. Weiss left Kenney a voicemail message asking “Do we have to wait until he kills himself or someone else before anyone does anything?”  Yet, notes Stone, “neither Kenney nor Dr. Olson thought this was worrisome enough to even notify the IRB, let alone to drop Dan from their clinical trial and place him on other medications, such as the Risperdal he had initially stabilized on, or Haldol, an older antipsychotic.”

Shortly after Ms. Weiss made her desperate plea, Dan Markinson killed himself by cutting his own throat.

Unbelievably, Mary Weiss’ ordeal didn’t end there.  Rather than taking any actions to right the wrongs done to Markingson, to discipline the responsible university employees, or to prevent such gross abuses from occurring again, the University of Minnesota lawyered-up and denied all wrongdoing.  When Weiss sued the university, the university won summary judgment on the basis that it was immune from suit under state law.  To this day, the University of Minnesota cites the court’s ruling as clearing the university of wrongdoing – which is a bit like a diplomat claiming he was “exonerated” for murder by virtue of diplomatic immunity.

But wait, there’s more.  Having hidden behind statutory immunity to avoid being held responsible for Markingson’s death, the University of Minnesota then stuck Markingson’s mother with the bill for the university’s litigation costs – more than $56,000.  It then used those costs as leverage to force Ms. Weiss to abandon an appeal of the trial court’s ruling.  (For more on this aspect of the case, check out my earlier post on this issue.)

Just to recap: A University of Minnesota employee forced Dan Markingson – a vulnerable, delusional young man – into a clinical trial.  That employee then delegated responsibility for Markingson’s treatment to a social worker with no medical training, ignored his deteriorating condition, and ignored his mother’s urgent pleas for help.  After Markingson killed himself, the university denied any wrongdoing and any responsibility for his death, hid behind statutory immunity from suit, and then sought to make Markingson’s mother pay the university $56,000 for its troubles.

It doesn’t end there.  A group of bioethicists at the University of Minnesota then called on the university’s Board of Regents to conduct an independent investigation into the CAFE study and the treatment of Dan Markingson.  When your own bioethicists – i.e., the people whose job is to assess whether doctors have acted ethically – are urging you to investigate your institution’s role in a patient’s death, you might want to heed that advice.  But instead the Board took the advice of its General Counsel Mark Rotenberg – the same lawyer who defended the university from Weiss’ lawsuit and stuck her with its court costs.  Not surprisingly, Rotenberg determined no investigation was necessary.

And yet, there’s more!  After Carl Elliott, the University of Minnesota bioethicist, refused to drop the matter, Rotenberg asked the university’s Academic Freedom and Tenure Committee to take up the question of “[w]hat is the faculty[’s] collective role in addressing factually incorrect attacks on particular university faculty research activities?” – a question that appeared both to accuse Elliott of “factually incorrect attacks” and to call for some unspecified action to “address[]” them.  Other faculty, including the president of the Minnesota chapter of the American Association of University Professors, viewed this as an attempt to intimidate Elliott into silence.  If so, it backfired.  The story ended up in the press, putting the Markingson case back in the public eye and once again making the University of Minnesota look really bad.

That’s the short version.  For more information, check out Elliot’s article, The Deadly Corruption of Clinical Trials, as well as Dr. Stone’s analysis for Scientific American.  Part 1 of Dr. Stone’s series looks at informed consent – in particular, the absence of it in Markingson’s case.  Part 2 examines investigators’ responsibilities, Olson’s failure to fulfill them, and the total absence of any consequences for the people responsible for the Markingson tragedy.

Matt Lamkin
Twitter: @lawbioethics

See also:

Carl Elliott, “A referenced summary of the Dan Markingson case

http://www.scribd.com/MarkingsonCase/documents

When Drug Trials Go Terribly Wrong: Lessons from a Bereaved Mother

Carl Elliott, “I Was Just Following Orders”: a Seroquel Suicide, a Study Coordinator, and a “Corrective Action.

Dan Markingson’s 2004 suicide: ‘Corrective Action’ issued to former U of M employee

What Problems? Seroquel Research & A University

University Exonerates Itself Over Seroquel Trial

20 Responses to “How not to run a drug study: The University of Minnesota puts on a clinic”

  1. Bill Gleason says:

    May I have permission to re-post this piece – with full attribution – on my blog: The Periodic Table?

    Please email me with permission if this is allowed.

    Thank you for your consideration of this request.

    Bill Gleason
    faculty at U of Minnesota

  2. Judy Stone says:

    Thanks for your great summary of the issues, Matt. I hope to take up some of these other issues in upcoming posts as well. The University of Minnesota should be ashamed of itself.

  3. Mike Howard says:

    One of these days in the very near future, Mark Rotenberg the lead Counsel for the University of Minnesota, will be forced to admit that his staunch defense of doctors Charles Schulz and Steve Olson, and the handling of the Markingson tragedy could be likened to rearranging the deck chairs on the Titanic. The same result.

  4. [...] The university’s General Counsel, Mark Rotenberg, has even threatened Carl Elliott’s academic freedom. Despite increasing evidence of wrongdoing, UMinn has refused to [...]

  5. Me says:

    As a student at the U, I experienced very similar conduct regarding a legal claim against the U. They (without my consent and without reason) processed my graduation as happening a semester EARLIER than it actually did. The fallout was that, retroactively, I was no long considered a ‘student’ for my final semester. My financial aid for that semester was revoked retroactively, as was my STUDENT insurance plan. This left me with thousands of previously-paid medical bills which were no charged back to me directly. The best part? I couldn’t apply to grad school because I couldn’t access my transcript, thanks to a $20,000+ debt caused entirely by the UofM which I never should have owed in the first place.
    The state insurance commissioner has no jurisdiction over the UofM, and they claim exemption to any financial claims for the same reason. All in all, it took me eight years to pay off the debt I never should have owed before I could *finally* access my transcript and apply to grad school. They made no apology or restitution, and actually committed FRAUD by claiming to a third-party resolution service that my graduation had officially occurred on the date it should have happened (not the back-dated date that screwed everything up).
    Seriously, more people should know about this “Land-grant” legal exemption from state law. It’s ridiculous.

  6. [...] According to the deposition of the central in assign of tellurian subjects protection, the university never even investigated the suicide, much reduction the ethics of the uneasy study, which has been subjected to withering criticism. [...]

  7. [...] According to the deposition of the official in charge of human subjects protection, the university never even investigated the suicide, much less the ethics of the troubled study, which has been subjected to withering criticism. [...]

  8. [...] According to the deposition of the official in charge of human subjects protection, the university never even investigated the suicide, much less the ethics of the troubled study, which has been subjected to withering criticism. [...]

  9. [...] According to the deposition of the official in charge of human subjects protection, the university never even investigated the suicide, much less the ethics of the troubled study, which has been subjected to withering criticism. [...]

  10. [...] According to the deposition of the official in charge of human subjects protection, the university never even investigated the suicide, much less the ethics of the troubled study, which has been subjected to withering criticism. [...]

  11. [...] According to the deposition of a central in assign of tellurian subjects protection, a university never even investigated a suicide, most reduction a ethics of a uneasy study, that has been subjected to withering criticism. [...]

  12. [...] According to the deposition of the official in charge of human subjects protection, the university never even investigated the suicide, much less the ethics of the troubled study, which has been subjected to withering criticism. [...]

  13. Jason Hunt says:

    This is really interesting work and short summary of this tragic and senseless way to put money in front of human lives. People should really wake up in the medical trial programs and see the real motivation. Thanks for the great article

  14. Chris says:

    Its shocking that anyone is treated in that manner. Unfortunately, people seem to view addicts as ‘less than human’ and not for what they are: people that need help.
    Clearly the well-being of the individuals in this study is last priority – money, as always when pharmaceutical companies are involved, is the only motivation.

  15. thomas hussman says:

    I have not been completely attentive to the activities inside the University of Minnesota’s Office of General Counsel, relative to the criminal conspiracy regarding the troubles at AstraZeneca and the Dan Markingson death.

    With all the money involved, and the posture by Mr. Mark Rotenberg, to take a rather selfish approach to the money involved, it appears that Mr. Mark Rotenberg has played a role, behind the scenes, where large amounts of money were involved, concerning the lack of transparency, which from the perspective of prima facia considerations, leaves little doubt that Mr. Mark Rotenberg has a single focus, that being, large amounts of other people’s money.

    Mr. Rotenberg, there is more to a medical school, than large amounts of other people’s money.

  16. thomas hussman says:

    I have not been thoroughly attentive to the behavior patterns by the lawyers in the University of Minnesota’s office of General Counsel. The Weiss’ attorney’s remark about feeling “sick” had loud reverberations. The public will continue to expect more from lawyers who are paid with tax money.

    After a cursory review of the Dan Markingson death case, I too felt sickened. The same sort of sick feeling has occurred as I have studied the case in Portugal involving Madeleine McCann. The rush to judgement feature, is never corrected by the rush to defend mistake. Both of these diseases have no cure in sight. As mere members of the proletariat, we continue, misguidedly to expect more from legal scholars, than we get.

    The lawyers, Mr. Mark Rotenberg included, continue to fail to surprise us with forthcoming truth. The total and sickening politicization of the pseudo government structure, that exists between the Minnesota Supreme Court justices, and the University of Minnesota’s office of General Counsel’s lawyers, is potentially the dirtiest game of law and politics in Minnesota.

    What Minnesotans know is that the big game is in play between these two bureaucracies. What makes Minnesotans sick, is the slick behavior, and the efforts by these lawyers and justices to fake honesty.

    Rotenberg is gone. He apparently took a tidy bankroll with him. What the people want now, is action on the Dan Markingson caper.

    President William Jefferson Clinton was videotaped as he was asked about the United States use of human expendables. His response was Monica(ish). He sidestepped. He was obviously not forthcoming. That, is his problem.

    Governor Mark Dayton has a reputation for being forthcoming. May I now ask you, publicly, for a continuation of this very fine trait, Mr. Dayton?

  17. thomas hussman says:

    There are some facts that can be used to evaluate the convoluted case, known as the Dan Markingson death. The facts I will discuss concern the money trail(s), and the sudden rise of a rather innocuous lawyer, and the rather sudden departure of a rather esteemed lawyer.

    The University of Minnesota has a legal department, known as the Office of General Counsel. Two names are predominantly gone from the staff. Why are they gone? The current Chief Justice of the Minnesota Supreme court, was, employed, in the OGC at the time of the creation of the CAFE study, as a lawyer. After the CAFE study was well on it’s way, Lorie Gildea was appointed to the supreme court on the very day she presided over the single criminal trial she would ever participate in as a local judge. This is significant because the subject of that trial has offered clear and convincing proof that the trial was a sham. The prosecutor, Fred Karasov, would also be appointed judge sometime later, but by the same governor, that being Tim Pawlenty. The sudden and rapid rise in power by Gildea appears to have been orchestrated. Her husband, Andrew Gildea, was a republican fund raiser at the time she arrived at the supreme court. The rather intense
    effort to create the illusion that Ms. Gildea had vast experience, is going to be examined now, from the perspective of her whereabouts at the beginning of the CAFE study.

    We know that around $700,000.00 was payed to two doctors for their participation. When Mary Weiss complained, she was treacherously dealt with. The now departed, esteemed leader of the OGC, Mr. MARK ROTENBERG, became rather excessively involved in the Markingson case. But now, Rotenberg had a secret weapon. It is his former employee, LORIE GILDEA, who is now, the Chief Justice of the Minnesota Supreme Court. Wow. Not a bad position to arrogantly deal with an ailing old woman and her now dead son.

    Political appointees are a reality, however, the public deserves the pure truth in the Markingson case. The question is whether the stench of the pseudo political/legal process that involves fancy lawyers, big pharmaceutical corporations, psychiatrists, and even the judgement by a former presidential candidate, can now be cleansed by simple truth.

    The job of the people who work at the University of Minnesota is to perform
    at a high level, worthy of the public’s trust, not to perform phoney drug tests
    and accept money for defending misconduct. And most of all, theses employees are never to kick an old lady, when she is already down.

  18. thomas hussman says:

    The most outrageous piece of evidence in the CAFE study case involves a document known as a “consent” form. A judge used extortion tactics to compel Dan Markingson to make a decision, a decision that his psychiatrist said he was incapable of making. Dan is dead. Who profited through Dan’s participation in the CAFE study? Who owned stock in the company?

  19. thomas hussman says:

    May I have permission to send this to some medical professionals in southeast Asia, who will then send it to Saudi Arabia. And with hopeful simultaneous blessings, it will go to Pensacola and Los Angeles as well. If there is a charge, please bill me.
    Thomas Hussman
    5715 S Linwood Drive
    Wyoming, Mn. 55092

  20. […] as detailed in a 2012 post in the Center for Law and Bioscience blog, not only did university officials rebuff this call, but […]

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