Science On Trial - The Clash of - Angell, Marcia

aa
THE CLASH OF MEDICAL EVIDENCE AND THE

LAW IN THE BREAST IMPLANT CASE
ISBN 0-393-03973-0 $27.50 USA
$35.00 CAN.
“An experienced medical editor renowned

for her independence and integrity, Marcia
Angell provides a powerful perspective on
what really is at risk in the implant contro-
versy—the core ‘principle that science,
not fear or profit, be the basis for clinical
medicine.”
— Bernadine Healy, dean of the Ohio State
University College of Medicine and former
director, National Institutes of Health
“Marcia Angell has produced a landmark

effort in exposing the dangers of ignoring
good science in the courtroom. She forces us
to think about the terrible consequences of
allowing emotion and money to rule our
legal system. It is a must read for anyone
who still thinks truth is important. | think it
is so valuable that | make this exception to a
longstanding rule of not endorsing books
about medical matters.”
—G. Timothy Johnson, M.D., M.P.H.,
medical editor, ABC News
re breast implants really dangerous?

When the FDA banned silicone
gel-filled breast implants in 1992, it
was responding to mounting concerns
that they caused autoimmune and con-
nective tissue disease. The ban triggered
a torrent of litigation, as women by the
thousands sued breast-implant manu-
facturers. Sympathetic juries awarded
huge damages, leading to a $4.25 bil-
lion class-action settlement that still
wasn’t large enough to cover all the
claims. Shockingly, rigorous scientific
studies of breast implants then began
(continued on back flap)
DATE DUE
NOV 13 1996
FEB 13 2003
fo 03
AUG 25 2004
FWL 9 1 2006
20 0¢ (3
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SCIENCE ON TRIAL
-~
Science
on Trial
THE CLASH OF
MEDICAL EVIDENCE
AND THE LAW IN THE
BREAST IMPLANT CASE
Marcia Angell, M.D.
W. W. NORTON & COMPANY
LONDON
NEW YORK
San Rafae! Public Library

San Rafael, CA 94901
Copyright © 1996 by Marcia Angell, M.D.
All rights reserved

Printed in the United States of America
First Edition
For information about permission to reproduce selections from this book,

write to Permissions, W. W. Norton & Company, Inc.,
500 Fifth Avenue, New York, NY 10110.
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Book design by Beth Tondreau Design
LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Angell, Marcia.
Science on trial : the clash of medical evidence and the law in
the breast implant case / Marcia Angell.
p. cm.
Includes bibliographical references and index.
ISBN 0-393-03973-0
1. Products liability—Breast implants—United States. 2. Breast implants—Law
and legislation—United States. 3. Breast implants—Complications.
I. Title.
KF1297.B74A96 1996
346.7303'8—dc20
[347.30638] 95-50081
CIP
W. W. Norton & Company, Inc., 500 Fifth Avenue, New York, N.Y. 10110
http://web.wwnorton.com
W. W. Norton & Company Ltd., 10 Coptic Street, London WC1A 1PU
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CONTENTS
Preface
Acknowledgments 15
. The Breast Implant Story: Once Over Lightly
- Breast Implants: What They Are

and Who Has Them oo
- The FDA Ban on Implants:

Regulation in Modern America 50
. The Rush to Court: Litigation

and More Litigation 69
- Scientific Evidence: What It Is

and Where It Comes From 90
. Science in the Courtroom:

Opinions without Evidence lll
. Greed and Corruption: All That Free Money 133
. Americans and Health News:

The Alarm of the Day 154
8 # Contents
9. Breast Implants and the Rejection of Science:

Other Ways of Knowing 177
10. Where We Stand . . . and for How Long 192
Notes Zit
Index 247
PREFACE
LA. years ago I would have been surprised to be told I

would one day write a book about breast implants. I had
no particular interest in the subject, and it would have seemed
unlikely that I would develop one. To be sure, as a physician
I was aware that cosmetic surgery was a part of health care. But
I considered it a relatively minor part, dwarfed by the many
more crucial matters facing doctors and patients—life-
threatening disease, unremitting pain, profound disability.
Nor would my responsibilities as executive editor of the New
England Journal of Medicine have been likely to involve me in
the study of breast implants. My job is to help evaluate the
many reports of medical research submitted to the Journal, of
which only about 10 percent are selected for publication. Re-
ports of breast implant research were rarely among the sub-
missions and, until recently, never among the papers selected
for publication. Not very much research was being done on
the subject, and what there was wasn’t very good. So how did
the idea for this book come to be?
The short answer is that I was drawn to the issue by two
manuscripts submitted to the Journal, one in 1992 and the sec-
ond in 1994. In 1992 David Kessler, the commissioner of the
FDA, banned silicone-gel-filled breast implants from the mar-
ket because they had not been proven safe. The ban caused
widespread alarm among the 1 million to 2 million women
10 & Preface
who already had implants. It also led to a torrent of lawsuits

against the manufacturers of breast implants. Shortly after
Kessler announced the ban, he submitted a manuscript to the
New England Journal of Medicine explaining his reasons. In re-
viewing the manuscript I began to realize that the matter was
more complicated than I had suspected. Kessler’s decision in-
volved not just science, but public opinion, politics, and the
law. I thought the consequences of the FDA’s decision would
be far more wide-ranging than Kessler seemed to believe, and
I wrote an editorial to that effect to accompany his article. That
was my first exposure to the subject.
Two years later, in 1994, Dr. Sherine Gabriel of the Mayo
Clinic submitted to the New England Journal ofMedicine her re-
port of the first epidemiologic study of whether breast im-
plants increase the risk of certain diseases and symptoms. By
this time, thousands of lawsuits had been filed alleging that
they did. Some women received huge damages from sympa-
thetic juries (the record was $25 million). For every jury ver-
dict, many more cases were settled for the plaintiff out of
court. The situation became unsustainable for the breast im-
plant manufacturers, and so they agreed to set aside $4.25 bil-
lion to meet the claims of all women with breast implants once
and for all—the biggest class-action settlement in history. Yet
the Mayo Clinic study, published shortly after the class-action
settlement was announced, did not show a link between breast
implants and disease. I was struck by the discrepancy between
the legal findings and the scientific evidence. Why were the
courts so sure, when the scientists were not at all certain? I sug-
gested some possible answers to this question in another edi-
torial, which accompanied the Mayo Clinic study. That was my
second foray into the subject, and by this time I was hooked.
But the most important reason I decided to write about
Preface #® 11
the breast implant controversy is because it illuminates im-

portant themes in American life. It richly illustrates the in-
terplay of regulation, litigation, commercial interests, media
coverage, and consumer pressure in the public confrontation
of a major health issue. In the decade leading up to the FDA
ban, the safety of implants was debated in the courts, in med-
ical journals, and in the popular media. The debate occurred
against a political backdrop of controversy about the relative
excesses of big business and government regulation. Were
large corporations like Dow Corning, the leading manufac-
turer of breast implants, knowingly foisting off dangerous
products on the public or were they responsibly meeting con-
sumer demands? Should the FDA have moved more promptly
to pull implants off the market or should women have been
allowed to make their own choices? After the ban, the focus
shifted to the courts, where matters of scientific fact were de-
cided not by scientists, but by lawyers, juries, and judges. On
what basis did they reach their conclusions? And what effect
did public opinion have on the outcome? The media covered
the controversy fully, if not always accurately, and the public
took a lively interest in the matter. Did public opinion drive
the FDA’s actions and the courts’ conclusions? And how was
the unfolding of the breast implant story affected by greed and
the expectation of personal profit? Vast amounts of money,
not just the $4.25 billion in the original class-action settle-
ment, are still at stake in the thousands of individual lawsuits
that have been filed and will be filed.
What fascinated me most about the contradictory opin-
ions and accusations, the frenetic legal activity, and the huge
sums of money at stake was the question of evidence. As I in-
vestigated the subject, I realized that the breast implant con-
troversy is simply one example of the difficulty we Americans
12 @ Preface
have in dealing with scientific evidence, particularly on mat-

ters of health. We depend greatly on science and its techno-
logical fruits, we like to talk about what research shows and
what it doesn’t, we think we understand risks, but when it
comes to the recurrent medical scares that sweep across the
land like locusts, all our sophistication goes out the window.
Just give us the conclusion, tell us whom to blame, and don’t
bother with the evidence.
In this book, I will use the breast implant story to illustrate
the broader themes that concern me. How do scientists reach
conclusions about questions of health risks, such as whether
breast implants increase the chance of developing a disease?
How does the legal system reach its conclusions about the
same question? Do the differences in methods account for the
vast differences in outcome? What are the essential distinc-
tions in the way science, the law, and the public regard evi-
dence, and what are the consequences for our society?
I will begin with a brief review of the breast implant con-
troversy to provide the narrative. To set the context further, I
will describe in some detail the implants themselves, as well as
the history of breast augmentation and the more recent use
of implants for reconstruction after cancer surgery. In the re-
maining chapters, I will widen the focus to the themes illus-
trated by the breast implant story: the role of regulation and
litigation in American life, the nature of scientific evidence,
the way in which legal evidence is different, the distorting ef-
fect of greed and corruption on the usual process for decid-
ing medical matters, the public’s all-or-nothing response to
health news, and the ripple effects of a paroxysm like the
breast implant controversy.
Finally, a brief personal note to give the reader some idea
of the point of view I bring to this subject. I consider myself a
Preface @® 13
feminist, by which I mean that I believe that women should

have political, economic, and social rights equal to those of
men. As such, I am alert to discriminatory practices against
women, which some feminists believe lie at the heart of the
breast implant controversy. I am also a liberal Democrat. I be-
lieve that an unbridled free market leads to abuses and injus-
tices and that government and the law need to play an active
role in preventing them. Because of this view, I am quick to
see the iniquities of large corporations. I disclose my political
philosophy here, because it did not serve me well in examin-
ing the breast implant controversy. The facts were simply not
as I expected they would be. But my most fundamental belief
is that one should follow the evidence wherever it leads. From
time to time, it is important to look up and see where you have
been led and who is there with you, but you should not turn
back. That is what this book is all about.
MARCIA ANGELL
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ACKNOWLEDGMENTS
[could not have written this book without Rachel Hart, my

extraordinary research assistant. Even before I put the first
word on paper, she had assembled a voluminous file of in-
formation on the breast implant controversy, which she con-
tinually supplemented and revised as events unfolded. As my
eyes and ears, and often my brain, she stayed in touch with
many of the principals in the saga, and tried to make certain
that no aspect of the controversy escaped us and that all our
facts were accurate. She also performed the onerous task of
writing endnotes for the chapters, so that interested readers
might follow the same trail we did. And finally, she went over
the book many times, offering insightful comments. It was my
good fortune that she cared as much as I did.
I am also extremely grateful to Dr. Jerome Kassirer, the
editor-in-chief of the New England Journal of Medicine, for his
unwavering support, encouragement, and friendship as I
struggled to fit together the schedules of writing the book
and editing the Journal. The Massachusetts Medical Society,
owners of the New England Journal of Medicine, also backed me
fully. The executive vice-president, Dr. Harry Greene, enthu-
siastically agreed to free me for four months to write, and he
was always available to offer advice and encouragement—but
only if I asked for it. The legal staff of the Journal, especially
Paul Auffermann, willingly provided whatever counsel I asked
16 &@ Acknowledgments
for during the preparation of the book. No one could work

for more supportive people.
The following people were kind enough to read sections
of the book and offer comments or expert advice: Bert Black,
John Getter, Shirley Hufstedler, Sheridan Kassirer, Martha
Minow, David Pate, Noel Rose, and Walter Willett. I am very
grateful to them. In addition, I received helpful information
or advice from Sherine Gabriel, Charles Hennekens, Deborah
Hensler, Matthew Liang, Frank Speizer, and Richard Wilson.
Hilary Hinzmann of W. W. Norton was a thoughtful and at-
tentive editor. I am also indebted to my talented friend Darcy
Tromanhauser, of Henry Holt, who provided a crash course
in book publishing and led me to my capable agent, Alice
Martell.
Bud Relman, my ultimate editor and partner in all things,
carefully read every word in the book and changed many of
them. His attention to the story I was telling and the way I told
it was invaluable. More important, his enthusiasm for the pro-
ject, along with the encouragement of my daughters, Lara
and Elizabeth Goitein, kept me at it. They were a great home
team.
MARCIA ANGELL
SCIENCE ON TRIAL
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1
THE
BREAST IMPLANT
STORY:
ONCE OVER
LIGHTLY ;
y the time FDA commissioner David Kessler decided in

1992 to ban silicone-gel-filled breast implants, an esti-
mated 1 million to 2 million American women already had
them.' (The precise number is unknown.) According to
Kessler, the manufacturers had not fulfilled their responsi-
bility to demonstrate the safety of the implants, and he there-
fore had no choice but to take them off the market. Thus
ended 30 years of the easy availability of breast implants (for
those who could afford the surgery). Most women with im-
plants had simply wanted to enlarge their breasts, but about
20 percent had obtained them for reconstruction after mas-
tectomy for breast cancer.” A 1990 survey commissioned by the
American Society of Plastic and Reconstructive Surgeons
found that over 90 percent of women with breast implants
were well pleased with the results. Nevertheless, many people
were jubilant about the FDA ban—including advocates of
tough government regulation, women who believed breast
implants had caused them to become ill, and feminists who
20 @ SCIENCE ON TRIAL
thought it was about time someone puta stop to women being

pressured to conform to male fantasies. What follows is the
story of the breast implant controversy. It is an astonishing
story, with implications far beyond the question of whether or
not silicone-gel-filled breast implants are safe.
As executive editor of the New England Journal of Medicine
and as a woman, I was aware that breast implants were con-
troversial on many counts, but I had not given the matter
much thought until Dr. Kessler submitted an article to the Jour-
nal explaining his reasons for banning the devices. The arti-
cle was important and we were happy to publish it.’ Still, I was
troubled by the likely consequences of Kessler’s action, as well
as by some of his arguments. He seemed disdainful of women
who wanted breast implants for purely cosmetic reasons, and
his decision, though welcomed by many women, struck me as
a little patronizing. More important, how would the sudden
ban strike the million or so women who already had implants?
Would they accept Kessler’s legalistic argument that he was
simply responding to the lack of evidence adduced by the
manufacturers? I thought not. Far more likely, they would see
the FDA ban as proof that the implants were extremely dan-
gerous.
And that is exactly what happened. Despite Kessler’s weak
assurances that removal of the implants was unnecessary,
women rushed to have them taken out, sometimes by the
same plastic surgeons who had implanted them in the first
place. One woman who could not afford the fee attempted to
remove her own implants with a razor blade; she survived the
ordeal, and was pictured in newspapers looking greatly re-
lieved after a surgeon had finished the job.* Most notably, the
small trickle of high-stakes court cases that began in the early
1980s swelled to a torrent.” Compassionate juries awarded
The Breast Implant Story: Once Over Lightly # 21
multimillion-dollar damages to women with a variety of com-

plaints that they and their lawyers attributed to breast im-
plants.° If Kessler thought the ban was the end of the matter,
he was wrong.
What did we know about the safety of breast implants?
Kessler was right about this: at the time the FDA made its de-
cision to ban them, we knew next to nothing. Incredibly, there
had been no systematic studies of the effects of breast im-
plants. We knew, of course, that there could be complications
from the surgery itself (as with any surgery), including infec-
tions and hemorrhage. We also knew that in many women the
tissue around the implants scarred excessively, distorting and
hardening the breasts, and that these contractures could be
uncomfortable. And finally, we knew that in a significant per-
centage of women (the best estimates are around 5 percent)
an implant ruptured, releasing silicone gel into the sur-
rounding tissues and flattening the breast.’ But these local
complications, unpleasant as they were, were not the basis for
most of the alarm about breast implants, nor were they the
focus of the multimillion-dollar lawsuits.
Instead, a growing number of Americans had come to be-
lieve that breast implants could cause devastating effects on
the rest of the body. In particular, silicone-gel-filled implants
were said to be responsible for a constellation of disorders
known as connective tissue diseases. These diseases—which in-
clude systemic lupus erythematosus (SLE), rheumatoid arthri-
tis, scleroderma, and polymyalgia, among others—are thought
to involve a disturbance in the immune system that turns the
body’s protective defenses against itself. The result is an au-
toimimune disease—that is, a prolonged civil war within the
body that can produce profound weakness and fatigue, along
with variable damage to the joints, skin, and internal organs.
It was theorized that silicone, leaking slowly from the implants,

provokes an immune reaction that then somehow turns into
an autoimmune process. This theory, not the local complica-
tions, was the basis for most of the alarm and the largest law-
suits. Earlier worries that implants could cause cancer were
largely eclipsed by the concern about connective tissue dis-
ease, in part because scientific studies were showing the can-
cer scare to be unfounded.’ It is harder to study connective
tissue disease than cancer, because it is more difficult to pin
down or rule out the diagnosis.
Eventually, the breast implant manufacturers, losing one
product liability case after another, agreed to the largest class-
action settlement in the annals of American law.’ Class actions
are lawsuits in which the claims of many people are decided
in a single court proceeding brought by representative plain-
tiffs. Through a class-action settlement, defendants can limit
their losses by paying a set amount to be distributed among
all those with a claim. In April 1994 the major manufacturers
agreed to pay $4.25 billion to women with breast implants, a
billion of which was explicitly set aside for the lawyers involved.
Although nearly any woman with implants would be entitled
to something under the terms of the settkement, women were
permitted to opt out if they thought they could do better in
court on their own. By June 1, 1995, 440,000 women had reg-
istered to participate in the class-action settlement (as many
as a third of all women with breast implants in this country),
but, with vigorous encouragement from plaintiffs’ attorneys,
about 15,000 (half Americans, half foreigners) had opted out
to seek higher damages individually.
The implant manufacturers could have warned of a link
between breast implants and connective tissue disease in the
informational pamphlet they are required to put in each pack-
The Breast Implant Story: Once Over Lightly @ 23
age of implants. If they had done so, they would have had less
trouble. In addition to dissuading many women from consid-
ering implants, such a warning would have disarmed those
who got implants anyway, since they could no longer have
claimed that the manufacturers had misled them. A product
liability suit is less likely to be successful if the buyer (in this
case, the plastic surgeon, who is expected to inform the pa-
tient) has been warned. But the manufacturers steadfastly
maintained that the implants were safe, despite the lack of sci-
entific evidence in either direction. To be sure, there were
many individual stories of connective tissue disease develop-
ing after the placement of breast implants, but these reports
alone (“anecdotes,” in scientific jargon) do not constitute ev-
idence that the implants caused the disease. They could well
have represented pure coincidence. Since connective tissue
disease can develop in women with or without implants, the
only way to demonstrate that implants actually cause the dis-
ease is to show that the risk is significantly higher in women
with breast implants than it is in those without implants. To do
so requires epidemiologic studies—scientific surveys of the
incidence of disease in samples of different groups. But it was
not until a few months after the class-action settlement was an-
nounced that the first such study of breast implants and con-
nective tissue disease was published.'°
How could the law have been so far out in front of the ev-
idence that huge amounts of money were changing hands
and $4.25 billion more was promised? And whose hands were
they? Many of those who welcomed the FDA ban believed that
the law was notin front of the evidence, but that the evidence
had been largely suppressed by rapacious implant manufac-
turers interested only in their profits and by the plastic sur-
geons who made a very good living implanting the devices.
However, not even this conspiratorial theory does justice to the

real complexity of the story. As suspected, the story is full of
greed, but this greed is hardly limited to implant manufac-
turers and plastic surgeons. Plaintiffs’ attorneys, doctors, re-
searchers, and even implant recipients themselves are ex-
ploiting the lucrative opportunities. Four billion dollars is a
lot of money, and there is even more to be had.
The breast implant story shows us some of the worst in
human nature; it also reveals the weaknesses of a number of
important U.S. institutions, including the media, parts of the
legal and medical professions, and the courts. It raises the
question of how we know what we think we know about the
causes of disease, and, in so doing, it calls into question the
systems we have devised for finding out. How does the public
decide whether silicone breast implants or any other product
is harmful? How do researchers and doctors decide, as com-
pared with judges and juries? These issues can be considered
within six broad themes that pervade and shape American so-
ciety. All of the themes are clearly sounded in the breast im-
plant controversy.
The first concerns the place of regulation in American
life. The FDA, as perhaps the most visible of the governmen-
tal regulatory bodies, faced a virtually impossible dilemma in
deciding whether or not to ban breast implants. Whatever its
decision, the FDA would be strongly criticized. If implants
were left on the market, the FDA would be seen as caving in
to the manufacturers. If they were banned, at least a million
women might wrongly conclude that they were at risk for se-
rious disease. The letter of the law requires that manufactur-
ers of devices demonstrate their safety before they market
them. But breast implants had been on the market for a dozen
years or so before that law was passed and another dozen af-
terward before the FDA decided to ask for evidence of safety.

The FDA’s decision to call for evidence after all that time is
open to a number of political interpretations. Some believe
that the manufacturers had a free ride during most of the
1980s because of the anti-regulatory philosophy of the Reagan
administration. On the other hand, it is hard to escape the
conclusion that the change in the FDA’s attitude toward the
end of the decade might also have reflected the mounting
public concern about the issue, which in turn was largely dri-
ven by the publicity surrounding a few spectacular court cases.
To the extent that this later interpretation is correct, the FDA
responded like a political body, not a regulatory body.
In addition, after David Kessler came to the FDA in 1991,
the controversy took on the character of a battle of wills.
Kessler clearly believed in a strengthened FDA. The manu-
facturers, who had not performed the necessary studies to
demonstrate safety, were cavalier in their response to the
FDA’s new hard line. Who would back down? Meanwhile, the
public pressure to do something about breast implants was in-
tensifying. Panels convened by the FDA to consider the mat-
ter included vocal partisans on the issue. Hearings were pub-
lic and included emotional testimony about the harm caused
by implants, but little critical analysis. The FDA’s action, then,
was taken in a charged atmosphere of advocacy and in the vir-
tual absence of evidence. The ban raises the question of the
degree to which regulatory decisions should be influenced by
political and social considerations. It also raises the issue of the
proper balance between regulatory protection of consumers
and individual choice. In this case, the letter of the law, but-
tressed by public opinion, dictated one course, but consider-
ation of the likely social consequences of a ban, particularly
the widespread alarm, might have supported another.
The second theme illuminated by the breast implant story

is the impact of tort law on American life. A tort is a wrongful
act or injury for which damages are sought in a civil (as op-
posed to criminal) court. Americans increasingly turn to the
courts to remedy a whole variety of complaints, and the num-
ber of tort cases—particularly product liability and malprac-
tice cases—is growing accordingly. The breast implant case il-
lustrates in the extreme the influence of the tort system. Even
before the ban, there had been a steady trickle of lawsuits al-
leging that breast implants caused connective tissue or au-
toimmune disease. Successful lawsuits bred more lawsuits,
which in turn bred publicity. Not surprisingly, as more women
with implants and their doctors became aware of the possible
risks, there were more reports of disease caused by implants.
As the chairman of one of the FDA’s panels said, “The lawyers
were ahead of the doctors, and the public was ahead of the
FDA.”¥
After the ban, the plaintiffs’ bar moved quickly, and many
thousands of lawsuits were filed within a matter of months.
The result has been an immense transfer of money from the
breast implant manufacturers to plaintiffs and their lawyers.
There has been little attention to the fact that the money orig-
inates from consumers who purchase the manufacturers’
other products. Nor has there been much attention to other
consequences of the lawsuits, although they are likely to be far-
reaching. In particular, manufacturers of other medical de-
vices and the suppliers of their raw materials are threatening
to pull out of the market because of the legal liabilities. What
accounts for the torrent of successful litigation, with all its rip-
ple effects, in the absence of solid scientific evidence about the
risks of breast implants? Several peculiarities of the American
tort system, which I will discuss in later chapters, bear on this
The Breast Implant Story: Once Over Lightly & 27
question. Tort reform is now a contentious political issue, and

the breast implant controversy throws the debate into sharp
relief. It well exemplifies the tension between the pressure to
curb the excesses of the tort system and the need to maintain
reasonable access to the courts to seek redress for injury.
The third theme is the marginal and ambiguous role of
scientific evidence in our society. To be sure, the United States
has a large scientific enterprise, and its research findings are
often widely publicized. But interest in scientific conclusions
is not the same thing as interest in how they originated. The
nature of evidence is simply not a front-burner item for most
Americans, a fact illustrated by the breast implant story. As it
happened, medical researchers did not systematically begin to
collect evidence on breast implants until around the time of
the FDA ban, when several large studies were initiated. These
were epidemiologic studies that sought to determine whether
the diseases said to be caused by breast implants are more com-
mon in women with implants than in women without im-
plants. Unless this question is answered, it is impossible to say
whether breast implants contribute to the diseases. Other
types of studies, including animal studies, laboratory studies,
and case reports, Can raise interesting questions and answer
some, but they cannot answer this one.
So far, none of the epidemiologic studies has been able
to demonstrate a clear link between breast implants and con-
nective tissue disease or suggestive symptoms. This does not
mean that there cannot be a link, just that it is too small to have
been detected by the studies that have been done. Possibly,
much larger studies will show some risk. The answer to the
question will come in incremental steps, one study at a time,
and represent the accumulated weight of evidence from many
sources. This is the way medical research works; evidence is ac-
28 @& SCIENCE ON TRIAL
cumulated slowly and the conclusion is inseparable from the

evidence. The lack of understanding about how scientific con-
clusions are reached causes a great deal of confusion in Amer-
ican society, as I will discuss in a later chapter.
The fourth theme concerns science in the courtroom.
When atrial involves a matter of scientific fact, such as whether
breast implants cause disease, the approach to answering the
question is very different in court than it is in scientific re-
search. In the courtroom, expert witnesses, chosen and paid
by the adversaries, are invited to give their opinion. The opin-
ion may include some reference to research, published or un-
published, but it doesn’t have to. If research is cited, there is
no procedure for evaluating its reliability. Expert witnesses
often simply refer vaguely to their “experience.” What they are
asked to provide, then, is essentially an educated guess. Al-
though they are expected to have certain credentials, they
needn’t give the basis for their conclusions, except in the un-
common circumstance of a scientifically sophisticated cross-
examination. This approach essentially reverses the scientific
process. In science, the evidence leads to the conclusion; in
the courtroom, the expert’s conclusion comes first and be-
comes the legal evidence. Not surprisingly, the answers yielded
by these two approaches may differ greatly.
Much of the discrepancy is simply a matter of how the
legal process has been structured. But I believe it is exacer-
bated by a genuine lack of understanding between the two dis-
ciplines. The law and science represent two strikingly differ-
ent ways of thinking, which reflect their different methods.
The law frames questions in adversarial terms, and lawyers see
problems as best resolved by controlled argument. In con-
trast, the scientific method is (ideally) not adversarial, but co-
Operative, and scientists usually find answers in the slow ac-
cumulation of evidence from many sources. The different

ways of thinking are so ingrained that they may be virtually un-
conscious. For example, a lawyer questioning an epidemiolo-
gist in a deposition asked him why he was undertaking a study
of breast implants when one had already been done. To the
lawyer, a second study clearly implied that there was some-
thing wrong with the first. The epidemiologist was initially
confused by the line of questioning. When he explained that
no single study was conclusive, that all studies yielded tenta-
tive answers, that he was looking for consistency among a
number of differently designed studies, it was the lawyer’s
turn to be confused. Similarly, I am occasionally asked by
lawyers why the New England Journal of Medicine does not pub-
lish studies “on the other side,” a concept that has no mean-
ing in medical research. An adversarial approach is very ef-
fective for settling many types of disputes, which is no doubt
why the law is based on it, but it is not the way to reach scien-
tific conclusions. Yet science in the courtroom, no matter how
inadequate, has great impact on people’s lives and fortunes.
Later I will discuss how the system might be reformed to make
it better able to deal with scientific questions.
The fifth theme is the pervasive effect of the profit mo-
tive on so much of our public life. Just as the struggle to de-
termine the facts about breast implants is between science and
the law, the struggle for financial gain is between the manu-
facturers and the plaintiffs’ attorneys. In their haste to cash in
on the rapidly expanding market for silicone breast implants,
the manufacturers glossed over their responsibility to perform
adequate studies of the biological effects of implants. Internal
memos from one manufacturer, Dow Corning, showed that
there were safety concerns within the company that were not
investigated. In fact, one memo instructed salespeople to wash
the oily slick off implants before showing them to plastic sur-
geons at trade shows, thereby removing evidence of leakage.
The overriding concern was to win the race against a com-
peting manufacturer.
After the FDA ban, when the manufacturers were clearly
on the ropes, the plaintiffs’ attorneys moved in to capture the
profits of the manufacturers. Since the lawyers are paid on a
contingency basis—that is, a percentage of the plaintiff's
award or out-of-court settlement—they had every interest in
filing as many lawsuits as possible. If they lost most of them, it
didn’t matter. With contingency fees customarily in the range
of 30 to 40 percent, all they needed was to win a few cases from
time to time and settle most of them out of court. The system
resulted in relatively small gains for many women and enor-
mous gains for a few lawyers. The stake of the lawyers in the
breast implant dispute is now so great that some of them have
embarked on a campaign to discredit and harass scientists
who are conducting epidemiologic research on the subject.
Dr. Sherine Gabriel of the Mayo Clinic, author of the first pub-
lished epidemiologic study of implants, was served with sub-
poenas demanding that she produce large numbers of docu-
ments about the women in her study. Authors of two other
epidemiologic studies were served with similar subpoenas.
These researchers say that responding to the subpoenas has
been extremely burdensome and time-consuming. They be-
lieve the harassment might well dissuade other investigators
from conducting epidemiologic studies. The avarice of man-
ufacturers is necessarily restrained to some extent; if they are
too obviously heedless of safety, they will lose their customers
and find themselves in trouble with the law. Plaintiffs’ attor-
neys are not similarly restrained. Their clients gain right along
with them, and they are not only acting within the law, but
using it as an instrument.
The Breast Implant Story: Once Over Lightly # 31
Finally, the sixth theme is the way in which the media pre-
sent medical issues to the public. Until about 1990 the media
had little to say about breast implants, except to report a few
large jury verdicts. But as the time approached for the manu-
facturers to produce evidence of safety, the intermittent media
reports became more frequent, until finally the media cover-
age was nearly incessant. It also grew more sensational and un-
critical with time. On television and in newspapers and mag-
azines, women—some of them celebrities—began to recount
stories of deformity and disease stemming from their implants.
The subject became a staple of talk shows. The tone of the cov-
erage was anything but analytical. Instead, the premise that
breast implants were dangerous seemed to be tacitly accepted.
In addition, it was often strongly implied that the FDA, as well
as the manufacturers, knew the devices were dangerous and
suppressed the fact. The story played to both the American fas-
cination with newly discovered, mass health hazards and the
penchant to assume a cover-up in any disaster. Instead of pre-
senting a complicated health story, the media simply gener-
ated outrage.
Which came first—the media spin or public opinion? As
in all media-intensive stories, it is impossible to say because
public opinion and media reports are so closely intertwined.
What can be said is that the tone of the coverage almost cer-
tainly reflects a predisposition of the public to see it that way.
The public is easily swept up in medical alarms, particularly
when there is an element of wrongdoing involved. The power
of the media and public opinion is immense, and that is by and
large appropriate in a democracy. But not all endeavors are
meant to be ruled by public opinion. Justice, for example,
should not be, nor should science.
In subsequent chapters, I will consider each of the above
themes using the breast implant controversy as a prism. But
first, it is necessary to review the nature of the implants them-

selves—how they were developed, what they are made of, how
the body reacts to them, and who has them and why. Under-
standing these devices makes it easier to see how the contro-
versy about them illuminates the themes of this book.
2
BREAST IMPLANTS:
WHAT THEY ARE AND
WHO HAS THEM
I like a large casaba melon size, you know, I

guess 40, 38.
—Unidentified man on CNN,
December 31, 1992
he female breast has always been a powerful symbol of

femininity and sexuality, and the fact that women feel dri-
ven to have perfect breasts should be no surprise. Exactly what
constitutes perfection changes with fashion. In the 1920s,
women bound their breasts to make them look smaller. But over
the following decades, until the waif look returned in the 1960s,
women instead padded their bras to make their breasts look
larger. After the anorectic look of the 1960s passed out of style
and large breasts came into fashion again, padding had be-
come aless feasible solution, since clothing was often too scanty
to hide it. If breast size was to be increased, it had to be done
from within. And that is what happened. During the 1970s,
there was an explosion in the use of breast implants.’ (Never-
theless, there is more than one way to be imperfect, and breast
reduction surgery is almost as common as augmentation.)
In 1994 breast augmentation was the third most common

cosmetic operation in the United States, despite the fact that
the FDA ban had been in effect for almost two years.? Since
implants filled with sterile saline (salt water) instead of silicone
gel were allowed to remain on the market, women simply ob-
tained them instead. The fee charged by surgeons was about
$3,000. Only liposuction and eyelid surgery were more com-
mon. (Ironically, the same year, removing breast implants was
the number-five procedure, no doubt reflecting the alarm fol-
lowing the FDA ban.) Breast augmentation is substantially
more common in the Sunbelt—the southern and southwest-
ern states and California—than it is elsewhere in the country.
At its peak, from 1979 to 1992, breast implant surgery was
performed on about 100,000 to 150,000 American women
each year. In today’s dollars, this represented roughly $300
million to $450 million in surgical fees and $50 million to $75
million in manufacturers’ revenues (assuming a price of $500
per set of implants). Although Dow Corning dominated the
market, other manufacturers offered stiff competition: Bristol-
Myers Squibb; Baxter International; Bioplasty, Inc.; Mentor
Corporation; and McGhan Medical Corporation (now In-
amed, once owned by the giant Minnesota Manufacturing
and Mining Corporation [3M]). After the ban, of course, sales
plummeted (Mentor stock fell from $30 in April 1991 to $8 in
February 1992). Mentor and McGhan, the only manufactur-
ers left in the market, continue to sell saline implants (about
40,000 of these are implanted each year). Mentor’s silicone-
gel-filled implants are offered for reconstruction only, and
only under research conditions (about 22,000 yearly). Within
months of the ban, the price of the saline implants had dou-
bled and that of the silicone-gel-filled implants had tripled.*
Whether women reshape their breasts to please men or
Breast Implants: What They Are and Who Has Them #8 35
to please themselves is a matter of debate. The distinction is

difficult, because self-image is so bound up with the opinions
of others. Women tend to interpret breast augmentation as a
matter of self-image and enhanced confidence, while men
tend to see it as a specific attempt to please them. For exam-
ple, Arthur Caplan, a bioethicist at the University of Pennsyl-
vania, in arguing that women do not have enough informa-
tion to make an informed choice, told the Boston Globe, “I
think having large breasts is an attempt to please males. It’s a
cultural fetish. American men are clearly enamored of mam-
mary glands, and I’m all for giant boobs. But to invoke the lan-
guage of choice is to invoke choice in a vacuum.”* Some fem-
inists, such as Naomi Wolf, author of The Beauty Myth, see the
pressure on women to enlarge their breasts as more sinister.
To Wolf, it is a way of stunting women’s sexual capacity, as well
as regimenting their appearance, since breast implant surgery
sometimes decreases sensation in the nipples. Whether
women get implants for themselves or to please men is not a
meaningful question to her, since they do it within the con-
text of a male-dominated society.°
The first known attempt to enlarge a woman’s breasts oc-
curred in Germany in 1895. (Interestingly, surgery to reduce
breast size had been performed for many years.) In that first
operation, fat from a benign tumor on the woman’s back was
transplanted to her breasts. Within a few years, surgeons were
experimenting with paraffin wax to enlarge breasts. Later,
other foreign substances were tried, including petroleum jelly,
beeswax, and vegetable oils, but paraffin remained the main-
stay. Probably the first women to turn to silicone were Japan-
ese prostitutes after World War IJ, trying to satisfy the taste of
American occupation forces for Western-style large breasts. In-
stead of having discrete packets of silicone surgically im-
planted in their breasts, as is now done, these women had liq-

uid silicone or paraffin injected by needle or tube directly
into their breast tissue, often along with assorted contami-
nants. Within a few years, breast augmentation by silicone in-
jection had spread to the United States, where it found par-
ticular favor among Las Vegas showgirls and aspiring actresses
in California.®
Silicone seemed like the perfect substance to enlarge
breasts. It is made by stringing together silicon and oxygen,
the two most common elements of the earth’s crust, and
adding organic groups to form chains or polymers. Depend-
ing on the length and configuration of the polymer, the sili-
cone can have nearly any consistency, including liquid, gel, or
rubbery solid (elastomer). First synthesized just before World
War II, silicone came into widespread use during the war for
insulation, lubrication, and sealing. In addition, it found al-
most immediate use in medicine because of its remarkable in-
ertness in the human body. It does not degrade appreciably,
it is highly resistant to bacterial contamination, and living tis-
sues seem to accept it readily.’ For these reasons, silicone is a
component of artificial joints and heart valves, shunts and
other tubings, disposable needles and syringes, and contra-
ceptive implants (Norplant), as well as testicular and penile
implants. Indeed, probably no American is without some sili-
cone in his or her body, put there by some type of routine
medical care—such as injections with silicone-lubricated nee-
dles and syringes. But despite its special properties and seem-
ing safety, injecting a large volume of liquid silicone of un-
certain purity directly into the breasts led to serious problems.
Any foreign substance or object introduced into the
body’s tissues provokes an inflammatory response. It is nec-
essary to have a general idea of the inflammatory response to
Breast Implants: What They Are and Who Has Them # 37
understand the breast implant controversy fully. Consider a

splinter, which is a foreign object. Ifa splinter is left under the
skin, even if it isn’t carrying bacteria, the area will become
slightly reddened and swollen because of an increased blood
flow carrying large numbers of special cells to the area. The
function of these cells—called white cells—is to try to engulf,
break down, and dissolve the foreign object. It is an attempt
by the body to get rid of something that doesn’t belong there.
Eventually, if the foreign object remains in the body, most of
the white cells are replaced with fibrous scar tissue, which con-
sists mainly of microscopic fibers made of a firm substance
called collagen.
The increased blood flow and gathering of white cells is
termed inflammation. When inflammation is a response to a
foreign object, like a splinter, it is called a “foreign-body re-
action.” The process can be mild or intense, depending on the
nature of the foreign object, the location in the body, and the
particular individual’s reactivity. If the object is contaminated
with bacteria, the inflammation is likely to be severe and on-
going. White cells will keep entering the area to battle the in-
fection, even while scar tissue is forming. When you have a
dirty splinter, for example, the area is very much redder and
more swollen than is the case with a clean one. Sometimes pus
forms, which is simply tissue fluid containing enormous num-
bers of dead white cells. When the foreign body is sterile, as
is the case with breast implants, the inflammation is replaced
by scar tissue. With time all scar tissue contracts and becomes
firm. (If you have a surgical scar, say, from an appendectomy,
you will know exactly what I mean. First the scar is pink and
raised; later it becomes smaller and white, and may even be-
come depressed below the level of the surrounding skin as it
contracts.) Scar tissue in the breast is no exception. As it would
anywhere else, it becomes firm with time and tends to contract.

This contracture has great significance in the breast implant
controversy, as we will see.
In general, silicone elicits only a very mild inflammatory
response. But when large amounts of liquid silicone were in-
jected directly into the breast, as was done to the Japanese
prostitutes, there were often terrible consequences. Bacterial
contamination from dirty needles or contaminated silicone
was common. It wasn’t just silicone that was being injected, but
all manner of other substances and bacteria. A severe inflam-
matory reaction often formed around each tiny globule of sil-
icone, making the breasts lumpy and hard, particularly as the
scar tissue contracted. Because the liquid silicone tended to
migrate into the soft tissues around the breasts or in the
armpits, it was customary to add irritating substances, such as
olive oil, so that there would be even more scar tissue to trap
the silicone and anchor it in place. The scarring around sili-
cone globules could then become so severe that it produced
grotesque lumps that resembled tumors. In addition, when the
breasts became infected, gangrenous sores sometimes devel-
oped on the overlying skin or nipple. Needless to say, besides
being disfiguring, the complications of directly injecting sili-
cone were often excruciatingly painful.®
BY THE EARLY 19608 the problems with injecting liquid silicone

into the breasts were all too apparent. For a while, there had
been attempts to augment breasts by implanting sponges
made of polyvinyl alcohol, rather than by injecting silicone,
but there were problems with this method, too. The scar tis-
sue that formed around each sponge also filled all the little
holes in it. Thus, when the scar contracted, it squeezed the
sponge into a small, hard ball.°
In 1961, two Houston plastic surgeons, Thomas Cronin

and Frank Gerow, began work on a different sort of im-
plantable device." It is said that Gerow was inspired by the sim-
ilarity between the consistency of a plastic transfusion bag
containing blood and the feel of a breast. Whatever his inspi-
ration, Gerow visited Dow Corning, then the leading manu-
facturer of silicone, to suggest that they collaborate in de-
signing a breast implant made of silicone. Dow Corning, which
was formed by Dow Chemical and Corning Glass Works to take
advantage of the burgeoning silicone market after World War
II, was at that time in the process of developing its Medical
Products Division. The following year, 1962, Gerow placed
the first modern breast implants (Dow Corning’s Silastic mam-
mary prosthesis) in a woman who wanted to enlarge her
breasts. (Now a sixty-four-year-old grandmother, she still has
her original implants today and professes to be content with
them.) The implants consisted of a rubbery silicone envelope
containing silicone gel. Packaging the silicone in this way was
intended to eliminate migration, as well as the irritating effects
of large liquid injections. This is still the basic design of breast
implants, which look like smooth, soft plastic bags of various
shapes, containing about a cup of clear jelly. In the early years
they often had Dacron patches attached to the back to gen-
erate more scar tissue to hold them in place, but that feature
was later abandoned.
Placement of the implants is remarkably simple. It re-
quires only two small incisions, usually in the crease under
each breast, although sometimes the incisions are made
around the nipples. Through the incision, the surgeon creates
a pocket behind the breast tissue and squeezes the implant
into it, so that it lies behind the breast and in front of the un-
derlying muscle. From this position, the implant pushes for-
ward the natural breast tissue.'!' The procedure is somewhat

more difficult in women who are getting implants for recon-
struction after mastectomy for breast cancer. In these cases,
the implant is usually not placed in front of the muscle, be-
cause, with the breast gone, it would be too close to the skin
and might actually rub through it. Instead, it is placed either
behind the muscle, against the ribs, or between layers of the
muscle. Sometimes reconstruction is done at the time of the
mastectomy; sometimes there is a delay of a few months, until
the mastectomy has healed. A nipple is usually reconstructed
from skin or mucous membranes taken from elsewhere on the
body.”
The gel-filled implants were almost immediately seen to
be a great improvement over direct injections, and they
quickly became the favored method of augmentation. They
looked and felt natural, they were sterile, and they did not mi-
grate. Nevertheless, at least four problems became apparent
almost from the beginning: contractures from scarring, leak-
age of silicone, rupture, and difficulties in performing mam-
mography.'* The major one was the scarring that inevitably oc-
curred around the implant envelope as a result of the
foreign-body reaction. This was not as extreme as the scarring
around globules of injected silicone, but it was still the same
basic process. In the case of implants, the fibrous scar tissue
formed all around each implant, encasing it in a “capsule.” In
and of itself, the capsule was not a problem. It was usually not
very thick and it was, of course, invisible. The problem came
as the scar tissue contracted. The capsule would then squeeze
the implant, making it hard and unnaturally rounded. Severe
contractures produced visible bulges in the upper part of the
breasts, which were often painful. No one knows what per-
centage of women with breast implants suffer from noticeable
contractures, but it is probably a substantial fraction, perhaps

as many as half. Nor is it clear why some women are more sus-
ceptible to this problem than others.
In the 1970s a second problem was discovered. It became
apparent that small quantities of silicone fluid from the gel
leaked through the envelope, even though the envelope was
intact. This slow leakage is called “bleeding” or “sweating,” and
it seems to be caused by tiny molecules of the gel migrating
through the pores in the surrounding envelope. Women are
not aware of the silicone leakage, because it is so slow and the
amounts are so small. Nevertheless, it has been a cause for
great concern, because silicone thereby escapes into the body.
Usually the leakage is contained within the encasing capsule
of scar tissue, but sometimes tiny particles of silicone can be
found in nearby lymph glands. Whether the leakage con-
tributes to the thickness of the capsule by exacerbating the in-
flammatory process is not known, but it is a reasonable con-
jecture.
For years surgeons would try to relieve excessive contrac-
ture by a procedure known as a “closed capsulotomy”—force-
fully squeezing the breast by hand to rupture the scar tissue.'*
The trouble with closed capsulotomy is that it not only rup-
tures the capsule, but often ruptures the envelope of the im-
plant as well, causing the sudden release of silicone gel into
the tissues, unimpeded by the presence of an intact capsule.
When this happens, small amounts of silicone may be en-
gulfed by white cells and transported through the lymphatic
system to distant parts of the body. In addition to the risk of
rupture, capsulotomy often causes acute inflammation (mas-
titis) from the trauma to the tissues (forcefully squeezing the
breasts is not easy on them). Even when closed capsulotomy
did not cause rupture of the envelope, it was often only par-
tially successful, so that the implant bulged out on one side.

And in any case the scar tissue almost always re-formed.'° Most
plastic surgeons no longer perform the procedure, although
it was once extremely common. By 1980 Dow Corning in-
cluded in its package insert a warning against closed capsu-
lotomy, which concluded, “Such abnormal trauma or stress to
the breasts could result in prosthesis rupture with extravasa-
tion of gel into surrounding tissue.” All this means is: Squeeze
the breast implants too hard and they will burst.
When an implant and its capsule rupture suddenly,
whether from a closed capsulotomy or a blow to the chest, the
breast loses its shape as the silicone escapes into the tissues.
Often, however, there is only a small tear, and the escaping
silicone gel remains trapped within the capsule. In this case,
the woman may not be aware that she has a rupture. The exact
incidence of rupture that is noticed by the woman remains
unknown. The manufacturers have estimated a rate of 1 per-
cent or less, but others estimate it to be higher, closer to 5 per-
cent. The incidence of slight rupture that is unnoticed and
contained within the capsule is even more difficult to deter-
mine. One study found unappreciated rupture in 5 percent
of women with implants who were having mammograms.'®
Difficulty in performing mammography is a fourth prob-
lem. It is not exactly a complication, but a necessary con-
comitant of having breast implants. The difficulty stems from
the fact that the implant obstructs the passage of x-rays
through the breast tissue. Whether this problem has resulted
in cancer being diagnosed later in its course is not clear. What
is Clear is that mammography in women with implants requires
more care. The implant must be manipulated so that it is held
against the chest wall, while the breast tissue is pulled away
from it. Multiple views may be required. The technical prob-
Breast Implants: What They Are and Who Has Them #® 43
lems in performing mammography are occasionally confused

with the issue of whether the implants themselves increase
the risk of cancer. There is no evidence that they do.
At first, Dow Corning had the breast implant market to
itself, but later other manufacturers began to make implants
and the market became very competitive. Innovations fol-
lowed rapidly, most of them designed to counter the twin
problems of contractures and leakage. One such innovation,
designed to reduce the tendency of the capsule to harden and
contract, was to coat the outside of the implants with
polyurethane foam. Because of the fuzzy texture of these im-
plants, the scar tissue that formed around them was more ir-
regular than the capsules that form around smooth implants.
It was thought that the irregularity would make strong con-
tractures less likely, because the scar tissue would not all be
pulling in the same direction. At first the idea seemed to work.
The breasts remained softer than with the smooth-textured
implants—at least for the first few months. But eventually the
contractures became just as bad, as a thick, regular capsule
formed around the initial irregular one. Furthermore, the
polyurethane-coated implants were extremely difficult to re-
move because there was no well-defined capsule to demarcate
them. They were all bound up in the breast tissue, with no
clear boundary. In addition, some women with polyurethane-
coated implants developed an angry, red rash on the skin over
the breasts.!”
Another innovation was designed to deal with the sili-
cone leakage problem by filling the envelope with sterile saline
instead of silicone gel. The leakage would then consist not of
silicone, but saline, which is known to be harmless. The prob-
lem with saline-filled implants is that their consistency is not
as natural as gel-filled implants. To deal with the unnatural
44 m8 SCIENCE ON TRIAL
consistency, manufacturers tried using a double envelope,

yielding two compartments, one inside the other. The inner
one contained silicone gel and the outer one contained saline.
The purpose was to limit the bleeding of the silicone through
the outer envelope by enclosing it in a layer of saline. The
double-envelope implants were banned along with ordinary
silicone-gel-filled implants in 1992. The single-envelope saline
implants have another problem, in addition to their relatively
unnatural consistency. Unlike silicone-gel-filled implants, they
are not pre-filled. Instead, the surgeon places the empty sili-
cone envelopes behind the breasts, then fills them with ster-
ile saline through avalve. If the envelopes are overfilled, they
are too hard; if they are underfilled, they crumple and cause
wrinkles in the skin above them. Furthermore, saline-filled im-
plants sometimes spontaneously empty. For all these reasons,
they have not been as popular as silicone-gel-filled implants.'®
Before the FDA ban about 97 percent of women who had
implants chose ones filled with silicone gel. A little over half
were smooth textured; most of the remainder were
polyurethane coated.!* Now, of course, only saline-filled im-
plants are generally available, so by default they are being
used a great deal more. Eventually, however, their manufac-
turers will have to submit evidence of their safety to the FDA
to keep them on the market. The most recent innovation is
to fill the silicone envelope with soybean oil, which, unlike sil-
icone and saline, is translucent to mammography. Not only
would these not interfere with mammography, but it is hoped
that the soybean oil would be innocuous if released into the
tissues after rupture. They, too, will require FDA approval.”
Rumors that this or that movie star had silicone injections or

implants have circulated freely since the 1950s, when Marilyn
Monroe and Jayne Mansfield set a very tough standard for the
female form—as Dolly Parton does now. But despite the ru-
mors, celebrities have in general kept the matter private, as
have most other women. Only in the last decade or so have
women, usually in court, been willing to tell of their efforts to
enlarge and reshape their breasts. One of the first celebrities
to go directly to the public with her breast implant story was
Jenny Jones, the TV talk show host. Jones, who projects a per-
sona of sweet vulnerability, told her story to People magazine,
as well as twice on her talk show. She said she had been
through five sets of implants, each of which caused rock-like
hardening and distortion of her breasts. She had dutifully
kneaded and squeezed her breasts, as advised by her plastic
surgeon, in an attempt to soften and reshape them, despite
the fact that at least some manufacturers warned in the pack-
age inserts that this could cause rupture. Because she had the
polyurethane-coated implants (and over the years a few of her
implants had ruptured), removing them was extremely diffi-
cult. Jones’s highly public revelations came at the time David
Kessler, with much attendant publicity, was trying to decide
whether to ban implants.
Why had Jones put herself through all this? She told Peo-
ple that as a young woman she had suffered because she was
flat-chested. “I would look at sexy nightgowns and lingerie,”
she said, “and think that I could never wear them.” In 1981
she sold nearly everything she owned (she was poorer then)
to pay for breast implants. This was shortly after her divorce,
and the timing was evidently not coincidental. As she ex-
plained, “My husband seldom touched my breasts when we
were intimate. I could only assume that they were not big
enough or attractive enough for him.” She also told of sur-
veying the men on her staff “about what makes a woman sexy,
and the number one thing on almost every sheet was big
boobs—big breasts.” I am skeptical that most men would sub-
scribe to this ranking, but still, it’s generally assumed that men
prefer large breasts. Appearances are very important in the
mating game, and the mating game is very important to most
of us. Jenny Jones showed us just how desperate the whole
thing could get.”
The actress Mariel Hemingway also spoke frankly about
her experience with breast implants. She got silicone-gel-filled
breast implants when she was eighteen years old and had been
chosen to play a Playboy centerfold in the film Star 80. She said
of her decision to get implants, “I didn’t do it for the movie,
I did it for myself. I don’t like to talk about it much, but yeah,
it gave me self-esteem. It made me feel like a girl, and I had
never felt like a girl. I always felt like this tall thing.” After the
FDA ban, she was concerned enough to have her silicone im-
plants removed and replaced by saline implants, which, inci-
dentally, were smaller. A year later, now thirty-two and mar-
ried, she was ready to do without implants altogether. As she
put it, “?'m a woman now. I’m married and have two kids. I
don’t need those things.”*?
Over the three decades that silicone breast implants were
freely available, there were marked changes in the pattern of
their use. Initially, like silicone injections, they were a tool of
the trade for showgirls and aspiring actresses. For them, the
bigger the breasts, the better for business. They wanted un-
naturally large implants to please their male audiences. Or-
dinary women were both envious and appalled. They did not
immediately rush to emulate women with breast implants. But
with time, women began to see breast implants as a way to im-
prove their figures, without necessarily seeking to have “casaba
melon size” breasts. Manufacturers responded by producing
implants of various sizes and shapes, including less protuber-

ant ones, known as “low-profile” implants, and implants with
round, oval, and teardrop shapes. By 1992, about 1 percent of
American women had breast implants—with enticing names
like Misti-Gold, Méme, Natural-Y, and Replicon.
The pattern of breast implant use in Olmsted County,
Minnesota, the location of the Mayo Clinic (and a conserva-
tive, rural midwestern community), is illuminating. Breast im-
plant surgery there increased rapidly from 1964 to 1979.
Whereas in 1964 there were only 3.5 implant recipients per
100,000 population, in 1979 there were 95 per 100,000. After
that initial burst, the use stabilized. As a fraction of the total,
women who had implants for reconstruction after breast can-
cer surgery grew from 10 percent in 1964 to 30 percent in
1991, and the average age of implant recipients increased
from twenty-eight to thirty-six. Over time there was also a
much greater variability in ages, with both much younger and
much older women receiving them. Initially, only married
women in Olmsted County got implants; in 1991 about 15 per-
cent were single. Although breast implant use is substantially
greater in some other parts of the country, the pattern of use
in Olmsted County is probably fairly representative of the rest
of the country. Unfortunately, we simply do not have very
good information on the subject. A smaller survey of women
who had implants for augmentation showed an average age
of thirty-eight; just over half were married. As in other surveys,
women with breast implants were relatively well-educated and
affluent.”
After the early years, most women who had breast im-
plants no longer wanted to be conspicuous, but rather to fit
in—to feel more normal. A 1990 survey commissioned by the
American Society of Plastic and Reconstructive Surgeons
found the most common reason given was to achieve better

body proportions.** Many women claim that the devices have
greatly increased their confidence and their enjoyment of life.
Even when there are local complications, as there frequently
are, these women do not want to lose their implants. When se-
vere contractures develop or an implant ruptures, many
women simply replace the implants with new ones. To them,
the complications are simply an annoyance, and well worth the
benefits. But others feel equally strongly that breast implants
are an affront to women’s dignity, and that those who acquire
them for augmentation have been victimized. As Jones said,
“If it was perfectly safe, there is still a bigger issue. Small breasts
are not the problem. It’s how harshly we judge ourselves and
how we judge each other.” To these women, any risk, no mat-
ter how small, is too high a price to pay for a procedure that
is so self-abnegating.
Whatever the cultural meanings, most women with cos-
metic implants are pleased with them. The 1990 survey men-
tioned above found that over 90 percent were satisfied with
them and would make the same choice again. However, in a
very small survey taken in 1991, as the controversy about safety
became more intense, only 60 percent said they were satisfied
and nearly 40 percent said they had experienced complica-
tions, principally contractures, although some complained
also of decreased sensation in the breasts or nipples. Still, only
about 10 percent said they were so dissatisfied that they re-
gretted having the implants and only 6 percent planned to
have them removed.” It is hard to interpret the answers to
polls and surveys, particularly when the samples are very small.
Nevertheless, there seems to be a good deal of ambivalence
about breast implants, as evidenced by the fact that the vast
majority of women who have them do not regret their deci-
Breast Implants: What They Are and Who Has Them & 49
sion, yet about a third have registered for a class-action set-

tlement based on the premise that implants are risky. Many
women seem to be simultaneously satisfied and apprehensive.
The debate about the meaning of breast implants for
women, whether they are exploitative or enhancing, leaves
open the question of exactly what the risk is. The FDA was sup-
posedly not taking a sociologic stand, but a regulatory one.
Why did it ban silicone-gel-filled breast implants? The next
chapter addresses that question.
4,
THE FDA BAN ON IMPLANTS:
REGULATION IN
MODERN AMERICA
Caveat emptor has never been—and never will

be—the philosophy at the FDA.
—David Kessler, Chairman of the FDA,
June 18, 1992
n November 1990, when President George Bush appointed

David Kessler as commissioner of the FDA, the Republican
president, presumably no proponent of government regula-
tion, was choosing someone utterly committed to the spirit
as well as the letter of the law of regulating drugs and devices.
Bush was also choosing someone with apparently superhu-
man energy. Kessler, an intense, wiry man in his forties, with
thick glasses and a trim carrot-colored beard and mustache,
has a medical degree from Harvard and a law degree from
the University of Chicago, obtained nearly simultaneously
while he commuted between Boston and Chicago. He then
trained in pediatrics at Johns Hopkins Medical School, while
serving as a consultant to Senator Orrin Hatch (R-Utah).
(His commute was then down to the distance between Balti-
more and Washington.) Later Kessler became medical direc-
The FDA Ban on Implants #@ 51
tor of the Albert Einstein Hospital in New York City, but here
again one full-time job was not enough. He also taught food
and drug law at Columbia Law School, and obtained an ad-
vanced professional certificate from New York University’s
Graduate School of Business Administration. Upon being
appointed commissioner of the FDA, he threw himself into
the job with his customary drive and with a zeal not seen in
earlier commissioners. '
When Kessler arrived in Washington, breast implants had
been on the market for nearly 30 years, but they had been
under the purview of the FDA only since 1976. That year the
Medical Device Amendment to the Food, Drug, and Cosmetic
Act extended the FDA’s authority to cover devices, as well as
food, drugs, and cosmetics. Under this amendment, manu-
facturers of new devices could, at the discretion of the FDA,
be required to submit an application for premarketing ap-
proval. The applications were to include data on safety and ef-
fectiveness from animal and human studies. Until FDA ap-
proval was obtained, new devices that required premarketing
approval could not be sold. Since breast implants were al-
ready on the market, they were “grandfathered” (exempted
because they predated the amendment), at least for the time
being. Presumably, given their long track record, they were
reasonably safe. Nevertheless, in 1982 the FDA proposed re-
quiring “premarketing approval,” which meant the manufac-
turers would have to supply evidence of the safety of implants.”
The FDA did nothing more about breast implants until
1988, when it finalized the 1982 proposal. This action came
in the wake of the first few anecdotal reports in medical jour-
nals of cases of connective tissue disease in women who had
undergone breast augmentation. The earliest reports em-
anated from Japan and concerned directly injected paraffin
or silicone, not implants.*? In 1982, however, an Australian

physician reported connective tissue disease in three women
who had silicone-gel-filled implants.* The FDA’s action was un-
doubtedly also influenced by successful lawsuits in the United
States that followed the 1982 report. The first of these, the
1984 case of Maria Stern, resulted in a jury award of nearly
$2 million.2 When the FDA in 1988 asked for evidence of
safety and effectiveness, the manufacturers were by law given
at least 30 months to gather the data. Despite the extended
time, producing the evidence was a daunting task and one the
manufacturers no doubt resented, since they had enjoyed
being grandfathered for so many years.
Events then began to move rapidly, driven largely by a
small number of people who happened to be in the right
place at the right time. One was Dan Bolton, a young plain-
tiffs’ attorney in San Francisco, whose firm handled the case
of Maria Stern. In preparing for the trial, Bolton, then fresh
out of Hastings Law School, was sent by his firm (Hersh and
Hersh) to the Dow Corning plant in Midland, Michigan, to see
what he could learn (a legal process called “discovery”). There
he found a number of internal documents that, according to
Bolton, indicated the implants were known by the company
to be unsafe. After the verdict in the Stern case, a settlement
was reached that included “sealing” the documents—that is,
forbidding them to be made public. Much was later made of
these “secret documents,” and I will come back to them.® An-
other influential player was Dr. Norman Anderson, associate
professor of medicine and surgery at Johns Hopkins Medical
School. Anderson was the chairman of a 1988 FDA advisory
panel that was convened to consider what safety data the man-
ufacturers would be required to supply. He apparently be-
came convinced early on that the implants were dangerous,
The FDA Ban on Implants #® 53
perhaps partly influenced by Bolton, who testified before the

1988 panel.’ As the controversy heated up, Anderson seemed
to turn up everywhere.
Ralph Nader’s consumer group, Public Citizen, also be-
came involved early. The director of its Health Research
Group, Dr. Sidney Wolfe, in 1988 petitioned former FDA com-
missioner Frank Young (who preceded Kessler in the position)
to ban breast implants and scolded him in aletter for taking
so long to demand assurances of safety: “You must explain why
six and one-half years elapsed before finalizing the FDA’s Jan-
uary 19, 1982, proposal to require Dow and other companies
making silicone gel breast implants to submit safety data. Your
agency negligently did not finalize this regulation until June
of this year.”* Bolton, Anderson, and Wolfe often reinforced
one another’s efforts. Bolton, for example, began to assist
other plaintiffs’ attorneys through Public Citizen’s breast im-
plant clearinghouse.’ Another influential player was Sybil
Goldrich, co-founder of an advocacy group called Command
Trust Network, devoted largely to referring women with im-
plants to plaintiffs’ attorneys. Goldrich is herself a survivor of
breast cancer who received breast implants for reconstruc-
tion. She has been indefatigable in her campaign against im-
plants, and her organization is well connected with a number
of highly successful plaintiffs’ attorneys specializing in breast
implant cases.'°
Perhaps the most important event to bring the growing
unease about breast implants to the attention of the public was
Connie Chung’s sensational treatment of the matter in 1990.
On her TV show, Face to Face with Connie Chung, she conveyed
the clear message that implants were dangerous devices foisted
off on unsuspecting women. Introducing the segment with,
“Coming up, some shocking information about breast im-
plants,” Chung interviewed women who claimed they had au-

toimmune disease caused by breast implants. Without ques-
tioning the presumed link between the disease and the im-
plants, Chung implicitly blamed the FDA for permitting such
risky products to be sold.'! At about the same time, the late
congressman Ted Weiss (D-N.Y.), chair of the Human Re-
sources Subcommittee (which oversees the FDA), held hear-
ings on the subject. In his testimony before the Weiss sub-
committee, Anderson said, “Despite estimates that 2 million
women bear these devices, we cannot even quantitate the
short-term risks for these consumers.” Less restrained was Sybil
Goldrich, who testified, “I’ve gone seven years without a re-
currence of cancer but what will happen from the silicone? I
shudder when I think about it.”!? Consumers were well mobi-
lized. What remained was for David Kessler to act.
When Kessler took over the FDA in 1991, the manufac-
turers had not yet responded to the FDA’s 1988 order to pre-
sent data on safety and effectiveness. On April 10, 1991, Kessler
notified the manufacturers that there was to be no more delay.
They had 90 days to file their premarketing applications.' Al-
most immediately, Bristol-Myers Squibb’s Surgitek Corpora-
tion, manufacturer of the polyurethane-coated implants, with-
drew them from the market, ostensibly because the foam
degraded into toluene diamine, known to be a carcinogen in
animals.'* When the deadline arrived, only four of the major
manufacturers—Mentor Corporation, McGhan Medical Cor-
poration, Dow Corning Corporation, and Bioplasty, Inc.—
even bothered to complete premarketing applications, and
these were clearly inadequate. The FDA asked for more and
better data.'* In November 1991, it convened another advisory
panel, this time chaired by Dr. Elizabeth Connell, professor
of gynecology and obstetrics at Emory University Medical
The FDA Ban on Implants # 55
School, although Norman Anderson was again a member.

The public meeting featured heated testimony and attracted
considerable publicity. Such venerable mainstream groups as
the AMA and the American Cancer Society, as well as, not sur-
prisingly, the American Society of Plastic and Reconstructive
Surgeons, favored leaving the implants on the market. But
they were up against determined consumer and advocacy
groups and, most important, a series of women who recounted
poignant stories of the suffering they had endured as a result
of their implants. The panel concluded that the manufactur-
ers had failed to provide reasonable assurances of the safety
and effectiveness of silicone-gel implants. Calling the lack of
data “appalling,” they suggested that the manufacturers gather
more and better evidence over the next year or two. Despite
the dereliction of the manufacturers, however, the panel
unanimously recommended that the devices be permitted to
remain on the market. In the panel’s view, they clearly filled
a consumer need and there was no reason to believe they
were unsafe. Kessler said he would make his decision over the
next month or two, but it was expected that he would follow
his panel’s recommendation and leave the implants on the
market.’®
Just a month later, on December 13, 1991, a federal jury
in San Francisco awarded what was then the largest verdict
ever in a breast implant case—$7.34 million.!’ The plaintiff,
Mariann Hopkins, claimed her implants had caused her to de-
velop a rare disorder—mixed connective tissue disease. She
was represented by none other than Dan Bolton, whom she
had decided to retain after seeing him on television.'* In the
trial, Bolton made much of the secret documents he had
found at the Dow Corning plant nine years earlier, while
preparing for the Stern case.'? After the walloping verdict in
the Hopkins case, which I will describe in more detail later,

Anderson and Bolton both urgently pressed Kessler to ban the
implants, at least until the FDA could review the secret docu-
ments.”’ Kessler responded by demanding the documents and
sending FDA investigators to Dow Corning to search their
records. In January 1992, instead of making a final decision,
Kessler called for a temporary moratorium on breast implants
while he considered the matter further. He explained that he
had come into possession of new information that compelled
him to take another look. “We cannot assure the safety of this
product,” said Kessler, and he reconvened his advisory panel
to consider the new evidence. In the meantime, in response
to FDA pressure, Dow Corning released 800 pages of the no-
torious documents on February 10, 1992.?!
When the advisory panel met again, on February 18, 1992,
again in open session, the publicity was even more intense
than it had been in November. Anderson had been stripped
of his vote, an action the FDA said was “necessitated by state-
ments in the mass media which led to an appearance of his
inability to render objective advice.” Still, he was permitted to
stay on the panel as a nonvoting member, and the FDA openly
acknowledged that he had been instrumental in getting them
to take another look at the manufacturers’ activities. (Later
Anderson claimed that Kessler was “moving forward to leave
silicone breast implants on the market,” and had reversed
himself only when Anderson presented him with Dow Corn-
ing’s secret documents.”*)
In the end, after a good deal of impassioned testimony,
the panel recommended that silicone-gel-filled breast im-
plants be removed from the market, except under stringently
limited conditions. They could be used only as a part of can-
cer treatment for women who agree to participate in research
The FDA Ban on Implants ® 57
studies and, possibly in the future, in research studies of a very

small number of healthy women receiving implants for breast
augmentation. Kessler accepted this recommendation, and
on April 16, 1992, announced the virtual ban of silicone-gel-
filled breast implants.”* (It was after the panel’s February meet-
ing and before Kessler’s final action that Jenny Jones told her
story on television. One of her guests was Norman Anderson,
who at the close of the show said of her crusade against breast
implants, “Jenny, you’ve started a national leadership whether
you like it or not.” Anderson himself was no bit player.)
WHILE THE NOOSE TIGHTENED, breast implant manufacturers

fought a rear-guard action, with one eye on their markets and
the other on their regulatory and legal problems. Thus, they
were in the odd position of arguing simultaneously that breast
implants were not associated with connective tissue diseases,
but, even if they were, the manufacturers had duly warned
their customers. After the success of the first lawsuit alleging
such a connection (the 1984 Stern case), Dow Corning had
acknowledged in its package inserts “reports of suspected im-
munological responses to silicone mammary implants,” but
added, “A review of the published experimental findings and
clinical experience shows that convincing evidence does not
exist to support a causal relationship between exposure to sil-
icone materials and the acquisition or exacerbation ofa vari-
ety of rheumatic and connective tissue disorders.”** The com-
pany was right about the lack of evidence that the implants
were dangerous. But there was also little evidence that they
were safe, because the manufacturers had not fulfilled their
responsibility to look for it.
As for the much ballyhooed “secret documents,” they
turned out to be a mix of things: an assortment of internal
memos and minutes of meetings of Dow Corning employees;

records of animal testing dating back to the 1960s; calculations
of leakage rates and other physical properties of the implants;
complaints from plastic surgeons, mainly concerning leakage
or rupture; and accounts of ruptured implants returned to the
company. The animal studies were fairly extensive, but mostly
involved the direct injection of various forms of silicone into
different parts of the animals’ bodies. Some of these suggested
that silicone could be carried from one part of the body to an-
other. Only a few studies simulated the use of implants in
women by placing similar devices in animals. One of these, a
study of four dogs, received a great deal of attention because
the documents showed there was chronic inflammation
around the implants. Was this evidence of an immune reac-
tion, as many critics assert, or was it merely a local, nonspecific
response, as Dow Corning maintains? The documents also re-
ferred to rats developing sarcomas in response to injected sil-
icone, but Dow Corning’s accompanying explanatory mater-
ial pointed out that sarcomas are common in rats in response
to nearly any irritant. In contrast, this type of tumor is rare in
humans and almost never occurs in human breast tissue. The
significance of all this was, and still is, unclear, since the ex-
periments had little in common with the ordinary use of breast
implants in women.
Perhaps the most incriminating of the “secret documents”
were the memos and minutes of meetings of a Mammary Task
Force formed in 1975 to develop a new, softer gel to give the
implants a more natural consistency. Headed by Arthur Rath-
jen, this task force was clearly under great pressure to bring a
new product to market by an established deadline (Rathjen’s
minutes of meetings usually included the number of weeks,
days, hours, and minutes left). There was concern in the task
The FDA Ban on Implants @& 59
force that the new, softer gel might tend to leak through the
envelope more than the firmer gel. As it turned out, the data
showed the leakage to be somewhat less, but there was reason
for the concern. The Dow Corning salespeople were finding
that plastic surgeons to whom they showed the new implants
complained that there was an oily coating on the surface of
the envelope. In response, a member of the task force wrote
the following memo to the salespeople:
It has been observed that the new mammaries

with responsive gel have a tendency to appear oily
after being manipulated. This could prove to be a
problem with your daily detailing activity where mam-
mary manipulation is a must. Keep in mind that this
is not a product problem; our technical people assure
us that the doctor in the O. R. will not see any ap-
preciable oiling on product removed from the pack-
age. The oily phenomenon seems to appear the day
following manipulation. You should make plans to
change demonstration samples often. Also, be sure
samples are clean and dry before customer detail-
ing. Two easy ways to clean demonstration samples
while traveling, 1) wash with soap and water in near-
est washroom, dry with hand towels, 2) carry a small
bottle of IPA and rag. I have used both methods and
the first is my choice. I will be interested to hear if any
of you are seeing the oiling.
This obviously duplicitous memo would come back to

haunt Dow Corning again and again. It showed unequivocally
that Dow Corning was willing to hide evidence that silicone
fluid leaked through the envelope.
60 ® SCIENCE ON TRIAL
The “secret documents” also showed that key employees

were well aware of how little Dow Corning knew about their
implants, and they anticipated the sorts of questions they
would need to address. Rathjen wrote in 1976, “We better get
going on a basic long-range project relative to gel, its formu-
lation, toxicology, etc., over and above what is now under-
way.” And more excitedly, “Is there something in the implant
that migrates out or off the mammary prosthesis? Yes or no!
Does it continue for the life of the implant, or is it limited or
controlled for a period of time? Does it come from the gel, or
envelope, or both? What is it?”
But the secret documents, revealing as they were, did not
yield a smoking gun. They did not show a clear risk that the
company had suppressed. Whether leakage, inflammation,
capsule formation, or rupture could be dangerous to women
was simply not systematically studied. What the documents
did indicate was how little was known, how inadequate the
studies had been, and how relentlessly the company pursued
its market goals.” Adding to Dow Corning’s problems was the
discovery in 1992 that employees falsified some of the data
about the manufacturing process, a charge that Dow Corning
admitted. Evidently, some of the employees doctored the the
automatic recordings of failures in the heat-curing process for
the implants. According to Dow Corning, they did it to avoid
the review they would undergo if the failures were faithfully
recorded.”
Dow Corning pulled out of the implant market the month
before Kessler’s final decision.” Only two American manu-
facturers remained in the implant business—Mentor Corpo-
ration and McGhan(now Inamed). Mentor was granted ap-
proval to begin clinical studies of silicone implants used for
reconstruction.”* McGhan’s saline implants were left on the
The FDA Ban on Implants @® 61
market, as were Mentor’s, but in 1993 the FDA announced

that saline implants, too, would be subject retroactively to a
premarketing application,”’ as would testicular prostheses.”
(The fate of the latter will surely test the view that women are
treated differently than men by the FDA.)
KESSLER IS KNOWN to be a man of strong opinions, and this,

along with his combative style, perhaps belied the extent to
which he was pressured by a variety of forces, most notably by
aggrieved breast implant recipients and various advocacy
groups. In view of the paucity of evidence of risk, Kessler knew
that the scientific community would be critical of a ban on im-
plants. Perhaps for this reason, he undertook to defend the
ban vigorously, most clearly in a 1992 article in the New Eng-
land Journal of Medicine. In it he acknowledged that his deci-
sion “was one of the most controversial decisions ever made
by the agency,” given the lack of evidence about safety and the
intense feelings on both sides. But, he said, “the burden of
proof rests squarely with the manufacturer.” According to the
law, Kessler said, the FDA did not have to show that breast im-
plants were unsafe; the manufacturers had to show they were
safe. As for a woman’s choice, Kessler said, “It has become fash-
ionable in some quarters to argue that women ought to be able
to make such decisions on their own. If members of our soci-
ety were empowered to make their own decisions about the
entire range of products for which the FDA has responsibil-
ity, however, then the whole rationale for the agency would
cease to exist.” And more grandly, in that pre-Gingrich era,
“Caveat emptor has never been—and never will be—the phi-
losophy at the FDA.”*!
I had doubts that the matter was as clear-cut as Kessler im-
plied. In an editorial in the same issue of the New England Jour-
nal of Medicine, I pointed out that all drugs and devices carry
risks of side effects, sometimes quite serious ones. The FDA
had never demanded that.a drug or device be risk-free, only
that the risks be commensurate with the benefits. The greater
the potential benefits, the greater the acceptable risks. The job
of the FDA, I pointed out, is to gather information on both
benefits and risks, and balance them. If the balance is rea-
sonable (a necessarily imprecise judgment), then the drug or
device should be approved.*” But in the case of breast im-
plants, there were special problems. First, as Kessler empha-
sized, we didn’t know enough about possible risks. He was
careful to say that this didn’t mean that implants were dan-
gerous, only that we did not have sufficient information to
know one way or the other. Our ignorance was not total, of
course. We had, after all, 30 years of experience with breast
implants in 1 million to 2 million women, and this was why
breast implants had been grandfathered in the first place. We
knew that the great majority of women with implants were sat-
isfied with them. As already noted, we also knew that in about
5 percent of women, implants ruptured and had to be re-
placed, and that there was hardening of the breasts in many
more women (although not necessarily enough to make them
dissatisfied). We knew from several research studies that ear-
lier concerns that implants might cause cancer were probably
unfounded. And finally we knew that there were anecdotes
that breast implants caused connective tissue disease, but the
question had not been properly studied. Thirty years’ experi-
ence, however, argued that if there were such a connection,
it was certainly not common. What we had, then, was a pretty
good feeling for an upper bound on the frequency and seri-
ousness of risks.**
Benefits were even more difficult to assess than risks, be-
cause they are entirely subjective and unique to each woman.

Most women would probably not choose implants, no matter
how low the risks, either for augmentation or for reconstruc-
tion after cancer surgery. But for many women who had cho-
sen to have implants, the matter was different. For whatever
reason, they expected substantial benefit or they would not
have been willing to endure an unpleasant and often expen-
sive procedure. One woman testifying before the Weiss sub-
committee said, “Having my body restored eased away much
of the trauma of breast cancer.”** Many women who had im-
plants for augmentation felt no less strongly. One woman told
Redbook magazine, “I’m thrilled that I did it. I used to feel
bottom-heavy, although I wasn’t overweight. Now I’m in pro-
portion for the first time ever.”*”
But Kessler seemed to be saying that the benefits were triv-
ial, at least when implants were used for cosmetic purposes,
and that therefore the FDA would tolerate almost no risks. He
was willing to cut a little slack for women who chose implants
after cancer surgery, but only if they agreed to the inconve-
nience and lack of privacy entailed in being a part of a research
study. But as for augmentation, Kessler said, “It makes little
sense for the FDA to consider breast augmentation of equiv-
alent importance with an accepted component of cancer ther-
apy (This last, of course, was a stretch, in that the implants
are not, strictly speaking, a part of the therapy. A mastectomy
can be performed without reconstruction, and usually is.) In
waving aside the benefits of breast implants for most women
who had them, Kessler appeared to be introducing an im-
possibly high standard for the devices: since there were no
benefits, there should be no risks.
At the time of the ban, the political context in which the
FDA’s action occurred was shifting markedly. The role of reg-
ulation in American life has grown increasingly contentious

over the last decade or so, particularly since the Republican
sweep of Congress in 1994. Not surprisingly, the FDA and, par-
ticularly, David Kessler have been special targets of Newt Gin-
grich’s troops. Some of the new breed take the libertarian po-
sition that people should be free to choose their own drugs
and devices; those that work will stay on the market, those that
don’t won’t (perhaps by killing off their customers). Accord-
ing to this swashbuckling view, the FDA deprives people of
choice and interferes with the wonders of a free market.*’
There can’t be many knowledgeable people who subscribe to
such silliness, but still, there is a real issue here. When should
individuals in a free society have the right to make choices,
even dangerous ones, and when should the government pro-
tect them?
Regulatory agencies such as the FDA were established in
large part to deal with the inevitable gap in information be-
tween consumers and those promoting the product being reg-
ulated. Congress passed the Food, Drug, and Cosmetic Act in
1938, in the midst of the New Deal, to monitor the safety of
food and drugs. How many Americans would be capable of
deciding for themselves whether a new antibiotic actually
works and what its side effects will be? How many could de-
termine the likely performance of a new artificial heart valve?
And how many would be willing to take the risk of being
wrong? The medical “market” regulated by the FDA is very dif
ferent from, say, a market in tennis shoes or television sets, in
which choices can be made pretty easily and, in any case, the
human cost of a mistake is small. Kessler is right: caveat emp-
tor should not be the watchword of the FDA. But in the case
of breast implants, as Kessler admitted, the FDA didn’t know
much more than the consumers. No one, in fact, could do
more than make seat-of-the-pants judgments based on the

same 30 years’ practical, clinical experience—an experience
that suggested the risks were small. To be sure, the implant
manufacturers had been derelict in failing to assemble the ev-
idence required of them. However, the FDA action was os-
tensibly taken not to punish them, but for the avowed purpose
of protecting consumers. If the information gap between con-
sumers and the FDA had been great and the risks large, the
action would have been easily justifiable, but neither of these
conditions obtained. It was therefore a matter of the FDA’s
judgment as to whether the risks (both known and unknown)
were worth taking versus the judgment of women who might
want implants. The tension was clearly between protection
and choice.
Adding to this tension was the disparity between the
FDA’s attitude toward breast implants and the enormous
range of risks that Americans are free to take quite regularly—
cigarette smoking, drinking, mountain climbing, motorcycle
racing, and worse. What sense does it make for a woman to be
able to smoke two packs of cigarettes a day, but not be able to
obtain breast implants? Kessler could counter—and probably
would—that these other risks are not his business. His busi-
ness is to regulate drugs and devices, and that is what he is
doing. (He has taken steps to bring cigarettes under FDA
purview, but the effort, while supported by President Clinton,
is being hard fought by the cigarette manufacturers and mem-
bers of Congress from tobacco-producing states.**) Neverthe-
less, the FDA does not exist in a vacuum, and for society as a
whole, the haphazard nature of regulation is odd. Further-
more, attempting to eliminate risks nearly always introduces
other risks, which may or may not be anticipated. If, for ex-
ample, inspecting meat lessens the incidence of food poison-
66 @® SCIENCE ON TRIAL
ing, it also increases the price of meat. The increased cost of

food for a poor family might very well reduce the family’s abil-
ity to pay for medical care or housing—perhaps with more dire
health consequences than occasional cases of food poisoning.
More to the point, it is possible that some women may delay
getting breast cancer diagnosed and treated if they cannot ob-
tain implants for reconstruction outside a research study. Such
trade-offs are rarely explicitly considered in developing regu-
lations, yet they may be substantial. Indeed, if the risks being
regulated are fairly small, the hazards of regulating them may
well be higher.
Women activists seemed to be sharply divided about the
breast implant ban. Some women were angry that they had
been deprived of the option of having silicone breast implants.
In an argument reminiscent of the abortion controversy, they
claimed the issue was whether they had the right to make
their own choice. They objected to the government treating
them like little girls. On the March 30, 1992, Jenny Jones show,
one woman, saying she had informed herself thoroughly be-
fore getting her implants, said she now worried that she would
not be able to replace them if they ruptured. She went on to
say, “It’s not for everybody, but leave us that choice. This is our
choice.” Jones herself, no fan of implants, agreed that women
should have the ultimate choice.*®
In contrast, other women were convinced that breast aug-
mentation was something that had been thrust on them by a
male-dominated society obsessed with impossible notions of
women’s beauty. According to this view, women do not choose
breast implants, any more than African women choose cli-
toridectomy or Chinese women once chose to bind their feet.
They are coerced. Naomi Wolf took this argument further. In
her view, part of the reason for the coercion is precisely be-
The FDA Ban on Implants #®& 67
cause the procedure maims women. Said Wolf, “It is not co-
incidental that breast surgery is expanding at a time when fe-
male sexuality is such a threat.”“” Women who take some vari-
ant of this view are naturally disposed to accept the theory that
breast implants are dangerous.
I have no tally of how many women are on each side, but
I suspect the great majority who have opinions on the issue be- .
lieve that breast implants are risky, that there is solid evidence
to this effect (some of which the manufacturers have with-
held), and that, if anything, Kessler was too slow in moving to
protect women. Some are sure he would have moved much
faster if men’s health had been at risk.
In 1995 the Republican-dominated Congress initiated ef-
forts to weaken the power of government regulation. It began
by passing legislation that would require federal regulators to
compare the costs of regulations with their benefits. On the
surface, this is a reasonable reform. The problem is that it can
become a cover for a general rollback of the philosophy that
underlies regulation—namely, that citizens need to be pro-
tected from the excesses of an unbridled market. According
to the Republicans, the federal regulatory apparatus has grown
bloated and hinders legitimate private enterprise. It needs to
be curbed for the sake of common sense and efficient gov-
ernment. What they are less likely to emphasize is the fact that
undermining government regulation, particularly standards
to protect the environment, is enormously appealing to big
business. The Democrats, in their typical mode these days, re-
sponded by agreeing that regulatory reform is a good idea,
but not too much of it. They maintain that the Republican
proposals will add to red tape, instead of cutting it, because
they will merely add roadblocks to the current regulations. In
the midst of this debate, Kessler is likely to emerge as an in-
68 #@ SCIENCE ON TRIAL
creasingly popular target.*’ His strongly activist approach and

the public nature of his stands on a variety of issues, includ-
ing breast implants and cigarettes, make him a well-recognized
symbol of government regulation. In addition, FDA rules are
major obstacles to many segments of the powerful drug, de-
vice, and biotechnology industry. Although Kessler was ap-
pointed by a Republican president, he is now championed
largely by Democrats, who find him much more congenial to
their philosophy. It is unclear, however, whether Democratic
support will be enough to protect him from the politics of reg-
ulation. If he leaves the FDA, it will almost certainly signal a
much weakened agency.
Before banning breast implants, Kessler agonized about
the decision publicly and, no doubt, privately. He could fore-
see many of the criticisms of a ban, and he was aware of the
scientific shakiness of his action. What he almost certainly
could not foresee, however, because of its extraordinary
sweep, was the frenzy of litigation touched off by the ban.
4
THE RUSH TO COURT:
LITIGATION AND MORE
LITIGATION
Get your lawyers who can help you help your-

selves. That’s what it’s all about.
—Denise Dunleavey, plaintiffs’ attorney,
on “Jenny Jones,”
March 30, 1992
he FDA ban was followed bya tidal wave of litigation. In

|pee next two years, more than 16,000 lawsuits, brought
by over a thousand lawyers, on behalf of women with breast
implants were filed in federal and state courts.’ Dow Corning
alone saw a surge in lawsuits from about 200 at the end of 1991
to 10,000 by the end of 1992.7 As Jack Weinstein, the senior
federal judge for the Eastern District of New York who
presided over the Agent Orange class action, observed, “The
speed with which the number of breast implant cases ex-
ploded on the scene is attributable in part to a well-organized
plaintiffs’ bar, which now has the capital, organizational skills,
and advertising techniques to seek clientele.”’ A small display
advertisement in the July 26, 1994, Washington Post exempli-
fied the spirit: “The law firm of Chandler, Franklin, and
O’Brien is pleased to announce the opening of our new Fair-
fax office devoted exclusively to representing women in breast

implant litigation,” followed by the toll-free number, 1-800-
488-4LAW. For those who preferred, Kresch & Kresch could
be reached at 1-800-LAW-HELP, or a Florida attorney at 1-800-
RUPTURE.' According to Barie Carmichael, corporate vice-
president of Dow Corning, computer networking among
plaintiffs’ attorneys made it possible to generate lawsuits with
unprecedented speed. Interested lawyers could easily learn
the status of relevant lawsuits throughout the country and
modify the wording of promising ones for their own use. By
the time of the class settlement, Dow Corning claimed to be
the target of 30,000 lawsuits, many of which were evidently
clones, since they contained the same typographical errors.°
Even as all but two of the manufacturers went out of the im-
plant business, the number of lawyers belonging to Public
Citizen’s breast implant clearinghouse increased from 4 in
1990 to 179 in 1992,° and the Breast Implant Committee of
the Association of Trial Lawyers of America (an organization
of plaintiffs’ attorneys) grew from 20 to 160 in just the six
months leading up to the ban.’
The flood of breast implant lawsuits was simply one more
manifestation of Americans’ fervor for suing one another (or
threatening to). As Harvard law professor Mary Ann Glendon
said in her book, A Nation under Lawyers, “While some lawyers
were touting litigation as a quick fix for social ills, others were
teaching that for nearly every injury suffered by a private in-
dividual there is someone with deep pockets, the government
or a large corporation, who can be sued and made to pay.”®
The sheer size of the court system buttresses her point. At the
end of the 1980s, about 18 million civil lawsuits were filed an-
nually in state and federal courts’—one lawsuit for every ten
adults in the United States. Nearly 2 million of these were tort
The Rush to Court: Litigation and More Litigation @® 71
cases'’—that is, they involved seeking monetary damages for

product liability, medical malpractice, or other personal in-
jury. Although the rate of increase in tort cases has been mod-
est over the last decade or so,!! that does not tell the whole
story. About three-quarters of tort claims are settled before a
lawsuit is filed, and there is evidence that the number of these
settlements is rising rapidly. Even those that are filed are usu-
ally settled before trial; only about 3 percent of personal in-
jury claims ever come before a jury.'* Nevertheless, there are
changes in the pattern of tort cases that justify concerns about
a litigation explosion. First, mass personal injury litigation—
thousands of lawsuits involving the same product or injury,
such as the breast implant litigation—has burgeoned, partic-
ularly since 1980.'° And second, the size of jury awards has
grown rapidly. In particular, punitive damages against manu-
facturers, while still rare, have grown enormously.'* Thus, de-
spite the fact that the absolute number of lawsuits has not in-
creased dramatically, the total costs of the tort system
increased from $46.6 billion to $132.2 billion in the decade
1980 to 1990 (accounting for about 2.3 percent of the gross
domestic product at.the end of the decade).' Solid data, how-
ever, are hard to come by, and these figures must be taken as
only approximate. The direction, however, is clear.
The number of lawyers has also increased. Whereas there
were 542,205 lawyers in the United States in 1980, at the end
of the decade there were 805,872. We now have about 900,000
lawyers in the country.'° Only a minority are trial lawyers, al-
though no one seems to know for sure what that percentage
is and how fast it is growing. One way to look at the increas-
ing numbers of lawyers is that they are merely keeping pace
with the demand. Butit is also plausible that lawyers to a great
extent create their demand. Certainly, like doctors, they have
a good deal of latitude to generate their own business. If a

lawyer says you need him or her, it’s difficult to argue, just as
it may be risky to argue with your doctor. In any case, lawyers
no longer simply wait for clients. Instead, they actively seek
them out. Soliciting clients was once universally condemned
by the bar, but it is now fairly standard practice. Lawyers even
appeal for clients on television. In one series of ads, for ex-
ample, a Massachusetts medical malpractice lawyer, looking
lugubriously at the camera, urges sympathetically, “Don’t go
it alone. Let us help you get the help you need.” Advertise-
ments also appear in newspapers and magazines, often with
800 numbers containing the letters LAW.
Glendon believes that excessive litigation is an unforeseen
fallout of the 1960s. In that decade, according to her thesis,
we began to turn to the courts to rectify nearly all social ills
and injustices. This has become an expensive habit, she ar-
gues, which is accompanied by atrophy of the more tradi-
tional, but slower methods of effecting change—including
the political process. People sue one another, instead of vot-
ing. As lawsuits have proliferated since the 1960s, the charac-
ter of the legal profession has itself changed. No longer does
it emphasize negotiation and conciliation, or measure suc-
cess by whether litigation can be avoided. Now it emphasizes
rights and combat, and success is measured by how big you win
in court. Even within the staid academic community, the legal
hero is no longer the corporate lawyer, but the trial lawyer, and
winning a weak case is even more celebrated than winning a
strong one. Harvard is proud of Alan Dershowitz.
Whatever the strength of Glendon’s thesis, there are also
more prosaic reasons for Americans to turn to the law when
they are ill or hurt. As the advanced nation most committed
to an unbridled free market, this country can be a harsh place.
The Rush to Court: Litigation and More Litigation ™& 73
Big business is powerful and often ruthless, and the safety net
for those who suffer harms of whatever kind is notoriously
threadbare. In particularly, medical care is expensive and by
no means assured for everyone who needs it. Thus, people
who are injured or sick have every interest in blaming the
problem on someone else and trying to coilect damages. A suc-
cessful lawsuit may be the only way to provide for medical ex-
penses and lost income (often called “economic” damages).
Sometimes there are also damages for emotional harm, and
these may be at least as large as the economic damages. Finally,
punitive damages are awarded in some cases. Although puni-
tive damages are rare, they receive a great deal more public-
ity than their frequency warrants, because they may be huge.
For example, in one breast implant case, the plaintiff was
awarded $5 million in economic and emotional damages, and
$20 million in punitive damages.'’ The size of punitive dam-
ages reflects their purpose; they are designed to punish or
deter the defendant. They are therefore based on the defen-
dant’s wealth and must be big enough to be felt. In one breast
implant case, the jury was instructed that the net worth of the
defendant, Dow Corning, was over $948 million, a figure the
jury was to keep in mind when deciding on punitive dam-
ages.'8 Although the great majority of product liability cases
are settled out of court, there are enough multimillion-dollar
jury verdicts to remind manufacturers that settling is usually
better. Losing just one case can generate multiple similar cases
and set the minimum going rate for compensation. The threat
of punitive damages is an added wild card.
American law has a number of unusual, even unique, fea-
tures that contribute to the large and growing number of law-
suits. First, we alone use the contingency fee as the customary
method of payment of plaintiffs’ attorneys in personal injury
cases. By this method the attorney is paid a percentage of the

plaintiff's award. If the plaintiff loses, the attorney may get
nothing. But if the plaintiff wins, the usual contingency fee is
a third of the award, plus expenses.'? Other countries do not
use contingency fees, and Great Britain does not permit
them.” In this country, it is argued, they are necessary because
many plaintiffs could not afford to sue without this arrange-
ment, given the high fees of lawyers. The problem is that the
contingency-fee system makes a lottery of the process and en-
tices plaintiffs and lawyers to play the game. It provides an in-
centive for lawyers to sue frequently, with scant consideration
of the merits of the case. Even though they expect to lose
most cases, every now and then they will win a large verdict that
can subsidize the losses. The high costs of defending against
multiple lawsuits generated by the contingency system are in-
centives for defendants to settle even weak cases out of court.
On the other hand, plaintiffs’ attorneys may be quick to set-
tle even strong cases, rather than go through the rigors of a
trial. In either case, justice is not well served.
Another unusual feature of the American tort system is
the use of juries.”’ Most other countries reserve juries for crim-
inal cases, but we also permit jury trials for tort cases, as well
as other civil cases in which monetary damages are sought. The
presence of juries increases the lottery aspects of the tort sys-
tem. Skillful plaintiffs’ attorneys may select only the most ap-
pealing clients, and focus their efforts primarily on mobiliz-
ing the sympathy of the jury. Sometimes, they draw on
consultants in jury selection to choose a jury most likely to be
sympathetic to a particular client. (Defense attorneys, for
their part, try to select unsympathetic jurors.) The resultant
verdict may have little to do with the merits of the case, and
everything to do with theater. If things go well, a sympathetic
The Rush to Court: Litigation and More Litigation @ 75
jury may award large damages for emotional distress, as well

as economic damages. The outcome is a gamble for high
stakes. An attorney may have to file a lot of lawsuits to ensure
a big win from time to time. The capriciousness of this sys-
tem—the disconnection between the merits of the case and
the verdict—ought to be sobering to those who care about jus-
tice, but it certainly is good business for the plaintiffs’ bar.
A RELATIVELY NEW and controversial movement in tort law is

the use of class actions and multidistrict consolidations to deal
with multiple lawsuits involving the same kind of product or
injury or the same defendants. Such mass tort litigation is be-
coming increasingly common, in part because large numbers
of people are more likely to be exposed to the same injurious
agent or event. According to a report by the Institute for Civil
Justice, a research arm of RAND, “The 1980’s marked the era
of mass personal injury litigation. Hundreds of thousands of
people sued scores of corporations for losses due to injuries
or diseases that they attributed to catastrophic events, phar-
maceutical products, medical devices, or toxic substances.””
The era was presaged in 1973, when the first successful prod-
uct liability litigation against asbestos manufacturers was de-
cided. Ultimately, well over 200,000 lawsuits were filed against
multiple manufacturers of asbestos. Other mass tort litigation
soon followed. Beginning in the 1970s and continuing into the
1990s, over a thousand lawsuits were filed against Eli Lilly, Ab-
bott Laboratories, and other drug companies on behalf of
women who developed vaginal carcinoma because their moth-
ers took the drug diethylstilbestrol (DES) to prevent miscar-
riage.” Starting about the same time and continuing into the
mid-1980s, 1,800 lawsuits were initiated against Merrell Dow
Pharmaceuticals claiming that the drug Bendectin, given to
76 & SCIENCE ON TRIAL
prevent morning sickness during pregnancy, had caused birth

defects.** Nearly 200,000 women sued A. H. Robins alleging
damage from the Dalkon Shield intrauterine contraceptive de-
vice”; 250,000 sued the makers of Agent Orange (dioxin)*°;
50,000 sued Pfizer, Inc., the makers of the defective Bjork-
Shiley artificial heart valve*’; and so on. By the 1980s, mass tort
cases were commonplace. The next mass litigation to rival the
breast implant case may be based on alleged damage from
lead paint. A story in the August 14, 1995, New York Times de-
scribed the liability explosion facing New York City from nearly
a thousand claims filed on behalf of children exposed to lead
paint in city-owned buildings. The report predicted that re-
solving the cases already filed could cost the city as much as
$500 million.”* These cases will surely be followed by others. It
is important to recognize that the size and outcome of mass tort
litigation may have very little to do with the actual risk of the
product. Among the mass litigation cases I have mentioned, the
products present widely varying degrees of risk. Some, such as
DES, are clearly dangerous; others, such as asbestos, are dan-
gerous only under certain circumstances; and others, such as
Bendectin, have been well studied and shown to be safe.
When large numbers of people claim to be injured by the
same product, individual lawsuits can be an extremely inefficient
and capricious way to deal with the claims. Plaintiffs have to race
one another to court to try to collect damages and hope they get
there before the defendants run out of money. Verdicts vary
greatly and seemingly arbitrarily. As an example, the asbestos
mass litigation is generally agreed to have been a disaster. The
courts were flooded, with chaotic and uneven results. Many of
the cases are still unsettled. In 1982, Johns-Manville, a major
manufacturer of asbestos, filed for Chapter 11 bankruptcy pro-
tection. This was the company’s only option for dealing with
The Rush to Court: Litigation and More Litigation ™ 77
both federal and state cases at the same time. Chapter 11 bank-
ruptcy entails the financial reorganization of a company, not its
liquidation. As a part of the reorganization, all creditors’ claims
are considered together in a single court—the bankruptcy court.
Asbestos suits against Johns-Manville Corporation must now be
resolved bya claims facility, the Manville Personal Injury Settle-
ment Trust. The damages will be paid only at greatly reduced
rates, if at all. Eventually 17 other companies involved in the
manufacture or use of asbestos also filed for bankruptcy pro-
tection. Similarly, A. H. Robins, the manufacturer of the Dalkon
Shield, filed for bankruptcy protection, leaving the claims of
many women unsettled. They will be resolved by the Dalkon
Shield Claimants’ Trust Facility.” There was very little equity
among the plaintiffs in these cases. Early claimants tended to fare
better than late ones. The large punitive damages early plain-
tiffs received simply increased the likelihood that the companies
went bankrupt before those injured last could file their claims.
The filing of class actions—lawsuits in which the plaintiffs
are alleged to represent a large number of similarly affected
people—is one way to deal with the inequities and inefficien-
cies of mass torts. Class actions have long been used for civil
cases involving injunctions—such as those dealing with school
segregation and job discrimination. What is new since the
1970s is the use of class actions in tort cases. Until the 1970s,
the general rule was one lawyer, one client.*? But with the ex-
plosion in mass tort litigation, it has become increasingly com-
mon for plaintiffs’ attorneys to file class actions. A class needs
to be certified by a federal judge, who must be satisfied that
class-action treatment is the best method for reaching a fair
and efficient resolution of the problem. The judge not only
certifies the class, but also chooses the class representative, in
whose name the lawsuit is filed on behalf of the other mem-
bers of the class. The judge also selects the lead attorneys for
the class and approves their fees.*! Pooling cases raises the
stakes enough to warrant hiring experts and conducting an ex-
haustive pretrial investigation. The plaintiffs’ lawyers in
essence become investors in the process.
Although attorneys’ fees for a class action tend to be a
smaller percentage than the standard one-third contingency
fee, they are nevertheless quite large because of the number
of plaintiffs. Filing a class action can therefore be a very lu-
crative proposition, and there is great competition to be cho-
sen to represent the class. Recall that the breast implant set-
tlement explicitly set aside a billion dollars for the lawyers.”
For this reason, class actions are now filed on behalf of all sorts
of dubious groups. Sometimes multiple class actions are filed
against the same manufacturer. For example, there have al-
ready been 46 class actions filed against Wyeth-Ayerst, the
manufacturer of Norplant.*® Here again, there is a lottery as-
pect to the practice. Most class actions are not certified, but
all it takes is one to make an attorney’s career. A class action
may be settled out of court either before or after the class is
certified. When the attorneys for both sides agree on the set-
tlement after a class has been certified, the judge decides
whether it is fundamentally fair, then notifies the members of
the class of a formal hearing in which they can present argu-
ments for and against the settlement. The judge then either
approves or disapproves the settlement.”
Often mass tort litigation involves plaintiffs from multiple
federal districts. In this case, it is necessary to consolidate the
cases within the jurisdiction of one federal court. In 1968,
Congress created the Judicial Panel on Multidistrict Litigation.
This group of judges is authorized to transfer civil actions in-
volving common questions of fact from multiple districts to
one. The purpose is to consolidate pretrial discovery—that is,

to conduct out-of-court questioning of parties and witnesses.
The defendants and their witnesses need present their docu-
ments and answers to plaintiffs’ inquiries only once. The cases
may then be completed in their original districts, or, as in the
breast implant class action, settled together. States may also
consolidate mass tort litigation within one state court. Because
mass tort litigation is still a relatively new field, the procedures
are fairly flexible or confused, depending on your point of
view. There is no question that the phenomenon involves a
good deal of legal pioneering.”
In early 1992, Stanley Chesley, the Cincinnati lawyer who
pioneered class actions in tort cases, sought to have the breast
implant cases treated as a class under his sole control. Ches-
ley’s action provoked outrage from his colleagues, who
charged that his real interest was the large fee that would ac-
crue to him if he were named to manage the settlement. In
1983, Chesley had managed to get the 250,000 Vietnam vet-
erans who claimed to be injured by Agent Orange certified as
a class. The case was ultimately settled for $180 million (Ches-
ley received over $525,000 for his efforts). Since then, he has
made a specialty of class-action settlements. Other plaintiffs’
attorneys tend to be higlily critical of him, ostensibly because
he is too quick to settle for too little. (Of course, they also lose
clients to him.) Initially Chesley got Judge Carl Rubin, an Ohio
federal judge, to certify the implant recipients as a class. When
other plaintiffs’ attorneys complained to the Judicial Panel on
Multidistrict Litigation, the panel transferred all federal cases
to Alabama federal judge Sam C. Pointer, an expert in com-
plex litigation. He appointed a 17-member plaintiffs steering
committee, headed by Chesley and Atlanta trial attorney Ralph
Knowles, to work out a settlement with the manufacturers.
The choice was diplomatic. Just as Chesley was a known cham-

pion of class actions, so Knowles had been a leader of the
Breast Implant Litigation Group of the Association of Trial
Lawyers of America, a group not enamored of class actions.*°
Two years later, on April 1, 1994, a proposed settlement
of the class action was finally approved by both sides.*” The
terms, revised over the next few weeks, were remarkably gen-
erous and broad. They provided for $4.25 billion to be set
aside for all women who had received breast implants of any
type before June 1, 1993—and their lawyers. Every effort was
made to help women make claims. The court compiled an
enormous list of all women thought to have breast implants,
based on multiple sources of information. Each woman was
mailed a comprehensive but readable description of the terms
of the settlement, a registration form, a claim form, and a form
to opt out of the settlement if she wished. Conditions that
would be compensated were listed, along with the criteria for
diagnosis. A very simple question-and-answer booklet was also
included, and a toll-free number for any additional questions.
According to the settlement, all women with breast im-
plants were entitled to compensation if they had, or within the
next 30 years developed, any of 10 connective tissue diseases
or symptoms suggestive of such diseases, provided the symp-
toms began or worsened after the implants were placed. Of
the $4.25 billion contributed by the manufacturers, $1.2 bil-
lion was set aside for women claiming to have already devel-
oped implant-related illnesses. By June 1, 1995, 248,500
women claimed to have such illnesses. The amount of com-
pensation they were entitled to was determined by the type of
disorder, its severity, and the woman’s age at onset. A chart or
“grid” sent to all women with breast implants showed the exact
amounts to be paid. For example, according to the grid, a
The Rush to Court: Litigation and More Litigation @® 81
woman under age thirty-six with severe scleroderma would re-

ceive $1.4 million; a woman over age fifty-six with mild Sj6-
gren’s syndrome (dryness of the eyes and salivary glands)
would receive $140,000. Claimants did not need to show that
the implants were related to the illness. In addition, women
who were not ill could receive lesser amounts for emotional
distress. They would also be reimbursed for all uninsured
medical costs related to breast implants, including evalua-
tions, treatment of implant rupture, and elective removal of
implants. Husbands and other “significant others,” who pre-
sumably suffered emotionally from the situation, and chil-
dren born before April 1, 1994, were also entitled to make
claims. Children, for example, could claim compensation for
injuries caused by their mothers’ implants (a particularly mys-
terious provision, since no such condition has ever been
demonstrated).
Women claiming current illness were required to submit
substantiating medical records. If these were not sufficient to
place the woman in the appropriate category on the grid, the
woman’s doctor was to send the diagnosis, along with copies
of relevant records. Beyond this, there would be no attempt to
verify the woman’s condition. A doctor’s diagnosis or the med-
ical records would be challenged only if they failed to meet the
eligibility requirements. Many of the eligibility requirements
can be objectively measured, such as swollen joints or abnor-
mal substances in the blood. But some cannot, such as fatigue
or muscle aches. Indeed, it would have been possible to qual-
ify for compensation without any objective manifestations of
illness whatsoever. For example, a woman could claim joint and
muscle aches, disturbed sleep, fatigue, and burning pain in the
chest, none of which can be objectively verified by her doctor
or anyone else, and collect up to $700,000.°8
82 m@ SCIENCE ON TRIAL
All this assumed that the settlement held together. There

were, however, two hitches that made that unlikely from the
beginning. First, any of the defendants could back out of the
class-action settlement if they believed its purpose was being
defeated by too many women opting out and pursuing large
individual settlements or jury awards. And second, if too many
women made claims under the class setthement, the amount
of compensation for each woman would have to be decreased.
According to the settlement terms, if the grid were revised
women would then be given another opportunity to opt out.
Because of these conditions, as well as the generous terms and
loose requirements for verification, the class settlement began
to unravel almost as soon as it was put together.*’ More about
that later.
IN THE FRENZY Of litigation that followed the FDA ban, it did

not take long for some plaintiffs’ attorneys to realize that they
could very easily extend their reach to other silicone-
containing medical devices. One target is penile implants.
Once again the class action is a favored method of enterpris-
ing lawyers. In 1994 Dan Bolton, of breast implant fame, filed
a class-action lawsuit in the U.S. District Court in San Francisco
on behalf of three Northern California men with penile im-
plants and roughly 300,000 others. He claimed that the de-
vices, in addition to causing local complications, could dam-
age the body’s immune system.*’ Penile implants are made by
American Medical Systems, a subsidiary of Pfizer. Like breast
implants, they came under FDA purview in 1976 and were
grandfathered. Bolton is quoted as saying, “In many ways this
case is very similar to the court battles waged against the man-
ufacturers of breast implants,” and he ought to know.*! Other
attorneys also filed class actions against American Medical Sys-
tems, one of which asked for $50,000 per class member.
Perhaps the most interesting fallout of breast implant lit-

igation is the new wariness about Norplant, the implantable
contraceptive introduced in 1991. Norplant is placed under
the skin of the arm in six very small, silicone-coated rods. Its
effects last for five years. Because users need not think about
it, Norplant, approved by the FDA in 1990, is probably the
most reliable contraceptive on the market, particularly for
teenagers.*” However, it has suddenly become a target for
product liability suits similar to those against breast implant
manufacturers. The number of lawsuits against Wyeth-Ayerst,
the manufacturer of Norplant, and the parent company,
American Home Products, rose from 20 in the first three years
that Norplant was on the market to 180 in 1994. In addition,
as already mentioned, nearly 50 class-action suits have been
filed. Dr. Elizabeth Connell, professor of gynecology and ob-
stetrics at Emory University and the chair of the 1992 FDA
panel on breast implants, told the New York Times that the par-
allels between the breast implant and Norplant controversies
are striking. In both cases, lawyers have been actively recruit-
ing women to sue manufacturers, and some medical experts
involved in the suits own laboratories that purport to test for
silicone-related illnesses—even though such tests are of un-
proven value. The first National Norplant Litigation Confer-
ence, to instruct lawyers and doctors on how to participate in
Norplant litigation, was held in Houston in June 1995. Some
of the lawyers who organized it are also heavily involved in
breast implant litigation. The illnesses attributed to Norplant
are similar to those said to be caused by breast implants, in-
cluding autoimmune and connective-tissue-like disorders and
neurologic problems. There is no medical evidence to impli-
cate Norplant in these disorders, but the fears are real enough.
Norplant use has plummeted from 800 implants a day to 60.*
The untoward consequences of trying to eliminate all theo-
retical risks are easily seen in this case. Would any silicone-
associated risks outweigh the many risks and costs of unwanted
pregnancies in women who are frightened away from Nor-
plant and unable to use another contraceptive?
More important than the expansion of litigation to other
silicone-containing products is the indirect threat to all med-
ical devices—whether they contain silicone or not. This threat
arises from a peculiar feature of our product liability laws. Ac-
cording to the law, plaintiffs can make claims against any party
involved in the manufacture of an allegedly harmful product,
even if the involvement is remote.** This means that suppliers
of raw materials can be sued, even if they have nothing to do
with the design and manufacture of the product. Since the sale
of raw materials for medical devices (called biomaterials) is a
small part of the business of most big suppliers, some of them
have calculated that their revenues from this stream would
quickly be dwarfed by the legal liabilities. For example,
DuPont once supplied Teflon to a small company, called
Vitek, that used it to manufacture jaw implants. Several years
ago, when there were problems with the implants, Vitek de-
clared bankruptcy. The aggrieved patients then sued DuPont
instead. Although the courts have ruled fairly consistently in
favor of DuPont, the company estimates it spent about $8 mil-
lion a year over five years defending itself against the suits. This
amounted to far more than the return on the five cents’ worth
of Teflon in each implant.
Ostensibly because of the legal risks, three large suppli-
ers of biomaterials have pulled back from the market. Dow
Corning, a supplier as well as a manufacturer, has drastically
scaled back sales of silicone to other manufacturers of med-
ical devices and may stop selling it altogether. The embargo
will probably affect a wide variety of silicone-containing de-
The Rush to Court: Litigation and More Litigation & 85
vices, ranging from useful to vital. Among them are cardiac

pacemaker wires, artificial joints, mechanical heart valves, in-
traocular lenses (used after cataract surgery), implantable ar-
teriovenous shunts for people on chronic dialysis, and shunts
for people with hydrocephalus (a potentially lethal condition
in which fluid accumulates in the brain). Dow Chemical Com-
pany has stopped supplying a material used in pacemaker
components. DuPont announced in 1993 that it would sever
connections with the permanent medical implant industry in
1994. It would no longer supply medical manufacturers with
Dacron polyester (used in vascular grafts), Teflon, or a num-
ber of other biomaterials. In DuPont’s calculus, what had hap-
pened with silicone could happen with any other constituent
of medical devices.
Under these conditions, a large number of very important
medical products may become scarce or even unavailable. At
the least, they will become more expensive. In May 1994, Sen-
ator Joseph Lieberman (D-Conn.), then chairman of the Gov-
ernmental Affairs Subcommittee on Regulation and Govern-
ment Information, held hearings on the impact of product
liability suits on the availability of medical devices. Among
those who testified was the father of a boy with hydrocephalus.
The boy, like many other people with hydrocephalus, is able
to live a normal life because the fluid in his brain is shunted
to his abdominal cavity bya silicone tube. Without the shunt,
he would die. But the shunt needs to be replaced periodically
as the boy grows. It can also break, requiring immediate re-
placement. The father testified that he lives in fear that shunts
for hydrocephalus may become unavailable.*”
Also testifying at the Lieberman hearings was Eleanor
Gackstatter, president of Meadox Medicals, a manufacturer of
vascular grafts and other devices. She said that she had tried
to contact 15 alternative suppliers of polyester yarn after

DuPont announced it would no longer supply Dacron to her
company. None of them, even foreign suppliers, would deal
with American manufacturers because of the liability risks.
Many manufacturers have a two- or three-year supply of bio-
materials on hand, but when that is depleted, there may be a
serious shortage. Senator Lieberman, arguing for reform of
the product liability system, said, “This is a public health time
bomb, and the lives of real people are going to be lost if it ex-
plodes.”*
Norplant and penile implants are important to those who
use them, of course, but an argument can be made that, as
elective devices, no great damage is being done by the threat
to their availability. It is far harder to accept the wholesale
threat to vital medical devices, regardless of whether they con-
tain silicone. How this tale will unfold as scarcity develops is
impossible to predict. Some critics believe that the suppliers
are withholding biomaterials only for political reasons. Ac-
cording to this view, suppliers are cynically attempting to cre-
ate a backlash against the product liability system.** On the
other hand, the facts of the matter are clear; suppliers of bio-
materials can be held liable for products they have not de-
signed, manufactured, or sold. And if, for this reason, the
suppliers continue to refuse biomaterials to American manu-
facturers of medical devices, some of the manufacturers may
find it necessary to relocate abroad.
The destructive effects of a runaway tort system are not
what juries are thinking about when they award large damages
to plaintiffs. They are thinking about the plaintiff's case. Peo-
ple who have been injured, by bad luck or careless behavior,
as well as by a defective product, look for some way to get help.
Since there is no reliable social system in the United States for
caring for the sick or injured, it is left to the tort system. Some
plaintiffs are vastly rewarded; most are not. The connection
between the verdict and the merits of the case is often tenu-
ous. Compassionate people may welcome large verdicts for
plaintiffs (and as jurors, they are happy to provide them).
Some believe that even if the injury was not caused by the de-
fendant, it could have been and, besides, someone should
compensate the victim. But this is a very haphazard and un-
economical way to provide assistance. As a way to deter busi-
nesses from marketing dangerous products, the system also
fails. To be sure, businesses grow more skittish, but the issue
for them becomes not whether a product is actually safe, but
whether the company will be vulnerable. They may shy away
from important innovations just to minimize their liability. Fi-
nally, as a way to redistribute wealth, the system fails utterly.
Since someone must pay for the jury awards, the costs are
merely passed along to ordinary consumers. For example, the
breast implant manufacturers will surely try to recoup their
losses by increasing the prices of their other consumer goods.
(Such price increases are sometimes called a “tort tax.”)
Tort reform, like regulatory reform, has been a recurrent
theme in Washington, but never more than now in the ultra-
conservative Republican Congress. Various reform measures
have been proposed. These include limitations on the size of
punitive and emotional damages, as well as restrictions on
contingency fees and more stringent standards for the ad-
missibility of scientific evidence in court. In addition, there has
been increasing attention to the problems of remote parties,
such as suppliers of biomaterials, drawn into product liability
suits. Product liability suits pit trial lawyers against big business.
Each side has its champions. Republicans and conservatives
tend to support big business. They are therefore eager to re-
form the tort system to limit contingency fees and punitive

damages. Democrats and liberals, on the other hand, see
themselves as championing the average citizen, and tend to
support the plaintiffs’ lawyers. They believe that retaining the
present tort system, with all its incentives to sue, gives every-
one a day in court and is necessary to protect consumers from
unscrupulous business practices.”
Although the view of the tort system tends to split along
party lines, with Democrats being more willing to tolerate the
abuses of the system and Republicans likely to seize on them
as an excuse to indulge big business, attitudes are no longer
as predictable as they once were. Even so thoroughgoing a lib-
eral as former senator George McGovern said, in 1994, “Amer-
ica is in the midst of a new Civil War, a war that threatens to
undercut the civil basis of our society. It is a war of lawsuits.
... We need more hard information on campaign contribu-
tions and lobbying by the trial lawyers. I have no hesitance in
asserting that this lobby is one of the most potent and selfish
bands in Washington.”*' Indeed, plaintiffs’ attorneys have
emerged as one of the largest single groups of contributors for
political office anywhere in the United States, particularly at
the state level. According to the American Tort Reform Asso-
ciation, a nonprofit group of about 400 organizations inter-
ested in tort reform, from 1990 to 1994 plaintiffs’ attorneys
contributed more for state and local candidates in just three
states (Alabama, Texas, and California) than either the Re-
publican or Democratic National Committees did in all 50
states. In Texas alone, they are said to have contributed $8.8
million to candidates for state office, including candidates for
the Texas Supreme Court.” I will revisit Texas later.
The rush to court following the FDA ban on breast im-
plants has had, as we have seen, immense effects on com-
The Rush to Court: Litigation and More Litigation @& 89
merce and the law, as well as on hundreds of thousands of

women with breast implants. But what is the truth about breast
implants? Are all the anguish, expense, and shifts in fortune
justified? To answer these questions, we need to turn to sci-
ence, which was conspicuous by its absence as the breast im-
plant story developed.
5
SCIENTIFIC EVIDENCE:
WHAT IT IS AND WHERE
IT COMES FROM
We found no association between breast implants

and the connective tissue diseases and other dis-
orders we studied.
—Mayo Clinic researcher Dr. Sherine Gabriel,
June 16, 1994
hether silicone-gel-filled breast implants cause con-

W nective tissue disease is not ultimately a matter of opin-
ion or legal argument; it is a matter of biological fact. Either
they cause connective tissue disease (alone or in conjunction
with other factors) or they don’t. Plaintiffs’ attorneys, con-
sumer advocates, implant manufacturers, and scientists can
debate the point as loudly and insistently as they like, but the
noise of the debate should not be allowed to obscure the basic
truth that the question has an answer and the answer lies in
nature. The only way to learn whether breast implants cause
connective tissue disease is by scientific studies.
Science plays a hugely important role in our daily lives,
and not just because we are dependent on its technological
fruits. In addition, we base many of our habits and activities
Scientific Evidence @ 91
on the results of research studies, as interpreted for us by the

media. Medical research, in particular, increasingly informs
our lives. We are subject to an almost incessant barrage of
warnings and recommendations based on new medical infor-
mation. Yet, despite the practical importance of science in our
lives, most Americans find the nature of scientific research a
complete mystery. To many of them, the conclusion is all that
matters. It’s as though Americans said to medical researchers,
“Tell us what we should and shouldn’t eat, which vitamins to
take, and how much to exercise, and don’t bother us with how
you found the answers or how sure you are.” But in science,
the conclusions cannot be separated from the process of
reaching them. We must know something about the way scl-
entists work before we can begin to make sense of medical
news.
Without some knowledge of the scientific process, people
tend to be whipsawed by speculation, pseudo-science, and
preliminary hints, many of which are contradictory. Further-
more, not knowing the broad contours of the process feeds
the false belief that medical research is somehow too complex
to be understood by nonscientists. This may be true of the de-
tails of any given study, but it is not true of the broad outlines.
The general approach is easy to understand, because it is
largely a matter of common sense. If nonscientists had a bet-
ter feeling for the approach, they could gauge the probable
strength of many scientific claims while knowing very little of
the technical details on which they are based. Because I be-
lieve so strongly that most nonscientists can understand much
more than they think they can about medical research, I will
discuss some of the general principles of the scientific ap-
proach, before illustrating them (often in absentia) in the
breast implant case.
Perhaps the most important hallmark of science is its

utter reliance on evidence. Furthermore, the evidence must
be objectively verifiable. This reliance on concrete evidence
distinguishes science from all other human endeavors. To
some, the reliance is unpalatable. It renders science somehow
dry andalittle inhuman. (Recall that in popular culture sci-
entists are usually “nerds.”) Certainly, science can seem less
rich than other aspects of life, such as religion or literature,
which draw on many more facets of human nature. But to
many scientists who find pleasure in the search for nature’s
secrets, the view that science is dry is a caricature. To them,
evidence anchors them to reality, which is what most fascinates
them. Whether reliance on physical evidence diminishes or
enhances the appeal of science is arguable. What is not ar-
guable is that we cannot reach scientific conclusions without
evidence. Medical conclusions are no different from other
scientific matters, because the body is a part of nature. The ef-
fect of breast implants on women’s health is no less a scien-
tific matter than the trajectory of a lunar space shot or the im-
pact of aerosolized sprays on the ozone layer.
How do medical researchers find the evidence on which
their conclusions are based? The approach is quite uniform.
First, they need to formulate the question they want to answer
and design a study that is capable of answering it. The ques-
tion is usually framed as a hypothesis. “Women with breast im-
plants are more likely to develop connective tissue disease
than other women” is a hypothesis.' (For technical reasons, it
is usually framed in the negative—that is, “women with im-
plants are no more likely to. . . .” This is termed the “null hy-
pothesis,” and the researcher tries to prove it wrong.) Al-
though this first step in approaching a scientific question
seems obvious and simple, mistakes are often made here. If,
Scientific Evidence @® 93
for example, researchers want to know whether breast im-

plants increase the risk of connective tissue disease, they need
to choose some suitable evidence of connective tissue disease
and determine whether it is more common in women with im-
plants than in women without implants. It would not be ade-
quate to study whether women with implants are fatigued be-
cause fatigue is not specifically enough related to connective
tissue disease and its presence or absence would not directly
address the question. There must be a close fit between the
question posed and what is being observed in the study.
After the study is designed, researchers must collect data.
Collecting data means measuring or counting something. This
is the notion that many nonscientists are least comfortable
with, because it “reduces everything to numbers.” “Everything”
can’t be reduced to numbers, of course, but some things can
and some things must be. To reach a conclusion about the
physical world (and our bodies are a part of that world), we
need numbers because they are often the only way that evi-
dence can be expressed. Ina study of breast implants and con-
nective tissue disease, for example, something must be mea-
sured or counted—the body temperature, the number of
women who have joint pains, or the number of white blood
cells (the cells involved in immune reactions). What is enu-
merated depends on the study design. When the data are as-
sembled, they must be analyzed appropriately. Often the
analysis consists of comparing one set of data with another set
to lead to a logical conclusion. For example, the number of
white blood cells in women with implants might be compared
with the number in women without implants.
The final step in a research study, after the data are ana-
lyzed, is to draw the proper conclusionJusts. as the first stage
of the study (formulating the question and designing the
94 m@ SCIENCE ON TRIAL
study) is more difficult than it may at first seem, so is the last

stage. Interpreting a study is perilous because of the strong
temptation to reach conclusions that are more encompassing
than the evidence will support. For example, if a study showed
that rats injected with silicone developed cancer, it would be
inaccurate to conclude that breast implants cause cancer in
women. The study did not deal with women and it did not deal
with implants but with liquid silicone. Similarly, if women with
breast implants were found to have more white cells in their
blood, it would be inaccurate to conclude that breast implants
cause autoimmune disease. The study did not deal with au-
toimmune disease. In both of these hypothetical cases, the
conclusions would go far beyond the evidence. Mistakes in
drawing conclusions are particularly likely when a researcher
has strong preconceptions about the question he or she is
studying. The conclusions of a research study must be limited
to those—and only those—that follow logically and necessar-
ily from the data.
In science, the requirement for verifiable evidence must
be met, no matter who the researchers are or what their cre-
dentials. Not even Nobel laureates are permitted to basea sci-
entific conclusion on an educated guess. (They can, of course,
make guesses or hypothesize, but those guesses will not be ac-
cepted as evidence unless they are put to the test.) These strin-
gent standards serve a purpose. In science as in all walks of life,
it’s not easy to know when you have leapt to an unjustified con-
clusion or simply made a mistake. Sometimes very successful
scientists, perhaps even more so than novices, come to believe
they are more or less infallible. A distinguished senior scien-
tist once insisted to me, when I was discussing with him the
need for more data in a paper he had submitted to the New
England Journal of Medicine, that he didn’t need more data. He
was, he reminded me, the discoverer of the disease that was

the subject of the paper and he knew his conclusions were cor-
rect. Although he was indeed the discoverer of the disease, his
eminence and expertise did not exempt him from having to
produce the data required to support his conclusions. Strict
adherence to scientific procedures—in particular, the re-
quirement for evidence—saves such people (and us) from
themselves.
Once a research study is completed, is that it? Do the re-
searchers simply announce their conclusions to the media?
Unfortunately, that happens from time to time, but it
shouldn’t. The usual procedure is for researchers to write up
their study in a standardized way and submit it to a scientific
journal. Research reports are divided into sections dealing
with the methods, results, and conclusions. Before a research
paper is published, other scientists usually evaluate the study
and its conclusions. This is termed “peer review,” and it is a
cornerstone of scientific research. The reason peer review is
so important is that even the most honest researchers cannot
be expected to judge their own work dispassionately. They are
likely to be enthusiastic about their ideas and, almost by def-
inition, not aware of flaws in the design of their study and in-
terpretation of their data. The process of interpreting data is
seldom clear-cut, and it is easy to be unaware that the data are
inadequate to support the conclusions. Without the discipline
of organizing and presenting their evidence, and without the
criticism and revisions stimulated by the peer-review process,
researchers may unconsciously misrepresent their work or ex-
aggerate its importance.
| Evaluating medical research is no easy matter. At the New
England Journal of Medicine, we have seven full-time physician
editors, six part-time physician specialists, three statistical con-
sultants, and one consultant in molecular medicine to do it,

and we call on thousands of outside peer reviewers who are
experts in the subjects under study.” Even with all this exper-
tise, we are often not confident of the validity of a study and
we sometimes make mistakes in judgment that are not cor-
rected until later. Because of the difficulty of evaluating med-
ical research, one should be extremely skeptical of research
findings that are announced directly to the media, without
peer review. The 1989 press conference of Stanley Pons and
Martin Fleischmann, two chemists at the University of Utah
who claimed that they had attained cold fusion, is an exam-
ple of the hazards of short-circuiting the peer-review process.*
They went directly to the media to announce that they had ini-
tiated a nuclear reaction at room temperature. According to
the laws of physics, enormously high temperatures are neces-
sary for such a reaction, yet Pons and Fleischmann were not
fazed by the improbability of what they had purportedly ac-
complished. Neither was the University of Utah, which par-
layed the spectacular announcement into a $5 million grant
from the state legislature to continue the work. Later, of
course, the claim could not be supported. Many other such
instances could be cited in which scientists promulgate con-
fusion or error by making claims before submitting their data
to expert critical review by their professional peers.
In addition to the reliance on objective evidence collected
in properly designed studies, science is also characterized by
its tentativeness. This may seem counterintuitive to nonsci-
entists who are accustomed to thinking of science as cut-and-
dried. But in fact, good scientists rarely reach absolute con-
clusions. Particularly in medical research, certainty is
extremely hard to come by. Instead, medical researchers al-
most always speak in terms of probabilities. When they do a
study comparing two antibiotics to treat pneumonia, for ex-

ample, they will couch their findings in terms of the proba-
bility that one is better than the other. When they look at the
link between cholesterol and heart disease, they frame their
results in terms of risks, not certainties. Very few studies are
by themselves definitive. In general we should not embrace the
conclusions of a research study until it has been confirmed by
other, independent studies. Even then, the studies taken to-
gether merely add to the probability that the conclusion is cor-
rect, without proving it absolutely. Of course, every aspect of
life involves considering probabilities. When we drive to work,
for example, we intuitively gauge the probability that an on-
coming car will miss us.* But scientific research is different in
that probability and uncertainty are explicitly considered,
measured, and expressed as part of the study. We can rarely
absolutely prove a hypothesis, although we can gather enough
evidence from enough different studies to make the hypoth-
esis so probable that we can say it is true for all practical pur-
poses.
THE BREAST IMPLANT CONTROVERSY well illustrates many of the

points I have been discussing. Although there was almost no
reliable scientific information at the time of the ban, several
research studies on the subject have been published since
then. What sorts of studies were these and what has been
learned from them? Before answering these questions, it may
be useful to review what was understood even before the re-
search was undertaken, because this influenced the kinds of
studies that were done. From the start it was clear that implants
could not be the sole cause of connective tissue disease, even
if they played some role, since women without breast implants
also develop these diseases. And it was also known that breast
implants do not invariably cause connective tissue disease,

since most women with implants remain healthy. Thus, the
most that could have been true is that breast implants contribute
to connective tissue disease—that is, they might have been a
“risk factor” (something that increases the chances of devel-
oping a disease). Whether arisk factor is one of several pos-
sible causes of a disease or whether it is merely correlated with
a real cause may not be known. For this reason, scientists often
say that a risk factor is “associated” with a disease, not that it
“causes” it.
Risk factors can be strong or weak. For example, cigarette
smoking is a strong risk factor for lung cancer. This means that
smokers have a very much higher chance of getting lung can-
cer than nonsmokers. The more they smoke, the greater the
risk. In fact, people are extremely unlikely to get lung cancer
unless they do smoke. Cigarette smoking is so strong arisk fac-
tor for lung cancer that we are justified in saying it “causes”
cancer, even though we do not yet know exactly how it does
so. In contrast, alcohol may be a weak risk factor for breast can-
cer. The chances of a drinker getting breast cancer, accord-
ing to some studies, are slightly higher than the chances of a
nondrinker, but abstaining from alcohol is unlikely to confer
much protection. It is difficult to prove that something is a risk
factor, unless it is a very strong one. The ideal way, scientifi-
cally, to prove that something is a risk factor for a particular
disease would be to get a large group of very similar people
and assign half of them (by random draw) to be exposed to
the risk factor and the other half not to be exposed. We would
then compare what happens to the two groups. Obviously, we
can’t do this with breast implants. Women are not likely to vol-
unteer to get breast implants by random draw. Even if such
women could be found, it would be unethical to exploit them
Scientific Evidence @™ 99
in this way. So we’re left with attempts to get at the same in-
formation in less than scientifically ideal ways.
This is where observational epidemiologic studies come
in. In this type of study—an increasingly important way of
studying connections between disease and potential risk fac-
tors—we do not assign people to be exposed to a potential risk.
Instead, we observe what happens in those who choose to be
exposed for their own reasons or who happen to be exposed
inadvertently. Then we compare the incidence of the disease
in these people with the incidence in those who are not ex-
posed. There are several forms of observational epidemio-
logic studies, but only two are of much value in demonstrat-
ing risk factors—cohort studies (“cohort” simply means
group) and case-control studies. A cohort study of the possi-
ble link between breast implants and connective tissue disease
would start with a group of women who have implants and a
group who do not, none of whom has connective tissue dis-
ease. Researchers would then keep track of the two groups
over time to see how many in each group develop connective
tissue disease. If more in the implant group get a connective
tissue disease, it would support (but not prove) the hypothe-
sis that breast implants are a risk factor. In contrast, a case-
control study would start with a group of women who already
had connective tissue disease (cases) and a group who did not
(controls). After the groups were assembled, the researchers
would find out how many women in each group had implants.
If more cases than controls had breast implants, it would sup-
port (but not prove) the hypothesis that breast implants are
a risk factor. In either type of study, the bigger the difference
between the two groups, the more likely it is that implants are
a risk factor. The trickiest part of epidemiologic studies is
making sure that the groups are similar to each other in all
ways except the possible risk factor (in cohort studies) or the
disease (in case-control studies). If they aren’t, differences
may show up because of other factors (termed “confounding
variables”) .°
Cohort and case-control studies each have advantages
and disadvantages, but one or the other is necessary to come
close to answering the question of whether breast implants are
a risk factor for disease. Just finding instances of women with
implants who develop connective tissue disease is not enough
to prove a connection, because we have to know whether such
instances are more common than in women who do not have
implants. After all, connective tissue disease might well occur
in some people with implants simply by coincidence. Nor can
we rely on animal studies, since animals may differ in relevant
ways from people. Other laboratory studies are also unable to
answer the question of whether breast implants cause con-
nective tissue disease. However, these studies can provide an-
cillary evidence that an association seen in epidemiologic stud-
ies really represents cause and effect. In addition, once a link
between a risk factor and a disease is established, laboratory
studies or studies of individual patients may be necessary to
tell us how the connection works. But they cannot establish the
link in the first place. The only way to get at the answer in the
implant case is by comparison of women with and without im-
plants (in a cohort study) or by comparion of women with and
without connective tissue disease (in a case-control study).
Even though the only way to find out whether breast im-
plants are associated with connective tissue disease is through
observational epidemiologic studies, the first reliable one was
not published until June 16, 1994.° As noted before, this was
over two years after breast implants were taken off the market
and two months after a class-action settlement was negotiated.
Scientific Evidence #® 101
The study, done at the Mayo Clinic and published in the New
England Journal of Medicine, was a retrospective cohort study,
which means that it compared women who had received im-
plants years ago with similar women who had not. The group
with implants consisted of all 749 women living in Olmsted
County, Minnesota (the location of the Mayo Clinic), who
had received breast implants between 1964 and 1991. The
group without implants consisted of 1,498 of their neighbors,
matched for age. (This control group was selected to minimize
confounding variables, such as geographic location or type of
medical care. The two groups were similar to each other, ex-
cept for implants.) The researchers found that the implant
group was no more likely to develop connective tissue disease
(or related symptoms and abnormal blood tests) than the
group without implants. This was not the final word, of course.
It was only one study, and it was not large enough to rule out
some increase in risk. But it was highly important, because it
cast doubt on the whole theory of a link between breast im-
plants and connective tissue disease at a time when many peo-
ple assumed the theory had been proven. Plaintiffs’ attorneys
did not like this message, and immediately began a campaign
to discredit the messengers. More about that later.
At the time the Mayo Clinic study was published, several
other epidemiologic studies were under way. Two were huge,
and targeted all connective tissue diseases and avariety of
other complaints. The largest was a retrospective cohort study
of roughly 400,000 American women in the health profes-
sions, about 11,000 of whom had breast implants. This study,
called the Women’s Health Cohort Study, was published in
early 1996 in the Journal of the American Medical Association.” It
found aslight increase in reports of connective tissue disease
among women with breast implants. Unfortunately, the au-
thors did not attempt to verify the diagnoses by examining

medical records. Since the survey was done after the 1992
FDA ban and the resultant publicity and legal activity, it is dif-
ficult to know how much to rely on these self-reports. The au-
thors intend to try to validate the diagnoses in the next phase
of the study. Another large retrospective cohort study, pub-
lished in the New England Journal of Medicine in June 1995,
could find no association between implants and connective tis-
sue disease in nearly 90,000 nurses, of whom 1,183 had breast
implants.* An advantage of the Mayo Clinic study and the
Nurses’ Health Study is that they validated the diagnoses by
reviewing medical records. They also investigated a whole
range of abnormalities, in addition to well-defined connective
tissue diseases. This was to deal with the contention of many
people that disease caused by breast implants may not fulfill
all the usual criteria of a “classic” connective tissue disease.
Two epidemiologic studies dealt just with scleroderma.
Scleroderma, a disease characterized by extensive hardening
and scarring of the skin and sometimes of internal organs (in
which case it is called systemic sclerosis), is the connective tis-
sue disease most closely linked by anecdotes to silicone breast
implants. Neither of the studies’ could find an association be-
tween breast implants and scleroderma. Studies of only
rheumatoid arthritis and lupus also did not show an associa-
tion with implants. Since 1994, then, several epidemiologic
studies have failed to find a clear link between breast implants
and connective tissue disease.”
Does this mean that breast implants do not contribute to
connective tissue disease? Not exactly. As explained above, no
study can absolutely prove that. All it can do is tell us how likely
or unlikely it is. Each study that fails to find a link adds to the
evidence that there is none. But since each of them is based
Scientific Evidence ® 103
7
on only a sample of women, it is possible to miss a connection.

Only if we studied all women with and without implants—an
impossible job—could we know for certain whether implants
are a risk factor for connective tissue disease. The study of a
representative sample simply yields an approximation. There
are, fortunately, statistical means for calculating the margin of
error, which depends on the size of the sample as well as on
the size of any real risk. In the Mayo Clinic study, for exam-
ple, although no connection was found between implants and
connective tissue disease, the study sample was not large
enough to rule out with reasonable certainty as much as a
threefold increased risk. As other studies are added to the ev-
idence, however, the conclusion that there is no connection
grows stronger. The only study that found a connection is dif-
ficult to interpret because of the likely bias in self-reports after
the FDA ban. Considering all the research together, any risk
would have to be very small. Nevertheless, it is still possible that
breast implants may cause connective tissue disease in a few
women or contribute to it slightly in others. Without an im-
possibly large study, we may never know.
GIVEN THE Fact that well-designed epidemiologic studies have

failed to detect an increased risk of connective tissue disease
in women with breast implants, where did the notion come
from in the first place? Probably from a combination of anec-
dotes and speculation that tended to amplify one another.
First, there were the poorly documented Japanese reports
about direct injections, beginning with a 1964 paper report-
ing two cases of connective-tissue-like disorders in women who
had undergone direct injections of paraffin many years be-
fore.!! (Ironically, this was published at about the time that
implants were beginning to replace direct injections in this
country.) The disorders did not fall into the usual categories
of connective tissue disease, and so the authors of this paper
termed them “human adjuvant disease,” because they thought
the symptoms resembled a disorder of rats injected with a for-
eign protein combined with an adjuvant (an adjuvant is a sub-
stance that enhances an immune response to something else).
Later, similar cases were reported in American scientific jour-
nals, but these, too, involved direct injections of paraffin or
silicone, not the new gel-filled prostheses.’ It was not until the
1982 Australian publication, mentioned in Chapter 3, that
connective tissue disease was reported in women who had
silicone-gel-filled breast implants.'*
Although some still use the term “human adjuvant dis-
ease,” it has fallen into disrepute, in large part because of the
vagueness and variability of the reported signs and symptoms.
The problem of vague or shifting definitions of disease con-
tinues to plague the study of breast implants. When a study
fails to find an increased risk of certain diseases or symptoms
in women with implants, adherents of the theory that implants
cause disease are quick to suggest that the diseases in question
are different. It is impossible to study whether something
causes illness, however, unless the illness is clearly described.
Otherwise, it cannot be consistently diagnosed and its relation
to breast implants cannot be examined. This sort of situation
is what Karl Popper, the philosopher of science, had in mind
when he said that a scientific hypothesis had to be “falsifiable”
to be meaningful. The hypothesis that breast implants cause
an undefined set of symptoms is neither provable nor falsifi-
able—it is simply an assertion.
The idea that breast augmentation caused connective tis-
sue disease had a superficial plausibility. Since local scarring
is inevitable in women with breast augmentation, particularly
in those who had direct injections, and scarring is also a fea-
ture of certain connective tissue diseases, particularly sclero-

derma, many people were drawn to the theory that they were
connected. As the isolated reports became the basis of lawsuits
and the publicity grew, more women came forward with sim-
ilar complaints. Altogether, there are now a few hundred pub-
lished reports of connective-tissue-like diseases (most without
a clear-cut diagnosis) following breast implants, including the
initial Japanese cases. But there is no way of saying how many
more such cases there are or whether the concurrence in
these women was due to chance alone. Since the ban, women
with implants who are ill are likely to come to attention be-
cause of the increased awareness of the problem. This extra
attention may add to the impression that there is a link even
if there isn’t. In addition, certain doctors develop a reputation
for believing in a connection, and they may be magnets for pa-
tients with breast implants and connective tissue disease or a
variety of symptoms. Studying such women, however, does not
speak to the question of whether implants increase the risk of
disease. The tendency of women with implants and disease to
come forward and the tendency of doctors to study these
women without comparing them with other women can
greatly bias the picture. The possibility of bias underscores why
cohort or case-control studies are so important. Anecdotes
and clinical experience simply can’t tell us very much about
the relation between implants and disease. But it is very easy
to believe that they do. A frequent consultant to plaintiffs’ at-
torneys, Frank Vasey, M.D., illustrates the problems with rely-
ing on uncontrolled observations. Vasey, the chief of the Di-
vision of Rheumatology at the University of South Florida
College of Medicine, became convinced, apparently largely on
the basis of his and others’ clinical experience, that breast im-
plants cause disease. In a 1993 book he asserted, “The most
serious conditions that result from the diffusion of silicone
106 &@ SCIENCE ON TRIAL
into the body are autoimmune disorders, whereby the body’s

immune system mistakenly and unceasingly attacks healthy
cells, tissues, and musculoskeletal structures.”'* In his view it
was confirmatory that 23 of 33 of his patients whose breast im-
plants were removed felt better. But this is precisely the sort
of situation in which a powerful placebo effect could operate
on both doctor and patient.
A completely different type of research is directed at the
question of whether silicone can cause an immune reaction,
just as viruses or injected serum can. This line of inquiry as-
sumes that breast implants are risky and seeks to determine
the mechanism by which they cause harm. Substances that
elicit an immune reaction are called “antigens,” which the
body combats by forming “antibodies” and special white cells.
If silicone elicits an immune reaction, that would lend cre-
dence to the theory that silicone causes autoimmune disease,
although it would by no means prove it. Many believers in the
autoimmune theory are influenced by the presence of in-
flammation around implants. Some of them mistakenly as-
sume that this is evidence of an immune reaction. In fact, any
foreign object embedded in the body elicits inflammation, as
explained in Chapter 2. Inflammation does not mean that
there is an immune reaction against the object, much less an
autoimmune reaction against one’s own body. Nevertheless,
a similar process in four dogs that Dow Corning used for its
experiments elicited a great deal of concern when the com-
pany’s records were made public, because many people as-
sumed that the inflammation reflected an immune reaction.'°
Believers in the autoimmune theory may also be influenced
by the fact that silica (a dust that is the cause of silicosis in min-
ers) is associated in epidemiologic studies with a high inci-
dence of autoimmune disease. But silica dust is different from
silicone (although a different type of silica is a constituent of
the silicone envelope). The weight of evidence indicates that

silicone probably is not capable of acting as an antigen and
causing an immune reaction. Nor is there evidence that
women with breast implants are more likely to have antibod-
ies against their own tissues (autoantibodies).
One of the adherents of the view that silicone can pro-
duce autoimmune disease is Nir Kossovsky, M.D., an assistant
professor of pathology at the UCLA Medical Center. He pos-
tulates that leaking silicone alters native molecules with which
it comes in contact, and forms a complex with them. The body
no longer recognizes the altered molecules as native, and
mounts an immune reaction against the complex (which
serves as the antigen). The reaction then spreads to other
parts of the body, where molecules were not altered by con-
tact with silicone. According to Kossovsky, this leads to au-
toimmune disease. (Autoimmunity refers to a mechanism;
connective tissue disease refers to a clinical effect, such as
arthritis. Not all connective tissue diseases are known to have
an autoimmune basis, but some do and it is strongly suspected
in others.) To buttress the theory, Kossovsky has shown that
guinea pigs will develop antibodies against silicone-serum
complexes, although not to silicone itself. It is quite a leap
from these observations to proof of the whole theory that sil-
icone causes autoimmune disease in women with implants.
Kossovsky also measured antibodies to fibrinogen (a protein
in the blood) and collagen in women with and without im-
plants, some of whom were sick and others of whom were not.
He claimed to find higher levels in the sick women with im-
plants, but his methods of analysis have been sharply criti-
cized. In any case, the significance of such a finding is un-
clear.'®
Another person who is convinced that silicone causes au-
toimmune disease is Marc Lappé, formerly a professor of
108 # SCIENCE ON TRIAL
health policy and ethics at the University of Illinois School of

Pharmacy. Lappé has a Ph.D. in experimental pathology. He
believes that silicone triggers an intense overstimulation of the
immune system, perhaps in response to the silica component
of the silicone envelope. Lappé published his theory in a jour-
nal called Medical Hypotheses. It is an interesting theory, but he
has produced no persuasive evidence to support it.'” Like
Kossovsky, Lappé is a frequent expert witness or consultant for
plaintiffs’ attorneys.
It is a long way from such theories to showing that im-
plants cause connective tissue disease. Kossovsky’s observa-
tions, for example, focus on one link in a long chain of pos-
tulated events. But before focusing on one link in a chain of
possible causation, scientists usually first try to establish a con-
nection between one end of the chain and the other—that is,
between the suspected cause and the disease. For example,
first we found out that cigarette smoking is associated with
lung cancer. Only then did scientists turn their attention to
how cigarettes might cause the disease. (Is it the nicotine or
the tars? How does it work? What can we learn from experi-
ments in animals?) In the breast implant controversy, there
has been a tendency to do it backwards. Assuming there is a
connection, some people have sought to explain how it works.
This backwards approach does not invalidate the observations,
of course. But it is an inefficient way to address a problem, and
it raises the question of bias. The British Department of Health
in 1994 issued a thorough review of all the published studies
of the immunologic effects of breast implants, and pro-
nounced most of the work “disappointingly poor.”!®
BEFORE LEAVING the subject of scientific research, let me give

a brief summary of the salient points I have tried to make. First,
Scientific Evidence ® 109
a scientific theory must be tested before it can be accepted.

Some theories cannot be tested and therefore belong to the
realm of assertion, not science. In the breast implant case, the
theory that implants cause undefined diseases cannot be
tested. It will remain simply a matter of speculation until those
attached to the theory describe the symptoms in a way that per-
mits the condition to be consistently diagnosed. No one can
study a disease that is not defined or whose definition shifts.
Once a testable hypothesis is proposed, research studies
must be designed that speak directly to the hypothesis. In the
breast implant case, the hypothesis that implants increase the
risk of connective tissue disease requires certain types of epi-
demiologic studies. The conclusions of a study must be sup-
ported by the data and not go beyond the data. For example,
in the Mayo Clinic study, the researchers concluded that they
could not find an association between implants and the dis-
eases and symptoms they studied. If they had said that implants
do not cause connective tissue disease, they would have gone
beyond what their data could support. The study did not rule
out a connection.
Even well-done scientific studies, appropriately inter-
preted, produce only probabilistic and tentative answers.
There are too many pitfalls in science to embrace any one
study uncritically. Researchers make mistakes, some of which
are not discovered even with rigorous peer review. Misleading
results can also occur just by chance. Each study should there-
fore be considered a part of a mosaic of information that
taken together yields the answer to a scientific question. Of all
the properties of scientific research that I have discussed, the
most important is the dependence on evidence. No scientific
conclusion can be accepted without evidence. This is perhaps
the only feature of science that is absolute.
At the time of the ban on breast implants, David Kessler

acknowledged that there was no evidence that breast implants
cause connective tissue disease. He simply felt he could not
wait for the evidence to be assembled before banning them.
For their part, the courts had long since decided that implants
cause connective tissue disease. Now, years later, the evidence
is beginning to emerge. We are beginning to see that any con-
nection between implants and connective tissue disease is
likely to be very weak, at most, since several good studies have
failed to detect it. Given the absence of scientific evidence at
the time, why were the courts so sure of their conclusions?
6
SCIENCE IN THE COURTROOM:
OPINIONS WITHOUT EVIDENCE
Dow’s conduct in exposing thousands of women

to a painful and debilitating disease, and the ev-
idence that Dow gained financially from its con-
duct, may properly be considered in imposing an
award of punitive damages.
—Judge Procter Hug,
August 26, 1994
s we have seen, Maria Stern and her lawyer, Nancy Hersh

fA ea Dan Bolton’s help), were the first to go for the
legal brass ring by alleging that implants cause connective tis-
sue disease. Stern’s disease was never clearly defined in the
media, although some press reports referred to it as “arthri-
tis.” Until this case, product liability suits against breast implant
manufacturers, of which there was a small trickle, had been
limited to settlements of no more than $15,000 to $20,000 for
local complications.' With the 1984 Stern case, all that
changed. It was inevitable that after Stern there would be
more such cases. After all, many women had connective tissue
(also
disease (about 1 in 100) and many had breast implants
about 1 in 100). Thus, one could expect—on the basis of
112) # SCIENCE ON TRIAL
chance alone—that about 10,000 of the roughly 100 million

adult women in the United States would have both.
Once it got out that a link between the two conditions had
been accepted in court, women who had both implants and
connective tissue disease would be bound to consider whether
they, too, should sue. Even those who only thought they might
have connective-tissue-like disease also began to take notice.
For any who lagged behind, there was plenty of encourage-
ment from many plaintiffs’ attorneys.
The issue in the Stern case, as would be true of any prod-
uct liability suit, was whether the manufacturer of the implants
(Dow Corning, in this case) had sold her a defective product
that caused her harm. To make the case required that Stern
demonstrate two conditions: first, that she was harmed, and
second, that the harm was most likely caused by the implants.
In addition to demonstrating these conditions, which would
satisfy the standard known as “strict liability,” there was the
question of negligence. Was the manufacturer guilty of know-
ingly or heedlessly selling a dangerous product? To show neg-
ligence required that a third condition be demonstrated—that
the manufacturer knew or should have known that the im-
plants were harmful. Theoretically, the first two of these con-
ditions must be met for any product liability suit to be suc-
cessful. That is theory. In practice, as we shall see, a product
liability suit can be spectacularly successful without any of the
conditions being fulfilled.
Conditions two and three depend on the satisfaction of
the one before it. The manufacturer cannot be held negligent
if the implants didn’t cause the harm, and the implants can-
not be blamed if there is no harm. In most of the breast im-
plant cases that have been brought to trial (but not necessar-
ily in the far more numerous cases settled out of court), the
Science in the Courtroom: Opinions without Evidence §& 113
plaintiff has been clearly ill. (In the Stern case, because the
records were sealed as a part of an out-of-court settlement
after the verdict, it is difficult to be certain about the nature
of her medical problems.) The major job of the plaintiff's at-
torney, therefore, has not been to show that the plaintiff is ill,
but to show that the illness was caused by the implants. To do
so requires convincing the jury by a “preponderance of the
evidence.” This is a more relaxed standard than the require-
ment in a criminal case that the verdict be “beyond a reason-
able doubt.” But aside from its relative liberality, the phrase
“preponderance of the evidence” tells us less than it might
seem. It suggests confusingly that there are two kinds of med-
ical evidence—evidence for and evidence against a causal re-
lationship. In practice, this is highly unlikely: either there is
evidence for a relationship or there isn’t. In the absence of
such evidence, the default position must be that there is no
link. The burden of proof is on those who assert the rela-
tionship.
Sometimes the phrase “preponderance of the evidence”
is translated to mean that the jury finds the disease more
likely than not to be caused by the breast implants. Or some-
times the same concept is expressed by saying that the breast
implants contributed more than 50 percent to the causation
of the disease—that is, but for the implants, the disease would
not have developed.” While neither of these alternative for-
mulations is entirely satisfying, they are an improvement over
the vague term “preponderance of the evidence.” Further-
more, they can be translated into epidemiologic terms. If
connective tissue disease in a typical woman with implants is
that
more likely than not to be caused by implants, it follows
in a large population of women, the majority of cases of con-
nective tissue disease would be due to breast implants. In
other words, this cause would have to outweigh all other con-
tributing causes put together. To outweigh all other causes
means that women with implants would have to be at least
twice as likely to develop the disease as women without im-
plants. (As we saw in the preceding chapter, there is no evi-
dence that they do.)
Notice that what is at issue here is not how certain we are
of the effect of implants, but how big the effect is. The degree
of certainty is an entirely different matter. I mention the dis-
tinction, because some legal scholars confuse the concepts of
the size of the effect (as, for example, when it is said that im-
plants contribute more than 50 percent to the disease) with
the degree of confidence we can have that it is true. For a sci-
entific finding to be accepted, it is customary to require a 95
percent probability that it is not due to chance alone (I am
here giving a shorthand version of a much more complicated
statistical concept). Comparing the size of an effect with the
probability that a given finding isn’t due to chance is com-
paring apples and oranges. It would be possible to find a huge
effect with a low degree of certainty, or a tiny effect with a high
degree of certainty. The distinction between the size of an ef-
fect and the probability that a particular finding is not due to
chance is important in debates about science in the court-
room. It is sometimes said that the reason plaintiffs in court
may be awarded damages without good scientific evidence is
that the legal standard is more liberal than the scientific stan-
dard. According to this argument, all the plaintiff has to do is
show preponderance of the evidence, whereas science re-
quires 95 percent confidence about a finding. Not only does
this argument confuse size with certainty, but it also confuses
the whole with the part. The degree of certainty scientists re-
quire refers to the results of a given study, not to a limitless
Science in the Courtroom: Opinions without Evidence ® 115
body of evidence. The fundamental issue in both science and

the courtroom should be the same—that is, the quality of the
evidence. Can we rely on it?
So far, I have been speaking mainly about populations.
But courtroom trials are not about populations, they are about
individuals. The question is whether breast implants caused
disease in this woman. Is there any basis for such a judgment?
I do not believe there is. Given the absence of any scientific
information on individual differences in women’s responses
to breast implants, we can only look at the individual as an av-
erage woman with implants. We have no basis, at least in the
current state of knowledge, for making a judgment about a
particular woman. We therefore must appeal to epidemiologic
data—that is, to studies of populations. We have to assume that
whatever is true on average is true of the particular woman.
As it happens, we think this way intuitively. When we wonder
whether someone we know developed lung cancer because he
smokes, we automatically consider what we know about the
risks of smoking in a population. We can’t be sure that ciga-
rette smoking caused disease in this particular man, because
there is no test to answer that question in his case, but we think
it probably did because we know a lot about the risks of smok-
ing in populations. Without considering what we know about
populations, we have no basis for our opinion. Despite our
intuitive realization that particular cases must be considered
in the light of what we know about the general situation, that
is not what juries are instructed to do. They are asked to judge
the particular case on the basis of the evidence presented in
court, and no matter how unsatisfactory that evidence is, they
must reach a verdict. They cannot say, as scientists can, that
they will not form an opinion until they get more or better ev-
idence.
Science in the courtroom is paradoxical in that it always

yields a firm conclusion, yet never does. Each plaintiff who
claims that breast implants caused her connective tissue dis-
ease requires a verdict, and a verdict is always reached. But
even though the issue is settled for the last plaintiff, it is not
settled for the next one. The question must be revisited over
and over, for every woman who comes to court claiming a con-
nection. Even so, it is not argued completely from scratch. An
earlier verdict for a plaintiff provides a powerful presumption
in the next case (for technical reasons, a verdict for a defen-
dant does not). Nevertheless, verdicts can differ, no matter
how similar the women’s cases. In contrast, scientists almost
never claim to have settled a “case.” Their findings are con-
ditional. More work is nearly always required. But for any one
scientific question, the weight of the accumulated evidence
tends to converge toward an answer. Eventually the probabil-
ity of the answer will be great enough to warrant general ac-
ceptance of the conclusion.
In product liability cases, expert testimony by scientists is
usually central. The question of causation is, after all, a sci-
entific one. But scientific questions are handled very differ-
ently in the courtroom than they are outside the courtroom.
The difference turns on the relationship between evidence
and opinion. In both science and law, of course, “expert”
opinion is important. But what that means in the two profes-
sions is as far apart as day and night. As discussed in the pre-
ceding chapter, scientists, no matter how expert, must provide
the evidence on which their opinions are based. When they
complete a research study, it is necessary to present their evi-
dence before their conclusions will be accepted. Even when
they are commenting on the general state of their field, it is
customary for them to cite explicitly the basis of their opin-
ions. For example, medical researchers sometimes publish

summaries of what is already known about a subject. Called
“review articles,” these summaries are analogous to expert tes-
timony in court, in that they are evaluations of the state of
knowledge. But even review articles must refer to the pub-
lished research being evaluated (unpublished work usually
counts for very little in science). In addition, it is expected that
authors of review articles will be as even-handed as possible—
that is, reasonably comprehensive and unbiased in the selec-
tion of the work they discuss. Indeed, an important question
for peer reviewers is whether a review article is objective and
balanced.
Expert testimony in the courtroom is very different. In
contrast to scientific procedures, an expert witness in court is
expected to give an educated guess, not to produce evidence.®
Whether expert testimony is admitted in court turns largely
on the witness’s “credibility’—which means his or her cre-
dentials. Does the expert have the appropriate training and
experience? Even these rather minimalist standards are often
only loosely applied. In the courtroom, one scientist can seem
much like another. Some distinctly second-rate scientists tes-
tify in trial after trial and consult in case after case, sometimes
even earning their living that way. In essence they become well-
practiced, professional witnesses, whose major talent is con-
vincing juries, not evaluating evidence. In fact, they may cite
no evidence at all, or allude to evidence only vaguely, without
giving its source. Sometimes, they refer to their own, unpub-
lished work as evidence, but no one has the opportunity to
evaluate its validity or even to know whether it exists. Many rep-
utable scientists refuse to be expert witnesses in court, proba-
bly in part because they find the adversarial process an un-
satisfactory way to arrive at scientific conclusions and therefore
feel uncomfortable participating in it. Often experts are cho-

sen whose field is not relevant to the scientific question that
needs answering. In many of the breast implant cases, for ex-
ample, plaintiffs’ attorneys have relied on pathologists or tox-
icologists to speculate about how breast implants might cause
connective tissue disease, rather than calling on epidemiolo-
gists who would get to the question of whether they actually
do. In the Stern case, for example, her key witnesses consisted
of a pathologist, a toxicologist, and an immunologist.* Even
more troubling, expert witnesses are selected by the contest-
ing lawyers, paid by them, and their testimony is rehearsed in
advance—circumstances unlikely to ensure competence, let
alone objectivity. In fact, the whole point is precisely to find a
“qualified” witness who will be scientifically committed to your
side. The irony here is that a lawyer may employ a scientist to
offer eccentric views in a court proceeding that is supposed to
hold manufacturers to generally accepted, mainstream stan-
dards.
AFTER CONTRIBUTING SO decisively to the handsome verdict in

the Stern case, Dan Bolton was on a roll. He left Hersh and
Hersh and went on to become a partner in another firm and
a magnet for breast implant suits. The decision in Bolton’s
next big case—the case of Mariann Hopkins—was appealed
all the way to the Supreme Court, which refused to review it.
In its own way, this case was even more influential than the
Stern case, because it was instrumental in the FDA ban.
Mariann Hopkins, of Sebastopol, California, a secretary
at Sonoma State University in nearby Rehnert Park and the
wife of a San Francisco firefighter, was in her early thirties
when she underwent a double mastectomy in 1976 because of
fibrocystic disease of the breast.° This is a very common con-
dition that produces tender nodules in the breasts, particularly

just before menstrual periods. Whether it is a precursor of
breast cancer or not has been debated for decades. The con-
sensus is that it usually isn’t, although some forms of it may
increase the risk. In any case, Hopkins evidently did not want
to take the chance. After her mastectomy she had her breasts
reconstructed with silicone-gel-filled implants, manufactured
by Dow Corning. Within a few months, one of them ruptured,
and to maintain symmetry she had them both replaced.
Three years later, in 1979, she was told she had an au-
toimmune disorder called mixed connective tissue disease.
This is a devastating disease, with clinical features of systemic
lupus, rheumatoid arthritis, polymyositis, and scleroderma,
all rolled into one. Typically, the disease produces very high
levels of antibodies against constituents of the patient’s own
cells. Mixed connective tissue disease is incurable, and Hop-
kins had to be treated indefinitely with corticosteroids, which
can produce a variety of serious side effects. In 1986, seven
years after the diagnosis, Hopkins gave up her job because of
her disabling disease. The same year she again had her breast
implants replaced because one had ruptured.
In 1987, Hopkins’s mother told her that she had heard
there was a link between ruptured breast implants and au-
toimmune disorders. Hopkins queried her doctors, who told
her they knew of no such connection. She later said the
rheumatologist who was treating her mixed connective tissue
disease, Dr. Stephen Gospe, was “very patronizing. He said
people always need something to blame and I might as well
accept my illness.” The next year, however, Hopkins happened
to turn on the evening news as she came into her house from
the grocery store and saw a clip of Bolton, along with Sybil
Goldrich, talking about the effects of silicone leakage on the
immune system. (Goldrich, you will remember, is co-founder

of the advocacy group Command Trust Network; Bolton was
at the time testifying before the November 1988 FDA advisory
panel.) To Hopkins, seeing Bolton on television was little
short of a miracle. As she said later, “If I’d turned it on one
minute later, I would have missed it.” But she didn’t miss it,
and she straightaway phoned Bolton in San Francisco. Hop-
kins said of that conversation, “I learned there were other
women besides myself who’d had problems with implants. I
said ‘Why haven’t I heard of this?’ He said, ‘Because there have
been suits filed against Dow Corning and they have settled out
of court, and then all the documents are kept under lock and
key.’ ” The next month, she and Bolton filed suit against Dow
Corning in federal court in San Francisco.®
At the trial three years later, in 1991, Bolton called three
expert witnesses to testify as to the cause of Hopkins’s dis-
ease—Marc Lappé, Nir Kossovsky, and Frank Vasey. Because
these three, whom I introduced in the preceding chapter,
have been so important in breast implant litigation, it is worth
examining their credentials in some detail. Lappé, who you
may recall from Chapter 5 has a Ph.D. in experimental pathol-
ogy, testified in the Stern case, as well as the Hopkins case, ac-
cording to an article in American Lawyer.’ In both cases, his tes-
timony primarily concerned his interpretation of the Dow
Corning laboratory studies. In his view Dow Corning’s animal
studies indicated that breast implants may have contributed
to Stern’s and Hopkins’s illnesses. A 1995 computer search of
Lappé’s own publications, as compiled by the National Li-
brary of Medicine, is revealing. As mentioned earlier, he pub-
lished his theory about the way in which implants might cause
autoimmune disease in an article in the journal Medical Hy-
potheses, confidently titled, “Silicone-Reactive Disorder: A New
Science in the Courtroom: Opinions without Evidence #® 121
Autoimmune Disease Caused by Immunostimulation and Su-

perantigens.” As a hypothesis, it contributed no new evidence.
In its 1994 review of the scientific evidence in the breast im-
plant controversy, the British Department of Health said
Lappé’s paper “has nothing to add to the issue of a causal re-
lationship between silicones, immunological responsiveness
and disease.”* Of Lappé’s 50-some scientific papers in the Na-
tional Library of Medicine’s database, only one other dealt
with the subject of breast implants. (His other papers have
dealt mainly with the ethics of genetic screening.) He also pub-
lished a 1991 book, Chemical Deception: The Toxic Threat to Health
and the Environment.
Kossovsky is an M.D. certified in anatomic pathology, the
study of diseased tissues.'? An assistant professor at the UCLA
Medical Center, he has been a very popular and effective
plaintiffs’ witness in breast implant cases. At the time of the
Hopkins trial, Kossovsky was in his early thirties and looked
younger. Pleasantly voluble, with an engaging, eager manner,
Kossovsky gives the impression of wanting nothing more than
to explain the immune system to the jury. He believes that sil-
icone changes body tissues in such a way that the body no
longer recognizes them as native. In its effort to reject what it
interprets as “foreign” invaders, the body mounts an autoim-
mune reaction that leads to connective tissue disease. Despite
Kossovsky’s long-standing attachment to this theory, there is
still no good evidence for it.
Bolton’s third witness on causation was Frank Vasey, the
chief of the Division of Rheumatology at the University of
South Florida College of Medicine.'! Rheumatology is the
medical specialty concerned with connective tissue disease.
Vasey, a physician, has reported a group of patients with breast
implants who had connective tissue disease or symptoms sug-
gestive of it, most of whom felt better after the implants were
removed. In medical practice, it is not unusual for a specialist
who attracts patients with a certain type of problem to gain er-
roneous impressions about its frequency or its association with
other conditions. Without controls and appropriate popula-
tion sampling techniques, it is easy to draw conclusions that
will not stand up to later, more careful epidemiologic analy-
sis. Even a large clinical experience, while possibly suggestive,
cannot substitute for a cohort or case-control study in getting
at whether implants cause disease. The history of medicine is
replete with examples of mistaken “clinical impressions” based
on uncontrolled and often undocumented personal experi-
ence. One of the major advances in modern medicine is the
realization that to be reliable, personal experience must be
supported by rigorous research.
None of Bolton’s witnesses was an epidemiologist. Yet this
is the only kind of specialist who could authoritatively speak
to the issue of a possible link between breast implants and con-
nective tissue disease.
Perhaps the most startling testimony on the other side was
that of Hopkins’s own rheumatologist, Stephen Gospe. Gospe
had definitively diagnosed Hopkins’s mixed connective tissue
disease in 1979, but he believed her symptoms began even be-
fore she received her first set of implants in 1976. Indeed, be-
cause of suggestive symptoms, her internist, Dr. Louis Pelfini,
had in 1975 ordered a test for autoimmune disease, which at
the time was inconclusive. Because her symptoms persisted,
Pelfini sent her to Gospe in 1979. Gospe’s testimony that her
symptoms had begun before her first implants were placed in
1976 might have been expected to undermine the plaintiff's
case. But evidently it didn’t trouble the jurors. On December
13, 1991, the jury awarded Hopkins $7.34 million. Dow Corn-
Science in the Courtroom: Opinions without Evidence @& 123
ing was found guilty of fraud and malice in marketing the im-
plants.'* The evidence included the Dow Corning memo in-
structing salespeople to wash off demonstration implants so
that plastic surgeons would not notice the oiliness of the en-
velope. The Hopkins case reached its climax just as David
Kessler was deciding whether to permit implants to stay on the
market. This timing, nearly everyone agrees, greatly influ-
enced the FDA’s ultimate decision.
Dow Corning (which went out of the implant business a
few months after the Hopkins decision)'*appealed to the U.S.
Court of Appeals for the Ninth Circuit. Signaling the signifi-
cance of the case, two renowned lawyers joined the fray in the
appeal. Harvard Law School professor Laurence Tribe headed
the Hopkins-Bolton team. Shirley Hufstedler, Jimmy Carter’s
former secretary of education and a former judge of the Ninth
Circuit, joined Frank Woodside III for Dow Corning’s defense.
The defense’s appeal was based on two arguments. The first
concerned the statute of limitations, a technical argument of
interest to lawyers but probably no one else. The second ar-
gument was whether the testimony had established that it was
more probable than not that there was a causal connection be-
tween Hopkins’s breast implants and her mixed connective tis-
sue disease—the second necessary condition for a product li-
ability judgment. The first condition had clearly been met: no
one doubted that Hopkins was sick. But the other two condi-
tions were in contention, and the satisfaction of the third (that
Dow Corning had been negligent or wanton) was contingent
on proving the second (that the implants most likely caused
the mixed connective tissue disease). The appellate court was
asked to consider whether the lower court had adequate evi-
dence for this finding. And in particular, was it correct in re-
lying on the expert testimony Bolton had assembled?
Dow’s Woodside (a physician as well as a lawyer) had ar-

gued in lower court that Lappé, Kossovsky, and Vasey were not
qualified to testify as experts on causation, but the trial judge
had disagreed. The appeal was largely based on the same ar-
gument, and again it was dismissed. Although the appeals
court noted that scientific testimony must be “not only rele-
vant, but reliable,” it ruled that the testimony of Kossovsky,
Lappé, and Vasey had met this standard. Kossovsky and Vasey,
according to the court, had based their opinions in part on
“preliminary results” of epidemiological studies they were con-
ducting. Four years later, in a search of the medical literature,
I was unable to find that either of them has published a rig-
orous epidemiologic study that could shed light on the ques-
tion of causation. Lappé was said to be “a recognized expert
on the immunological effects of silicone in the human body,”
although a search of the National Library of Medicine’s com-
prehensive database shows that he has published very little on
the subject.
Judge Procter Hug, writing for the Court of Appeals, not
only accepted the testimony of the three witnesses, but his
opinion indicated that he was utterly convinced about the
substance of the matter—not just about the procedural ques-
tions.!° He was certain, even if most scientists were not, that
breast implants cause mixed connective tissue disease. Refer-
ring to the many thousands of women who have Dow Corn-
ing implants, the judge said, “Each of these women was at risk
of encountering the same fate from which Hopkins suffered.”
As for Dow Corning, he said, “Dow’s conduct in exposing
thousands of women to a painful and debilitating disease, and
the evidence that Dow gained financially from its conduct, may
properly be considered in imposing an award of punitive dam-
ages.” The harshness of Judge Hug’s conclusion reflected the
Science in the Courtroom: Opinions without Evidence @ 125
emphasis in the case on the Dow Corning documents. Dow

Corning petitioned the U.S. Supreme Court for review. The
petition was refused, thus letting stand the appellate court’s
decision.'° Bolton’s experts had done their job well.
WITH THE ASTONISHING EXPLOSION of scientific knowledge over

the last century, and particularly in the last 50 years, expert tes-
timony has become increasingly important in the courts. In
particular, there are few product liability suits in which expert
testimony is not central. In the Hopkins case, for example, the
testimony of Lappé, Kossovsky, and Vasey was pivotal. But even
as expert testimony became commonplace in the courtroom,
legal scholars and judges began to fret about its role. Who was
an expert? How should expert testimony be received and what
weight should it have? As far back as 1858, the U.S. Supreme
Court foresaw the problems in store. It observed then that “ex-
perience has shown that opposite opinions of persons pro-
fessing to be experts may be obtained to any amount,” and it
went on to complain that cross-examination of all these ex-
perts was virtually useless, “wasting the time and wearying the
patience of both court and jury, and perplexing, instead of elu-
cidating, the questions involved.”!”
In 1897, possibly because it had heard enough, the
Supreme Court decided to cut things short by limiting cross-
examination of experts. In considering an insanity defense for
a man accused of murder, an expert witness had been asked
in lower court, “What does medical science teach as to that?”
Incredibly, the witness was told by the trial judge that he didn’t
have to answer that question. On appeal, the Supreme Court
agreed, saying that once an expert gives his opinion, the court
should take it or leave it. It would be “opening the door to too
wide an inquiry to interrogate him as to what other scientific
men [sic] have said upon such matters, or in respect to the gen-
eral teachings of science thereon, or to permit books of sci-
ence to be offered in evidence.” The message, then, was not
to delve into something as arcane as scientific evidence. What-
ever a qualified witness said was okay.
This decision pretty much settled the issue until a federal
trials court in 1923 reached the polar opposite conclusion in
Frye v. United States. In Frye, the issue in contention was whether
a “lie detector test” (which in those days was simply a blood
pressure reading) would be admitted as evidence. The court
refused to admit it, on the grounds that there was not yeta sci-
entific consensus about the validity of this new method. Far
from agreeing with the Supreme Court that experts needn’t
take into account the work of other scientists, the Frye court
said that testimony must speak to the work of others—that is,
it was admissible only if it incorporated principles and meth-
ods generally accepted by the relevant scientific community.
The Court of Appeals agreed. Thus was born the “general ac-
ceptance” standard for expert testimony, a subject of intense
legal debate for the next 70 years. This standard had the ef-
fect of excluding a good deal of what has become known as
“junk science”—patently absurd testimony by zealots, incom-
petents, or opportunists. But the Frye standard was by no
means accepted in all courts. Its opponents claimed, some-
what improbably, that it would tend to exclude novel, far-
sighted testimony by modern-day Galileos.'* There is no
record of this happening once, let alone often. Furthermore,
even if a modern-day Galileo did not make it into court at first,
that fact would not stop him from prevailing in the scientific
community. Courts do not determine scientific acceptance, as
implied by the argument that we need to keep our courts
open to the hidden Galileos in our midst.
What the don’t-ask-don’t-tell approach of the 1897

Supreme Court had in common with the Frye decision was that
both avoided coming to grips with the substantive issue of
how to define good scientific evidence that would qualify for
admissibility in court. Frye evaded the issue by setting up a
proxy, and a very good proxy it was: Good science was deter-
mined by other scientists through their usual methods—peer
review and publication, criticism, replication—and, most im-
portant, by its reliability in predicting future results. (These
were not the words of Frye, but they are its effect.) In 1975 new
Federal Rules of Evidence were signed into law by President
Ford. These detailed rules for admitting evidence into federal
courts contain criteria for scientific testimony that include va-
lidity but omit the requirement for general acceptance in the
scientific community. Whether the new, more liberal Rules su-
perseded Frye or not was not clear. Some courts went with Frye,
others with the Rules, and others simply followed their own
instincts. The courts thus continued their chaotic approach
to the problem, even while product liability suits were bur-
geoning and scientists themselves were having a difficult time
keeping up with the rapid advances in their own fields.
In 1993 the U.S. Supreme Court finally grasped the net-
tle and attempted to deal substantively with the problem of ex-
pert testimony in the courts. The case that occasioned the
Supreme Court’s attention, Daubert v. Merrell Dow Pharmaceu-
ticals, was in many respects similar to the breast implant cases."
The case was brought against Merrell Dow Pharmaceuticals in
1984 by the parents of two boys who had been born with only
rudimentary arms, a well-known congenital mishap (these
sorts of defects occur in about 1 in 1,000 births). The parents
alleged that the defect had been caused by Merrell Dow’s Ben-
dectin, an antihistamine-like drug that the two mothers had
taken during pregnancy to combat morning sickness. Ben-

dectin was an extraordinarily popular drug, prescribed for
pregnant women almost as routinely as vitamins. Some 17 mil-
lion women took it (as did I) between 1958 and 1983. It is not
surprising, then, that even if there were no connection, babies
with upper-limb defects would sometimes be born to mothers
who had taken Bendectin, just as connective tissue disease
would sometimes develop in women who had breast implants
even if there were no causal connection between the implants
and the disease.
Merrell Dow’s Frank Woodside (who would later be Dow
Corning’s attorney in the Hopkins case) had argued at first
that the case should not be tried at all. He pointed out that
there had been many epidemiologic studies published in the
scientific literature, involving some 130,000 women, none of
which had been able to showa connection between Bendectin
and birth defects. The plaintiffs, however, produced eight ex-
pert witnesses who testified to Bendectin’s ability to cause
birth defects, although they could point to no epidemiologic
evidence. One witness testified that she had reanalyzed the
published studies that Woodside cited and had come to the
opposite conclusion, although she had not published her
work. The trial court, citing Frye, agreed that the plaintiffs had
produced no admissible evidence. The appeals court agreed.
The Supreme Court was then asked to speak to the narrow
issue of whether Frye was the approriate standard or whether
it had been superseded by the 1975 Rules of Evidence. Mer-
rell Dow favored Frye, since it had worked well for them, but
the plaintiffs wanted the less stringent Federal Rules of Evi-
dence to prevail.
The Supreme Court dispensed quickly with the narrow
question. Yes, the Federal Rules did supersede Frye, and the
case was passed back to the appeals court to hear again under
those rules. The Supreme Court made no attempt to decide
whether Bendectin caused birth defects, only what the stan-
dards for the admissibility of expert evidence should be. But
the Court also devoted considerable attention to elucidating
the meaning of those standards and how they were to be ap-
plied, thus finally dealing with the issue of what constitutes
good science. A large number of interested individuals and or-
ganizations, including the New England Journal of Medicine,
were aware of the enormous impact the Daubert decision might
have. The Court was therefore flooded with amici briefs on
both sides. These revealed interesting schisms within the sci-
entific community. Many favored the Frye standard (as did
we), because they felt it would reduce the amount of junk sci-
ence finding its way to the courts. We argued that testimony
should be based on research that had been duly published in
peer-reviewed journals. But equally reputable scientists came
down on the other side, because they felt the “general accep-
tance” criterion was too restrictive and elitist. And many
lawyers also opposed the Frye standard because they believed
it would preempt the responsibility of juries to decide the
facts. :
In the end both sides in the Daubert case claimed victory—
or defeat, depending on whether one is inclined to see the
glass as half full or half empty. The Supreme Court said that
while the Federal Rules applied, this did not mean that all ex-
pert testimony would be admissible. Far from it. Federal judges
are now required to undertake “a preliminary assessment of
whether the reasoning or methodology underlying the testi-
mony is scientifically valid and of whether that reasoning or
methodology properly can be applied to the fact in issue.”
Thus, judges are to be the gatekeepers who decide whether
to admit expert testimony. This was not what either side

thought they wanted. The Frye proponents wanted the scien-
tific community to be gatekeepers. The other side didn’t want
any gatekeepers; let the juries decide on the basis of the cross-
examination. But in Daubert, the Supreme Court said that
judges must decide, and they must do so by learning how to
think like scientists. Expert testimony must be both “reliable”
and “relevant,” and judges should decide in advance whether
it was. Writing for the majority, Justice Harry Blackmun em-
phasized the importance of relevance by pointing out that tes-
timony about the effect of the phases of the moon on irrational
behavior might be quite valid as to the astronomical data, but
totally irrelevant in drawing any inference about behavior.
What is relevant in one context may not be in another. This
requirement that expert testimony be apposite to the matter
at hand was at issue in the appeal of the Hopkins decision.
Many concerned about the increasingly contentious re-
lations between law and science welcomed the Daubert deci-
sion. Bert Black, a lawyer and then-chair of the American Bar
Association’s Standing Committee on Scientific Evidence, and
Francisco Ayala, a scientist and then-president of the Ameri-
can Association for the Advancement of Science, together
with a colleague, Carol Saffran-Brinks, wrote a celebratory
analysis in the Texas Law Review.*° Despite the fact that both
Black and Ayala had participated in an amicus brief on behalf
of Merrell Dow—technically the losing side—they saw the ac-
tual written judgment as a cause for hope that the days of junk
science in the courtroom were numbered. In particular, they
approved of the sophisticated analysis of what good science is.
The Supreme Court embraced the notion of Karl Popper, the
philosopher of science, that good science requires formulat-
ing a question that can be answered. In other words, any hy-
Science in the Courtroom: Opinions without Evidence #® 131
pothesis must be capable of being tested. It is useless to come

up with a theory, no matter how plausible, that cannot be
proved or disproved. Black and his colleagues, in a section on
the “pathological science” that stems from ignoring the ne-
cessity for testing and corroboration, describe it as “charac-
terized by a fixation on effects that are difficult to detect, a
readiness to disregard prevailing ideas and theories, and an
unwillingness to conduct meaningful experimental testing.”
This description is relevant in the breast implant controversy.
The common contention that breast implants cause diseases
that cannot be objectively described is a theory that cannot be
tested. Doctors who believe in it simply assert that such dis-
eases exist and that they know them when they see them.
For those who might have thought the Supreme Court’s
Daubert decision heralded a new, more rational era in the
courts, let alone mere consistency, subsequent events are in-
structive. The Supreme Court decided the Daubert case in
1993, sending it back to the Ninth Circuit Appeals Court for
reconsideration. By coincidence, this was the same court that
considered the appeal in the Hopkins case in 1994. The
Daubert decision was handed down after the Hopkins verdict
but before the appéal. A major issue in the petition to the U.S.
Supreme Court was the failure of the Ninth Circuit Appeals
Court to adhere to the Daubert criteria. As we have seen, the
appellate court found the expert testimony in Hopkins ad-
missible, even though its decision was handed down after the
Daubert decision. Just a year later, however, the same court
found that the testimony that Bendectin caused birth defects
was not admissible.*' I believe that in neither case had the tes-
timony clearly met the Supreme Court’s requirement for re-
liability and relevance. Even more difficult to comprehend is
the fact that the Supreme Court itself, after its insightful analy-
132. @ SCIENCE ON TRIAL
sis of good science in Daubert in 1993, let stand the Hopkins

decision in 1995. (If you are having trouble following all this,
it is not your fault, or even mine.) The inconsistency of the de-
cisions surely underscores the continuing confusion about
what kind of scientific evidence should be admitted in court.
The Daubert decision doesn’t seem to have helped much, at
least not yet.
As I have noted, scientific testimony in the courtroom is
often at most only marginally related to scientific evidence. To
be sure, there are superficial matters of form that may suggest
a resemblance between science in and out of the courtroom.
Expert witnesses may wear white coats, be called “doctor,”
purport to do research, and talk scientific jargon. But too
often they are merely adding a veneer to a foregone, self-
interested conclusion. Sometimes they spin theories that they
say are supported by their expertise or experience. Or they
may refer vaguely to research. Very often, however, the “re-
search” is their own and it is unpublished and unavailable. The
point is that they are not required to produce their evidence,
and they usually do not. The result is a growing gap between
scientific reality and what passes for it in the courtroom. The
Daubert decision was a brave step toward remedying the situa-
tion, but it was not enough. In Chapter 10, I will discuss other
solutions.
7
GREED AND CORRUPTION:
ALL THAT FREE MONEY
Q: Your family wants you to take the money

and run?
A: I think so.
—Healthy woman with implants interviewed on
KHOU-TV, Houston,
October 10, 1994
ny moralist who wanted to preach about the corrupting

A effects of money could find no better parable than the
story of silicone breast implants. The lure of money perme-
ates all aspects of the saga. It goes without saying that the man-
ufacturers and plastic surgeons had financial interests in
maintaining that the implants were safe—even when they
didn’t know whether that was true. What is far less obvious
are the outsized interests of the other players—the plaintiffs’
and defense lawyers, the doctors who diagnose and treat
women with breast implants, the witnesses and consultants
who sell their expertise for around $500 hourly,’ and the
women with breast implants who are most probably not sick
but will not pass up the opportunity to gain from the dispute.
As billions of dollars change hands, we should remember
where the money originates. It comes from consumers who

buy any of the goods made by breast implant manufacturers
or by other manufacturers who are insured for liability costs
by the same insurors. Whenever a consumer purchases a
Corning Ware dish, for example, he or she also pays a “tort
tax.” Case by case, settlement by settlement, the billions of dol-
lars collected in this way are transferred to the plaintiffs, their
lawyers, and the doctors and scientists who help them, as well
as the inevitable administrative apparatus that oversees the
transfer.
Sometimes the transfer of funds from manufacturer to
plaintiff and lawyer occurs in large, seemingly arbitrary
chunks. The best example is the $25 million verdict awarded
in 1992 to Pamela Johnson of Houston.’ This verdict eclipsed
the record $7.34 million awarded to Mariann Hopkins. Para-
doxically, despite the size of the verdict, the Johnson case was
weak. Pamela Johnson, a forty-six-year-old administrative as-
sistant, claimed that when one of her breast implants rup-
tured, the silicone gel released into her tissues caused her to
become ill. The nature of the illness was not clear. According
to her lawyer, she had asilicone-induced “autoimmune dis-
order, in which she feels like she has a bad case of the flu all
the time.” But she had apparently not been diagnosed as hav-
ing any well-recognized immune disorder or connective tissue
disease. Instead, she had a variety of vague, nonspecific com-
plaints, such as recurrent sinusitis, sore throats, colds, and
bladder infections.* Thus, this case did not clearly fulfill even
the first of the usual conditions for a product liability suit, since
the medical harm suffered by Pamela Johnson was nebulous.
With the Johnson case, the center of breast implant liti-
gation shifted from San Francisco to Houston, where John
O’Quinn, of the law firm O’Quinn, Kerensky & McAninch,
quickly established himself as the plaintiffs’ attorney who
Greed and Corruption: All That Free Money #® 135
could make the most from the least. His tactic was to glide over
the issue of whether Johnson was sick, and concentrate instead
on her concern that she might get sick. He also seized every
opportunity to shift the jury’s focus from Johnson to all the
other women with breast implants. He suggested that Johnson
was somehow a proxy for these other women, all of whom
shared fears engendered by the implants—certainly a self-
fulfilling prophecy, if ever there was one.
Johnson had breast implants for augmentation in 1976,
the year implants came under the purview of the FDA. At the
time she was twenty-nine years old. The implants were made
by Medical Engineering Corporation (MEC), later a sub-
sidiary of Bristol-Myers Squibb. Johnson was apparently fine
until 13 years later, when her breasts became hard. She went
to see her plastic surgeon, Philip Rothenberg, who performed
a closed capsulotomy to break up the scar tissue—despite the
fact that the package inserts had for six years (during which
Rothenberg performed many implantations) warned that this
procedure was known to carry a high risk of rupture. Within
a few days, her left breast was swollen and painful. Rothenberg
operated, and found, not surprisingly, that her left implant
had ruptured. According to the testimony in the trial, Rothen-
berg found it so difficult to clean out the spilled silicone gel
that he had to do a partial mastectomy. He then put in an-
other set of implants, also made by MEC. Unhappy with the
appearance of her breasts, Johnson consulted another plas-
tic surgeon, Fabian Worthing, who replaced her implants with
a pair made by another manufacturer. Three years later, in
1992 (the year of the FDA ban), she returned to Worthing
complaining of fatigue and other vague symptoms that she
said doctors had attributed to the implants. Worthing re-
moved them.
O’Quinn had a weak case. Everything depended on cre-
ating sympathy for Johnson, on the face of it not an easy

prospect. Johnson’s implants were cosmetic, which many peo-
ple frown on. More important, unlike Mariann Hopkins, John-
son did not have a recognized autoimmune or connective tis-
sue disease. Although she spoke tearfully of “sinus infections,
sore throat infections, upper respiratory infections, bladder in-
fection ... one right after the other,” this is not usually the
stuff of multimillion-dollar suits. The complaints might seem
more likely related to her cigarette habit, rather than her
breast implants. Furthermore, since Rothenberg may have
ruptured her left implant, shouldn’t he be the target of the
suit? O’Quinn had to convince the jury that the implants had
ruptured because they were defective, not because Rothen-
berg performed a closed capsulotomy. Subtly, O’Quinn
shifted the usual burden of proof. Instead of the plaintiff hav-
ing to show harm, the manufacturers had to show the im-
plants were safe.
There were good, practical reasons for suing the manu-
facturer rather than the plastic surgeon. First, it is safe to as-
sume that Bristol-Myers Squibb had deeper pockets than
Rothenberg. Second, juries are generally less sympathetic to
large, impersonal corporations than they are to doctors.
Rothenberg had originally been named as a defendant, but
Johnson dropped her claim against him before the trial.
Rothenberg ultimately testified for Johnson and O’Quinn.
O’Quinn’s partner, Richard Laminack, first realized the
advantages of suing the manufacturer instead of the plastic
surgeon in 1988, when, according to an interview in Texas
Monthly, a surgeon told him, “I know you’re suing me, but I
could be your best witness.”* A case of medical malpractice was
thus converted to a product liability case. In Texas, however,
it is best to name the surgeon in the suit initially, as well as the
manufacturer, then drop the surgeon’s name. This maneuver

helps to ensure that the case is tried in a state court instead of
a federal court. If the surgery was done in the state and the
lawsuit includes the surgeon, it is a state case. That is a tremen-
dous advantage in Texas where the courts are notoriously
friendly to plaintiffs’ attorneys.
The pattern of suing the doctor along with the manufac-
turer, then dropping the suit against the doctor in return for
his or her cooperation, is well recognized in breast implant
cases.° Helpful doctors can greatly strengthen a plaintiff's case.
Implant manufacturers themselves have contributed to the
likelihood of the surgeon supporting the plaintiff by refusing
to indemnify plastic surgeons when they are sued—in contrast
to automobile companies, which routinely indemnify car deal-
erships for the costs of litigation. This is a very short-sighted
economy. The plastic surgeons are then at the mercy of the
plaintiffs’ attorneys. They can either cooperate with the plain-
tiff or risk being a target of the suit themselves.
So successful was O’Quinn in the Johnson case that it was
the subject of a teaching videotape (Video Trial Report, a
joint venture of American Lawyer magazine and Courtroom
Television Network). Titled “Look Over Here: Johnson v.
Bristol-Myers Squibb Company,” the tape was subtitled, “How
Houston Plaintiff's Lawyer John O’Quinn Won the Largest
Breast Implant Verdict to Date by Keeping a Jury on the
Strongest Elements of His Case.” The narrator makes it clear
that O’Quinn had to avoid the issue of whether Johnson was
sick and instead concentrate on the possibility that she might
in the future become ill because of the silicone in her body.
O’ Quinn spoke of “all the lymphomas and the cancer and all
the real serious diseases of that nature that are found among
these hundreds of thousands of women with this condition.”
More specifically, he evoked the story of Johnson’s mother,

who had breast cancer, implying that breast implants might
increase Johnson’s risk of suffering a similar fate.
O’Quinn’s most successful witness was the youthful, in-
gratiating Nir Kossovsky (whom I introduced in Chapters 5
and 6), by now well experienced in breast implant cases. Using
markers and a large pad mounted on a tripod, Kossovsky de-
livered an eager lesson in immunology, illustrated with draw-
ings of white cells. He showed the white cells taking part in in-
flammation, which he said could progress to an immune
reaction, then an autoimmune reaction—a hypothetical se-
quence stated as fact. He also said that the sequence could be
caused by breast implants, despite the lack of evidence on this
point. Quite apart from the unproved assertions in Kossovsky’s
testimony, it was not at all clear that his theory had anything
to do with Johnson. Although the plaintiffs side implied that
breast implants had affected Johnson’s immune system, it was
not claimed that she was suffering from a known autoimmune
disease, such as rheumatoid arthritis or systemic lupus ery-
thematosus (diseases Kossovsky himself mentioned when
asked for examples of autoimmune disorders). But unless
Johnson had an autoimmune disease, it is difficult to under-
stand how Kossovsky’s testimony fulfilled the Supreme Court’s
requirement for relevance.
One of Bristol-Myers Squibb’s expert witnesses, Noel
Rose, professor of pathology and of molecular microbiology
and immunology at Johns Hopkins University and a widely rec-
ognized authority on autoimmune diseases, said that on the
basis of Johnson’s medical records he thought it “highly un-
likely” that she had an autoimmune disorder. Yet the narra-
tor of the videotape referred to Rose ironically as “one of the
best witnesses for the plaintiff.” Perhaps this characterization
Greed and Corruption: All That Free Money ® 139
was partly because of his scholarly mien and cautious answers,

which contrasted with Kossovsky’s quick certainties. But it was
also because when O’ Quinn asked Rose whether he could un-
derstand the fears of women with silicone in their bodies,
Rose answered, “I can imagine how they feel. Of course, I’m
not in that position myself.” When O’Quinn responded,
“You’re lucky,” Rose answered, “Iam indeed.” Did Rose mean
he was lucky not to be Johnson, or did he mean he was lucky
to be Rose? It was impossible to tell. He has since told me he
was merely affirming his “sympathy for all of the women who
have had breast implants and been told that they have silicone
‘time bombs’ in their bodies.” In any case, this double enten-
dre was apparently all it took to undercut Rose’s substantive
testimony that Johnson most probably did not have autoim-
mune disease and that there was no scientific evidence of a
connection between breast implants and such diseases, any-
way. On such subtle theater turns a $25-million verdict.
The jury in the Johnson case was acting in the generous
tradition of juries hearing product liability suits. When a plain-
tiff seems hurt, vulnerable, and appealing (Johnson was very
tearful), and the company is large, anonymous, and impervi-
ous, juries are predisposed to even up the score. O’ Quinn also
was very careful in selecting his jury. He hired consultants
from the Wilmington Institute, a jury research organization in
Dallas, who studied the attitudes of potential jurors on the
breast implant issue and helped to rehearse the testimony. Ac-
cording to the National Law Journal, O’Quinn did not accept
jurors who were reluctant to award damages for pain and suf-
fering or verdicts larger than $1 million. He was also very
watchful for prospective jurors who might be biased against
women who had implants for augmentation.° O’ Quinn is said
to be convinced that blue-collar men make ideal jurors in
breast implant cases, because they are guilty about pressuring

women to acquire large breasts; upper-middle-class white
women are the worst, because they are likely to have consid-
ered implants, but rejected the idea.’
The jury was generous to O’Quinn, as well as to Johnson.
His fee was 40 percent of the award (45 percent if there had
been an appeal), plus expenses.® Although O’Quinn had al-
ready established a highly successful career as a plaintiffs’ at-
torney, winning more than a billion dollars in his three largest
verdicts—a 1986 case against Monsanto, a 1988 case against
Tenneco, and (after Johnson) a 1993 case against Amoco®’—
this was his first breast implant case and he clearly intended
to make it good. After his stunning victory, his firm overnight
became the vortex of breast implant litigation, with some 700
cases pending by the end of 1992."°
Plaintiffs’ attorneys like to present themselves as the
champions of the little people, and some of them are. But
many of them are far from being little people themselves.
John O’Quinn, for example, was listed in a 1989 Forbes mag-
azine article as the eighth highest paid trial lawyer in the
United States, with a gross income of $8 million in 1988. (Of
the top ten, six were from Texas, five from Houston.) In 1989,
according to Forbes, he was expected to make over $50 million,
because of the breach-of-contract verdict against Tenneco."!
With his explosive entry into breast implant litigation in the
Pamela Johnson case, his fortunes improved. By mid-1995 his
firm had 2,000 clients with breast implants, very few of whom
intended to take part in the class-action settlement.” Forbes
featured O’Quinn again inaJuly 1995 issue, referring to him
as the “king of torts.” O’Quinn told Forbes that his average ver-
dict in a breast implant case is $10 million (yes, that would be
$20 billion if all of his 2,000 clients went to court).!° This
prospect is a powerful incentive for the implant manufactur-

ers to do business with O’Quinn and settle out of court. Ac-
cording to his partner, by mid-1995 the firm had settled 200
cases for over $1 million each and another 300 for less than
that. About 70 percent of the firm’s cases are referred to it by
other lawyers, who receive a portion of the fee.’ This con-
solidation of Houston cases in the hands of O’Quinn, Keren-
sky, McAninch, and Laminack increases the firm’s consider-
able clout with the manufacturers. It is impossible to say
exactly how much in fees the firm’s 2,000-some clients with
breast implants will generate for it, but its average out-of-
court settlement is now rumored to be about a million dol-
lars.!° One can only imagine how the name “O’Quinn” is
greeted within the walls of Bristol-Myers Squibb and Dow
Corning.
There is no doubt that John O’ Quinn stands out ina city
full of vivid, swashbuckling characters. According to Fortune
magazine, he is now worth about halfa billion dollars.!® Not
that his demeanor is aggressive or combative. Far from it. At
fifty-three, O’Quinn is big and imposing, but his manner in
the courtroom is soft-spoken and deliberate. He talks to the
jury in a direct, down-home manner, and treats the plaintiff
with courtly solicitude. In the breast implant cases, he appears
as the compassionate protector of helpless women, a formula
that probably goes over better in Houston than it would in
NewYork. Like Kossovsky, O’ Quinn is very careful not to over-
tax the jurors’ minds. He told the National Law Journal that he
always begins with “a five-minute explanation that is so simple
a 12-year-old child could understand.”"” His easy manner, how-
ever, cloaks an implacable will to win, undeniable shrewdness
in knowing just how to do it, and the cockiness that comes with
doing it so often.
O’Quinn is simply an extreme example of the way in which

many plaintiffs’ attorneys have benefited from the breast im-
plant controversy. For every successful verdict or out-of-court
settlement, a plaintiffs’ lawyer receives a contingency fee of
roughly a third. Dow Corning has estimated that cases that go
to court cost them on average a million dollars (less than
O’Quinn’s firm gets, but not bad). Although manufacturers
refuse to disclose the average amount of out-of-court settle-
ments, they cannot be trivial or women would not accept them.
For a lawyer with many cases, then, the fees add up rapidly.
When Judge Sam Pointer stipulated that a billion of the $4.25
billion class-action settlement would go to the lawyers involved,
it seemed that he was handing them a windfall. In reality, he
was curbing them by limiting them to a 25 percent contin-
gency fee, considerably lower than they are accustomed to.
PLAINTIFFS’ ATTORNEYS in breast implant cases who were not in-

volved in the class settlement had two clear interests: first, that
women opt out of the settkement to make individual claims,
and second, that scientific evidence not emerge to undermine
the premise that breast implants cause disease. Women were
initially given a deadline of June 17, 1994, to opt out of the
settlement. By coincidence, that was one day after the Mayo
Clinic study was published in the New England Journal of Med-
icine. The Journal was as usual available to the media a few days
before the publication date, with the understanding that news
releases would be delayed until publication. In the same issue
was my editorial commenting on the disjunction between the
courtroom activity and the scientific findings. Almost imme-
diately I received phone calls from reporters who had spoken
with plaintiffs’ attorneys eager to discredit the Mayo Clinic, the
New England Journal of Medicine, and me personally. They
pointed out that the Mayo Clinic research was partially funded
by the American Society of Plastic and Reconstructive Sur-
geons’ Educational Foundation, which in turn received funds
from Dow Corning and other breast implant manufacturers.
According to the plaintiffs’ attorneys, this automatically dis-
qualified the study from serious consideration.
A few plaintiffs’ attorneys went so far as to imply that I had
for some reason colluded with the implant manufacturers to
delay publication of the Mayo Clinic study until precisely the
opt-out week.'* The ostensible purpose was to dissuade women
from opting out of the class-action settlement and hiring their
own attorneys. According to this reasoning, if there was evi-
dence casting doubt on a link between implants and connec-
tive tissue disease, women might not do as well in court as they
expected. They might decide it was better just to stay in the
class settlement. When Ifirst heard this accusation, I was puz-
zled. Assuming for the moment I was captive to the breast im-
plant manufacturers, why would I wait until the last minute to
publish the Mayo Clinic study? Wouldn’t I want to publish it
as soon as possible so that even fewer women would opt out?
The answer, according to reporters who had spoken with
plaintiffs’ attorneys; was that by waiting I would sow confusion
in the minds of undecided women, but do so when they no
longer had time to check with their attorneys (who presum-
ably would have straightened them out by assuring them the
Mayo Clinic study was invalid). Aside from the irrationality of
the theory, it ignored the fact that Dr. Sherine Gabriel, first
author of the study, had already presented her findings at a
meeting the previous fall.'° It also overlooked the fact that the
alleged plot would have required the collusion of the other
editors at the New England Journal of Medicine, including the
editor-in-chief. What was clear was that the plaintiffs’ attorneys
144 @8 SCIENCE ON TRIAL
wanted to blame the messenger (the New England Journal of

Medicine) for the message (the results of the Mayo Clinic study).
In fact, the Mayo Clinic study was accepted and scheduled
in the usual way on April 14, about two months before the pub-
lication date. Dow Corning had indeed been a contributor to
the educational arm of the American Society of Plastic and Re-
constructive Surgeons, which had in turn awarded a grant to
the Mayo Clinic for the breast implant study. The grant from
the plastic surgeons was only a part of the funding of the
study, most of which came from the NIH and the Mayo Clinic
itself. The source of funding for the study was duly disclosed
in the Journal, as is our general practice, but not the fact that
Dow Corning had contributed to it. However, the terms of the
grant precluded any influence of Dow Corning on the study.
The grant, which I was later assured was awarded after the
study was designed and launched, was accepted by the Mayo
Clinic on condition that the plastic surgeons’ Educational
Foundation (and, of course, Dow Corning) would not have ac-
cess to the results until after the study was completed. They
would also have no control over whether or where the study
was published. (This is standard practice when a reputable re-
search institution receives a grant from industry.) The plain-
tiffs’ attorneys, however, despite their own obvious financial
interest in the matter, insisted that the grant from the plastic
surgeons invalidated the study.
When the paper was scheduled for publication, neither I
nor any of the other editors had yet heard about the class-
action settlement, let alone the opt-out provision. We did,
however, realize that the study would receive a good deal of
public attention. Anticipating this, we faxed the authors a
query: because of the intense concern about breast implants,
did they wish to disseminate their findings immediately to the
media? We thus made an exception to our usual policy of ask-

ing authors not to discuss their work with reporters until the
full report is published. Dr. Gabriel, the senior author of the
study, immediately responded that she preferred to wait until
the publication date. So much for the theory that the editors
had kept the study quiet to cause last-minute panic.
Some plaintiffs’ attorneys were not satisfied. In October
1994, I was called from a meeting in the editorial offices of the
Journal and handed a subpoena that originated with a Hous-
ton plaintiffs’ attorney. It demanded that I produce a large
number of documents, most of which do not exist. In addition
to all records of the peer review of Gabriel’s study, I was to
hand over any documents that showed that breast implant
manufacturers paid me to publish the Mayo Clinic study. For
example, I was to produce “all documents reflecting or relat-
ing to any payments made by any of the above listed entities
[several manufacturers of breast implants and their parent
companies were named above] to deponent or the New Eng-
land Journal of Medicine concerning the Mayo Clinic study of
Dr. Sherine E. Gabriel.” There were no such payments, and
therefore no documents reflecting or relating to them. The
Massachusetts Medical Society, owners of the New England
Journal of Medicine, filed a motion to quash the subpoena,
which was successful. Our attorneys pointed out that the sub-
poena constituted a blatant fishing expedition. Nevertheless,
in April 1995, I received another subpoena from the same at-
torney. Again, the Massachusetts Medical Society filed a mo-
tion to quash, which again was successful.
I was not the only one to be handed subpoenas originat-
ing in Texas. Gabriel herself was subpoenaed, as were other epi-
demiologists working in the field. As mentioned in Chapter 1,
they were asked to produce absurdly large volumes of docu-
ments, many of no conceivable relevance. The harassment

took its toll. Gabriel described her ordeal in a May 16, 1995,
New York Times article.”” According to the report, plaintiffs’ at-
torneys in Houston have demanded that she produce “over 800
manuscripts from researchers that were here, they want hun-
dreds of data bases, dozens of file cabinets and the entire med-
ical records of all Olmsted County women, whether or not
they were in the study.” Gabriel found the burden of these de-
mands staggering. Dealing with them has taken an enormous
amount of her time and energy and compromised her ability
to do her work. In her view, her experience and that of others
will have a chilling effect on implant research. No one will
want to do it, given the likely consequences. Even more im-
portant, this use of subpoena powers threatens the very exis-
tence of several large epidemiologic databases, including the
one at the Mayo Clinic. These databases depend on the coop-
eration of large numbers of individual doctors. If doctors be-
lieve that their patients’ records cannot be kept private be-
cause they might be subpoenaed, they will simply pull out.
WHAT IS GOING ON IN TEXAS? Readers will wonder why so much

of the breast implant shenanigans seem to be centered there.
Of the nearly 8,000 American women who opted out of the
class-action settlement, most are from Texas.*! Why is that?
And why do the plaintiffs’ attorneys do so well there? A con-
vergence of factors makes for a fascinating story of justice,
Texas style. First, Texas is one of a minority of states that elects
all its state judges, including members of the state supreme
court. There are no limits on the amount an individual may
contribute to these political contests.” Plaintiffs’ attorneys
give handsomely and it is hard to believe that they do this for
purely altruistic motives.
Texas also demonstrates a casual attitude toward the so-

licitation of clients by attorneys. Texas plaintiffs’ attorneys so-
licit women with breast implants openly and aggressively.”
(They are now launched on a similar campaign to find women
with Norplant contraceptive implants.) When women an-
swer these solicitations, which virtually promise free money,
plaintiffs’ attorneys work with certain doctors to build a case.”
In 1989, John O’Quinn apparently attracted attention even in
Texas for his methods. According to Forbes and other pub-
lished sources, he was brought before the bar for violating pro-
fessional standards involving solicitation and fee splitting.
(This was before he got into breast implant litigation.) He re-
ceived a public reprimand and agreed to perform 100 hours
of community service and pay a fine of $38,000.”°
To me, as a physician, the most sobering aspect of breast
implant litigation in Texas is the collaboration between a small
group of doctors and plaintiffs’ attorneys. This is by no means
unique to Texas, but it seems to have reached its most extreme
forms there. Plaintiffs’ attorneys send potential clients to cer-
tain doctors, whose practices may consist largely of such pa-
tients and who may be paid directly by the attorneys. The
arrangement is problematic at best. It is all the more worri-
some in view of the fact that the diseases sought are so ill-
defined.”’
Dr. Robert I. Lewy, a Houston hematologist, is an exam-
ple of a doctor whose work is now largely devoted to women
with breast implants who are considering litigation. He set up
a foundation called Breast Implant Research, Inc. The foun-
dation’s brochure suggests, without explicitly saying so, that
autoimmune disease may be inevitable in women with breast
implants.” He hastens to add that the disorder is unlikely to
conform to the usual diagnostic criteria, in part because it has
components of both connective tissue disease and multiple

sclerosis. Lewy employs a large battery of tests for diagnosis,
including an MRI of the brain and a bone scan, some of them
very expensive. Despite the length of the list, the fact remains
that there is no specific test or group of tests that is known to
diagnose silicone-related illness.
If women are not alarmed for themselves by the dire pre-
dictions in Lewy’s brochure, they must surely be frightened for
their children. The brochure alleges that children of mothers
with implants may have “scleroderma problems of the esoph-
agus causing swallowing difficulties in children who were
nursed, though we see similar problems in those not nursed.”
It goes on to say, “We test children the same way we test moth-
ers, and often, even if there are no symptoms, they have sim-
ilar results at times almost as if they have implants themselves
with antibodies to silicone or lupus or brain masses.” This is
scary stuff. (Remember, the class-action settlement provides
for claims by children of women with implants.)
Lewy implies that breast implants should be removed
(“The more we know about silicone, the less we want to be any-
where near it!”). He also recommends repeat tests every three
months or oftener for women who are takinga variety of med-
ications. (Lewy points out, however, that women can still have
autoimmune disease even with normal tests and no symp-
toms.) He promises a complete report of the test results, con-
tained in a letter addressed to the person who referred the
woman. The diagnosis, he says, may be in “conventional med-
ical terms (‘lupus,’ etc.),” despite the fact that it may not be
strictly accurate. Lewy suggests that the clinical evaluation
could be done by another doctor using a form supplied by
Lewy. (The woman is instructed to reassure the second doc-
tor that he or she will not be called on to testify.) The second
Greed and Corruption: All That Free Money ® 149
doctor simply needs to document the relevant symptoms (and

they are listed in detail for both client and doctor). As Lewy
candidly explains in the brochure, “the manufacturers (and
frankly, jurors) value a woman’s case much lower who claims
that lots of things are wrong with her, but who has never com-
plained of these problems to a doctor or sought treatment,
than a claim that has outside documentation of the com-
plaints. Documentation of the complaint by medical person-
nel is important, but diagnosis of a condition related to them (such
as chronic fatigue, myalgia, fibromyalgia, scleroderma, nerve
abnormalities) is of great value to your claim” (Lewy’s italics).
Lewy apparently does not hold out much hope that women
with breast implants may be healthy. According to the New York
Times, 93 percent of the implant recipients he has seen were
diagnosed as ill. Over 90 percent were referred to him by
lawyers—who, of course, receive the results and diagnosis.
Lewy’s income in 1994 was $2 million.”
At least one woman, a nurse, was apparently frightened
enough by Lewy to seek a second opinion. She later told her
story to reporter John Getter on KHOU, a Houston CBS af-
filiate. Identified only as “Marsha” and filmed in shadow, the
nurse said she did not think she was ill or had connective tis-
sue disease. She visited a plaintiffs’ attorney merely to find out
what she might be entitled to under the class-action settle-
ment. The attorney sent her to Lewy. Although she said she
did not actually see Lewy, a large number of tests were per-
formed, including an MRI, which she was instructed to have
at a particular facility across town, not at her own hospital.
After the tests, she was told she had a lupus-like disease, and
was givena letter to that effect addressed to the attorney who
had referred her. The nurse was genuinely alarmed to hear
that she had what she knew was a serious disease. She was par-
ticularly concerned because she was told she should be treated

with corticosteroids, which she knew could cause damaging
side effects.*° Frightened, she went to see her longtime physi-
cian, Dr. David Pate, who could find no evidence of illness.
When I spoke with Pate, he said that he assumed the diagno-
sis was based on a borderline antinuclear antibody test (which
is not uncommon in normal people) and an MRI that was re-
ported as “abnormal.” Marsha told her doctor that her con-
science would not let her go ahead with the virtual invitation
to sue or make a claim under the class settlement. But in her
interview with Getter, she added “my family will kill me.” Get-
ter asked whether they had wanted her to “take the money and
run.” Marsha replied, “I think so.”
Lewy is not the only doctor in Texas to make a good liv-
ing from women with breast implants. Houston neurologist
Dr. Bernard Patten was featured in a 1994 “CNN Presents” pro-
gram on breast implants called Fire and Fury, Part 4: “The Mer-
chants of Fear.”*! Judy Woodruff, in her introduction to the
program, said, “In the medical debate over the dangers of
breast implants it is easy for women to fall prey to panic and
to grasp at any hope for help. Are there medical hucksters out
there cashing in on that panic for personal profit?” Answer-
ing the question, correspondent Kathy Slobogin spoke of “a
thriving cottage industry of doctors, labs and treatment cen-
ters selling dubious science, pushing questionable diagnoses
and treatments.” Patten performed nerve biopsies on women
with breast implants, and, according to CNN, contended that
80 percent of these women had nerve damage. Colleagues at
Baylor College of Medicine, where Patten was on the faculty
(he has since retired), examined some of the biopsy specimens
at CNN’s request and could find no such damage, nor had
other neurologists seen the phenomenon. This did not stop
Patten from prescribing risky and expensive treatments. One

woman interviewed on CNN said that her treatments, which
included intravenous gamma globulin, corticosteroids, and
antimetabolites, cost about $10,000 a month. Her three hos-
pitalizations cost $30,000 each. She said that she did not feel
any better, but that Patten told her that without the treat-
ments, “You'll be very surprised how quickly you will go down-
hill, and you could potentially die.” According to CNN, Pat-
ten admitted in legal depositions to making more than
$300,000 a year from his breast implant patients.
And what of the scientific experts, those who testify in
court or, more often, consult for attorneys? There are paid wit-
nesses and consultants on both sides. Some of them un-
doubtedly involve themselves because they have strong feel-
ings about the merits of the case. But the money is not bad.
Medical-Legal Aspects of Breast Implants, a newsletter published
by Leader Publications, reports in its April 1995 issue that the
going rate for plaintiffs’ experts is $300 to $600 per hour.
(The board of editors of this newsletter, which costs a hefty
$155 for 12 issues, includes a number of plaintiffs’ attorneys,
as well as Norman Anderson and Sybil Goldrich of Command
Trust Network.) In the same story, the newsletter reports that
one doctor who specializes in filling out paperwork said he
charges about $950 for a consultation and dealing with the
forms. He estimates that he has earned about a million dol-
lars doing this.*”
Nir Kossovsky, who testified in the Hopkins and Johnson
cases, developed a blood test for silicone-related disease, called
Detecsil Anti-SSAA(x) Test Battery. The test was performed by
SBI Laboratories in Pittsburgh, a company founded for the
purpose by Kossovsky, along with his wife and father.” All that
is required for the test is a sample of blood and $350. SBI pro-
moted Detecsil (the name is a contraction of the words “de-

tect silicone”) as providing “a definitive answer to whether sub-
jects are experiencing an immune response to silicone.” This
promotional material, which appeared in lawyers’ magazines,
got SBI in trouble with the FDA, because it suggested the test
could diagnose silicone-related illness (if it exists). In fact,
there is no test that can do this. Kossovsky, according to CNN,
received two FDA warning letters stating that his company
had misbranded the test and was in violation of federal regu-
lations.™ Interestingly, the Dow Corning secret documents re-
veal that in 1982, when Kossovsky was a medical student, his
adviser asked the company to fund Kossovsky while he con-
ducted a study of implants. He was turned down. Since then,
Kossovsky has been a key figure in promulgating the theory
that implants cause disease.
To a remarkable extent, the breast implant story is about
greed and its consequences—particularly the opportunism of
plaintiffs’ attorneys and their medical associates. But what
about the plaintiffs themselves? Are they venal or are they in-
nocent victims? This is perhaps the most vexing of the issues
in this story. The answer is undoubtedly different for differ-
ent women. Some of them, like Mariann Hopkins, are indeed
seriously ill. They have heard that breast implants cause dis-
ease, and they cannot be blamed for accepting that proposi-
tion. After all, in their minds, they are living proof of it. To
them, the implant manufacturers are clearly guilty of selling
dangerous devices, perhaps knowingly, and the companies
should be made to pay for it. Many more women with implants
are not seriously ill. But because they are already convinced
that implants cause disease, they immediately attribute ordi-
nary symptoms of life, such as fatigue, muscle aches, or in-
somnia, to the devices. To them, even minor symptoms take
on ominous meaning as portents of serious disease. And their

conviction that they are at risk probably magnifies their symp-
toms. When people are afraid that they might have a serious
disease, they often feel worse than they would if they had no
such concerns. A third group of women feel fine, but because
of the publicity, they are concerned that they might become
sick in the future. About half the women who registered for
the class-action settlement fall into this category. Finally,
among all large groups of people are some opportunists.
There is no reason to believe that women with breast implants
are any different in this respect. The opportunists among
them see that easy money is available and they decide to reach
for some of it. Women like the nurse who was sent to see Lewy
(and was dismayed by the gravity of Lewy’s diagnosis) can be
powerfully tempted by the situation. Although she resisted
the temptation, it is unlikely that all such women do. Women
with breast implants are just as diverse as any other large pop-
ulation, and there is no reason to believe that they are all the
same—either in their health or in their character. But it can
be very difficult to distinguish the ill from the worried well and
from the opportunists. What is certain is the widespread and
genuine alarm. The next chapter considers why the public is
so ready to embrace stories of health hazards.
8
AMERICANS AND HEALTH NEWS:
THE ALARM OF THE DAY
There seems to be some sort ofplanned obsolescence

now to medical news.
—Ellen Goodman,
April 17, 1994
he breast implant story was, I believe, all but inevitable,

li the social context in which it unfolded. Its shape
conformed almost exactly to a number of important features
in contemporary American society. One feature is the way the
media convey health news. Television, radio, newspapers, and
magazines were eager to trumpet the dangers of breast im-
plants. Danger isa story; safety is not. With the extraordinary
growth in media outlets, reporters must compete ever more
desperately for stories. All important news tends to be rapidly
exhausted by blanket coverage on all sides. Reporters who
still have time and space to fill are then reduced to spinning
out and inflating increasingly trivial details and ever more
baseless speculation (witness the exhaustive, often tedious
coverage of the O.J. Simpson trial). Health news, like celebrity
murders or political sex scandals, is a particularly rich lode to
mine, because the interest is already there—it doesn’t have to
Americans and Health News: The Alarm of the Day #& 155
be drummed up. Everyone would like to live a long, healthy

life, and everyone wants to avoid health hazards. Thus, the
media compete particularly avidly for stories about medical
risks. Turn on any network morning television show or pick
up any newspaper, and there is almost certain to be a story
about some new peril to our health. The march of stories is
remarkably rapid and fickle. Today’s hazard tends to obliter-
ate yesterday’s. The fear that asbestos insulation causes lung
cancer yields to the fear that exposure to lead causes mental
retardation, which in turn gives way to concern that electro-
magnetic fields from household appliances and power lines
generate leukemia and brain cancer. It is, after all, difficult to
worry about everything at once. Concern that Agent Orange,
used as a defoliant in Vietnam, caused a variety of illnesses gave
way to worries that veterans of the Gulf War are suffering from
their own mysterious malady. And so on: Alar on apples, radon
in the basement, alcohol, estrogen, cigarette smoke, and hot
dogs—all said to cause cancer. Pregnant women are particu-
larly vulnerable to the anxieties generated by medical news sto-
ries. The list of cautions for them is virtually endless.
The price of this barrage is that we begin to feel we live
in a sea of toxins arid dangerous habits. The sense of peril is
exacerbated by the fact that we know full well we are increas-
ingly dependent in our daily lives on technology and the sci-
ence that generates it. Naturally, the more curious among us
wonder what all this technology is doing to us. Should we
worry about electromagnetic fields, sick buildings, insecti-
cides, food additives, lead, and asbestos? Are they destroying
our health without our even knowing it? As the media inces-
santly discover and inflate new threats, many of us feel in-
creasingly vulnerable to unseen dangers we don’t understand.
Unfortunately, too many Americans react with an odd mix of
cynicism and gullibility, stemming from an increasingly dis-

trustful view of the world.
Distrust as a worldview is not hard to understand in a so-
ciety as complex as ours, particularly when there are indeed
all sorts of things “out there” that can harm us. Difficult times
add to the paranoid view. When people are worried about los-
ing their jobs or maintaining their standard of living, when
they are concerned about crime and social unrest, when they
see greed and corruption all around them, they come to dis-
trust nearly everything. This includes big government and big
business—the institutions that should be making our lives bet-
ter but seem always to be making them worse. Thus, if we hear
that asbestos insulation is causing a plague of lung cancer, it
must be true and it must be because rapacious businesses
don’t care and corrupt government is covering for them. In
the case of breast implants, there is no doubt that there was a
predilection to believe that the breast implant manufacturers
had knowingly marketed dangerous devices and that the FDA
had let them get away with it for years.
Citizens’ advocacy groups, while in many cases perform-
ing great service, have tended to feed the paranoia. When
Ralph Nader first began his consumer crusades, he provided
a useful antidote to the mythology that business somehow
“cares” about its customers. Nader and other consumer ad-
vocates supplied a dose of reality: business cares primarily
about its market share, not the welfare of its customers. To be
sure, manufacturers cannot be too obviously cavalier about
matters of safety or they will lose their customers, but they have
little reason not to try to get away with as much as possible. But
as the consumer movement itself became a sort of industry,
the method of carefully collecting evidence of wrongdoing,
then exposing it, gave way to a fusillade approach. Never mind
Americans and Health News: The Alarm of the Day #&® 157
the evidence, everyone who might be doing wrong probably

is. If Dow Corning is competing with McGhan to sell as many
breast implants as possible and doesn’t bother to establish
their safety, then it is tempting to leap to the conclusion that
implants probably aren’t safe. And from there, it’s another
easy jump to assuming that they are very dangerous, and that
the manufacturers knew that all along. I suspect that these
kinds of leaps in logic led Sidney Wolfe, the director of Nader’s
Health Research Group, to assume the worst and act on that
basis.’
If Americans responded to medical news stories more
critically, we would not be as vulnerable as we are to recurrent,
often baseless health scares. How should we respond? With a
large dose of skepticism—which is not the same as cynicism.
If, for example, there is a report that some food or habit or
device is dangerous, people should ask themselves whether the
news comes from a usually reliable source, whether it comes
from one source or many, whether the alleged danger is large
or small, and whether it is consistent with everything else we
know about the subject. Then, unless the evidence is over-
whelming or the problem urgent, we should defer a final judg-
ment. The information can be stored away on a mental shelf
until further information is forthcoming. Not all Americans
are knowledgeable enough to perform such a preliminary
analysis, at least not in all cases, but in my view most could do
much better than they do. Why don’t they?
One possible reason lies in the entertainment value of sci-
entific scares. Recent books (The Hot Zone, for example) and
movies (Outbreak) about runaway viruses are ample evidence
of this, adding variations on the venerable Frankenstein sta-
ples. As the line between fiction and nonfiction is increasingly
blurred in the media, news of medical dangers takes on some
of this entertainment value. Reports that cellular phones may

cause brain cancer or that the nearby nuclear power plant is
unsafe intrigue us and give us lively topics for conversations
with friends. Recall that Connie Chung was the person who
alerted us to the putative dangers of breast implants and the
conspiracy to hide them. Her forum was one of an increasingly
popular genre of television magazine shows that are hybrids
of entertainment and news. Yes, we really do want to learn
what will keep us healthy and what is a threat to our lives, but
that is not the only motivation in embracing news of health
risks. We also want to be entertained. Charges of a conspiracy
by big business to unleash dangerous products on the public,
often with the alleged complicity of government agencies, add
to the inherent interest of the story and therefore to its en-
tertainment value. Righteous indignation is a strong stimulant
and it can be a tight social bond among like-minded people.
Cynicism is much easier than skepticism, because it re-
quires no distinctions. We needn’t distinguish between reli-
able evidence and unreliable evidence, between big dangers
and small ones, between likely effects and unlikely ones, be-
tween the reasonable and the bizarre. Yielding to cynicism
over skepticism is therefore an easy way out. It also dovetails
with our increasingly paranoid interpretation of all sorts of
events.” Blanket cynicism gives the illusion of understanding
and even certainty in an increasingly unpredictable world. It
offers a consistent worldview. Any health scare can be inter-
preted by the cynic as the “establishment” once more ne-
glecting the interests of the public in favor of big business or
some other elite. There are no uncertainties. In addition, if
we are cynical enough, we don’t have to think too much about
the substance of each health scare. Being absolved from think-
ing about science can be a great relief to people who find the
Americans and Health News: The Alarm of the Day #& 159
prospect daunting. Many people willingly abandon whatever

scientific skepticism they might muster in favor of political cyn-
icism.
But the opposite side of the coin of cynicism is gullibility.
If there are no distinctions to be made, then everything is
equally likely. Imagining white cells gobbling up malignant
cells is as likely to cure cancer as surgery. So are coffee ene-
mas and macrobiotic diets. Acupuncturists, herbalists, and
homeopaths are as effective in treating heart disease as car-
diologists. And new diseases that are impossible to define are
accepted wholesale every generation, with very little evidence,
usually to account for fatigue and malaise—inevitable ac-
companiments of human existence since the beginning of
time. Early in this century these symptoms were attributed to
something called neurasthenia. Later, chronic mononucleo-
sis was the favored diagnosis, until it was supplanted by chronic
fatigue syndrome. More recently, a group of self-styled ex-
perts known as clinical ecologists have introduced the diag-
nosis of total body allergy or total chemical sensitivity for the
same sort of nonspecific complaints. Each incarnation has
been embraced by a large section of the public, who prefer the
modish diagnosis to interpreting the symptoms as overwork
or depression—or simply chalking them up to an unknown
disorder.
Cynicism and gullibility together produce a penchant for
magical thinking and the suspension of logic. Cynicism pro-
duces disdain for the traditional methods and sources of in-
formation; gullibility leads us to embrace idiosyncratic ones in-
stead. Charlatans and opportunists have been quick to take
advantage of these traits. Bookstores are filled with self-help
books that imply that sickness and death are optional or char-
acter flaws. Their authors tell us that we can overcome even
the most deadly diseases. If readers will only follow the au-
thor’s regimen, which usually has to do with exercising the au-
thority of the mind over the body, they are assured of a long,
healthy life. Some authors, of course, proudly claim that their
regimens are resisted or suppressed by the “medical estab-
lishment,” thereby tapping into the cynicism that is so im-
portant in promoting these books. In addition, of course, the
whole notion that each of us can somehow ward off disease
and death more or less indefinitely is enormously appealing
to our wish for more control in our lives.*
The breast implant story contains all the elements guar-
anteed to generate public ferment and misunderstanding.
Big business is accused of selling a dangerous product to its
customers and covering up proof of the danger. The FDA in-
explicably sits on its hands for 16 years. The diseases caused
by implants are deadly, but very subtle. There is no sure test
for them. The disorders may be different from classic con-
nective tissue disease, but then again they may not be. Only
certain people can diagnose the diseases for sure. The med-
ical profession is suppressing the truth, but gallant individu-
als—plaintiffs’ attorneys, consumer advocates, and a few may-
erick scientists—are forcing it out. Adding to the mix is a
strong anti-science mood among many Americans.* Perhaps
the mood is a reaction to the exalted intellectual status scien-
tists enjoyed for several decades after World War II. Whatever
the reason, a growing number of Americans view scientists as
Just one more group of elitists and the scientific establishment
as no more to be trusted than any other establishment. This
view is particularly pronounced among a small segment of
the feminist movement.
Given all the social forces at work in the breast implant
controversy—the desperate competition within the media for
Americans and Health News: The Alarm of the Day #® 161
a story, the reciprocal desire of the audience for entertain-

ment, the cynicism and gullibility of the public about science,
the widespread tendency toward paranoid interpretations of
events, and the anti-scientific position of many Americans—
it is perhaps not so surprising that most Americans believe that
breast implants cause terrible diseases, despite the lack of any
evidence that they do. In the next chapter, I will discuss the
ambivalent view of the American public toward science and
the consequences of this ambivalence. In the remainder of this
chapter I will consider in more detail the public response to
news of health risks and why it is sometimes so at odds with
the scientific view.
IN CHAPTER 5, I described epidemiologic studies as the scientific

method by which we can learn about risk factors in our lives.
Habits of daily life are becoming increasingly important in epi-
demiologic research for several reasons. First, the most im-
portant causes of illness and death in the United States are
chronic diseases of unknown cause, such as coronary heart dis-
ease and cancer. No longer do Americans get sick or die pre-
dominantly from infections, for which the causes are usually
well known. Until the early twentieth century, infectious dis-
eases were still major scourges, but with the introduction of
good sanitation and a vast armamentarium of antimicrobial
drugs, that changed. Since then, the life expectancy of Amer-
icans has nearly doubled, and we are now living long enough
to develop a whole host of chronic diseases that come with age,
such as hardening of the arteries, cancer, and arthritis. By
and large, the causes of these diseases remain mysterious, but
there is a good deal of evidence that most of them have mul-
tiple, not single, causes. Each contributing cause is therefore
a risk factor, not the sole cause. Eliminating one risk factor
may lower the chances of getting the disease, but not elimi-
nate the risk altogether. There is plenty of evidence that many
chronic diseases are influenced by environmental as well as ge-
netic factors. For example, heart disease is far more common
in the United States than it is in Japan. At first glance, this fact
may seem to suggest a genetic cause. But Hawaiians of Japa-
nese descent have a risk intermediate between that of the
Japanese and that of white Americans. Furthermore, the risk
in the United States is declining at a rate too fast to ascribe to
genetic changes.’ The inescapable conclusion is that there
are features of the two cultures—not genes—that underlie
much of the differences in incidence. Clearly, the way we live
and the things we eat, drink, and breathe matter.
Americans want very much to know what the risk factors
are for heart disease and cancer and Alzheimer’s disease and
birth defects, and all the other more or less mysterious dis-
eases that threaten our health. We are particularly avid for
news of medical research that focuses on diet and lifestyle.
After all, we can do something about that. If something we
eat or do is a threat or a benefit, we want to know so that we
can change our lives accordingly. This emphasis has become
so extreme that for many Americans good health is largely a
matter of living right. No one gets sick anymore just because
of bad luck or factors beyond our control. Instead, we feel we
can ward off many if not most diseases and illnesses simply by
knowing what foods to eat, what supplements to consume,
and what leisure activities to pursue. This belief is fed by the
new emphasis on preventive medicine as a solution to rising
costs in health care. We are responsible for our own health.
Millions now eat low-fat, high-fiber diets, take antioxidant vi-
tamin supplements, drink alcohol only in moderation, stay
slim, and exercise regularly. And in some respects the efforts
seem to be paying off. The incidence of heart disease in the

United States, for example, has plummeted—particularly
among the well educated—as these lifestyle changes have be-
come more common.
But there are problems. We are getting too much advice
from too many directions. No one could possibly follow it all.
Furthermore, much of the advice is contradictory. One re-
search study reaches one conclusion; another on the same sub-
ject reaches the opposite conclusion. No sooner do Americans
substitute margarine for butter than it is announced that a new
study shows margarine is worse.° After research shows that oat
bran lowers cholesterol’ and Americans are learning to like it,
another study shows it doesn’t work.® When we substitute low-
calorie saccharin for high-calorie sugar, we find that one study
shows saccharin causes bladder cancer,’ but another study
doesn’t.'° Some research demonstrates that beta carotene and
vitamin E are good for you,"' but other studies show that not
only aren’t they good for you, but they could be dangerous.”
One study shows that electromagnetic fields are associated
with an increased risk of leukemia!*; another finds no in-
creased risk of leukemia, but an increased risk of brain can-
cer.!* Women who are grappling with the seemingly impossi-
ble task of deciding whether to take postmenopausal estrogen
hear of a study that shows it increases the risk of breast can-
cer,'° only to learn a few weeks later that another study shows
it doesn’t.'° What is a health-conscious American supposed to
believe? Sometimes the media echo the sense of frustration,
or pretend to. Under the title “Diet Roulette,” the New York
Times editorialized about the margarine/butter controversy,
“No wonder health-conscious Americans often feel they just
can’t win.”!” Columnist Ellen Goodman implied it was all a
plot. “There seems to be some sort of planned obsolescence
now to medical news. Today’s sure cure is tomorrow’s poison

pellet. Fresh research has a sell-by date that is shorter than the
one on the cereal box.”'® Her exasperation may have been
more feigned than real, but it certainly played into the feel-
ings of her readers.
Why the barrage of contradictory reports? Why can’t med-
ical researchers get it right the first time? The problem, in my
view, has to do with the differences in the way scientists do
their work and the way the media do theirs. Consider how sci-
entists study risk factors. When researchers investigate a pos-
sible risk factor, they do an epidemiologic study to see whether
the disease in question is more likely in people who are ex-
posed to the possible risk factor than it is in those who are not.
As explained in Chapter 5, the usual method is a cohort or
case-control study. To review briefly, a cohort study looks at a
group of people who are exposed to the possible risk and a
group who are not, and follows them over time to see how
many people in each group get the disease in question. A
case-control study looks at a group of people who already have
the disease and a group who do not, and looks back to see how
many in each group were exposed to the possible risk factor
under study. In either case, the important questions are
whether there is a difference between the two groups, how big
the difference is, and how certain we are that the difference
we find in the sample groups is not due to chance or a mis-
take in the study design.
The difference between groups is often expressed as the
ratio between the incidence of the disease in the exposed
group and the incidence in the unexposed group. This ratio
is expressed as a relative risk (or, in case-control studies, an
odds ratio). For example, the relative risk for prostate cancer
in men with a vasectomy, compared with men without a va-
sectomy, was found in one study to be 1.6.'° This means that

for every 10 men who don’t have a vasectomy and develop can-
cer of the prostate, 16 men with a vasectomy will. Similarly, one
of the recent studies of postmenopausal estrogen and breast
cancer showedarelative risk of 1.3 for users of estrogen.” This
means that for every 10 women who do not take estrogen and
get breast cancer, 13 estrogen users will. The same result can
be stated in different ways. Instead of saying a relative risk of
1.3, we could say that postmenopausal estrogen is associated
with a 30 percent increase in the risk of breast cancer. Alter-
natively, since we already know that 3 or 4 of every 100 post-
menopausal women will get breast cancer in the next 10 years,
we could say that this study shows that estrogen increases that
risk to 5 in 100. Or, to put it in yet another way, if you are a
postmenopausal woman trying to decide whether to take es-
trogen, this study shows that your chances of remaining free
of breast cancer for 10 years would decrease from over 96 per-
cent to about 95 percent. I go through all these equivalent
ways of expressing the same finding for a reason. As you can
see, they have very different psychological impacts on the
reader, even though they are saying the same thing. The issue
of how to express or “frame” results of medical research is im-
portant, as I will show later.
There are many pitfalls in epidemiologic research.”! In co-
hort studies, the two groups of people, who are well at the be-
ginning of the study, may not have much motivation to dis-
close their exposure to the risk factor very accurately. I was
recently asked to participate in a cohort study and was sent a
formidable questionnaire to fill out. It asked for information
about a wide variety of health habits over my entire life. Even
if I had wanted to fill it out accurately, I doubt whether I could
have. I chose not to enter the study, in part because the ques-
tionnaire was so daunting. I suspect that many women who did

elect to respond simply filled the form out carelessly. In that
case, many real associations between risk factors and disease
might be missed. On the other hand, case-control studies may
lead to spurious associations. Since the “cases” are already
sick, they are more likely than well people to recall exposure
to the possible risk factor. For example, mothers of babies with
birth defects are more likely than mothers of healthy infants
to recall being exposed to cigarette smoke or insecticides or
hair spray or anything else they believe might explain what
happened.
Probably the chief difficulty in epidemiologic studies is
choosing groups of people who are alike in every way except
for the exposure in question (in cohort studies) or the disease
in question (case-control studies). Yet this is essential. Other-
wise, some other difference between the groups might ac-
count for the results and badly mislead everyone. Other dif-
ferences between groups that may confuse the results are
termed “confounding variables.” For example, cigarette smok-
ers are more likely to drink alcohol than are nonsmokers. So
when an epidemiologic study shows a link between cigarette
smoking and adisease, it is necessary to determine whether
the real association is with smoking or whether it might pos-
sibly be with drinking (the confounding variable in this case).
It could be the combination—or even some other factor that
might be different between smokers and nonsmokers.
Although there are statistical methods for neutralizing
confounding variables, they are not perfect, and they are of
no use whatsoever unless the confounding variables are known
and measured. For example, epidemiologic studies have
shown an association between premature births and lack of
prenatal care, but maybe there are confounding variables that
explain the association. Maybe it has nothing to do with pre-

natal care itself. For example, it could be that women who can
afford prenatal care are more likely to carry babies to term be-
cause such women are better nourished. Similarly, one can
imagine other, unknown confounding variables in this asso-
ciation, or ones, such as education, that are difficult to char-
acterize. Furthermore, if a confounding variable is very im-
portant compared with the risk factor being studied, attempts
to control for it may easily be inadequate. If, for example,
some aspect of socioeconomic status is a major confounding
variable in a study of a weak association, it may be necessary
to characterize socioeconomic status very precisely, and even
then attempts to factor out its influence may not succeed.
Similarly, it’s almost impossible to study other risk factors for
lung cancer in people who smoke. Cigarette smoking is so
powerful a risk factor that it swamps the effects of others. Even
if researchers try to control for cigarette smoking by dividing
the subjects into subgroups according to the number of ciga-
rettes they smoke, it may not eliminate the confounding. Any
remaining differences in smoking habits between groups
might still obscure the effect of the risk factor being studied.
In addition to finding out whether the relative risk of dis-
ease is higher in people exposed to a possible risk factor, we
also want to know the size of the effect. How much higher is
the relative risk? Does the exposure increase the risk manyfold,
twofold, or perhaps by only 20 percent (a relative risk of 1.2)?
An important reason for being concerned about the size of the
effect is that unknown factors or confounding variables that
are inadequately accounted for can easily produce spurious
small effects or mask real ones. It is far less likely that con-
founding variables obscure large effects. Cigarette smoking
can badly confound a study of smog and lung cancer, but
168 #& SCIENCE ON TRIAL
smog cannot seriously confound a study of cigarette smoking

and lung cancer. This is why weak risk factors are so much
harder to be sure of than strong ones.
As discussed in Chapter 6, the question of the size of the
effect is very different from that of the statistical significance
of the association (usually expressed as a P value or confi-
dence interval). The P value is a measure of the probability
that the finding is due to chance, and it reflects the size of the
sample studied. If a study is large enough, even a very small
effect may be pretty certain, just as a large effect may be due
to chance in a small study. But even astatistically significant
effect may still be wrong because of confounding variables or
a systematic bias, such as cases being more likely to recall ex-
posures than controls. Statistical tests of significance cannot
eliminate the effects of such errors; they only deal with the ef-
fects of chance in sampling the populations being compared.
The limitations of epidemiologic research lead to certain
cautions about the results. First, no one study should be taken
as the final word. Nor should several very similar studies, since
the same confounding variables or unappreciated biases may
affect all of them. Instead, each study should be seen as one
piece in a puzzle. The more studies of different designs in dif-
ferent populations that show similar results, the more confi-
dent we can be of the conclusions. Epidemiologists rarely
place much stock in their findings without such consistency,
and they shouldn’t. Second, a strong risk factor is more likely
to be real than a weak one. This is because confounding vari-
ables and biases are less able to confuse the situation, either
by masking a risk factor or by suggesting one that doesn’t
exist. But they can easily mask or falsely suggest a small risk
factor. For this reason, most epidemiologists are very skepti-
cal of a relative risk below 3.0 or 4.0 if the finding is new and
unanticipated. A relative risk smaller than this requires a good

deal of confirmation. If the finding is biologically plausible, a
weak effect is more likely to be accepted. For example, if a
study showed that patients in hospitals where nurses did not
wash their hands after tending each patient were twice as likely
to get infections as those in other hospitals, that would be bi-
ologically plausible. If the finding were the reverse, it would
not be plausible and arelative risk of 2.0 wouid almost cer-
tainly be chalked up to a confounding variable or to some un-
suspected bias.
1 GO THROUGH these technical points for a reason. They provide

a backdrop for contrasting the very different way that the
media deal with epidemiologic research. The news media, by
definition, report new findings, not old ones. Their purpose
is not to tell the world that everything is as they thought it was
yesterday, but to tell us something new. And, given the frenetic
competition within the media, the more unexpected the find-
ing, the more coverage it gets. Thus, the assertion by Pons and
Fleischmann, the University of Utah chemists who announced
a few years ago that they had produced nuclear fusion at room
temperature (cold fusion) —a highly implausible claim—was
big news.” On the other hand, a confirmatory finding of a sci-
entifically plausible effect is unlikely to make the news. Fur-
thermore, a study that finds no effect will receive almost no
attention from the media, even when it is important. One of
the consequences of the emphasis on both newness and pos-
itive effects is that a study that erroneously finds an effect gets
more attention than ten studies that didn’t. For example,
about 10 years ago a study was published purporting to find
an association between drinking coffee and cancer of the pan-
creas.’ It received an enormous amount of publicity; the au-
thors were on television network news, and the newspapers

and newsmagazines gave the study prominent coverage.”*
Later, when it became apparent that the finding was almost
certainly spurious, this news was relegated to the back pages.”
Reporters are reluctant to downplay their stories by
adding caveats. When a study finds a weak risk, reporters are
not likely to emphasize how small the risk is and therefore how
likely it is to be spurious. If they do, these qualifications are
usually buried near the end of the story. Caveats are simply not
a winning feature of news reports. Thus, weak risks, such as
moderate obesity or eating red meat, may receive the same em-
phasis as strong risks, such as cigarette smoking or heavy drink-
ing, and the public may react equally strongly to both. Fur-
thermore, media reports are also likely to frame risks in the
most impressive way. For example, a recent study, called the
GUSTO trial,”° compared two anti-clotting agents in the treat-
ment of heart attacks—one agent was t-PA, the other strep-
tokinase. At the end of the trial, 6.3 percent of the patients re-
ceiving t-PA had died, compared with 7.3 percent of the
patients receiving streptokinase. This one percentage point
improvement was hardly a great difference. In fact, stated an-
other way, the study showed that the chances of surviving a
heart attack increased from 92.7 percent with streptokinase to
93.7 percent with t-PA—pretty good odds with either drug.
Equally accurate would be the statement that t-PA was associ-
ated with a 14 percent reduced mortality. Somehow, framed
this way, the finding sounds much more impressive. And that’s
exactly how the media tended to frame it. Even when reporters
caution their readers not to embrace too enthusiastically news
of a weak effect from a single study, the headline writers may
have other ideas. In the Boston Globe, the t-PA finding was re-
ported under the headline “Anti-Clotting Therapy Found to
Spare Lives.”*” While technically true, the effect of t-PA was

meaningful only when applied to a large population. For an
individual patient, the drug offered only a trivial increase in
the odds of survival.
All of this is not to say that the media are not doing their
job. They are. It’s just that the job is not what we might think
it is. The job of reporters is to tell the public what happened,
and to do so in as engaging a way as possible. In medical re-
porting, this means telling the audience, as dramatically as pos-
sible, what researchers did and what they concluded. Re-
porters do not usually include in the scope of their job
providing a context—that is, analyzing the strengths and weak-
nesses of a whole body of scientific evidence. Nor does the job
include coming up with a reasoned conclusion for the public,
although good reporters often do this. Instead, most reporters
simply inform the public, study by study, of whatever research
is most newsworthy that day—that is, most startling.
But startling research is more likely to be wrong than con-
firmatory research. Solid conclusions are usually reached bit by
bit. The more studies done of a particular question, the more
accurate they are likely to be, as the errors of earlier studies are
avoided. News of the entire sequence is unlikely to make it to
the media, at least not toward its end, when it is most reliable.
To be sure, the media often present very good feature stories
about medical subjects. In these, reporters analyze at some
length what is known about the field, what questions remain to
be answered, and what the implications are. These longer, more
analytic stories often appear in newsmagazines, in the health
sections of large newspapers, or in the Sunday feature pages.
They emphasize a body of research, not just a single study. But
the lion’s share of media coverage of medical research is news
of a single, dramatic study, and this is where the problems lie.
One frequent justification for the media making much of

weak risk factors is that they are important for the public
health, if not for individuals. An individual may not see much
difference between his or her chances of surviving a heart at-
tack with t-PA or streptokinase, but for the public health, it
matters. Since there are nearly 1.5 million heart attacks a year
in this country, a one-percentage-point improvement in the
chances of surviving translates into 15,000 lives saved. Another
example: A trial using cholestyramine to lower serum choles-
terol about 9 percent in middle-aged men with high choles-
terol levels reduced their seven-year risk of heart attacks or
sudden death from 8.6 to 7.0 percent.” Although such a re-
duction may not seem like much to an individual, particularly
since it requires taking a drug with side effects, when spread
over the estimated 1 million to 2 million Americans with sim-
ilar cholesterol levels, it could account for up to 32,000 fewer
heart attacks a year. The public health perspective has been
gaining steadily in importance in the past several years, as pol-
icymakers have grown increasingly concerned about costs.
Anything that reduces health-care expenditures, even if it
doesn’t reduce risks much for individuals, is important. But
this switch in emphasis has occurred nearly subliminally. Re-
porters are rarely explicit about it. They may not always be
aware of it themselves. Health risks continue to be reported
as though they were meaningful for the individual, and, of
course, people assume that the risks would not be in the news
unless they were. But even well-established risk factors may
have little importance for individuals. For example, the 10-year
risk of death from cardiovascular disease is 4.9 percent in
middle-aged men with high cholesterol levels, as compared
with 1.7 percent in those with low cholesterol levels.?° This dif-
ference in risk of about three percentage points may not be
Americans and Health News: The Alarm of the Day & 173
enough to induce an otherwise healthy man to try to lower his

cholesterol level. Yet many American men have been led to be-
lieve that high cholesterol is a death sentence, and low cho-
lesterol means they will have a long life.
Ellen Goodman’s lament is a little different from the
problems of distinguishing weak from strong risk factors, sen-
sational from solid studies, and news of importance to indi-
viduals from news of importance to the public health. She was
complaining that studies were inconsistent and often contra-
dictory. Let’s look at these complaints more closely. It is true
that one study may find, say, that postmenopausal estrogen is
associated with breast cancer and the next study may find that
it isn’t. Such inconsistency is common in medical research. It
is particularly common in epidemiology, because these stud-
ies are so difficult to do. Instead of being a cause for lament,
the phenomenon ought to suggest more caution in accepting
the results of any one study. Caution is what inconsistency
teaches scientists, and there is no reason why the public—and
reporters and columnists—cannot draw the same lesson. Fur-
thermore, the inconsistency may be more apparent than real.
If a risk factor is very weak, but statistically significant, the
media report this as showing an effect. Another study may have
found exactly the same relative risk, but because the study was
smaller, the difference was not statistically significant. The
media would report the second study as showing no effect. The
possibility that there was really no difference between the two
study results would simply not be reported.
Goodman was also complaining about another problem.
Some studies show that something is good for you in one way
and bad in another. As she said, “estrogen may protect against
heart disease and give you a better shot at breast cancer. If you
run a lot, your bones may get brittle but your heart will stay
strong. If you drink wine, you could wreck your liver but lower
your bad cholesterol.” There is no answer for this lament. Na-
ture simply did not set out to make things uniformly good or
uniformly bad for us. They are what they are. But the situation
underscores another important problem in reporting health
news. Media stories about a research study that focused on jog-
ging and osteoporosis (Goodman’s “brittle bones”) too often
reported the results in isolation. In reality, almost any food or
activity that affects health in one way also affects it in others. It
is a disservice to the public not to try to put stories about single
research studies in their larger context. People feel whipsawed
by science. when they are really being whipsawed by the media.
As the recent epidemiologic studies of breast implants
and the diseases they are said to cause have been reported in
the scientific literature, how have the media responded? By
and large, very well. Since the studies have been so consistent,
there has been little necessity to deal with contradictions. The
limitations in the strength of the findings caused by the size
of the studies have been appropriately mentioned, as were the
flaws in the one study that found alink. Failure to find a dif-
ference between women with and without implants does not
mean that there is no difference. The smaller the study, the
more likely that a real difference will be missed. This fact is
usually expressed by a “confidence interval,” that is, a range
of possible risks that is compatible with the evidence. In the
Mayo Clinic study, for example, the relative risk for the dis-
eases studied in women with breast implants was 1.0. This
meant that compared with women without breast implants,
those with implants were no more or less likely to develop the
diseases in question. But because there were only 749 women
with breast implants in the study, it was 95 percent possible
that the relative risk was anywhere from 0.5 to 3.0. The closer
to the extremes of the confidence interval, the more improb-

able, but it was still quite possible that breast implants were as-
sociated with as much as a threefold increase in these dis-
eases. The press made this clear. Larger studies will have a
narrower confidence interval. Therefore, the more large stud-
ies that can find no association between implants and disease,
the smaller any real risk must be not to have been detected.
On the other hand, if there is a risk that has been missed,
larger studies are more likely to find it.
What if it turns out that there is a small risk? A quick an-
swer would be that no risk is acceptable. In this view, if there
is any risk, no matter how small, implants ought to remain
banned. After all, we should accept no unnecessary threats to
health. Unfortunately, the real world cannot work that way.
We accept unnecessary risks to health every day. Whenever we
drive our cars or take an antibiotic or eat peanut butter, we
take risks. (Antibiotics, after all, can have serious side effects,
peanuts contain a mold that increases the risk of liver cancer,
and automobile accidents are far more important causes of
death and injury than most of the health hazards that occupy
our attention.) Paradoxically, then, unnecessary risks may be
necessary. The important question is the size of each risk and
the costs, not just in dollars, of avoiding it. If a risk is so small
that it is nearly impossible to detect, then perhaps it doesn’t
matter, just as it might not matter to an individual whether he
or she receives t-PA or streptokinase after a heart attack. Maybe
we should just stop worrying and include whatever risk there
is from breast implants with the multitude of small (and not
so small) risks we accept willingly every day. On the other
hand, we might be unwilling to accept certain small risks, but
quite ready to accept others.” The crucial point is that we owe
it to ourselves to decide these matters explicitly. Unfortu-
nately, Americans are not very good at evaluating risks of

health hazards and deciding which ones we are willing to take.
Oddly enough, many of us are also reluctant to rely on science
to tell us about health hazards. Increasingly, we look to other
sources, and some of these sources are strange indeed. In the
next chapter, I will discuss the anti-science movement that is
sweeping this country and its unfortunate consequences.
.
BREAST IMPLANTS AND THE
REJECTION OF SCIENCE:
OTHER WAYS OF KNOWING
It’s a forebodingI have—maybe ill-placed—of an

America in my children’s generation, or my
grandchildren’s generation . . . when, clutching
our crystals and religiously consulting our horo-
scopes, our critical faculties in steep decline, un-
able to distinguish between what’s true and what
feels good, we slide, almost without noticing, into
superstition and darkness.
—Carl Sagan,
1995!
he United States is in the midst of a groundswell of anti-

lies feeling. (The renewed rejection of evolution ex-
emplifies this feeling.) It comes at a time when we are most
dependent on science and the technology it generates. At first
thought, it may seem paradoxical to reject science when we
are most dependent on it, but perhaps it isn’t. Perhaps it is
human nature that the more we feel dependent on some-
thing, the more we rebel against it, much as dependent ado-
lescents rebel against their parents. Be that as it may, the re-
bellion is spearheaded by a variety of groups within American

society, each with its own political stance and reasons for turn-
ing against science and technology. They include humanists,
multiculturalists, environmentalists, ecologists, feminists, and
proponents of alternative medicine. Not all members of these
groups, of course, reject science. But each movement is no-
table for having large contingents that do. They view science
somewhat differently.
Many humanists believe that science has been oversold as
the discipline with the answers. In their view, the deference
to science that has characterized intellectual life for much of
this century has contributed to a devaluation of humanist
thought and the emergence of a callous, technology-
enthralled society. In rejecting the uses to which science has
been put, they also reject the scientific method and, to some
extent, those who espouse it. As Paul Gross, professor of life
sciences and director of the Center for Advanced Studies at
the University of Virginia, and Norman Levitt, professor of
mathematics at Rutgers University, point out in their book,
Higher Superstition, rejecting science also offers academic hu-
manists the opportunity to settle old scores.”
After World War II, science and scientists enjoyed a vir-
tually unchallenged primacy in the intellectual hierarchy. Sci-
entists, after all, were the people who were necessary to win
the war, arm us for the cold war, find cures for diseases, and
give us our technological creature comforts. In academia, they
enjoyed the relatively lush funding that came with their use-
fulness. They also enjoyed great intellectual prestige. Gross
and Levitt outline the implicit ranking of the various acade-
mic fields that prevailed until very recently. Academics in the
“hard” sciences (physics, chemistry, biology) ranked first be-
cause they produced reliable knowledge; historians, second,
Breast Implants and the Rejection of Science @ 179
because they, too, generated factual knowledge, although

often tainted by speculation; economists, third, because at
least their analytical methods were rigorous, even if their as-
sumptions and sometimes their raw data were not. Next to the
bottom of the hierarchy were social scientists, because they in-
dulged in impressionistic theories dressed up in statistical cos-
tumes, and last were those in literature, because they were sub-
jective beyond redemption. With the rejection of science, that
hierarchy stands to be reversed. Humanists now speak of sci-
ence as just another mode of discourse constructed by its prac-
titioners, no more objective than any other and probably less
interesting. With this reevaluation, there is no longer any rea-
son to defer epistemologically to scientists.
Multiculturalists also have quarrels with science. To many
of them, it glorifies a white, male, European construct, at the
expense of the contributions of other races and cultures. And
indeed, the emphasis on science and technology isa hallmark
of Western civilization. Some multiculturalists react by dis-
daining science altogether. Others, however, do not reject sci-
ence, but rather appropriate it, often in novel forms. Hunter
Adams, for example, a proponent of Afrocentric science who
was commissioned by the Portland, Oregon, public schools to
design a more inclusive curriculum, accepts scientific ad-
vances, but attributes many of them to the ancient Africans.
In addition, he referred to ancient Africans as “masters of
magic .. . psychokinesis, remote viewing and other underde-
veloped human capabilities.”* Presumably, these are other
branches of science.
The anti-science environmentalists and ecologists dislike
science for its hubris. To them, the technological imperative
fed by science has led to an arrogant and ultimately self-
destructive assumption of dominion over nature.* Other
groups reject science for political reasons. Many radicals, for

example, see the technological fruits of science as bolstering
the power of the governing classes. Technology thereby be-
comes one more tool of economic subjugation.’ Moving
nearer the mainstream, even good liberals are often very crit-
ical of science without rejecting it altogether. Consumer ad-
vocates such as Public Citizen’s Sidney Wolfe exemplify the
views of those who find the rapid progress of science as much
a cause for vigilance as celebration.®
A particularly influential group to turn against science is
a segment of the feminist movement. Feminist philosophers
such as Sandra Harding, professor of philosophy at the Uni-
versity of Delaware, provide the intellectual framework. To
them, science is inherently “androcentric,” because it was
largely developed by men in patriarchal societies. It is only be-
cause of the power of men that the scientific method has be-
come universally accepted as the way to gain knowledge about
the natural world. To these feminists, the scientific method
would be different if it had been developed by women. Hard-
ing, for example, believes that “value-free research is a delu-
sion,” and she has compared the scientific method to “mari-
tal rape, the husband as scientist forcing nature to his wishes.”
She writes as though the scientific method were just one more
convention that could easily be replaced by another.’ Many
feminists are receptive to this view, because they believe that
the scientific method leaves out other, equally valid ways of
knowing. The 1986 book Women’s Ways of Knowing suggests
that women find the scientific method uncongenial because
it emphasizes logical, linear thinking at the expense of intu-
itive, multi-faceted thinking.® Of course, intuition and imagi-
nation often do play an important role in generating hy-
potheses in science, but logical analysis is the most useful tool, .
Breast Implants and the Rejection of Science #@ 181
and all scientific hypotheses must ultimately stand the test of

objective evidence. Some feminists do not accept these con-
straints, and many other women are to some extent influ-
enced by their ideas without embracing them explicitly.
In addition to these anti-science groups, there are many
individuals who react in particular against medicine and med-
ical science. For years, the public has been ambivalent about
their doctors. While most people seem to like and trust their
own physicians, many believe the medical profession as a whole
needs to be brought down to size. In their view, doctors for too
long have been allowed to get away with insufferable arro-
gance. They are often not available to their patients, and when
they are, they do not take the time to listen to them carefully
and understand their problems. Instead, doctors either dismiss
the patient altogether or rush to a high-cost technological fix.
(Much of this, of course, is changing, as both doctors and pa-
tients are brought under the aegis of “managed care.” Doctors
will be less likely to reach for a technological fix and perhaps
be less arrogant, but no less busy.) The public is also critical
of medical science because it seems to promise “medical mir-
acles” that too often aren’t delivered. The media imply that
medical science can do nearly anything. For example, a recent
story about a substance that causes mice to lose weight ap-
peared in one newspaper under the headline “Flabulous Dis-
covery!”? The story implied that we were on the brink ofa new,
definitive treatment for human obesity, a highly unlikely pos-
sibility. Other media stories suggest that similar medical mir-
acles are at hand. Many doctors feed these unrealistic expec-
tations by being unwilling to tell patients when they do not
know how to help them. Instead, they sometimes reach for one
more drug or procedure, raising false hopes. Yet people still
become obese, and they still get sick and die, the implied
promises notwithstanding. When the public’s expectations

are so inflated, disillusionment is inevitable.
For women, the medical profession has presented special
problems. There is no question that when medicine was an
almost entirely masculine profession, women patients often
were patronized. Sometimes they were the victims of what was
little more than professionally sanctioned prejudice. When I
was in medical school in the 1960s I was taught that dysmen-
orrhea was a psychiatric disorder—the physical manifestation
of an attempt by women to reject the feminine role. Similarly,
morning sickness was ascribed to rejection of the fetus. Pa-
tients with these problems were often treated with tranquiliz-
ers and fatherly lectures about their role in life. This sort of
thing is for the most part behind us, but some of the residual
outrage among women remains. Furthermore, in the view of
some women, researchers have not paid enough attention to
diseases that predominantly affect women, such as breast can-
cer and osteoporosis. That charge is debatable; what is not de-
batable is that the ranks of doctors and researchers have until
recently consisted overwhelmingly of men.
The anti-science, anti-medicine strain in the feminist
movement finds expression in the breast implant controversy.
Many women see the controversy as a women’s issue in a po-
litical context, as well as a biological one. Some female plain-
tiffs’ attorneys make much of the fact that they are women
championing other women in a man’s world.’ The epidemi-
ologic studies that fail to find a connection between breast im-
plants and disease are met with cynicism. To many feminists,
scientific studies seem irrelevant and distracting in the context
of a perceived widespread assault on women—first in sub-
jecting them to implants, then in failing to respond promptly
to the hazard. After all, implants are unnatural substances put
Breast Implants and the Rejection of Science #® 183
in the body, and many women who have implants get sick.
When scientific data are put up against their own “ways of
knowing,” some women ignore the science. Add to this anti-
science bias the view of many women that breast implants are
a manifestation of a discredited, masculine attitude that judges
women primarily by their looks, and it is no wonder that some
feminists believe breast implants cause disease. They want to
believe it.
Note that the various elements of the anti-science move-
ment have somewhat distinct grievances. Some, such as the
radical environmentalists, are reacting primarily against the
uses to which science is put. Others, like the academic hu-
manists, are reacting against what they see as the exaggerated
status of science. And many, like the anti-science feminists
and the multiculturalists, are rejecting the scientific method.
THE ATTACK ON SCIENCE leaves a vacuum that must be filled. If

science cannot provide the answers, what can? People still
want to know why they are sick or unhappy, and they still want
to know how the world originated and how it works. In short,
while many have turned from science, people are still curious
about nature and. their bodies and minds. The anti-science
movement inevitably carries in its wake all manner of con-
tenders for the job of providing answers. What they have in
common is a surrender, partial or complete, of reason to spec-
ulation and mysticism. But because we are people accustomed
to the sound of scientific language, the surrender is often
cloaked in a patois of scientific jargon.
A current example of this surrender is the apparently
widespread acceptance of the proposition that large numbers
of people are being abducted by aliens (who, not surprisingly,
are given to a lot of sexual experimentation). The chief pro-
ponent of this proposition, Harvard psychiatrist John Mack,

makes the case in a best-selling book, Abduction: Human En-
counters with Aliens.'! Mack, a great favorite on talk shows, gives
the whole thinga scientific veneer, despite its utter lack of sci-
entific support. He told a gathering of critics, “Other cultures
have always known that there were other realities, other be-
ings, other dimensions. There is a world of other dimensions,
of other realities that can cross over into our own world.””* All
of this sounds remotely like science, particularly the part about
dimensions, which is reminiscent of physics. The problem is
that Mack and the other believers in alien abduction have not
produced objective evidence for their proposition, which is
the true hallmark of science. What we are left with, then, in
the words of the philosopher Wittgenstein, is “the bewitch-
ment of thought by language.”!®
Much of the surrender to mysticism doesn’t even bother
with a veneer of science. The talk shows are the forum for the
most extreme examples. Once the preserve of tortured rela-
tionships and sexual idiosyncrasies, talk shows increasingly
delve into the occult.'* Psychics predict the future and reveal
the identity of criminals (although seldom by name) before
our very eyes. Witches explain their powers to enthralled au-
diences. A hypnotist on Oprah Winfrey’s show described her
method of marriage counseling. She simply takes the couple
back through time to their past lives (called “regressing”) to
try to gain insight into their present problems. These are just
a few of the many examples of the growing acceptance of the
occult. It has an irresistible fascination for many people, per-
haps because it evokes a form of magical thinking we all en-
gaged in as children. Wish for something and it will happen.
Step on a crack, break your mother’s back. (If you don’t want
her back broken, don’t step on the cracks.) Monsters are
under the bed, and aliens are in the closet. As we grow older,
Breast Implants and the Rejection of Science #™ 185
we learn to substitute reason for magic, but the attraction of

mysticism remains.
Mysticism finds its greatest appeal in healing. Sickness
and death have always held terror for us, and until recently
medical science itself was little more than witchcraft. Indeed,
until this century, “alternative” ways of understanding disease
and healing were probably more effective than orthodox med-
icine, since they tended to be gentler than the leeches and
purges of conventional treatment. As medicine became in-
creasingly scientific and effective, however, alternative medi-
cine faded from the picture. Particularly after World War II,
with the advent of spectacularly effective antibiotics, a num-
ber of other life-saving drugs, and safe surgery, medical science
seemed to have totally eclipsed other approaches to healing.
But now, with the anti-science movement, alternative med-
icine is making a comeback. An article in the New England Jour-
nal ofMedicine described the widespread use of alternative med-
icine in the United States in 1990.!° It was based on telephone
interviews with 1,539 randomly selected adults. The authors de-
fined alternative or “unconventional” medicine as any mode
of therapy not taught widely in American medical schools and
not generally available in American hospitals. Included were
relaxation techniques, chiropractic, massage, imagery, energy
healing, biofeedback, hypnosis, homeopathy, and acupunc-
ture (among others). Surprisingly, about | in 3 of those inter-
viewed had used at least one unconventional therapy over the
past year, and | in6 had visited a provider of unconventional
treatment—on average, 19 times. On the basis of their study,
the authors estimated that in 1990 there were 425 million vis-
its to providers of unconventional therapy, which exceeded the
388 million visits to primary-care physicians.
Given the widespread use of alternative medicine, it is not
surprising that the establishment is taking respectful notice.
In 1992, under the prodding of Senator Tom Harkin (D-

Iowa), an Office of Alternative Medicine was created at the
National Institutes of Health. It is charged with studying a
host of practices, such as healing by “Lakota medicine
wheels,” mental healing at a distance, “biofield therapeutics,”
and the use of shark cartilage to treat cancer, most of which
would never even have engaged the attention of serious sci-
entists a generation ago, much less the attention of the sci-
entific establishment. Now they are taken seriously. Already
in its short history, the Office of Alternative Medicine has be-
come the center of intense controversy.'® The dispute is fun-
damentally about whether the mission of the office is to eval-
uate alternative treatments scientifically (which would
undoubtedly show many treatments to be worthless) or to
take alternative treatments on their own terms and essentially
document anecdotes. Obviously, the research projects funded
could be expected to differ depending on which of these mis-
sions predominates. As of now, there has been no explicit res-
olution of the controversy, and the OAM continues ina state
of uneasy ambivalence. In addition to the NIH, other bul-
warks of the establishment are beginning to look at alterna-
tive medicine. One of Harvard Medical School’s teaching
hospitals, for example, now has a Mind-Body Medicine Insti-
tute.
Homeopathy, the school of healing based on the propo-
sition that “like cures like,” is making deep inroads on the es-
tablishment. Homeopaths believe in treating diseases with
very dilute amounts of a substance that produces the same
symptoms as the disease being treated. For example, if a pa-
tient has a head cold, he or she might be treated with an ex-
tremely dilute solution of onion extract (which, in larger
doses, would cause a runny nose). According to the theory, the
Breast Implants and the Rejection of Science ™ 187
more dilute, the greater the effect—a theory that, if true,

would violate most of the principles of chemistry and phar-
macology. Three states—Connecticut, Nevada, and Arizona—
now license homeopaths. The NIH is obligingly launching a
clinical trial of the method." A study, of course, is the only way
to find out whether a treatment method works. Usually, how-
ever, there is some a priori biologic plausibility or expectation
of an effect before resources are spent on a large trial. After
all, not every hypothesis can be tested. But because of the
popularity of many forms of alternative medicine, they will be
tested anyway—and they probably should be.
In response to the anti-science movement and the grow-
ing tolerance, if not acceptance, with which it is received,
some scientists are fighting back. In the summer of 1995,
Gross and Levitt organized a conference of some 200 scien-
tists, physicians, and humanists under the auspices of the New
York Academy of Sciences. Called “The Flight from Science
and Reason,” the conference was devoted to analyzing and
countering the anti-science movement. The participants dis-
cussed the paradox of people rejecting the technology on
which they depend and the Western scientific tradition that
created it. The most sobering aspect to many of the partici-
pants was the fact that the theoretical basis for the rejection—
which some termed a romantic rebellion—comes not from re-
ligious fundamentalists, whose quarrel with science is well
understood and long-standing, but from academics who re-
gard themselves as intellectuals. Other than inspiring some
op-ed pieces on the subject,'® the conference probably did not
have much effect. The horse is already out of the barn.
AND WHAT IS THE DAMAGE? Why not encourage many “ways of

knowing”? What’s wrong with “alternative” healing? Why not,
188 #& SCIENCE ON TRIAL
indeed, indulge our fascination with the mystical and the oc-
cult? In my view, the disdain for science has enormous impli-
cations that reverberate far beyond the answer to any one of
these questions. Throwing over science means throwing over
an attachment to evidence. Viewing science as just one possi-
ble “way of knowing,” amounting to little more than the cus-
toms of a white men’s club, has the same result. The scientific
method was not put together and then applied to questions
of nature, or, as Harding would have it, forced on nature. It
evolved painfully over many years, through trial and error, be-
cause it was the only method that worked. It had to be what it
is. Contrary to Harding, nature forced itself on those who
would study it, not the reverse. Science is the only way to reach
conclusions about the physical world, including the human
body. Try predicting the time and place of the next solar
eclipse without it, or the sex of a baby before it is born. As
Robert Park, professor of physics at the University of Maryland,
said, “Science is the only means we have to sort out the truth
from ideology or fraud or mere foolishness.”'’ It is therefore
dismaying to scientists to find that many Americans not only
do not understand science, but they don’t want to understand
it and they don’t think it’s necessary that they do.
Anti-science feminism is particularly difficult for me, as a
feminist, to accept. After years of women fighting for entry to
the world of science, it is ironic that some of them would turn
away now. Women should not permit themselves to be ex-
cluded from science, much less abandon the field. We should
instead work to bring women into science at the main point
of exclusion—the earliest years of grade school and even be-
fore. Girls receive strong social messages that science and
math are boy subjects; English and the social sciences are girl
subjects. As a woman who herself bucked this attitude (I re-
Breast Implants and the Rejection of Science @ 189
member being told in college that I “thought like a man” and

not having enough sense to be offended by this alleged com-
pliment), Iam dismayed to see many feminists embracing the
prejudice. And I am particularly appalled at the move to dis-
miss the scientific method itself. There are many problems
with the assertion that women have their own, equally valid
ways of reaching what are essentially scientific conclusions. Be-
sides playing into the anti-feminist conceit that women can’t
get their little minds around scientific concepts, it caricatures
the nature of science, as well as the nature of both men and
women. Good scientists will attest to the role of intuition and
inspiration—that is, creativity—in their work. But while such
nonlinear thinking lies behind many a brilliant hypothesis, it
is still necessary to test it. This requires the application of the
scientific method—the dogged accumulation of evidence that
will logically speak to the question. (Unfortunately, the cre-
ative revelation often turns out to be ill-conceived. In the
words of Carl Sagan, “the vast majority of ideas are simply
wrong.””°) There is nothing wrong with postulating appar-
ently unscientific hypotheses, but there 7s something wrong
with failing to put them to the test. Ifan unconventional med-
ical practice really works, it should be possible to demonstrate
that fact. Of course, many conventional “scientific” beliefs
about health and disease also are vulnerable to the same crit-
icism of never having been tested. Some practices in medicine
are based on little more than hearsay and habit. These, too,
should be subjected to scientific testing.
The best reason for women not to turn against science is
the same as it is for men: The scientific method works. Make
no mistake, the astonishing advances in science and technol-
ogy over the past couple of centuries, particularly in recent
years, would have been impossible without the scientific
method. Without it, we would have no immunizations, no an-

tibiotics, no painless, safe surgery, no blood transfusions, in-
deed, not even clean water or electricity. We would still have
a life expectancy of less than 40 years, and half our children
would die before adulthood of diphtheria, measles, tetanus,
and diarrhea. (Many feminists who disdain science vote with
their feet on this one, taking their children to be immunized
against childhood diseases even though the immunizations
were developed by white men using the scientific method.)
Dismissing science because it was developed by men is unwise.
What needs to be done is for women to wield this powerful tool
on their own behalf, not to cede the ground.
What does all this have to do with breast implants? I have
discussed the anti-science movement in some detail, because
it establishes the context in which the breast implant contro-
versy developed and it greatly influences how it will unfold.
When the first reports of a link between breast implants and
systemic disease appeared, it was a time for skepticism. It was
a time for filing away the information as unsubstantiated anec-
dotes, not throwing it away altogether, but certainly not giv-
ing it credence. It was a time to gather evidence. Instead,
many people who heard about the reports (and the ensuing
lawsuits) responded according to their political or social po-
sitions. More important, they filled the vacuum resulting from
a lack of understanding about what would constitute such ev-
idence. People could feel pretty certain about the matter
based on all manner of considerations except what science
had to say. Those who had dismissed the scientific method as
an androcentric tool, in particular, could believe that implants
caused disease because they “knew” it. To them, the anecdote
was the new scientific method.
The breast implant controversy should be seen not only
Breast Implants and the Rejection of Science #® 191
in the context of the anti-science movement, but also in the

context of many of the other health scares that erupt period-
ically. As a result of a combination of publicity, anti-science at-
titudes, paranoia, profiteering, and, yes, scientific evidence, a
great many such scares come and go. There is sometimes lit-
tle follow-up as to which ones turn out to have substance and
which ones are baseless. How many Americans know that there
was no evidence whatsoever that the anti-nausea drug Ben-
dectin caused birth defects? How many know that there is no
evidence for a unique syndrome that afflicts veterans of the
Persian Gulf War? How many know that the hazards of as-
bestos and radon are probably very small except at high lev-
els of exposure?”! In this context, the notion that breast im-
plants cause disease is plausible. (It is certainly a lot more
plausible than alien abductions.) After all, implants are capa-
ble of doing a lot of local damage when they rupture or con-
tractures form. The fact that the scientific evidence seems not
to have affected the general view of breast implants is also not
surprising, given the record on this score.
We do indeed have other “ways of knowing.” They seem
to satisfy all sorts of needs and wishes in our complex society,
but they can’t tell us whether breast implants cause disease.
That question remains to be answered in the only way it can
be—through science. The controversy is not over and it may
not be resolved for years. In the final chapter, I will discuss the
prospects for its resolution and what we can learn from this
whole story.
10
WHERE WE STAND...
AND FOR HOW LONG
n May 15, 1995, Dow Corning filed for Chapter 11 bank-

ruptcy protection. This is the latest, but by no means the
first, example of a company brought to its knees by mass liti-
gation. Bankruptcy protection does not mean the dissolution
of the company; rather, it means that the company must be re-
organized to pay its debts as ordered by the bankruptcy court.
With bankruptcy, all of the claims against Dow Corning in both
federal and state courts were brought under the jurisdiction
of this single court. That is one advantage of bankruptcy. In-
stead of dealing with creditors in countless jurisdictions, the
company is subject to a coherent plan crafted by one court.
Even before Dow Corning claimed bankruptcy, the class-
action settlement was unraveling. Because so many women
had registered, Judge Sam Pointer announced in early May
that the size of the compensation for each woman would have
to be reduced.’ The original settlement included a grid show-
ing specific amounts to be awarded to each claimant, de-
pending on her age, the typeofillness and the severity. Of the
$4.25 billion, $1.2 billion was set aside for women claiming to
be sick already. The remainder (minus the billion dollars for
the lawyers’ fees) was to cover those who became sick over the
next 30 years.” With the registration of 440,000 women,
Where We Stand...and for How Long ® 193
248,500 of whom claimed to be sick already, it was abundantly

clear that the settlement, huge as it was, would not begin to
cover all the claims.*
The number of women claiming to be sick is roughly 20
percent of all women with breast implants. I do not know the
details of their claims, but if only 10 percent of them claim to
have classic connective tissue disease, it would be at least dou-
ble the rate in the general population. But the epidemiologic
studies indicate that such a high risk is extremely unlikely. All
we can Say is that a very large number of women have or claim
to have an unidentified illness. Ralph Knowles, of the plain-
tiffs’ steering committee, expressed amazement at the num-
ber of claims. “There are just too many sick women,” he said.
“I didn’t think it was going to be anything like that. If I did,
we would have never agreed to the $4.25 billion.”* Given the
publicity and the extremely easy terms of the settlement, Iam
surprised that he was surprised. It would be natural for any
woman with implants who experienced even ordinary fatigue
or muscle aches to attribute her symptoms to the implants.
Regardless of whether the results should have been fore-
seen, it was obvious that the grid would have to be revised.
Under the terms of the settlement, any such revision would
require that women have an opportunity to pull out of the set-
tlement and, if they chose, to sue individually. But if too many
did, manufacturers would also pull out of the settlement, since
it would no longer serve the purpose of limiting their liabil-
ity. Judge Pointer, faced with the collapse of the settlement,
charged the attorneys representing both sides to try to reach
an accommodation—presumably involving some combina-
tion of increased contributions from the manufacturers and
decreased awards for the claimants.° Thus, the dominoes were
set to topple even before Dow Corning filed for bankruptcy.
With Dow Corning’s bankruptcy, the class-action settle-

ment fell apart, although it was not officially pronounced dead
until four months later. As the company that had sold half of
all breast implants, Dow Corning had pledged nearly half the
$4.25 billion to the settkement. Now Dow Corning was no
longer a part of it. All claims against the company would be
settled by the bankruptcy court in Michigan, its home state. It
could take years to determine which of its creditors would be
paid and how much. The remaining three companies in the
settlement—Bristol-Myers Squibb, Baxter Healthcare, and
Minnesota Mining and Manufacturing (3M)—negotiated with
the plaintiffs’ steering committee throughout the long sum-
mer, but failed to reach an agreement by Judge Pointer’s Au-
gust 30 deadline.® Phone calls to Pointer’s information line
(800-887-6828) were greeted with increasingly pessimistic
recorded messages. The deadline was extended. Finally, on
September 7, Judge Pointer acknowledged that the original
settlement was dead, but that the remaining three manufac-
turers would try to negotiate a new one.’
On October 2, 1995, Judge Pointer announced a new, pre-
liminary agreement.® Unlike the original settlement, which ap-
plied to all women with implants made by any manufacturer,
the new terms would apply only to women with implants made
by the three participating manufacturers. Women with these
implants who claim to be sick would have three options: They
could opt out of the settlement and go it alone, they could ac-
cept a much reduced compensation based on the criteria of
the original settlement, or they could apply for higher com-
pensation by meeting more stringent criteria for illness. Those
not claiming to be sick would be able to make claims if they
became ill in the next 15 years. Unlike the original agree-
ment, this one would not permit compensation amounts to be
reduced or manufacturers to pull out. The costs to the man-
Where We Stand...and for How Long #® 195
ufacturers were therefore open-ended, but they were esti-

mated to be $3 billion, of which $180 million would be set
aside for the lawyers.
As this book went to press, it was not at all clear that the
new agreement would hold together any better than the old
one. Many women felt betrayed by the more stringent re-
quirements and the lower amounts of compensation.® Fur-
thermore, the agreement did not apply to about half of all
women with implants—that is, those whose implants were
manufactured by Dow Corning. But as the scientific evidence
increasingly weighed in against a connection between im-
plants and disease, the option of suing individually seemed to
grow less promising. Thus, women who thought they had a
choice between accepting the terms of a very generous class-
action settlement or trying for a larger amount individually
found themselves with both options closing off—theoretically.
On the other hand, two developments were promising for
them. First, the federal courts and a few states decided that
Dow Corning’s wealthier parent company, Dow Chemical
Company, could be held liable for the claims of women with
breast implants made by Dow Corning. In the fall of 1995, a
jury in Nevada awarded $14.1 million ($10 million of which
was punitive damages) to a woman with Dow Corning im-
plants who sued Dow Chemical. Second, the emerging scien-
tific evidence may have little impact. In the Nevada case, Dow
Chemical pointed to the Mayo Clinic study and the Nurses’
Health Study, but to no avail. The only certainty is that, with
the collapse of the class-action settlement, plaintiffs’ attorneys
and the women they represent have every interest in getting
to court as quickly as possible.
AND WHAT ABOUT the scientific evidence? So far, several good epi-
demiologic studies have failed to show an association between
implants and a host of connective tissue diseases, symptoms,

and abnormal lab tests.'!° The Women’s Health Cohort Study
found a relative risk of 1.2 that women with implants would re-
port connective tissue disease, but the reports have not yet
been validated. Although it is certainly possible that new stud-
ies might find a small association, enough is already known to
say that a strong association is extremely unlikely. At most,
breast implants could be a very weak risk factor for disease.
Let’s assume, for purposes of discussion, that the relative
risk turns out to be low—say, 1.2. What would that mean? The
relative risk, as discussed earlier, simply indicates how high
above the background level the risk is. In this case, it would be
slightly elevated. For every 10 women withoutimplants who de-
velop connective tissue disease, 12 women with implants in an
equal population would develop it. (For comparison, the rel-
ative risk of lung cancer among cigarette smokers is about 15;
that is, for every 10 nonsmokers who develop lung cancer, 150
smokers do.) It is important to realize that we do not know ex-
actly what a relative risk of 1.2 means for each of those 12
women who develop connective tissue disease. It could mean
that in 2 of them, the implants were the sole cause of their dis-
ease and in the other 10 they played no role. Or it could mean
that implants played a major role in 3 or 4 women and a very
small one in the others. Or it could mean that implants con-
tributed a varying amount to the disease in all 12. There is no
way to know for sure on the basis of epidemiologic research.
We would need to know more precisely how the implants con-
tribute to or cause disease and why some women are more sus-
ceptible than others. Finding those answers would take.a dif-
ferent sort of research—basic research and clinical studies. All
we could say for sure with a relative risk of 1.2 is that, on aver-
age, implants contributed about 17 percent (0.2/1.2) to the
Where We Stand...and for How Long 8 197
disease. For any one woman among the 12, then, we could not
say that but for the implants, she would not have developed
the disease. Further, we would have to say that some other fac-
tor or group of factors was the dominant cause.
Now let’s assume that the relative risk turns out to be 2.1
instead of 1.2 (although the present epidemiologic evidence
indicates this level of risk would be extremely unlikely). What
would that mean? For every 10 women without implants who
develop connective tissue disease, 21 women with implants
will develop it. Implants would therefore be more important
than all other causes put together, since the relative risk would
be more than double the background level. As in the exam-
ple of a relative risk of 1.2, with a relative risk of 2.1 we would
have no way of knowing the precise contribution of implants
to connective tissue disease in each particular woman. They
could be the sole cause in 11 and play no role in 10, or they
could play a varying role in all of them. But we would know
that, on average, they were the dominant cause, and so for any
one woman, we could say that she would probably not have
developed the disease if she had not received implants.
In fact, however, the epidemiologic studies to date have
not found a relative.risk of 2.1 and only one study—the largest,
but likely to be biased because it was based on what women
with implants said about their health after the FDA ban—has
found a risk as high as 1.2. The best evidence now isa relative
risk of 1.0, indicating no contribution of implants to disease.
I assumed relative risks of 1.2 and 2.1 to illustrate a point—
that is, that moving from a focus on the average results in a
group of women to a focus on a particular woman is difficult.
Nevertheless, unless we know something about individual sus-
ceptibilities, using the average as a proxy for the particular is
the best we can do. And, from ascientific and logical per-
spective, it is the best the courts can do. Unfortunately, they

have not done that, because of the way our judicial system
works in tort cases.
As pointed out in Chapter 6, the courts are asked to make
a judgment not about a population of women, but about an
individual. For example, a court had to decide whether it was
probable that implants caused Mariann Hopkins’s mixed con-
nective tissue disease.'' At the time of the Hopkins case, there
was no evidence of any increased risk, much less a relative risk
greater than 2.0. Therefore, the only logical conclusion was
that implants did not cause her disease. But the jury did not
draw the logical conclusion. Instead, they attempted the im-
possible: to decide in the absence of evidence whether im-
plants caused disease in a particular woman.
To a great extent, however, the courts have avoided the
issue of causation altogether. Plaintiffs’ attorneys have been
remarkably successful in shifting the focus away from it. In-
stead of trying to demonstrate that the implants probably
caused the plaintiff's disease, they simply assumed causation.
They then focused on the manufacturers’ behavior. Had they
demonstrated safety? Were they negligent? Did they hide ev-
idence? This shift in focus has received very little attention.
Perhaps we are simply used to thinking of the controversy in
terms of proven safety, because at the time of the FDA ban, at-
tention was focused on whether safety had been demon-
strated. Kessler was right in saying that from the FDA’s view-
point, the burden of proof was on the manufacturers. But in
court, the burden of proof should be on the plaintiff. Can the
plaintiff show that implants probably caused her disease? Since
a torrent of lawsuits followed the FDA’s decision, it may be that
there was a natural tendency to assume that the basis for the
decisions would be the same. Whatever the explanation, this
Where We Stand ...and for How Long #® 199
shift was pervasive, and it made the job of the plaintiffs’ at-
torneys much easier.
Another shift taking place was in the nature of the harms
being attributed to breast implants. I have already discussed
the change in concerns from cancer to autoimmune or con-
nective tissue disease, and then to “non-classic” disease.!* As
the diseases became vaguer and harder to define, it became
increasingly difficult to study their association with implants.
Doctors who make their living diagnosing implant-related dis-
eases and the lawyers who pay them have every reason to pos-
tulate increasingly obscure syndromes, as the well-defined
ones come under scientific scrutiny. To them, the best diseases
are those that can’t be defined, because they can’t be studied
systematically. A more reasonable shift was taking place at the
FDA. The agency was changing its major focus from systemic
diseases to local complications of implants. Kessler told Con-
gress in August 1995, “We now have, for the first time, a rea-
sonable assurance that silicone-gel implants do not cause a
large increase in traditional connective-tissue disease in
women.”!? He was now concerned primarily with the local
complications—contractures, leakage, rupture, and problems
with mammography. In justifying the continuation of the ban,
he rightly pointed out that just as we didn’t know the risk of
systemic complications, we also didn’t know the incidence of
local ones. Fortunately, this was an easier matter to study than
an ever-shifting constellation of nonspecific symptoms.
And who should do the research? When the FDA banned
breast implants, it was because the manufacturers had not ful-
filled their obligation to produce evidence of safety. One way
for a company to do this is to fund research done by scientists
in established research institutions. In the case of breast im-
plants, in particular, outside research is necessary, since
demonstrating safety requires large epidemiologic studies,

which can only be conducted by epidemiologists who have ac-
cess to large numbers of people. The manufacturers them-
selves do not have access to the subjects, nor do they have the
expertise to carry out the studies. Since the ban, and under
the prodding of the FDA, the manufacturers have begun to
fund serious research into the safety of breast implants. This
is the research they should have supported years before. Dow
Corning, for example, contributed to the Mayo Clinic study
through the American Society of Plastic and Reconstructive
Surgeons’ Educational Foundation. The company also sup-
ported the Women’s Health Cohort Study. Funding such re-
search was precisely what the FDA faulted the manufacturers
for not doing earlier. Ironically, after the manufacturers began
to fund research, plaintiffs’ attorneys implied that the research
was invalid for that very reason.'* Surely, this was a Catch-22.
The charge, however, did raise the larger issue of conflicts of
interest in medical research. As government funding of re-
search declines, more of it is supported by private industry.
Does private support by a company with an interest in the drug
or device under study automatically taint the research?
Much depends on how the research grant is given. Re-
search institutions such as the Mayo Clinic and the Brigham
and Women’s Hospital (the Harvard hospital that houses the
Nurses’ Health Study and the Women’s Health Cohort Study)
have given a good deal of attention to preventing bias in pri-
vately funded research. They have established guidelines to
prevent research from being influenced by a company that
provides funding. First, the grant is customarily given to the
institution, not to the researchers, so that the rules can be en-
forced. Full public disclosure of the source of funding is re-
quired. The company is usually not permitted to participate
in the design of the study or in the analysis of the results.

Often there is an agreement that the company will not be told
about the results until the study is published or presented at
a scientific meeting. Most important, there is usually an agree-
ment that the results will be reported, regardless of the out-
come. A recent study of the effects of large doses of vitamin A
on pregnant women is a good example.’® This study found vi-
tamin A in high doses to cause birth defects. By prearranged
agreement, the researchers reported these results, despite the
fact that the study was funded by a manufacturer of vitamin
supplements. Such precautions are necessary to prevent com-
panies from distorting or withholding the results of research
on their products. When the rules are followed, there is no rea-
son to dismiss the study simply because it has been funded by
a company with an interest in the outcome. (If there were,
much of the biomedical research done in this country would
have to be disregarded.)
Other countries have responded quite differently to the
unfolding evidence about breast implants. Spain, for example,
followed the lead of the FDA and banned breast implants in
1992, but lifted the ban later the same year, after reviewing the
data.!° The French Health Ministry can’t seem to make up its
mind. Like Spain, it followed the FDA’s lead and pulled breast
implants off the market in 1992. As the epidemiologic evi-
dence accumulated, however, France reevaluated the situa-
tion, and in January 1995 lifted the ban.’” Later the same year,
they reinstituted it.’* Great Britain chose to buck the trend al-
together, and never followed the FDA’s lead. The British De-
partment of Health issued a report in 1993 saying they found
no reason for a moratorium.'? A 1994 update stated, “The
conclusions from this updated analysis remain unchanged in
that there remains no scientific evidence from the literature
of any increased risk of connective tissue disease associated

with silicone gel breast implants.” *° Committees established by
the Canadian and French governments reached the same con-
clusion, as did the American Medical Association, the Ameri-
can Society of Plastic and Reconstructive Surgeons, and the
American College of Rheumatology.
Whether the new evidence will lead the FDA to reverse its
decision is unclear. The effect on the legal situation is also dif-
ficult to predict. Given Dow Corning’s bankruptcy, the melt-
down of the class-action settlement, and the precariousness of
the new agreements with the other manufacturers, the legal
situation may very well remain in flux for years. Adding to the
complexity is the likelihood of a new rush to court now that
Dow Chemical has been found liable for Dow Corning’s im-
plants in some jurisdictions. Although studies failing to find
a link between implants and connective tissue disease, or stud-
ies finding only a weak link, may influence pending lawsuits,
there is very little basis for optimism on that score. Almost cer-
tainly in this volatile situation, much will depend on public
opinion.
WHATEVER THE END RESULT Of the breast implant controversy,

the story should give us all pause. Many people expect big busi-
ness to be concerned primarily about profits and only as con-
cerned about the safety of its customers as the law and public
relations require. When I began looking into the breast im-
plant story, I fully expected to find that the implant manu-
facturers fit this mold. What I was not prepared to find was the
extent of the financial involvement of the plaintiffs’ attorneys
and the possible complicity of some physicians in their pur-
poses. The derelictions of the manufacturers paled in com-
parison. As the breast implant story unfolded, three profes-
sions—law, medicine, and journalism—failed in their re-

sponsibilities to hold the controversy within the bounds of rea-
son. The failure reflected certain underlying weaknesses
within these professions. What were the problems revealed in
each profession, and how might they be addressed?
The peculiar incentives within the legal profession are
perhaps the most obvious problem. Our tort system enables
lawyers to prey on people’s fears, to destroy thriving compa-
nies, and, in the breast implant case, even to threaten an en-
tire industry (medical devices) and an important area of med-
ical research (epidemiologic studies)—and at the same time
to make huge amounts of money in fees. The legal system vir-
tually invites this sort of abuse. The practice of paying lawyers
contingency fees in tort cases, along with the easy electronic
exchange of information about lawsuits all over the country,
means that plaintiffs’ attorneys can mass-produce lawsuits of
very little merit with almost no risk to themselves. If they win
only one of every ten or twenty, they can still do very well. On
the other hand, each lawsuit from every lawyer requires a re-
sponse from the defendant. The costs of defending all the law-
suits can be very high, even if successful. Recall that DuPont
spent $8 million successfully defending itself against lawsuits
filed against it because it had supplied Teflon to the manu-
facturer of allegedly defective jaw implants. If a defendant
loses just one of every ten or twenty cases, the costs can be
enormous. Furthermore, losing just one lawsuit can stimulate
an avalanche of others, and each loss usually means the stakes
grow higher in the next case. Manufacturers therefore are
usually eager to settle claims out of court, even when they be-
lieve the product has not caused the injury and they think they
could probably win in court. Maybe contingency fees should be
forbidden in this country, as they are elsewhere. At the very
least, they should be much smaller than they are and perhaps
restricted to clients who cannot afforda set fee.
The use of juries for tort cases is also problematic. Deci-
sions by judges would almost certainly be sounder than those
made by juries, because judges are educated to be dispas-
sionate and to evaluate evidence. Many tort cases involve ex-
pert witnesses, who speak to fairly technical matters. To eval-
uate whether a product has caused a disease is difficult for
nearly anyone. For a jury it is especially difficult, because its
members usually have no competence in the area. They are
often left to make judgments largely on the basis of the emo-
tional appeals of the lawyers and their expert witnesses. Judges,
too, may have no competence in the technical area, but they
are much more resistant to lawyers’ emotional appeals than
juries usually are, and they can learn how to approach scien-
tific questions—as, indeed, they are required to do by the
Supreme Court in the Daubert decision (discussed in Chapter
6). The growing size of jury awards, especially punitive dam-
ages, also is problematic. Although judges often reduce the
size of the damages after the verdict, large awards still create
strong inflationary pressures. Other countries do not have
jury trials for civil cases, and we should consider eliminating
them for tort cases.
Other needed legal reforms should include some atten-
tion to the growing abuse of class actions as windfalls for at-
torneys. In addition, we should probably review the laws that
permit suppliers of biomaterials to be sued for damages
caused by products they had no part in designing or testing.
Addressing these problems is important. But even more im-
portant, in my judgment, is to reform the way science is han-
dled in the courtroom. If it were not for the nearly total lack
of scientific standards in the breast implant cases, even a badly
flawed legal system could not have worked such mischief.

There is no reason that science in the courtroom cannot be
as reliable as science elsewhere.
The most important reform we could make to raise sci-
entific standards in the courtroom would be for judges to ap-
point expert witnesses, rather than to rely on witnesses hired
by the opposing lawyers. Reputable experts could be recom-
mended to courts by established scientific organizations, such
as the National Academy of Sciences or the American Associ-
ation for the Advancement of Science. These witnesses would
be neutral—that is, they would represent neither side. In
essence, they would interpret for the court the current scien-
tific knowledge about the matter at hand. The task would be
similar to the task of writing a review article for a journal. The
experts would be expected to cite evidence from the scientific
literature to support their interpretations. Although judges
now have the option of appointing such witnesses, they rarely
do so. The practice should be routine. And without reliable
expert witnesses, science in the courtroom will continue to be
a baffling mix of fact and speculation, of objectivity and self-
interest. The verdicts will be no less baffling.
The breast implant story shows how courtroom proce-
dure can ignore or misinierpret science. It also illustrates how
the unrestrained use of subpoenas outside the courtroom can
harass and even intimidate scientists engaged in research, to
the detriment of all of us. The Mayo Clinic, for example, has
collected medical information on the residents of Olmsted
County for many decades. Because most patients in this rela-
tively isolated, rural county receive their specialized medical
care from the Mayo Clinic, the database (known as the
Rochester Epidemiology Project) is not only huge, but com-
prehensive. And its yield has béen prolific. Over 800 scientific
studies on all sorts of medical questions have emanated from

this one database. It is a unique resource. But it depends on
the cooperation of the local doctors and their patients. When
the plaintiffs’ attorneys subpoenaed Sherine Gabriel for the
records of all women in her study, as well as all who were con-
sidered for it, the Mayo Clinic was concerned that doctors, wor-
ried about maintaining the confidentiality of their patients,
would withdraw from the Rochester Epidemiology Project.
Similarly, the Nurses’ Health Study is an ongoing study of
some 100,000 women, which yields information about a wide
range of medical questions, of which the effect of breast im-
plants is only one. As in the case of the Rochester Epidemiol-
ogy Project, subpoenas for the participants’ records threaten
confidentiality and therefore the existence of the database. Sci-
entists working on both these projects are alarmed by this
threat to their ability to continue their research. They are also
worried about the time and effort involved in meeting what at
least some of them perceive to be excessive and unreasonable
demands for documents. If such concerns were to discourage
further epidemiologic studies of breast implants, the plaintiffs’
attorneys who have been largely responsible for issuing sub-
poenas for clinical records conceivably might have cause for
satisfaction, but the rest of us should not.
Long-standing epidemiologic databases, such as those of
the Rochester Epidemiology Project and the Nurses’ Health
Study, are all the more important because it would now be ex-
tremely difficult to assemble a new database to do research on
breast implants. The reason is that the widespread publicity
about breast implants since 1991 would color women’s re-
sponses to questions about their health. Since women with
breast implants have heard that the devices may cause all sorts
of diseases and symptoms, it would be human nature for them
to remember and magnify even ordinary complaints, as dis-
Where We Stand ...and for How Long # 207
cussed earlier. Add to this unconscious tendency the fact that

a great Many women with implants have pending legal claims,
and it becomes all but impossible to obtain unbiased infor-
mation about their health. Even recent medical records could
be biased. In contrast, studies based on the older databases
considered only illnesses reported before a cutoff date (in the
Mayo Clinic study, 1991; in the Nurses’ Health Study, 1990).
What about the medical profession’s role in this story?
The lawyers could not exploit the breast implant controversy
without the help of doctors who collect fees for making what
are often dubious diagnoses. Not only are these doctors guilty
of putting personal gain before their professional commit-
ments, but they also subject women to unnecessary, costly,
and sometimes risky treatments. Most doctors, to their credit,
have resisted the temptation to join in the lucrative arrange-
ment. Nevertheless, the medical profession as a whole bears
some responsibility for the fact that a small group of doctors
is able to get away with such blatantly unethical behavior. At
least one of these doctors was reported to his state’s Board of
Medical Registration. When this book went to press, a year
after the report, the board had still taken no action.
Finally, the media must share the blame for events in the
early stages of the breast implant controversy. Despite the
total lack of evidence, reporters were quite happy to feed and
amplify the public’s fascination with yet another health scare.
There was little effort to provide a critical analysis of the issue,
much less to put it in context. The public soon became utterly
convinced that breast implants cause serious disease. It then
exerted pressure on the FDA, which is necessarily a political
body as well as a regulatory one. The FDA’s advisory panels in-
cluded advocates who were certain, despite the lack of evi-
dence, that implants cause disease. Public hearings in this cli-
mate all but guaranteed the outcome. The legal system, whose
unscientific and outsized verdicts had largely initiated the

scare, then became the victim of the monster it created. With
each spectacular verdict, another was sure to follow, along
with a much larger number of out-of-court settlements. As the
Washington Post editorialized in the fall of 1995, “What’s odd-
est about the implant situation at present is the continued di-
vergence between the results of medical studies (mandated by
the Food and Drug Administration when it took most im-
plants off the market after its hearing in 1992) and the results
of legal proceedings unrelated to those hearings.”*! In trans-
mitting health news to the public, reporters have an obliga-
tion to be critical and to put any given story in its larger con-
text. Too often they succumb to the temptation to fan fears.
And, unfortunately, that is all too easy to do. The breast im-
plant controversy shows the proclivity of the public—unable
to tolerate uncertainty, unwilling to make minimal efforts to
evaluate scientific stories, and reinforced by the media—to
embrace uncritically the medical scare of the day.
Underlying the failings of the legal, medical, and jour-
nalistic professions in the breast implant story is the lure of fi-
nancial gain. Lawyers become fabulously wealthy suing breast
implant manufacturers. Doctors and expert witnesses who co-
operate with them share in some of the wealth. And the media
are often more interested in ratings and sales, which are par-
layed into financial gain, than in responsible reporting. Many
members of these three professions pursue their private in-
terests with utter disregard for the larger consequences. Even
the many healthy women with breast implants who now want
to take advantage of the furor over them are responding to the
lure of big financial awards. As Barry Schwartz points out in
his book, The Costs of Living, “Business is business, and the pro-
fessions are business too.”** But when all activities are based
on maximizing financial rewards, other considerations, in-

cluding ethical standards, are lost. Money makes kings of
rogues, sages of idiots, and heroes of thieves. A society too
much in its thrall is left with no one to tend the public good.
The breast implant controversy shows every sign of con-
tinuing on its irrational course for years. Only an unyielding
commitment to scientific evidence can stop it, and that does
not seem very likely, given the money and passions involved.
If all parties had accepted the discipline of evidence at the out-
set, the controversy would never have reached such propor-
tions. It would hardly have gotten off the ground. But without
a commitment to objective data, people were free to believe
whatever they liked. Instead of basing their conclusions on the
evidence, they willed the evidence to fit their favored conclu-
sions. Do breast implants cause disease? If you were a plain-
tiffs’ attorney, you would say they do. If you were a defense at-
torney, you would say they don’t. Witnesses for both sides
follow suit. Those who are critical of the supremacy of big busi-
ness in American life would say they do. Those who believe
that America’s business is business would say they don’t. This
indifference to the need for evidence is a common thread in
the many medical alarms that are sounded periodically in this
country; the breast implant story simply illustrates it writ large.
Whether or not breast implants are dangerous is not a ques-
tion to be left to public opinion, corporate self-interest, and
legal machinations. We ought to want to know the truth (or
as near as we can come to it). But finding it requires careful
scientific research and unbiased interpretation of the results.
There are no shortcuts. Only by relying on scientific evidence
can we hope to curb the greed, fear, and self-indulgence that
too often govern such disputes. That is the lesson of the breast
implant story.
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NOTES
1: The Breast Implant Story
1. Estimates of the number of women with breast implants vary, but

the FDA, in “Background Information on the Possible Health Risks
of Silicone Breast Implants” (December 18, 1990; rev. February 8,
1991), says 2 million women in the United States “presently have”
implants.
2. The 80 percent augmentation/20 percent reconstruction figure
is used by almost everybody, including the FDA (in particular, the
number appears in the June 1992 issue of the FDA Consumer). Also,
Independent Advisory Committee on Silicone Gel-Filled Breast Im-
plants, “Summary of the Report on Silicone-Gel-Filled Breast Im-
plants,” Canadian Medical Association Journal, 147 (1992):1141-46.
3. See D. Kessler, “The Basis for the FDA’s Decision on Breast Im-
plants,” New England Journal of Medicine, 326 (1992):1713-15.
4. A few newspaper articles chronicles the stories of women who at-
tempted to remove implants with razor blades. See W. Bunch,
“Under the Knife: Woman Uses Razor to Remove Implants,” News-
day, April 18, 1992, p. 7; also R. Bragg, “Desperation Forces Removal
of Implants,” Houston Chronicle, May 15, 1992, p. Al.
5. The explosion of breast implant cases in the courts was detailed

in the following articles: B. Wiser, “Feud in Implant Settlement Stirs
Debate over Tactics,” Washington Post, May 11, 1994, p. D1; G. Ko-
lata, “Details of Implant Settlement Announced by Federal Judge,”
New York Times, April 16, 1994, p. A16.
212 @ Notes
6. Juries bestowed several very large awards to breast implant recip-

ients in the early 1990s. See W. Carlsen, “Jury Awards $7.3 Million in
Implant Case,” San Francisco Chronicle, December 14, 1991, p. A13;
also “Record $25 Million Awarded in Silicone Implants Case,” New
York Times, December 24, 1992, p. A13.
7. Many of the local complications related to implants are detailed

by Council on Scientific Affairs, American Medical Association, “Sil-
icone Gel Breast Implants,” JAMA, 270, no. 21 (December 1993):
2602-6. The FDA included risk information on these complications
in the Federal Register, September 26, 1991:49098-99.
8. Information on breast implants and cancer risk can be found in

Council on Scientific Affairs, American Medical Association, “Sili-
cone Gel Breast Implants,” JAMA, 270, no. 21 (December
1993):2602-6. See also D. M. Deapen and G. S. Brody, “Augmenta-
tion Mammaplasty and Breast Cancer: A 5-Year Update of the
Los Angeles Study,” Plastic and Reconstructive Surgery, 89, no. 4
(April 1992):660-65; D. M. Deapen et al., “The Relationship be-
tween Breast Cancer and Augmentation Mammaplasty: An Epi-
demiologic Study,” Plastic and Reconstructive Surgery, 77, no. 3 (March
1986) :361-68.
9. Details of the settlement were widely covered by the general media.

See, for example, T. M. Burton, “U.S. Judge Clears Breast-Implant
Accord,” Wall Street Journal, September 2, 1994, p. B2. For full details,
see the settlement notice, entitled “Proposed Breast Implant Litiga-
tion Settlement,” which was distributed by the U.S. District Court of
the Northern District of Alabama.
10. The first epidemiologic study of the possible link between breast
implants and connective tissue disease was S. E. Gabriel et al., “Risk
of Connective-Tissue Diseases and Other Disorders after Breast Im-
plantation,” New England Journal of Medicine, 330 (1994):1697-1702.
11. Norman Anderson is quoted in A. Frankel, “From Pioneers to

Profits,” American Lawyer, June 1992: 82.
Notes @ 213
2: Breast Implants
1. The increasing use of breast implants is detailed in S. E. Gabriel

et al., “Trends in the Utilization of Silicone Breast Implants,
1964-1991, and Methodology for a Population-Based Study of Out-
comes,” Journal of Clinical Epidemiology, 48, no. 4 (April 1995) :527-37.
2. Breast augmentation statistics, demographic material, and fee in-

formation come from the American Society of Plastic and Recon-
structive Surgeons (Arlington Heights, III.),“1994 Plastic Surgery Sta-
tistics.”
3. Changes in the pattern of breast implant use are discussed in J.

Foreman, “Breast Implant Field Altered by FDA Edict,” Boston Globe,
March 13, 1994, p. Al; S. E. Gabriel et al., “Trends in the Utilization
of Silicone Breast Implants, 1964-1991, and Methodology for a
Population-Based Study of Outcomes,” Journal of Clinical Epidemiol-
ogy, 48, no. 4 (April 1995):527-37; Independent Advisory Commit-
tee on Silicone Gel-Filled Breast Implants, “Summary of the Report
on Silicone-Gel-Filled Breast Implants,” Canadian Medical Association
Journal, 147 (1992):1141-46; and D. Hilzenrath, “Surviving the
Breast-Implant Siege,” Washington Post, June 24, 1994, p. F1.
4. Arthur Caplan quoted in J. Foreman, “Implants: Is Uninformed

Consent a Woman’s Right?” Boston Globe, January 13, 1992, p. 25.
5. See N. Wolf, The Beauty Myth: How Images of Beauty Are Used against
Women (New York: William Morrow, 1991).
6. For more information about the history of breast augmentation

and early silicone use see G. T. Grace and I. K. Cohen, “Silicones and
Breast Surgery,” in R. B. Noone (ed.), Plastic and Reconstructive Surgery
of the Breast (Philadelphia: Mosby, 1991); E. H. Kopf, “Injectable Sil-
icones,” Rocky Mountain Medical Journal, 63 (1966):34—36; J. P.
214 & Notes
Lalardie and R. Mouly, “History of Mammaplasty,” Aesthetic Plastic

Surgery, 2 (1978):167-76; and Council on Scientific Affairs, Ameri-
can Medical Association, “Silicone Gel Breast Implants,” JAMA, 270,
no. 21 (December 1993):2602-6.
7. For more information about the basic chemistry of silicone and

its uses see S. A. Bradley, “The Use of Silicones in Plastic Surgery: A
Retrospective View,” Plastic and Reconstructive Surgery, 51
(1973) :280-88; G. T. Grace and I. K. Cohen, “Silicones and Breast
Surgery,” in R. B. Noone (ed.), Plastic and Reconstructive Surgery of the
Breast (Philadelphia: Mosby, 1991); and R. R. LeVier, M. C. Harri-
son, R. R. Cook, and T. H. Lane, “What Is Silicone?” Plastic and Re-
constructive Surgery, 92 (1993):163-67.
8. Some of the side effects of injecting silicone directly into the
breasts are documented in E. H. Kopf, C. A. Vinnik, J. J.Bongiovi,
and D.J.Dombrowski, “Complications of Silicone Injections,” Rocky
Mountain Medical Journal, 73, no. 2 (1976):77-80.
9. Polyvinyl alcohol is discussed in G. T. Grace and I. K. Cohen, “Sil-

icones and Breast Surgery,” in R. B. Noone (ed.), Plastic and Recon-
structive Surgery of the Breast (Philadelphia: Mosby, 1991).
10. More information about Cronin and Gerow’s collaboration with

Dow Corning on the first silicone-gel-filled breast implants can be
found in S. A. Braley, “The Use of Silicones in Plastic Surgery: A Ret-
rospective Review,” Plastic and Reconstructive Surgery, 51, no. 3
(1973):280-88; J. P. Lalardie and R. Mouly, “History of
Mammaplasty,” Aesthetic Plastic Surgery, 2 (1978):167-76; and M.
Swartz, “Silicone City,” Texas Monthly, August 1995:65.
11. Suggested surgical procedures for augmentation mammaplasty

were detailed by Dow Corning Corporation in a September 1976 bul-
letin (#51-266); also in T. D. Cronin and R. L. Greenberg, “Our Ex-
periences with the Silastic Gel Breast Prosthesis,” Plastic and Recon-
structive Surgery, 46, no. 1 (1970):1.
12. Suggested surgical procedures for reconstruction after mastec-
tomy are detailed in the U.S. Food and Drug Administration’s pub-
Notes @ 215
lication “Breast Implants: An Information Update,” June 1994 (rev.

October 1994), Rockville, Md. See also R. H. Guthrie, The Truth
about Breast Implants (New York: John Wiley & Sons, 1994).
13. Each of these problems is detailed in Council on Scientific Af-

fairs, American Medical Association, “Silicone Gel Breast Implants,”
JAMA, 270, no. 21 (December 1993):2602-6. See also G. T. Grace
and I. K. Cohen, “Silicones and Breast Surgery,” in R. B. Noone
(ed.), Plastic and Reconstructive Surgery of the Breast (Philadelphia:
Mosby, 1991).
14. For years, implant manufacturers recommended that physicians

perform this procedure. Closed capsulotomy was detailed in J. L.
Baker, R. J. Bartels, and W. M. Douglas, “Closed Compression Tech-
nique for Rupturing a Contracted Capsule around a Breast Implant,”
Plastic and Reconstructive Surgery, 58, no. 2 (1976):137-41, and also in
C. A. Vinnik, “Spherical Contracture of Fibrous Capsules around
Breast Implants, Plastic and Reconstructive Surgery, 58, no. 5
(1976) :555-60.
15. For more on complications from closed capsulotomy, see R. H.

Guthrie, The Truth about Breast Implants (New York: John Wiley &
Sons, 1994).
16. Estimates of rupture rates vary greatly. The general consensus

among physicians, however, puts the rate at 4 to 6 percent. See Coun-
cil on Scientific Affairs, American Medical Association, “Silicone Gel
Breast Implants,” JAMA, 270, no. (December (December
1993) :2602-6;J.M. Destouet et al., “Screening Mammography in 350
Women with Breast Implants: Prevalence and Findings of Implant
Complications,” American Journal of Radiology, 159 (1992):9'73-78;
and D. Kessler, “The Basis for the FDA’s Decision on Breast Im-
17. Complications associated with polyurethane-coated implants are

discussed in Independent Advisory Committee on Silicone Gel-Filled
Breast Implants, “Summary of the Report on Silicone-Gel-Filled
Breast Implants,” Canadian Medical Association Journal, 147
216 & Notes
(1992):1141-46; also C. S. Kasper, “Histologic Features of Breast

Capsules Reflect Surface Configuration and Composition of Silicone
Bag Implants,” American Journal of Clinical Pathology, 102, no. 5
(1994) :655-59.
18. Features of saline-filled and double-lumen implants are dis-
cussed in Independent Advisory Committee on Silicone Gel-Filled
Breast Implants, “Summary of the Report on Silicone-Gel-Filled
Breast Implants,” Canadian Medical Association Journal, 147
(1992):1141-46.
19. Data about the prevalence of different types of implants are dis-
cussed in N. Handel et al., “Knowledge, Concern, and Satisfaction
among Augmentation Mammaplasty Patients,” Annals of Plastic
Surgery, 30, no. 1 (1993):13-20, discussion 20-22.
20. A Swiss company, LipoMatrix, Inc., is conducting clinical trials

on soybean-oil-filled implants. See “New Breast Implant to Be Tested
in U.S.,” Boston Globe, August 2, 1993, p. 48.
21. Complete transcripts of Jenny Jones’s television programs from

February 27 and March 30, 1992, are available from Burrelle’s In-
formation Services. Ms. Jones’s story was featured in People magazine
on March 2, 1992.
22. Mariel Hemingway’s story is recounted in K. Muir, “Look Me in

the Eyes and Tell Me They’re Safe,” The Times (London), May 7, 1994.
23. Information about the use of breast implants in Olmsted County
can be found in S. E. Gabriel et al., “Trends in the Utilization of Sil-
icone Breast Implants, 1964-1991, and Methodology for a
Population-Based Study of Outcomes,” Journal of Clinical Epidemiol-
ogy, 48, no. 4 (April 1995):527-37.
24. Information about the 1990 survey is available from the Ameri-
can Society of Plastic and Reconstructive Surgeons (Arlington
Heights, Ill.).
25. See N. Handel et al., “Knowledge, Concern, and Satisfaction

among Augmentation Mammaplasty Patients,” Annals of Plastic
Surgery, 30, no. 1 (1993):13-20, discussion 20-22.
Notes @ 217
3: The FDA Ban on Implants
1. For a biographical sketch of Dr. David Kessler, see A. Gibbons,

“Can David Kessler Revive the FDA?” and “New FDA Head: Profile
of an Overachiever,” both in Science, 252, no. 5003 (1991):200-3.
2. One comprehensive general chronology of the regulatory history

of breast implants is R. Stombler, “Breast Implants and the FDA: Past,
Present, and Future,” American College of Surgeons Bulletin, June
1993:11-15. Dr. Kessler also recapped the history in his August 1,
1995, testimony before the Subcommittee on Human Resources and
Intergovernmental Relations of the Committee on Government Re-
form and Oversight of the U.S. House of Representatives.
3. The very first of these reports, by K. Miyoshi et al., was published

in a Japanese medical journal in 1964: “Hypergammaglobulinemia
by Prolonged Adjuvanticity in Man: Disorders Developed after Aug-
mentation Mammaplasty,” Japan Medical Journal, 2122 (1964):9-14.
Other reports from Japan of connective tissue diseases from injec-
tions of paraffin or silicone were published in American medical jour-
nals. See Y. Kumagai et al., “Scleroderma after Cosmetic Surgery:
Four Cases of Human Adjuvant Disease,” Arthritis and Rheumatism, 22,
no. 5 (1979):532-37. Also Y. Kumagai et al., “Clinical Spectrum of
Connective Tissue Disease after Cosmetic Surgery: Observations on
18 Patients and a Review of the Japanese Literature,” Arthritis and
Rheumatism, 27, no. 1 (1984):1-12.
4. See S. A. Van Nunen et al., “Post-Mammaplasty Connective Tissue

Disease,” Arthritis and Rheumatism, 25, no. 6 (1982):694-97.
5. The Stern verdict went out on the UPI wire on November 5, 1984,
but was not widely reported in the general press. The case was re-
visited in 1992 by U. Thomas, “Woman’s Breast Implant Suit Started
the Dominoes,” Idaho Statesman, March 14, 1992.
218 @& Notes
6. Dan Bolton’s trip to Midland, Michigan, and the details about how
and why the Dow Corning documents were sealed are recounted in
A. Frankel, “From Pioneers to Profits,” American Lawyer, June 1992:82.
7. Anderson first met Bolton at the November 1988 hearings, which
Anderson chaired and where Bolton testified. See A. Frankel, “From
Pioneers to Profits,” American Lawyer, June 1992:82. See also P. Hilts,
“Breast Implant Maker Accused on Data,” New York Times, Decem-
ber'21, 19910 pS:
8. Sidney Wolfe’s letter is cited in R. R. Cook et al., “The Breast Im-

plant Controversy,” Arthritis and Rheumatism, 37, no. 2 (1994):153-57.
9. A Frankel, “From Pioneers to Profits,” American Lawyer, June

1992:82, notes Bolton’s involvement with Public Citizen’s breast im-
plant clearinghouse.
10. For more on Command Trust Network, see C. Palmeri, “A Texas
Gunslinger,” Forbes, July 3, 1995:42—45.
11. See transcript of Face to Face with Connie Chung, December 10,
1990, available from Burrelle’s Information Services.
12. Anderson and Goldrich are quoted in an Associated Press arti-

cle describing the hearings. D. Mesce, “Breast Implant Controls
Urged,” AP, December 18, 1990.
13. For a full chronology of the regulatory process, see R. Strombler,

“Breast Implants and the FDA: Past, Present, and Future,” American
College of Surgeons Bulletin, Jane 1993:11-15.
14. See N. Benac, “Companies Seek to Prove Breast Implants Are
Safe,” AP, June 10, 1991.
15. The FDA’s reaction to the manufacturers’ data was reported in

P. J. Hilts, “Drug Agency Questions Companies’ Safety Data on Breast
Implants,” New York Times, November 17, 1991, p. B6.
16. Proceedings of the November 12-14, 1991, FDA advisory panel

are documented in Council on Scientific Affairs, American Medical
Association, “Silicone Gel Breast Implants,” JAMA, 270, no. 21 (De-
Notes @® 219
cember 1993):2602-6; “Breast Implant Use Allowed,” Facts on File

World News Digest, December 31, 1991, p. 993D1; R. Stombler, “Breast
Implants and the FDA: Past, Present, and Future,” American College
of Surgeons Bulletin, Jane 1993:11-15; and Kessler’s August 1, 1995,
testimony to the Subcommittee on Human Resources and Inter-
governmental Relations of the Committee on Government Reform
and Oversight of the U.S. House of Representatives.
17. See W. Carlsen, “Jury Awards $7.3 Million in Implant Case,” San
Francisco Chronicle, December 14, 1991, p. A13.
18. SeeJ.M. Adams, “Victim of Silicone Breast Implants Wants Value

Placed on Women’s Lives,” Chicago Tribune, February 9, 1992, p. 21.
19. Several sources cited Bolton’s reference to the secret documents

during the Hopkins trial. SeeJ.M. Adams, “Victim of Silicone Breast
Implants Wants Value Placed on Women’s Lives,” Chicago Tribune,
February 9, 1992, p. 21; M. McKee, “Breast Implant Maker Tries to
Reopen Case,” The Recorder, April 9, 1992, p. 1; and “Woman Wins
Implant Suit,” New York Times, December 17, 1991, p. A16.
20. Anderson and Bolton both tried to pressure the FDA to remove
implants from the market. Their efforts are noted in A. Frankel,
“From Pioneers to Profits,” American Lawyer, June 1992:82; also in M.
Gordon, “FDA Said to Have Reversed Policy after Seeing Secret Doc-
uments,” AP, April 20, 1994.
21. Kessler recounted the events leading up to the January 6, 1992,

moratorium in his August 1, 1995, testimony before the Subcom-
mittee on Human Resources and Intergovernmental Relations of the
Committee on Government Reform and Oversight of the U.S. House
of Representatives. Also see Council on Scientific Affairs, American
Medical Association, “Silicone Gel Breast Implants,” JAMA, 270, no.
21 (December 1993) :2602-6; P. J. Hilts, “Breast Implant Maker Ac-
cused on Data,” New York Times, December 21, 1991, p. 8; and R. E.
Stombler, “Breast Implants and the FDA: Past, Present, and Future,”
American College of Surgeons Bulletin, June 1993:11-15.
220 @ Notes
22. Kessler, in his August 1, 1995, congressional testimony, described

the February 18-20, 1992, FDA advisory committee meeting. The sta-
tus of Anderson at the meeting is discussed in R. L. Vernaci, “FDA
Removes Doctor from Breast Implant Panel,” AP, February 12, 1992;
also in M. Cimons, “Member of FDA Breast Implant Advisory Com-
mittee Loses Vote,” Los Angeles Times, February 13, 1992, p. A24. An-
derson’s later comments were made ina letter to Senator Herb Kohl
in 1994. See M. Gordon, “FDA Said to Have Reversed Policy after See-
ing Secret Documents,” AP, April 20, 1994.
23. The panel’s recommendations are detailed in R. E. Strombler,
“Breast Implants and the FDA: Past, Present, and Future,” American
College ofSurgeons Bulletin, June 1993:11—15. Kessler explained the de-
cision, and the FDA’s rationale, in “The Basis for the FDA’s Decision
on Breast Implants,” New England Journal of Medicine, 326
(1992):1713-15.
24. See Dow Corning’s package insert for the Silastic MSI mammary
implant, p. 8 (1991).
25. The 800 pages of documents are available, for a fee, from Dow
Corning.
26. See T. M. Burton, “Dow Corning Employees Falsified Data on
Breast Implants, Counsel Concludes,” Wall Street Journal, November
3, 1992, p. A3. Also B. Rensberger, “Breast Implant Records Were
‘Faked.’ ” Washington Post, November 3, 1992, p. A3.
27. Dow Corning pulled out of the implant business in March 1992.
See E. Neuffer, “Maker Quits Implant Market,” Boston Globe, March
March 1992, p. 1.
28. Mentor began its controlled study of implants in 1992. See
“Silicone-Gel Breast Implants Resume with Restrictions,” Boston Globe,
November 4, 1992. Also U.S. Food and Drug Administration, “Breast
Implants: An Information Update,” June 1994 (rev. October 1994),
Rockville, Md., p. 14.
29. The FDA announced the requirements for saline-filled implant
PMAs in the Federal Register, January 8, 1993:3436-43. The regulatory
Notes @ 221
process is explained in “Breast Implants: An Information Update,”

June 1994 (rev. October 1994), Rockville, Md., p. 16.
30. The FDA announced its proposed rule requiring premarketing

approval for testicular prostheses in the Federal Register, January 13,
1993:4116—25. The final rule was published in the Federal Register on
April 5, 1995 (pp. 1728-16).
32. See M. Angell, “Breast Implants: Protection or Paternalism?” New
England Journal of Medicine, 326 (1992):1695-96.
33. For more on known risks from breast implants, see Chapter 2.
34. This quote, from Rosemary Locke, is taken from D. Mesce,
“Breast Implant Controls Urged,” AP, December 18, 1990.
35. See A. Fischer, “A Body to Die For,” Redbook, September 1991:96.

37. For an example of this perspective, seeJ.Bovard, “Double-Crossing
to Safety,” American Spectator, January 1995: 24-29. See also M. Charen,
“Save Us from the FDA,” Boston Globe, December 29, 1994, p. 13.
38. Kessler’s fight for regulatory authority over cigarettes peaked in
the summer of 1995. See, for example, A. Devory and J. Schwartz,
“FDA Given Power for Cigarette Rules,” Washington Post, August 10,
1995, p. Al. Also G. Collins, “Companies Sue to Prevent Control of
Cigarette Sales,” New York Times, August 11, 1995, p. A18.
39. See Jenny Jones transcript, March 30, 1992, available from Bur-
relle’s Information Services.
40. See N. Wolf, The Beauty Myth: How Images ofBeauty Are Used against
Women (New York: William Morrow, 1991), p. 245.
41. See J. Bovard, “Double-Crossing to Safety,” American Spectator,

January 1995: 24-29. See also M. Charen, “Save Us from the FDA,”
Boston Globe, December 29, 1994, p. 13.
222 @ Notes
4: The Rush to Court
1. See G. Kolata, “Details of Implant Settlement Announced,” New

York Times, April 5, 1994, p. A1l6. Also B. Wiser, “Feud in Implant
Settlement Stirs Debate over Tactics,” Washington Post, May 11, 1994,
p. D1.
2. Barie S. Carmichael, Dow Corning corporate vice-president and
executive director of corporate communications, cited this increase
in an interview in the June 1995 issue of TJFR Health News Reporter, a
monthly newsletter for health-care public relations specialists pub-
lished in Ridgewood, N,].
3.J.B. Weinstein, “Ethical Dilemmas in Mass Tort Litigation,” 88 NW
ULL. Rev 469, 480 (1994).
4. The display ad for Chandler, Franklin, and O’Brien appeared on

p- 2 of the Health section of the July 26, 1994, Washington Post. Phone
numbers for other plaintiffs’ attorneys come from S. Torry, “Breast
Implant Settlement Fund Sparks a Scramble,” Washington Post, April
4, 1994, Business section, p. 7. See also T. Schroth, “Breast Implants:
Latest Toxic Tort; Plaintiffs’ Bar Launches Aggressive Drive for
Clients,” New Jersey Law Journal, April 13, 1992:1.
5. Details about the suits pending against Dow Corning come from
the Q&A with Barie Carmichael (corporate vice-president and ex-
ecutive director of corporate communications) in the June 1995
issue of TJFR Health News Reporter, a monthly newsletter for health-
care public relations specialists published in Ridgewood, N,J.
6. The membership increase to Public Citizen’s breast implant clear-
inghouse is cited in A. Frankel, “From Pioneers to Profits,” American
Lawyer, June 1992: 82.
7. The growth of the ATLA breast implant group is cited in
T. Schroth, “Breast Implants: Latest Toxic Tort; Plaintiffs’ Bar
Notes @ 223
Launches Aggressive Drive for Clients,” New Jersey Law Journal, April
13, 1992:1;
8. M. A. Glendon, A Nation under Lawyers (New York: Farrar, Straus

& Giroux, 1994). For a scholarly treatment of tort law, see R. Epstein,
Cases and Materials on Torts, 6th ed. (Boston: Little, Brown & Co., Law
and Business Education, 1995).
9. For information about the number of civil suits filed annually in

state and federal courts, see “Background” section of House of Rep-
resentatives’ Judiciary Committee Report (104-62) on HR-988, the
Attorney Accountability Act of 1995.
10. For information about the number of tort cases, see Facts and
Trends (a publication of the RAND Institute for Civil Justice), 3,
no. 3 (spring 1995).
11. This modest growth, according to RAND (see note 10), is about
3 percent ayear for state courts. In the federal courts, civil filings de-
clined from 1985 to 1992, but began to increase once again in 1992.
12. See Facts and Trends, 3, no. 3 (spring 1995). Also E. C. Bassett,
“The Litigation Explosion,” Journal of the Massachusetis Academy of
Tnal Attorneys, 2, no. 4 (1995):16. Also D.J. Murphy, “When State
Judges Are Elected,” Investor’s Business Daily, November 7, 1994,
p. Al.
13. The increase in mass personal injury claims since 1980 is docu-
mented in D. Hensler and M. Peterson, “Understanding Mass Per-
sonal Injury Litigation: A Socio-Legal Analysis,” Brooklyn Law Review,
59, no. 3 (1993):961—1063.
14. For more on trends in the use of punitive damage awards, see
“Punitive Damages,” Facts and Trends, 3, no. 3 (spring 1995).
15. Estimates of the increased total costs of the tort system between
1980 and 1990 come from D. J. Murphy, “When State Judges Are
Elected,” Investor’s Business Daily, November 7, 1994, p. Al. The
source cited by Murphy is Tillinghast, the insurance consulting unit
of Towers Perrin.
224 | Notes
16. The number of lawyers in the United States comes from the
American Bar Association (personal communication). The 1980
(542,205) and 1991 (805,872) statistics are from The Lawyer Statis-
tical Report: The U.S. Legal Profession in the 1990s, published by the
American Bar Foundation. This source projected the lawyer pop-
ulation in 1995 to be 896,172. The ABA derived its own 1995 esti-
mate of 896,140 from reports of licensing authorities in the 50
states.
17. See “Record $25 Million Awarded in Silicone Gel Implants Case,”
New York Times, December 24, 1992, p. A13.
18. The jury was informed of Dow Corning’s value ($948 million)
and instructed to keep it in mind when awarding punitive damages
in the Hopkins case, according to Dow Corning’s Petition for a Writ
of Certiorari (note 4 on pp. 7-8).
19. See P. Brimelow and L. Spencer, “The Plaintiff Attorneys’ Great
Honey Rush,” Forbes, October 16, 1989:197.
20. For more information about how the U.S. tort system differs
from other countries’ systems, see M. A. Glendon, A Nation under
Lawyers (New York: Farrar, Straus & Giroux, 1994), p. 54.
21. See M. A. Glendon, A Nation under Lawyers (New York: Farrar,

Straus & Giroux, 1994), p. 272.
22. Information about the history of asbestos in the courts is con-

tained in D. Hensler and M. Peterson, “Understanding Mass Personal
Litigation: A Socio-Legal Analysis,” Brooklyn Law Review, 59, no. 3
(1993):961-1063 [1003-6]; the quote is on p. 961. See also D.
Hensler, “A Glass Half Full, a Glass Half Empty: The Use of Alter-
native Dispute Resolution in Mass Personal Injury Litigation,” Texas
Law Review, 73 (1995) :1587-1626.
23. For information about the history of DES in the courts, see
D. Hensler and M. Peterson, “Understanding Mass Personal
(1993) :961-1063 [981-82].
Notes @ 225
24. For information about the history of Bendectin in the courts,

see D. Hensler and M. Peterson, “Understanding Mass Personal
(1993) :961-1063 [978-81].
25. For information about the history of Dalkon Shield litigation, see
(1993) :961-1063 [983-86].
26. For more about the history of Agent Orange litigation, see
(1993) :961-1063 [1001-3].
27. For information about the litigation history of the Bjork-Shiley
heart valve, see D. Hensler and M. Peterson, “Understanding Mass
Personal Litigation: A Socio-Legal Analysis,” Brooklyn Law Review, 59,
no. 3 (1993):961-1063 [989-92].
28. See M. Purdy, “New York Girding for Surge in Suits over Lead
Damage,” New York Times, August 14, 1995, p. Al.
29. The effect of bankruptcy on litigation involving corporations
like Johns-Manville and A. H. Robins received new attention after
Dow Corning filed for bankruptcy. See S. Walsh, “Plaintiffs May Have
Years to Wait in Implant Cases,” Washington Post, May 16, 1995, p. A6;
also S. Labaton, “Don’t Sue, They Say. We Went Bankrupt,” New
York Times, May 21, 1995, p. E16. For more information about this,
see D. Hensler and M. Peterson, “Understanding Mass Personal
Injury Litigation: A Socio-Legal Analysis,” Brooklyn Law Review, 59,
no. 3 (1993) :961—1063.
30. The increase in the use of class actions asa litigation tool start-
ing in the 1970s is detailed in D. Hensler and M. Peterson, “Under-
standing Mass Personal Injury Litigation: A Socio-Legal Analysis,”
Brooklyn Law Review, 59, no. 3 (1993):961-1063. Also recapped in
RAND Institute for Civil Justice Research Brief, January 1995.
226 @ Notes
31. Technical details of mass tort litigation—including class actions—

are contained in The Manual for Complex Litigation, 3rd ed. (St. Paul,
Minn.: Federal Judicial Center/West Publications, 1995).
32. See S. Torry, “Breast Implant Settlement Fund Sparks a Scram-

ble,” Washington Post, April 4, 1994, Business section, p. 7.
33. For more on lawsuits pending against the manufacturer of Nor-

plant, see G. Kolata, “Will the Lawyers Kill Off Norplant?” New York
Times, May 28, 1995, Sec. 3, p. 1.
34. See The Manual for Complex Litigation, 3rd ed. (St. Paul, Minn.:
Federal Judicial Center/West Publications, 1995).
35. For more on the Judicial Panel on Multidistrict Litigation, see

The Manual for Complex Litigation, 3rd ed. (St. Paul, Minn.: Federal
Judicial Center/West Publications, 1995). Also The Guide to American
Law: Everyone’s Legal Encyclopedia (St. Paul, Minn.: West Publications,
1983), p. 389, and K. Jost, “Wrestling with Mass Torts,” The Recorder,
May 18, 1993, p. 1.
36. For more on Chesley and the genesis of the breast implant set-
tlement, see H. Weinstein, “When Law, Tragedy Intersect,” Los An-
geles Times, March 26, 1994, p. Al. See also B. Wiser, “Feud in Implant
Settlement Stirs Debate over Tactics,” Washington Post, May 11, 1994,
p- D1; A. Frankel, “Et tu, Stan?” American Lawyer, January/February
1994:68; and A. Blum, “Questions Raised on Class Action; Breast Im-
plants,” National Law Journal, March 30, 1992: 3.
37. See G. Kolata, “Details of Implant Settlement Announced by

Federal Judge,” New York Times, April 5, 1994, p. Al6. Also United
States Law Week, 62 USLW 2640 (April 19, 1994).
38. For complete details of the original settlement, see the “Settle-
ment Notice,” which Judge Sam Pointer’s office sent with registra-
tion information to women with breast implants (“Proposed Breast
Implant Litigation Settlement,” U.S. District Court, Northern District
of Alabama).
Notes ® 227
39. See D. Hilzenrath, “Renegotiation Order May Undo $4 Billion

Implant Settlement,” Washington Post, May 5, 1995, p. F1. Also D. R.
Olmos and H. Weinstein, “Breast Implant Settlement in Peril,”
Los Angeles Times, May 5, 1995, p. Al.
40. Bolton’s case against American Medical Systems was reported in
S. Rosenfeld, “Penile Implant Maker Sued: Health Problems, Defects
Concealed, Three Men Allege,” San Francisco Examiner, May 21,
1994, p. Al.
41. Bolton is quoted in “California Class Action Filed over Penile Im-
plants,” Liability Week, 22, no. 9 (May 31, 1994).
42. Norplant’s reliability, particularly for teenagers, was reported in

M. Polaneczky et al., “Use of Levonergestrel Implants (Norplant)
for Contraception in Adolescent Mothers,” New England Journal of
Medicine, 331 (1994):1201-6.
43. See G. Kolata, “Will the Lawyers Kill Off Norplant?” New York
Times, May 28, 1995, Sec. 3, p. 1.
44. The feature of American law that allows people to make claims
against any party involved in an allegedly harmful product is dis-
cussed by R. F. Service, “Liability Concerns Threaten Verdict in Im-
plant Research,” Science, 266, no. 5186 (1994) :726-27.
45. The Vitek/DuPont case is discussed in “Implant Market a Mine-

field for Raw Material Suppliers,” Chemical Marketing Reporter, 245,
no. 22 May 30, (1994):20.
46. For more on the changing biomaterials market, see the Wilkerson
Group’s report, “Forces Reshaping the Performance and Contribution
of the U.S. Medical Device Industry,” prepared for the Health Indus-
try Manufacturers’ Association (Washington, D.C.), June 1995.
47. See L. Richwine, “Houston Dad Urges Legal Reforms,” Houston
Chronicle, May 21, 1994, Business section, p. 1.
48. Eleanor Gackstatter’s testimony and Senator Lieberman’s quote
were reported in Bureau of National Affairs, Inc., “Senator to Seek
228 & Notes
Changes in Product Liability Law” (Washington, D.C.: Daily Report

for Executives, May 23, 1994, vol. 97: A2). See also L. Richwine,
“Houston Dad Urges Legal Reforms,” Houston Chronicle, May 21,
1994, Business section, p. 1.
49. This theory is discussed in B. J. Feder, “Implant Industry

Is Facing Cutback by Top Suppliers,” New York Times, April 25,
1994, p. Al:
50. For more background information on tort reform in Congress,
see T. Gest, “Reversal of Fortunes,” U.S. News and World Report, March
20, 1995:30; also “Is Lawsuit Reform Good for Consumers?” Consumer
Reports, May 1995:312.
51. See G. McGovern, “Don’t Reverse Medical Liability Reforms,”
Christian Science Monitor, August 22, 1994, p. 19.
52. See “America’s Third Political Party: A Study of Political Contri-

butions by the Plaintiff's Lawyer Industry,” a report released by
the American Tort Reform Association (Washington, D.C.), Sep-
tember 1994.
5: Scientific Evidence
1. For more information about the design and analysis of studies, see
C. H. Hennekens, J. E. Buring, and S. L. Mayrent (eds.), Epidemiol-
ogy in Medicine (Boston: Little, Brown, 1987), pp. 244—46.
2. The peer-review process for the New England Journal of Medicine is

described in detail in “The Journal’s Peer Review Process,” New Eng-
land Journal of Medicine, 321 (1989):837-39.
3. The cold fusion incident became the subject of a book by science

journalist Gary Taubes. See G. Taubes, Bad Science: The Short Life and
Hard Times of Cold Fusion (New York: Random House, 1993).
Notes ® 229
4. For a general discussion of risks, see R. L. Keeney, “Decisions

about Life-Threatening Risks,” New England Journal of Medicine, 331
(1994) :193-96.
5. This material is presented in more detail in M. Angell, “The In-

terpretation of Epidemiologic Studies,” New England Journal of Med-
icine, 323 (1990) :823-25. For a broader discussion of epidemiologic
research, see G. Taubes, “Epidemiology Faces Its Limits,” Science,
269 (July 14, 1995):164-69.
6. See S. E. Gabriel et al., “Risk of Connective-Tissue Diseases and

Other Disorders after Breast Implantation,” New England Journal of
Medicine, 330 (1994):1697—1702.
7. See C. H. Hennekens et al., “Self-Reported Breast Implants and

Connective Tissue Diseases in Female Health Professionals,” Journal
of the American Medical Association, 275 (1996): 616-21.
8. This study is known as the Nurses’ Health Study. See J. Sanchez-

Guerrero et al., “Silicone Breast Implants and the Risk of Connective-
Tissue Diseases and Symptoms,” New England Journal ofMedicine, 332
(1995) :1666-70.
9. See H.J. Englert and P. Brooks, “Scleroderma and Augmentation

Mammoplasty—A Causal Relationship?” Australia and New Zealand
Medical Journal, 24 (1994):74-80, and M. C. Hochberg et al., “Fre-
quency of Augmentation Mammoplasty in Patients with Systemic
Sclerosis: Data from the Johns Hopkins—University of Maryland Scle-
roderma Center,” Journal of Clinical Epidemiology, 48, no. 4 (April
1995) :565-69.
10. For a list of controlled epidemiologic studies of the question, see

S. E. Gabriel et al., “Trends in the Utilization of Silicone Breast Im-
plants, 1964-1991, and Methodology for a Population-Based Study
of Outcomes,” Journal of Clinical Epidemiology, 48 (1995) :535.
11. This study was published in a Japanese medical journal. See K.

Miyoshi et al., “Hypergammaglobulinemia by Prolonged Adjuvan-
230 @ Notes
ticity in Man: Disorders Developed after Augmentation

Mammaplasty,” Japan Medical Journal, 2122 (1964) :9-14.
12. These studies of directly injected silicone, published in U.S. med-
ical journals, are Y. Kumagai et al., “Scleroderma after Cosmetic
Surgery: Four Cases of Human Adjuvant Disease,” Arthritis and
Rheumatism, 22, no. 5 (1979):532-37; Y. Kumagai et al., “Clinical
Spectrum of Connective Tissue Disease after Cosmetic Surgery: Ob-
servations on 18 Patients and a Review of the Japanese Literature,”
Arthritis and Rheumatism, 27, no. 1 (1984):1-12.
13. This first paper, linking silicone-gel-filled breast implants and

connective tissue disease, was S. A. Van Nunen et al., “Post-
Mammaplasty Connective Tissue Disease,” Arthritis and Rheumatism,
25, no. 6 (1982):694-97.
14. F. B. Vasey, M. D., and
J. Feldstein, The Silicone Breast Implant Con-
troversy (Freedom, Calif.: The Crossing Press, 1993), p. 55.
15. The dog studies described here were the subject of wide-
spread speculation when Dow Corning released 800 pages of
internal documents in 1992. For example, see the transcript of
ABC’s Primetime Live for February 13, 1992, available from Nexis.
See also A. Frankel, “From Pioneers to Profits,” American Lawyer,
June 1992:82.
16. See N. Kossovsky, “Immunology of Silicone Breast Implants,”
Journal of Biomaterials Applications, 8 (1994):237-46. Also N.
Kossovsky, “Surface Dependent Antigens Identified by High
Binding Avidity of Serum Antibodies in a Subpopulation of
Patients with Breast Implants,” Journal of Applied Biomaterials,
4 (1993) :281-88.
17. See M. Lappé, “Silicone-Reactive Disorder: A New Autoimmune
Disease Caused by Immunostimulation and Superantigens,” Medical
Hypotheses, 41 (1993) :348-52.
18. See D. M. Gott and J. J. B. Tinkler, “Evaluation of Evidence

for an Association between the Implantation of Silicones and
Notes ® 231
Connective Tissue Disease: Data Published from the End of 1991

to July 1994” (London: Medical Devices Directorate, December
1994).
6: Science in the Courtroom
1. See A. Frankel, “From Pioneers to Profits,” American Lawyer,

June 1992:82.
2. For a fuller analysis, see B. Black, “Matching Evidence about Clus-

tered Health Events with Tort Law Requirements,” American Journal
of Epidemiology, 132 (1990):579-86.
3. For more information on the role of expert testimony in the

courtroom, see L. Loevinger, “Science as Evidence,” Jurimetrics
Journal, winter 1995:153-90. Also B. Black, “Evolving Legal Stan-
dards for the Admissibility of Scientific Evidence,” Science, 239,
no. 4847 (1988) :1508-12.
June 1992:82.
5. Biographical details about Mariann Hopkins, and the case
chronology, primarily come from two sources: the decision of the
United States Court of Appeals for the 9th Circuit, August 26, 1994
(Manann Hopkins v. Dow Corning Corp. 33F.3d 1116 1994), and the
Petition for a Writ of Certiorari to the U.S. Supreme Court (Dow Corn-
ing v. Mariann Hopkins, No. 94-861, 1994). See alsoJ.M. Adams, “Vic-
tim of Silicone Breast Implants Wants Value Placed on Women’s
Lives,” Chicago Tribune, February 9, 1992, p. 21.
6. Hopkin quotes are taken from J. M. Adams, “Victim of Silicone

Breast Implants Wants Value Placed on Women’s Lives,” Chicago
Tribune, February 9, 1992, p. 21, and A. Frankel, “From Pioneers to
Profits,” American Lawyer, June 1992:82.
232 @ Notes

June 1992:82.
8. See D. M. Gott andJ.J. B. Tinkler, “Evaluation of Evidence for an

Association between the Implantation of Silicones and Connective
Tissue Disease: Data Published from the End of 1991 to July 1994”
(London: Medical Devices Directorate, December 1994).
9. See M. Lappé, Chemical Deception: The Toxic Threat to Health and the
Environment (San Francisco: Sierra Club, 1991).
10. Kossovsky’s credentials are documented in the Official ABMS

Directory of Board Certified Medical Specialists, 27th ed. (Philadelphia:
Reed Reference Publishing, 1995).
11. Vasey’s credentials are documented in the Official ABMS Directory

of Board Certified Medical Specialists, 27th ed. (Philadelphia: Reed
Reference Publishing, 1995).
12. For Vasey’s position, see his book, F. B. Vasey and J. Feldstein,
The Silicone Breast Implant Controversy: What Women Need to Know (Free-
dom, Calif.: Crossing Press, 1993).
13. The verdict was widely publicized. See, for example, W.

Carlsen, “Jury Awards $7.3 Million in Implant Case,” San Francisco
Chronicle, December 14, 1991, p. Al3, and J. M. Adams, “Victim
of Silicone Breast Implants Wants Value Placed on Women’s
Lives,” Chicago Tribune, February 9, 1992, p. 21. See also the de-
cision of the United States Court of Appeals for the 9th Circuit,
August 26, 1994 (Mariann Hopkins v. Dow Corning Corp. 33F.3d
1116 1994).
14. Dow Corning announced it was pulling out of the breast implant
market in March 1992. See E. Neuffer, “Maker Quits Implant Mar-
ket,” Boston Globe, March 20, 1992, p. 1.
15. See the decision of the United States Court of Appeals for the
9th Circuit, August 26, 1994 (Mariann Hopkins v. Dow Corning Corp.
33F.3d 1116 1994).
Notes @ 233
16. The U.S. Supreme Court’s refusal to review the Hopkins case re-
ceived widespread attention. See, for example, R. Carelli, “Justices
Uphold Breast Implant Award,” Boston Globe, January 10, 1995, p. 6.
17. For an account of the history of science in the courtroom, in-
cluding Fryeand the Federal Rules of Evidence, see L. Loevinger, “Sci-
ence as Evidence,” Jurimetrics Journal, winter 1995:153-90.
18. For more on the debate, see S. Begley, “The Meaning of Junk,”
Newsweek, March 22, 1993, and D. Freedman, “Who’s to Judge? New
Guidelines for Scientific Evidence,” Discover, 15, no. 1 (1994):78.
19. Details of the Daubert case come primarily from the Supreme
Court’s decision (Daubert v. Merrell Dow Pharmaceuticals, No. 92-102,
June 28, 1993, 113 S Ct 2768 1993) and “Brief of the New England
Journal of Medicine, Journal of the American Medical Association,
and Annals of Internal Medicine of Amicus Curiae in Support of Re-
spondent” (Daubert v. Merrell Dow Pharmaceuticals, No. 92-102), Kaye,
Scholer, Fierman, Hays & Handler (New York), January 19, 1993.
20. See B. Black, F.J.Ayala, and C. Saffran-Brinks, “Science and the

Law in the Wake of Daubert:A New Search for Scientific Knowledge,”
Texas Law Review, '72, no. 4 (1994):715-802.
21. The 9th Circuit’s decision in the Bendectin appeal was written
by Judge Alex Kozinski. See Daubert v. Merrell Dow Pharmaceuticals, No.
90-55397, January 4, 1995. The decision received widespread atten-
tion in the popular and scientific press. See, for example, “Birth-
Defect Lawsuit that Set Science Standard Is Dismissed,” New York
Times, January 8, 1995, p. 19, and M. Barinaga, “Bendectin Case Dis-
missed,” Science, 267 (January 13, 1995):167.
7: Greed and Corruption
1. The going rate for expert witnesses is $300-$600 per hour, ac-
cording to “Breast Implant Expert Witnesses Can Find Themselves
234 @ Notes
Facing Conflicts of Interest,” Medical-Legal Aspects of Breast Implants,

3, no. 5 (April 1995):8.
2. See “Record $25 Million Awarded in Silicone Gel Implants Case,”

New York Times, December 24, 1992, p. A13.
3. Details of Pamela Johnson’s medical condition and the descrip-

tions of her trial come primarily from A. Singer, “Look Over Here,”
American Lawyer, March 1993:86, and an accompanying videotape
produced by Court TV, subtitled “How Houston Plaintiff's Lawyer
John O’Quinn Won the Largest Breast Implant Verdict to Date by
Keeping a Jury on the Strongest Elements of His Case.”
4. Laminack is quoted in M. Schwartz, “Silicone City,” Texas Monthly,

August 1995:65.
5. O’Quinn himself talked about the tactic of suing the doctor and
then dropping the suit in “State the Case Simply by Starting with Voir
Dire,” National Law Journal, February 8, 1993:S10. The tactic is also
discussed in T. Moran, “Battle Scars: For Plastic Surgeons, Psycho-
logical Effects Linger from Silicone Breast Implant Controversy,”
Texas Medicine, 91, no. 1 (1995):30-34.
6. O’Quinn talked about the type of juror he selected in this case in

“State the Case Simply by Starting with Voir Dire,” National Law
Journal, February 8, 1993:S-10.
7. O’Quinn’s contention that blue-collar men are good jurors and

upper-middle-class white women are not comes from C. Palmeri,
“A Texas Gunslinger,” Forbes, July 3, 1995:42—45.
8. O’Quinn’s fee (40 percent if no appeal, 45 percent if appeal) was

noted in A. Singer, “Look Over Here,” American Lawyer, March
1993:86.
9. O’Quinn’s big wins were recapped in C. Palmeri, “A Texas Gun-

slinger,” Forbes, July 3, 1995:42—45. See also P. Burka, “Taking the Law
into His Own Hands: John O’Quinn,” Texas Monthly, September
1994:109.
Notes @ 235
10. For information about how the Johnson verdict affected

O’Quinn’s breast implant case load, see “Record $25 Million
Awarded in Silicone Gel Implants Case,” New York Times, December
24, 1992, p. A13. See also G. Taylor, “Breast Implant Suits Pouring
In after $25 Million Verdict,” National Law Journal, January 18,
1993:3.
11. See P. Brimelow and L. Spencer, “The Best Paid Lawyers in
America” and “The Top Ten,” Forbes, October 16, 1989:197, 204.
12. O’Quinn’s 2,000-plus breast implant clients are often cited in the
media. See G. Kolata, “Legal System and Science Come to Differing
Conclusions on Silicone,” New York Times, May 16, 1995, p. D6. See
also M. McKee, “Deadline Looms for Implant Makers,” The Recorder,
September 9, 1994, p. 1, and C. Palmeri, “A Texas Gunslinger,”
Forbes, July 3, 1995:42—45.
13. See O’Quinn’s comments in C. Palmeri, “A Texas Gunslinger,”
Forbes, July 3, 1995:42—45.
14. Information from Richard Laminack about the number of cases
settled out of court (500) and the percentage referred by other
lawyers (70 percent) comes from C. Palmeri, “A Texas Gunslinger,”
Forbes, July 3, 1995:42-45.
15. O’Quinn’s average out-of-court settlement is noted in J. Nocera,
“Fatal Litigation” (Part 2), Fortune, October 23, 1995:138.
16. O’Quinn’s personal worth is cited in J. Nocera, “Fatal Litigation”

(Part 1), Fortune, October 16, 1995:60-82.
17. “State the Case Simply by Starting with Voir Dire,” National Law
Journal, February 8, 1993:S-10.
18. These accusations were outlined in M. McKee, “Timing Is

Everything,” The Recorder, July 8, 1994, p. 1.
19. Dr. Sherine Gabriel first presented her findings at the annual
meeting of the American College of Rheumatology, San Antonio,
Texas, November 7-11, 1993.
236 @ Nofes
20. See G. Kolata, “Legal System and Science Come to Differing

Conclusions on Silicone,” New York Times, May 16, 1995, p. D6.
21. See “About 14,700 Women Leave Implant Deal,” Wall Street Jowr-
nal, July 25, 1994, p. B4. See also B. Sapino, “Houston Threatens
$4.25B Implant Deal,” Texas Lawyer, August 1, 1994, p. 1.
22. The lack of campaign contribution limits in Texas is discussed

(in the context of new limits on the length of campaigns) in J. D.
Montgomery, “Reforming Judicial Elections: State Supreme Court
Has Ordered a Step in the Right Direction,” Houston Post, Novem-
ber 13, 1994, p. Cl.
23. Tactics to solicit breast implant clients were detailed in R. Con-

nelly, “From Flood to Deluge in Breast-Implant Cases: Houston’s Hot
in Latest Mass Tort Craze,” Texas Lawyer, January 11, 1993:1.
24. Texas plaintiffs’ attorneys are specifically mentioned in
G. Kolata, “Will the Lawyers Kill Off Norplant?” New York Times,
May 28, 1995, Sec. 3, p. 1. See also “Breast Implants and Norplant:
The Silicone Connection,” Medical-Legal Aspects of Breast Implants, 3,
no. 7 (1995):1.
25. Two investigative reports by TV journalists have examined how

doctors work with lawyers on implant cases. The first, by John Get-
ter of KHOU in Houston, was broadcast on October 10, 1994. The
second, broadcast on CNN on October 16, 1994, called “The Mer-
chants of Fear,” was part of a CNN series called Fire and Fury.
26. O’Quinn’s run-in with the Texas bar association was widely re-
ported. See P. Brimelow and L. Spencer, “The Best Paid Lawyers in
America” and “The Top Ten,” Forbes, October 16, 1989:197, 204. See
also P. Burka, “Taking the Law into His Own Hands: John O’ Quinn,”
Texas Monthly, September 1994:109. Information about O’Quinn’s
public reprimand can be confirmed by the Texas State Bar in Austin,
telephone number (512)463-1463.
27. For more on physicians’ roles, see G. Kolata and B. Meier, “Im-
plant Lawsuits Create a Medical Rush to Cash In,” New York Times,
September 18, 1995, p. Al.
Notes @ 237
28. Lewy’s point of view is represented in his public education

brochure, “Frequently Asked Questions from Breast Implant
Research” (Houston: Breast Implant Research, Inc., 1994).
29. For more on Lewy’s practice and income, see G. Kolata and B.
Meier, “Implant Lawsuits Create a Medical Rush to Cash In,” New York
Times, September 18, 1995, p. Al.
30. This report by John Getter of KHOU in Houston was broadcast

on October 10, 1994.
31. This CNN report, Fire and Fury, Part 4: “The Merchants of Fear,”
was broadcast on October 16, 1994.
32. See “Breast Implant Witnesses Can Find Themselves Facing Con-
flicts of Interest,” Medical-Legal Aspects of Breast Implants, 3, no. 5
(April 1995):8.
33. For details about Nir Kossovsky’s company, SBI Laboratories, see
G. Taubes, “Silicone in the System,” Discover, December 1995:65-75.
34. Kossovsky’s disagreement with the FDA is detailed in the CNN

report Fire and Fury, Part 4: “The Merchants of Fear,” broadcast on
October 16, 1994.
8: Americans and Health News
1. Sidney Wolfe’s involvement in the breast implant story is discussed

in Chapter 3.
2. For a discussion of American paranoia, see M. Kelly, “The Road

to Paranoia,” New Yorker, June 19, 1995:60-75.
3. For examples of this genre of self-help health books, see

D. Chopra, Quantum Healing: Exploring the Frontiers of Mind, Body,
Medicine (New York: Bantam, 1990); D. Chopra, Ageless Body, Time-
less Mind (New York: Crown, 1993); B.S. Seigel, Peace, Love and Heal-
ing: The Bodymind and the Path to Self-Healing—An Exploration (New
238 | Notes
York: HarperCollins, 1989); B. Siegel, Love, Medicine, and Miracles

(New York: HarperCollins, 1986); and A. Weil, Spontaneous Healing:
How to Enlist and Enhance the Body’s Own Gifts for Maintaining and
Healing Itself (New York: Knopf, 1995).
4. For more on the anti-science sentiment, see Chapter 9.
5. See E. L. Bierman, “Atherosclerosis and Other Forms of Arte-

riosclerosis,” in K. J. Isselbacher et al. (eds.), Harrison’s Principles of
Internal Medicine, 13th ed. (New York: McGraw-Hill, 1994), p. 1106;
R. Benfante et al., “Elevated Serum Cholesterol Is a Risk Factor for
Both Coronary Heart Disease and Thromboembolic Stroke in Hawai-
ian Japanese Men: Implications of Shared Risk,” Stroke, 25
(1994) :814—20; andJ. Pekkanen et al., “T'en-Year Mortality from Car-
diovascular Disease in Relation to Cholesterol Level among Men
with and without Preexisting Cardiovascular Disease,” New England
Journal of Medicine, 322 (1990):1700-7.
6. See W. C. Willett and A. Ascherio, “Trans Fatty Acids: Are the Ef-
fects Only Marginal?” American Journal of Public Health, 84
(1994):722-24.
7. Studies on the beneficial effects of oat bran include R. W. Kirby
et al., “Oat-Bran Intake Selectively Lowers Serum Low-Density
Lipoprotein Cholesterol Concentrations on Hypercholesterolemic
Men,” American Journal of Clinical Nutrition, 43 (1981):824-29, and J.
W. Anderson et al., “Hypocholesterolemic Effects of Oat-Bran or
Bean Intake for Hypercholesterolemic Men,” American Journal of Clin-
ical Nutrition, 40 (1984):1146—-55.
8. A study showing no beneficial effects for oat bran is J. F. Swain et
al., “Comparison of the Effects of Oat Bran and Low-Fiber Wheat on
Serum Lipoprotein Levels and Blood Pressure,” New England Journal
of Medicine, 322 (1990):147-52.
9. Astudy showing a correlation between saccharin and bladder can-

cer is G. R. Howe et al., “Artificial Sweeteners and Human Bladder
Cancer,” Lancet, 2 (1977):578-81.
Notes @® 239
10. A study showing saccharin doesn’t cause bladder cancer is R. N.

Hoover and P. H. Strasser, “Artificial Sweeteners and Human Blad-
der Cancer: Preliminary Results,” Lancet, 1 (1980):837-40.
11. Studies showing beneficial effects of antioxidants are M. J.

Stampfer et al., “Vitamin E Consumption and the Risk of Coro-
nary Disease in Women,” New England Journal of Medicine, 328
(1993):1444—49; E. B. Rimm etal., “Vitamin E Consumption and the
Risk of Coronary Heart Disease in Men,” New England Journal ofMed-
icine, 328 (1993):1450-56; R. M. Bostick et al., “Reduced Risk of
Colon Cancer with High Intake of Vitamin E: The lowa Women’s
Health Study,” Cancer Research, 52 (1993):4230-37; and L. Roncucci
et al., “Antioxidant Vitamins or Lactulose for the Prevention of the
Recurrence of Colorectal Adenomas,” Diseases of the Colon and Rectum,
36 (1993) :227-34.
12. A study showing antioxidants could be bad for you is Alpha-

Tocopherol, Beta Carotene Cancer Prevention Study Group, “The
Effect of Vitamin E and Beta Carotene on the Incidence of Lung
Cancer and Other Cancers in Male Smokers,” New England Journal
of Medicine, 330 (1994):1029-35.
13. See B. Armstrong et al., “Association between Exposure to Pulsed
Electromagnetic Fields and Cancer in Electric Utility Workers in
Quebec, Canada, and France,” American Journal of Epidemiology, 140
(1994) :805—-20.
14. See D. A. Savitz and D. P. Loomis, “Magnetic Field Exposure in
Relation to Leukemia and Brain Cancer Mortality among Electrical
Utility Workers,” American Journal ofEpidemiology, 141 (1995):123-34.
15. The study showing that postmenopausal estrogen increases the
risk of breast cancer is G. A. Colditz et al., “The Use of Estrogens and
Progestins and the Risk of Breast Cancer in Postmenopausal
Women,” New England Journal of Medicine, 332 (1995):1589-93.
16. The study showing no increase of breast cancer with post-

menopausal estrogenis J. L. Stanford et al., “Combined Estrogen and
240 & Notes
Progestin Hormone Replacement Therapy in Relation to Risk of

Breast Cancer in Middle-Aged Women,” JAMA, 274 (1995):137-42.
17. See “Diet Roulette,” New York Times, May 20, 1994, p. A26.
18. Ellen Goodman’s column appeared in the Boston Globe on April

17, 1994, p. A27.
19. See E. Giovannucci et al., “A Retrospective Cohort Study
of Vasectomy and Prostate Cancer in U.S. Men,” JAMA, 269
(1993) :878-82.
20. G. A. Colditz et al., “The Use of Estrogens and Progestins and

the Risk of Breast Cancer in Post-Menopausal Women,” New England
Journal of Medicine, 332 (1995):1589-93.
21. For further reading on epidemiology, see C. H. Hennekens,J. E.
Buring, and S. L. Mayrent (eds.), Epidemiology in Medicine (Boston:
Little, Brown, 1987), pp. 244-46.
22. The cold fusion incident is detailed by Gary Taubes in Bad
Science: The Short Life and Hard Times of Cold Fusion (New York:
Random House, 1993).
23. The coffee-and-pancreatic-cancer study cited is B. MacMahon et

al., “Coffee and Cancer of the Pancreas,” New England Journal of Med-
icine, 304 (1981):630-33.
24. For examples of the media treatment given to the coffee-and-
pancreatic-cancer study, see H. M. Schmeck, “Study Links Coffee
Use to Pancreas Cancer,” New York Times, March 12, 1981, p. B15;
“Coffee Nerves: Is There Cancer in the Cup?” Time, March 23,
1981:73; M. Clark and P. Malmaud, “Coffee—A Cancer Culprit?”
Newsweek, March 23, 1981:87; and M. Sinclair, “America’s
Favorite Pick-Me-Up Comes under Fire,” Washington Post, March 23,
196Ty p. AT.
25. The original group of authors revisited and revised their findings
in 1986. See C.-C. Hsieh et al., “Coffee and Pancreatic Cancer (Chap-
ter 2),” New England Journal ofMedicine, 315 (1986):587-89. This cor-
rection was not as widely reported as the 1981 study. Typical treat-
Notes @ 241
ment included that of the Chicago Tribune, which ran a wire-service

story (“Coffee Link to Cancer Questioned,” August 29, 1986, p. 4),
and the Los Angeles Times (“Drink Up: New Research Disputes
Reported Link between Coffee, Cancer,” August 31, 1986, Metro,
Part 2, p. 4).
26. See GUSTO Investigators, “An International Randomized Trial

Comparing Four Thrombolytic Strategies for Acute Myocardial
Infarction,” New England Journal of Medicine, 329 (199):673-82.
27. B. A. Lehman, “Cancer Drug Is Found to Have Heart Benefit:
Anti-Clotting Therapy Found to Spare Lives,” Boston Globe, Septem-
ber:2, 1993, p. 3.
28. Lipid Research Clinics Program, “The Lipid Research Clinics

Coronary Primary Prevention Trial Results. I. Reduction in the
Incidence of Coronary Heart Disease,” JAMA, 251 (1984):351-64.
29. Rates for 10-year risk of death from cardiovascular disease come
fromJ. Pekkanen et al., “Ten-Year Mortality from Cardiovascular Dis-
ease in Relation to Cholesterol Level among Men with and without
Preexisting Cardiovascular Disease,” New England Journal ofMedicine,
322 (1990):1700-7.
30. For general arguments about risk see R. L. Keeney, “Decisions
about Life-Threatening Risks,” New England Journal of Medicine, 331
(1994) :193-96. Also P. E. Ross, “Lies, Damned Lies and Medical Sta-
tistics,” Forbes, August 14, 1995:130-35.
9: Breast Implants and the Rejection of Science
1. See C. Sagan, “Wonder and Skepticism,” Skeptical Inquirer, 19, no.

1 (January/February 1995) :24-30.
2. See P. Gross and N. Levitt, Higher Superstition: The Academic Left
and Its Quarrels with Science (Baltimore: Johns Hopkins University
Press, 1994).
242 @ Notes
3. For more on Afrocentric science, seeJ. Travis, “Clashing Cultures:

Schools Stumble on an Afrocentric Science Essay,” Science, 262
(November 12, 1993):1121-22.
4. For an example of a backlash against science by environmental-

ists, see K. Sale, “Setting Limits on Technology,” The Nation, 260,
no. 22 (June 5, 1995):785.
5. The most infamous example of such an individual is the Un-
abomber, whose bombing campaign—begun in 1978—has resulted
in 3 deaths and 16 injuries. This individual’s 35,000-word manifesto,
“Industrial Society and Its Future,” was published in the Washington
Post on September 19, 1995.
6. Sidney Wolfe’s involvement in the breast implant controversy is

discussed in Chapter 3.
7. See S. Harding, The Science Question in Feminism (Ithaca: Cornell
University Press, 1986).
8. See M. F. Belenky et al., Women’s Ways of Knowing: Development of

Self, Voice, and Mind (New York: Basic Books, 1986).
9. See B. Rensberger, “Flabulous Discovery! Drug Found that Burns

Fat in Mice; Human Test Next,” Washington Post, July 27, 1995, p. Al.
10. This attitude is exemplified by Margaret Branch, an Albuquerque
lawyer, who says her breast implant practice allows her “to do some-
thing about our hea!th care for women in this country”; quoted in
K. S. Hirsh, “Storm Warning: Breast-Implant Lawsuits Approach
Flood Stage,” Chicago Tribune, January 10, 1993, Womanews, p. 9.
Other lawyers interviewed in the article concur.
11. See J. E. Mack, Abduction: Human Encounters with Aliens (New
York: Macmillan [Charles Scribner’s Sons], 1994).
12. Mack is quoted in T. Genoni, “Exploring Mind, Memory, and the

Psychology of Belief,” Skeptical Inquirer, 19, no. 1 (January/February
1995):10-13.
13. Wittgenstein quote is from his Philosophical Investigations, 3d ed.

(New York: Macmillan, 1968), Part 1, Section 109.
Notes @ 243
14. For a discussion of daytime talk shows and the paranormal, see
C. E. Emery, “Tales from the TV Talk Shows,” Skeptical Inquirer, 19,
no. 3 (May/June 1995) :12-13.
15. See D. Eisenberg, “ ‘Nonconventional’ Medicine in the United

States—Prevalence, Costs and Patterns of Use: Results of a National
Survey,” New England Journal of Medicine, 328 (1993) :246-52.
16. For a summary of the controversy surrounding the NIH’s Office

of Alternative Medicine, see E. Marshall, “The Politics of Alternative
Medicine,” Science, 265 (September 30, 1994):2000-2.
17. For more on the current state of homeopathy, see J. Foreman,

“Homeopathy Makes No Sense but Science Takes a Look Anyway,”
Boston Globe, July 17, 1995, p. 25.
18. See R. L. Park, “The Danger of Voodoo Science,” New York Times,
July 9, 1995, Sec. 4, p. 15, and C. H. Sommers, “The Flight from Sci-
ence and Reason,” Wall Street Journal, July 10, 1995, p. Al4.
19. See R. L. Park, “The Danger of Voodoo Science,” New York Times,
July.9,,1995-See:4, po 15:
20. See C. Sagan, “Wonder and Skepticism,” Skeptical Inquirer, 19,

no. 1 (January/February 1995):24-30.
21. Risks from Bendectin, asbestos, and radon are discussed in K. R.

Foster, D. E. Bernstein, and P. W. Huber (eds.), Phantom Risk: Scien-
tific Inference and the Law (Cambridge: MIT Press, 1993). Gulf War syn-
drome is discussed in A. Pine, “Government Study of Veterans Finds
No Evidence of a ‘Gulf War’ Disease,” Los Angeles Times, August 2,
1995, p. Al0.
10: Where We Stand...
and for How Long
1. See T. Burton, “Implant Fund Is Too Small to Cover Claims,” Wall

Street Journal, May 2, 1995, p. A3. Also D. R. Olmos and H. Weinstein,
244 | Notes
“Breast Implant Settlement in Peril,” Los Angeles Times, May 5,

1995, prAl.
2. See “Proposed Breast Implant Litigation Settlement,” which was
prepared and distributed by the U.S. District Court, Northern Dis-
trict of Alabama.
3. As of June 1, 1995, 248,500 women had submitted claims for cur-
rent illness under the terms of the settlement, according tothe July
31, 1995, message on Judge Pointer’s recorded settlement informa-
tion line (800-887-6828).
4. See “Money Shortage Looms in Implant Case,” New York Times,
June 17, 1995, p. 8.
5. See D. S. Hilzenrath, “Renegotiation Order May Undo $4 Billion

Implant Settlement,” Washington Post, May 5, 1995, p. F1.
6. See B. Meier, “Implant Pact in Jeopardy as Lawyers Miss Deadline,”
New York Times, August 31, 1995, p. Al2.
7. Judge Pointer’s acknowledgment that the settlement would have

to be dissolved was included in the September 7, 1995, message on
his settlement information line.
8. Judge Pointer announced the new settlement on his recorded in-

formation line on October 2, 1995. Also see B. Meier, “Three Implant
Companies Offer New Settlement,” New York Times, October 3, 1995,
p-. Al4.
9. See B. Meier, “Three Implant Companies Offer New Settlement,”
New York Times, October 3, 1995, p. Al4.
10. For a more complete discussion, see Chapter 5.

11. For more on the Hopkins case, see Chapter 6.
12. For more on this topic, see Chapter 1.
13. See Dr. Kessler’s August 1, 1995, testimony before the Subcom-
mittee on Human Resources and Intergovernmental Relations of the
Committee on Government Reform and Oversight of the U.S. House
of Representatives.
Notes @ 245
14. See comments by Richard Laminack in D. R. Olmos and

H. Weinstein, “Breast Implant Settlement in Peril,” Los Angeles Times,
May 5, 1995, p. Al.
15. See K. Rothman et al., “Teratogenicity of High Vitamin A Intake,”
New England Journal of Medicine, 333 (1995):1369-73.
16. See C. Vanchieri, “European Surgeons Call for Independence
from U.S. Food and Drug Administration,” Journal of the National Can-
cer Institute, 85 (March 3, 1993):353-54.
17. See “Health Ministry Ends Moratorium on Silicone Breast Im-

plants,” AP, February 28, 1995. See also French Ministry of Social Af-
fairs press release of January 24, 1995: “Objet: protheses mammaires
implantables.”
18. The French government announced the reinstated ban in May
1995. See Journal Officiel de la Republique Francaise, May 17, 1995.
19. See J. J. B. Tinkler et al., “Evidence for an Association between
the Implantation of Silicones and Connective Tissue Disease” (Lon-
don: Department of Health, Medical Devices Directorate, February
1993).
20. See D. M. Gott andJ. J. B. Tinkler, “Silicone Implants and Con-
nective Tissue Disease” (London: Medical Devices Agency, Decem-
ber 1994).
21. “The Strange World of Implants,” Washington Post, October 9,
1995, p. A26.
22. See B. Schwartz, The Costs of Living: How Market Freedom Erodes the
Best Things in Life (New York: W. W. Norton, 1994).
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INDEX
Abbott Laboratories, 75 autoimmune disease, 21-22, 97-98,

Abduction: Human Encounters with 101-3, 104-5, 106, 107-8
Aliens (Mack), 184 connective tissue disease vs., 107
Adams, Hunter, 179 increased awareness of, 105
Afrocentric science, 179 local scarring and, 104—5
alcohol, risk of breast cancer and, 98 Mariann Hopkins and, 118-24
alien abductions, 183-84 Pamela Johnson and, 134-36
alternative medicine, 178, 181-82, Texas doctors and, 147-52
185-88 see also immune reaction; inflam-
AMA (American Medical matory response; specific diseases
Association), 55 Ayala, Francisco, 130
American Cancer Society, 55
American Society of Plastic and Re- Baxter International, 34, 194
constructive Surgeons, 19, 47-48, Beauty Myth, The (Wolf), 35
55, 143 Bendectin, 75—76, 127-32
Anderson, Norman, 52, 53, 55 biomaterials, 84-85, 204
Jenny Jones and, 57 Bioplasty, Inc., 34, 54
androcentric science, 180 Black, Bert, 130
anecdotal evidence, 23, 55, 103-5, Bolton, Dan, 52, 53, 55, 82, 111, 118,
190 119-22, 125
antibodies, 106, 107 breast augmentation, see augmenta-
antigens, 106 tion, breast
anti-science movement, 177-91 breast cancer, see cancer, breast
arthritis, 107, 111 Breast Implant Research, Inc., 147-49
Association of Trial Lawyers of Amer- breast implants, silicone-gel-filled, 11,
icas/0 12, 19-32, 202-9
attorneys, see lawyers autoimmune disease and, see au-
augmentation, breast: toimmune disease
cosmetic reasons for, 9, 19, 20, 63 cancer linked to, 42, 43, 62, 139-40
historical view of, 35-36, 38 capsules and, 40, 41
implants for, see breast implant class-action settlements and, see
surgery; breast implants, silicone- class-action settlements
gel-filled connective tissue disease and, see
injections for, 51-52; see also sili- connective tissue disease
cone injections contractures from scarring and, see
women’s vs. men’s view of, 35 contractures, scar tissue
248 Index
breast implants (continued) saline-filled, 34, 43-44, 60-61

controversy of, summarized, 19-32 scar tissue and, 37-38
costs of, 34 soybean-oil-filled, 44
demand for safety data on, 52-53, breast implant surgery:
54-55 complications of, 21
development of, 39 FDA ban’s effects on, 34
double envelope and, 43-44 frequency of, 34
Dow Corning and, see Dow Corning history of, 39
Dow Corning documents on safety implant removal and, 20, 34, 106
of, 52-55, 56, 57-60, 64 informed consent and, 35
early problems of, 40—43 placement of, 39-40
FDA authority over, 51-52, 61-62 for reconstruction, see reconstruc-
FDA ban (1992) on, 9-10, 19, 34, tive surgery
56-57, 100 revenues from, 34
feminist view of, 35 breasts:
as foreign bodies, 36-38, 41, 106-8 cancer of, see cancer, breast
grandfathering of, 51, 62 concepts of perfection for, 33
greed and corruption linked to, cultural pressure for perfection of,
133-53 33
healthy women and, 97-98 disfigurement of, 38, 40
inflammatory response to, 36-38, enlargement of, see augmentation,
106-7 breast
innovations in, 43—44 hardening of, 62
lack of evidence on, 57-60, 61-64 scar tissue and, see scar tissue
lawsuits on, see lawsuits silicone-liquid injections into, see
leakage of, 30, 41 silicone injections
leakage problem memo on, 59 surgery for augmentation of, see
local complications of, 21, 111 breast implant surgery
manufacturers of, see manufactur- surgery for reduction of, 33, 35
ers, breast implant as symbols, 33
Mayo Clinic study of, confidence women’s self-image and, 35, 47-48,
interval in, 174~75 63
medical overview of, 33-49 Bristol-Myers Squibb, 34, 54, 135-41,
medical research and, see medical 194
research; medical research, see also Surgitek Corporation
process of burden of proof, 113, 198
opportunists and, 133-34, 152-53 FDA ban and, 61
other countries’ regulation of, Bush, George, 50
201-2
pattern of use of, 46-48 cancer, breast, 22, 40, 42-43, 199
polyurethane coating of, 43, 54 detection of, 42-43
price of, 34 estrogen and, 165
proven problems with, 40-43 risk factors for, 98-99
removal of, 20, 34, 106 treatment of, as exception to FDA
rupture of, 40, 62 ban, 56-57
safety record of, 21, 51-52, 202 see also mastectomy
Index m@ 249
cancer, prostate, 164-65 see also autoimmune disease; im-

Caplan, Arthur, 35 mune reactions; specific diseases
capsulotomy, closed, 41-42 Connell, Elizabeth, 54-55
Carmichael, Barie, 70 consumer and citizen advocacy
case-control studies, 99-100, 164, 166 groups, 11, 53, 55, 64-65, 156
see also epidemiologic studies contingency-fee system, 30, 73-74, 78,
causation, in product liability, 203
112-14, 116, 198 contractures, scar tissue, 21
certainty, degree of, 96, 114-15 breast implants as cause of, 38, 40,
Chesley, Stanley, 79-80 43
Chung, Connie, 53-54, 158 relief from, 41—42
cigarette smoking, 98, 167, 196 silicone-liquid injections and,
regulation of, 65 37-38
civil litigation, see torts statistics on, 40-41
class actions, 11, 21, 22, 75-80 corporations, excesses of, 11, 13, 73,
on breast implants, see class-action 156, 208-9
settlements cosmetic surgery, see specific types of cos-
certification of, 77 metic surgery
injunctions and, 77 Costs of Living, The (Schwartz) ,208-9
see also lawsuits; product liability courts, see judicial system
class-action settlements, 10, 11, Cronin, Thomas, 39
79-82, 143
claimants of, 192-93 damages:
new (1995) terms of, 194-95 economic, 73, 75
opting out of, 22, 143—44; see also for emotional harm, 73
specific lawsuits jury awards of, 10, 21, 52, 55, 204;
status of, 192-209 see also specific lawsutts
Clinton, Bill, 65 punitive, 73
closed capsulotomy, 41-42 women claims of, 10, 192-93; see
cohort studies, 99-100, 164, 166 also class-action settlements; law-
see also epidemiologic studies; med- suits
ical research, process of Daubert v. Merrell Dow Pharmaceuticals,
collagen, 37 127-32, 204
Command Trust Network, 53, 120 degree of certainty, 96, 114-15
complications, local, 21, 111, 199 Dershowitz, Alan, 72
confidence interval, 168-69 Detecsil Anti-SSAA(x) Test Battery,
confounding variables, 166-67 151-52
Congress, U.S., 67, 68 devices, medical, 26, 51
connective tissue disease, 97-98, 105, consumers and, 64-65
111, 119 market pullout of, 26, 60, 123
autoimmune disease vs., 107 raw materials (biomaterials) for,
early reports on, 51-52 84-85, 204
implants linked to, 21-22, 57, risks vs. benefits of, 62-63
101-3, 106, 107-8, 195-99 scarcity of, 84-86
increased awareness of, 105 see also breast implants, silicone-gel-
local scarring and, 104-5 filled
250 @ Index
discovery, pretrial, 79 Frye standard of, 126-30

of Dow Corning’s documents, 52, history of, 125
55, 56, 57-60 eyelid surgery, 34
doctors, see surgeons
Dow Chemical, liability of, 195, 202 Face to Face with Connie Chung, 53-54
Dow Corning, 11, 29, 54 fashion, breast size and, 33
alternative defenses of, 57 FDA (Food and Drug Administration):
bankruptcy and, 192-94, 202 Advisory Panels of, 52, 54—55, 56
class-action settlements and, see Caveat emptor policy and, 50, 61,
class-action settlements 64
discovery of documents of, 52, 55, cigarette regulation and, 65
56, 57-60 consumer groups and public pres-
“evidence” against, 57-60 sure on, 53—54, 55, 56
guilt of, 122-23 “grandfathered” exemption and,
Hopkins’ verdict and, 122-25 24, 51, 62
implant design and, 39 Medical Device Amendment
implant innovations of, 43-44 (1976) and, 51
as implant-market leader, 34, 43 1982 proposal of, 51-52
lawsuits against, 69, 73; see also spe- 1988 order of, 52, 54
cific lawsuits as political body, 25
Mammary Task Force, 58-59, 60 post-ban political climate and,
market goals of, 60 63-68
market pullout by, 60, 123 premarketing approval by, 51, 54
Mayo Clinic Study and, 144 public opinion on, 24-25
package insert warnings of, 57 regulating implants vs. other risks
sealing documents of, 52 and, 65
secret documents of, 52, 55, 56, 57-60 responsibility of, 11
suppressing evidence by, 59, 60 safety data demands of, 51, 52-53,
Dunleavey, Denise, 69 54-55, 64
Dupont, 84, 203 silicone-filled breast implant ban
(1992) by, 9-10, 19, 20, 26-27,
ecologists, 178, 179-80 34, 56-57, 69, 100, 123, 199
economic damages, 73, 75 see also Kessler, David
Eli Lilly, 75 federal regulation, see regulation, reg-
environmentalists, 178, 179-80 ulatory agencies, federal
epidemiologic studies, 99-106 Federal Rules of Evidence, 127, 128,
association vs. cause in, 98-100 129
implant risks and, 23 feminists, 13, 19-20, 35
see also breast implants, silicone-gel- anti-science movement and, 178,
filled; medical research; medical 179-81, 182-83, 188-90
research, process of; scientific ev- science education and, 188-90
idence Fleischmann, Martin, 96, 169
error margin, 103 Food, Drug and Cosmetic Act, 51, 64
ethics, medical, 133-53, 207-9 Food and Drug Administration, see
evidence, see scientific evidence FDA
expert witnesses, 116-18, 120-24, foreign-body reaction, 37-38; see also
125, 205 inflammatory response
Index @ 251
free market, unbridled, 13, 67, 72 nective tissue disease; inflamma-

Fryev. United States, 126-30 tory response
implant removal:
Gabriel, Sherine, 10, 30, 90, 143, 145, frequency of, 20, 34
206 placebo effect of, 106
Gackstatter, Eleanor, 85 implants:
Gerow, Frank, 39 breast, see breast implants, silicone-
Getter, John, 149, 150 gelfilled
Gingrich, Newt, 64 contraceptive (Norplant), 36,
Glendon, Mary Ann, 70, 72 83-84, 86
Goldrich, Sybil, 53, 54, 119-20 as foreign bodies, 36-38, 41, 106-8
Goodman, Ellen, 163-64, 173-74 jaw, 84
Gospe, Stephen, 119, 122 sponges as, 38
government regulation, federal, 11, testicular and penile, 36, 61, 82,
64-66 86
of cigarettes, 65 Inamed (McGhan Medical Corpora-
FDA ban on implants, 19, 24-25, tion), 34, 54, 60
50-68, 207-8 inflammatory response, 36-38
reform of, 67-68 silicone leakage and, 41
see also FDA informed consent, 22-23, 35, 37
greed, 11, 24, 29-30, 202
breast implants and, 133-53 Johns-Manville, 76
Gross, Paul, 178-79, 187 Johnson, Pamela, 134-42
gullibility, medical news and, Jones, Jenny, 45—46, 57, 66, 69
159-60 Journal of the American Medical Associa-
GUSTO trial, 170-71 tion, 101
judicial system, 70-71
Harding, Sandra, 180 abuses of, 203-4
Hatch, Orrin, 50 scientific evidence in, 28-29,
Health Department, British, 108 112-18, 125-32, 142, 202-7
health risks, exposure to, 12, 65, torts and, 73-89, 203-4
97-99, 158, 163-65, 167, 196 junk science, 126, 129, 130
Hemingway, Mariel, 46 jurisdiction, 78-79, 136-37
Hersh, Nancy, 111 jury awards, 10, 20-21, 52, 55, 71-73,
Higher Superstition (Gross and Levitt), 74-75, 204
178-79 limits on, 204
homeopathy, 186-87 persuasive tactics and, 111-12,
Hopkins, Mariann, 55-56, 118-25, 118-25, 134-42, 204
130, 134, 136, 152, 198 see also lawsuits
Hot Zone, The (Preston), 157 jury consultants, 139
Hug, Procter, 111, 124-25 jury trials, use of, 74-75, 204
human adjuvant disease, 104
humanists, 178-79 Kessler, David, 9, 50-51, 61, 62, 64,
67, 199
immune reactions, 22, 106—7 article by, 10, 20, 61, 63, 110
Dow Corning “evidence” of, 58 Democratic support of, 68
see also autoimmune disease; con- public pressure on, 25, 54
252 Index
Kessler (continued) leukocytes (white blood cells), 37, 41

silicone implant ban by, 19-20, specialized, 106
26-27, 45, 56-57, 123, 199 Levitt, Norman, 178-79, 187
see alsoFDA Lewy, Robert I., 147-50
Knowles, Ralph, 79-80 Lieberman, Joseph, 85-86
Kossoysky, Nir, 107, 108, 120, 121, liposuction, 34
124, 138-39, 151-52 local complications, 21, 111, 199
“Look Over Here: Johnson v. Bristol-
Laminack, Richard, 136 Myers-Squibb Company,” 137-38
Lappé, Marc, 107-8, 120-21, 124 lupus erythematosus, systemic (SLE),
lawsuits: 102
class-action settlements of, see class- lymph glands, 41
action settlements
collaboration in, 143-44, 147 McGhan Medical Corporation (In-
cottage industry of, 150 amed), 34, 54, 60
explosion of, 69-89, 133-53 Mack, John, 184
FDA affected by, 56-57 mammaplasty, see breast implant
FDA ban and, 26, 56-57 surgery
injuries alleged in, 55, 57 Mammary Task Force, 58-60
Mariann Hopkins, 55-56, 118-25, mammograms, 42-43
130, 134, 136, 152 Mansfield, Jayne, 45
Maria Stern, 52, 57, 111-12 manufacturers, breast implant, 10,
Pamela Johnson, 134—42 29-30, 43, 60, 123, 156, 202
personal injury, see torts alternative defenses of, 57
science and, 28-29, 111-32 biomaterial suppliers and, 84-85,
scientific evidence vs., 28-29, 204
112-18, 125-32, 142, 202-9 class-action settlements and, see
Texas and, 134, 136-37, 145, 146-51 class-action settlements
see also product liability effect of 1988 order on, 54
lawyers, 4, 70, 71-72 “evidence” against, 20, 23, 57-60;
advertising of, 69-70, 71-72, 147 see also legal findings, scientific
computer networking and, 70 evidence vs.,
contingency fees and, 30, 73-74, FDA ban’s effect on, 60-61
78, 203 FDA vs., 25
gross incomes of, 140-41 lawsuits against, see lawsuits
litigation tactics of, 74-75, 111-12, Medical Device Amendment and,
118-25, 134-42, 204 51
for plaintiffs, see plaintiff's bar package insert warnings of, 22-23,
see also specific lawyers 35, 57,135
leakage of silicone-gel-filled breast premarketing applications and, 51,
implants, 30, 41, 59 54
legal ethics, breast implants and, safety evidence and, 19, 51-57
133-53, 202-7, 208-9 sales and revenues of, 34
legal findings, scientific evidence vs., see also specific manufacturers
28-29, 57-60, 112-18, 125-32, margin of error, 103
142 mass tort litigation, see class actions
Index = 253
mastectomy, 40, 42, 43 medical research, process of, 90-110,

breast implants after, 19 115, 164-69, 189-91
reconstructive surgery and, 19, 63 bias in, 105
mastitis, capsulotomy and, 41 breast implant controversy and, 91,
Mayo Clinic study (1994), 10, 47, 93, 94, 97-110, 190-91
100-102, 142-46, 174-75, 200, confirmation in, 97, 169
205-7 data collection in, 93
media, mass, 20'7-8 drawing conclusions in, 12, 92,
breast implants and, 160-61 93-94, 95, 96-97
celebrity implants and, 44—46 epidemiologic studies in, 99-106
critical review of, 157, 158-59 illustration of, 97-110
direct contact of, 95-96 Mayo study confidence interval,
entertainment value and, 157-58 174-75
medical issues reporting of, 31 media announcement in, 95, 96, 169
medical-news alarms in, 154—76 media vs., 161-76
medical research vs. studies re- peer review, 95
ported in, 171-72 question formulation and, 92-93
message on implants in, 11, 53-54, rejection of, 177-91
56, 57 research reports in, 95-96
news distortions of, 154, 173-74 review articles, 117
newsworthiness in, 154—55, 169-71, study design in, 92, 93
172-73 medical scares and alarms, 12, 21,
public opinion vs. spin of, 31 154-76
Medical Device Amendment, 51 see also media, mass
medical devices, see devices, medical Mentor Corporation, 34, 54, 60
medical ethics, breast implants and, Merrell Dow Pharmaceuticals, 75,
133-53, 207-9 127-32
medical malpractice, see lawsuits Minnesota Manufacturing and Min-
medical research, 9, 101—2, 163-64, ing Corporation (3M), 34, 194
195-99 see also McGhan Medical Corpora-
animal studies in, 58, 100, 103 tion
autoimmune link and, 101-2; see Monroe, Marilyn, 44-45
also autoimmune disease multiculturalists, 178, 179
confidentiality and, 146, 206 mysticism, 183-85
as exception to FDA ban, 56-57
funding of, 143-44, 199-201 Nader, Ralph, 53, 156
GUSTO trial, 170-71 National Institutes of Health (NIH),
immune reaction studies, 106-7 186-87
insufficient evidence and, 102-3 Nation Under Lawyers, A (Glendon), 70
lawsuits vs., 111-32 negligence, 112
Mayo Clinic study, 10, 47, 100-102, see also product liability
142-46, 174-75, 200, 205-7 New England Journal of Medicine, 9, 10,
Nurses’ Health study, 102, 200, 206-7 20, 29, 94, 95, 142, 143, 144, 145
scleroderma studies, 102 Angell’s editorials in, 61
silicone immune reaction, 106—7 Kessler’s article in, 61, 63
Women’s Health Cohort Study, 200 news, medical, see media, mass
254 Index
nipples: preponderance of the evidence, stan-

loss of sensation in, 35 dard of, 113-14
reconstruction of, 40 Preston, Richard, 157
Norplant, 36, 83-84, 86 probability, 96-97
“null hypothesis,” 92 product liability:
Agent Orange (dioxin), 69, 76, 79
odds ratio, 164-65 asbestos cases and, 75, 76-77
Office of Alternative Medicine Bendectin, 75-76, 127-32
(OAM), 186, 187 Bjork-Shiley heart valve, 76
Olmsted County, Minnesota, breast implants, see lawsuits
100-101, 146 class actions and, see class actions;
pattern of implant use in, 47 class-action settlements
opting out, 143-44, 194 conditions of, 23, 112-14, 116,
O’ Quinn, John, 134-42 198
Outbreak, 1577 Dalkon Shield, 76, 77
out-of-court settlements, 10, 71, 73, DES (diethylstilbestrol), 75
111, 141-42, 203 design flaws and, 43-44
see also class-action settlements implant innovations and, 43-44
lead paint, 76
paraffin, 35, 51 see also torts
Parton, Dolly, 45 proof, evidentiary standard of, 112,
Pate, David, 150 113, 114-15
Patten, Bernard, 150-51 prostate cancer, 164-65
peer-review process, 95-96 Public Citizen, 53
short-circuiting process of, 96 public opinion, 10, 11, 31
People, 45 FDA and, 24-25
personal injury lawsuits, see class- Pvalue, 168-69
action settlements; lawsuits;
product liability; torts Rathjen, Arthur, 58, 60
Pfizer, Inc., 76 reconstructive surgery, 19, 42, 43, 63
plaintiff's bar, 25, 53, 69, 73-74, 75, placement of implants in, 40
140, 142-46, 202 silicone implant research and, 34
contingency fees and, 30, 73-74, 78 Redbook, 63
plastic surgeons, see surgeons; specific regulation, regulatory agencies, fed-
doctors eral, 11, 64-66
Pointer, Sam C., 79, 193, 194-95 of cigarettes, 65
polymyalgia, 21 FDA ban on implants, 19, 24-25,
polyurethane-coated implants, 43, 54 50-68, 207-8
Republican-dominated Congress reform of, 67-68
and, 67-68 Republican-dominated Congress
polyvinyl alcohol, 38 and, 67-68
Pons, Stanley, 96, 169 see alsoFDA
Popper, Karl, 104, 130-31 relative risk ratio, 164-65
population studies, see epidemiologic connective tissue disease and,
studies; medical research; med- 195-98
ical research, process of research, see medical research; med-
premarketing approval, 51, 54 ical research, process of
Index @ 255
review articles, 117 silica, 106

rheumatoid arthritis, 21, 102 silicon, 36
risk factors, 97-99, 161-65, 167-69, silicone:
195-97 devices other than breast implants,
A. H. Robins, 76 36
Rochester Epidemiology Project, 205-6 first use of, 35-36
Rose, Noel, 138-39 liquid, see silicone injections
Rothenberg, Philip, 135, 136 properties of, 36
silicone injections, 52
Saffran-Brinks, Carol, 130 contractures and, 40
Sagan, Carl, 177, 189 effect of, 35-38, 103-4
saline-filled breast implants, 34, pain and, 38
43-44, 60-61 SLE (systemic lupus erythematosus),
double envelope and, 43-44 21, 102
see also breast implants, silicone-gel- Slobogin, Kathy, 150
filled soybean-oil-filled implants, 44
scar tissue, 37-38, 104—5 splinters, 37
capsule formation of, 40 standard, evidentiary legal, 112, 113
contracture of, 37-38, 40 scientific standards vs., 114-15
rupture of, 41 Star 80, 46
silicone-gel implants and, 40, 41 state courts, choice of jurisdiction
see also contractures, scar tissue and, 78-79, 136—37
Schwartz, Barry, 208-9 statistics, 165-69
science, 90-92, 94, 96, 173, 179, 180 see also medical research, process of
anti-, 177-91 Stern, Maria, 52, 57, 111-12
scientific evidence, 11-12, 27-28, 51, strict liability, 112
90-110 see also product liability
breast implants and, 20, 62-63, studies, scientific, see epidemiologic
97-110, 195-99 studies; medical research; med-
courts and vagueness of, 132, 142 ical research, process of; scien-
FDA ban and, 61 tific evidence
gathering of, see medical research, subpoena, for documents, 145-46,
process of 205
lawsuits and, 111-32 Supreme Court, U.S., 125-26, 127-32
legal findings vs., 10, 28-29, 57-60, surgeons:
112-18, 125-32, 142 evidence-suppression by, 23
verifiable, 94 fees of, 34
see also epidemiologic studies; med- indemnification of, 136-37
ical research plastic, 133
scleroderma, 21, 102 warnings of, 23
sclerosis, systemic, 102, 199 see also specific types of surgery
self-image, breast size and, 33, 47-48 Surgitek Corporation, 54
settlements, breast implants, 71, 73, sweating, of silicone gel implants, 30,
111, 141-42 41, 59
out-of-court, 10, 203 systemic lupus erythematosus (SLE),
see also class-action settlements 21
Silastic mammary prosthesis, 39 systemic sclerosis, 102, 199
256 Index
Teflon, 84, 203 cancer treatments for, as exception

Texas, implant lawsuits and, 134, to FDA ban, 56-57
136-37, 145, 146-51 connective tissue disease and,
3M (Minnesota Manufacturing and 97-98
Mining Corporation), 34, 194 cross cultural beauty ideals of,
see also McGhan Medical Corpora- 66-67
tion cultural pressures on, 33, 66-67
toluene diamine, 54 damage claims of, 10, 192-93; see
torts, 23, 26, 70-71, 73-89, 203-4 also class-action settlements; law-
king of, 140 suits
reform of, 27, 87-88, 204 discrimination against, 13
see also lawsuits; product liability FDA ban’s effects on, 9-10
tort tax, 87, 134 FDA treatment of, 61
Tribe, Laurence, 123 free choice of, 11, 61, 65, 66
healthy, breast implants and,
vasectomy, 165 97-98
Vasey, Frank, 105-6, 120, 121-22, 124 Hopkins’s appeal and, 124
Japanese, 35-36, 51, 103
warning, package insert, 22-23, 35, selfimage and, 35, 47-48
57, 135 silicone leakage concerns and, 41
Washington Post, 69, 208 statistics on implant problems in,
Weinstein, Jack, 69 19, 40-41
Weiss, Ted, 54, 63 see also feminists
white blood cells (leukocytes), 37, 41 Women’s Health Cohort Study, 101,
specialized, 106 196
witnesses, see expert witnesses Women’s Way of Knowing (Harding),
Wolf, Naomi, 35, 66-67 180
Wolfe, Sidney, 53 Woodruff, Judy, 150
women: Woodside, Frank, III, 123, 128
activists, 66 Worthing, Fabian, 135
attitude of, toward implants, 46-48,
139-40 Young, Frank, 53
i
\\
\\
AY
ay my
(continued from front flap)
to show that there is no significant link
between breast implants and disease.
Why were the courts and the public
so certain that breast implants were
dangerous when medical researchers
were not? The answer to this question
reveals important differences in the
way science, the law, and the public
regard evidence—and not just in the
breast-implant controversy. As our
society becomes ever more dependent,
at all levels, on science and technology,
misconceptions about scientific evi-
dence become an increasing danger to
the public good—with consequences
that extend far beyond the question
of whether silicone gel-filled breast
implants are safe.
“Marcia Angell exposes the breast implant

legal mess for what it is: greed capitalizing
on fear, based on non-science, fueled by
media recklessness and a tort system run
amuck.”
— George D. Lundberg, M.D., editor of the
Journal of the American Medical Association
b
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<
4
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aw
oe
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=
ad
Marcia Angell, M.D., is executive editor of

the New England Journal of Medicine.
Printed in the United States of America 6-96

“This may be one of the most important books of recent times. Marcia Angell
documents, in lucid prose and for all readers, that there is no scientific evidence
that breast implants cause illness! However, this is only one example of the
failure of the culture of law and the culture of science to merge gracefully, as dra-
matically set forth in Angell’s book. Our world is changing as science-based
technology increasingly affects our wealth, our health, and our futures. Science
on Trial evokes the chilling possibility of a nation of scientific illiterates slipping
back from the- 500-year-old commitment to rationality. Marcia Angell’s book
should, in the widest interpretation of this case study, energize the need for bet-
ter science education for all.” — Leon Lederman, Nobel Laureate in Physics
“Marcia Angell’s outstanding book explains clearly and fairly the combination of
greed, fear, ignorance, junk science, and media hype that created this national
litigation nightmare. Everyone interested in the tort system, science, and medi-
cine should heed the lessons that Dr. Angell teaches.”
—Shirley M. Hufstedler, former U.S. Secretary of Education and
former judge in the U.S. Court of Appeals, 9th Circuit
“The breast implant case is short on heroes and long on overweening greed.
Science on Trial dishes out stinging criticism to the legal, medical, and journalis-
tic professions. Above all, it makes a forceful case for adhering to the standard of
science in judging questions about the material world, a plea whose importance
extends far beyond the case of breast implants. With so much emotion and
money at stake in the breast implant controversy, the book will surely enrage
some readers. Many more will be enlightened by it.”
—Harvey V. Fineberg, M.D., Ph.D., dean of Harvard School of Public Health
“Part scientific detective story, part cultural commentary, Marcia Angell’s Science
on Trial follows the evidence about breast implants’ risks to women’s health to a
surprising and searing conclusion: the legal system supported massive settle-
ments against manufacturers despite the absence of reliable scientific evidence
of harm. This is a cautionary tale for anyone concerned about the relationship
between truth and justice.” — Martha Minow, professor, Harvard Law School
Etec a(t ace) |

ISBN 0-393-03973-0
POSTE §€60002788441
Re CENCE ON TRIAL THE CLASH OF |ll| |
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THE CLASH OF MEDICAL EVIDENCE AND THE

“An experienced medical editor renowned

“Marcia Angell has produced a landmark

re breast implants really dangerous?

Marcia Angell, M.D.

W. W. NORTON & COMPANY

San Rafae! Public Library

All rights reserved

For information about permission to reproduce selections from this book,

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

W. W. Norton & Company Ltd., 10 Coptic Street, London WC1A 1PU

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. The Breast Implant Story: Once Over Lightly

- Breast Implants: What They Are

- The FDA Ban on Implants:

. The Rush to Court: Litigation

- Scientific Evidence: What It Is

. Science in the Courtroom:

. Greed and Corruption: All That Free Money 133

. Americans and Health News:

9. Breast Implants and the Rejection of Science:

10. Where We Stand . . . and for How Long 192

LA. years ago I would have been surprised to be told I

who already had implants. It also led to a torrent of lawsuits

the breast implant controversy is because it illuminates im-

have in dealing with scientific evidence, particularly on mat-

feminist, by which I mean that I believe that women should

we: “ane. va ele Yak CK ee

[could not have written this book without Rachel Hart, my

for during the preparation of the book. No one could work

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ea ae oe ae wea tease? as | oO; Aivaml/s v a

pith, ta NE, gage ae PU aeee

y the time FDA commissioner David Kessler decided in

thought it was about time someone puta stop to women being

multimillion-dollar damages to women with a variety of com-

It was theorized that silicone, leaking slowly from the implants,

However, not even this conspiratorial theory does justice to the

terward before the FDA decided to ask for evidence of safety.

The second theme illuminated by the breast implant story

question. Tort reform is now a contentious political issue, and

cumulated slowly and the conclusion is inseparable from the

cumulation of evidence from many sources. The different

first, it is necessary to review the nature of the implants them-

I like a large casaba melon size, you know, I

he female breast has always been a powerful symbol of

In 1994 breast augmentation was the third most common

to please themselves is a matter of debate. The distinction is

planted in their breasts, as is now done, these women had liq-

understand the breast implant controversy fully. Consider a

anywhere else, it becomes firm with time and tends to contract.

BY THE EARLY 19608 the problems with injecting liquid silicone

In 1961, two Houston plastic surgeons, Thomas Cronin

ward the natural breast tissue.'!' The procedure is somewhat