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http://www.theage.com.au/articles/2003/12/17/1071337024455.htmlDoctors, drugs and ethics
December 18, 2003
The relationship between doctors and drug companies is too cosy. A
cultural shift is needed, writes Paul Komesaroff.It is easy to understand why relationships between doctors and the
pharmaceutical industry arouse alarm (see The Age investigation
published last Saturday). The primary role of doctors is to care
for sick and vulnerable members of the community, in return for
which they receive significant social and material privileges.
Pharmaceutical companies are among the largest and most powerful
organisations in the world and their primary interest is to reap
profits for their shareholders, which they do on a huge scale.There are concerns that liaisons between doctors and drug companies
will corrupt the primary purpose of medicine and squander the
resources of the community, advancing the commercial objectives of
industry and the acquisitive interests of clinicians in preference
to legitimate care, education and research goals.These concerns are well founded. The practice of medicine in the
community is critically susceptible to influence by some of the
core activities of drug companies.For example, promotion and marketing, which make up a large part
of these activities - totalling more than $A15 billion each year -
have a profound impact on medical decision-making. While doctors
generally deny that they are influenced by pharmaceutical advertising,
there is overwhelming evidence from published studies that contact
with drug company representatives leads to increased prescribing
of drugs, acceptance of commercial rather than scientific views and
a propensity to engage in non-rational prescribing behaviour.Gift-giving is another widely used and pernicious device, with gifts
ranging from trivial promotional items to business-class air tickets.
As with advertising, the evidence that gift giving influences
behaviour is clear: for example, an American study showed that
doctors who meet pharmaceutical representatives are 13 times more
likely, and those who accept money to speak at symposiums 21 times
more likely, to recommend use of their products.It is important that the community is able to have confidence in
the independence of medical practitioners and researchers.Sponsorship of meetings, on which many professional societies have
come to depend, provides the pharmaceutical industry with unparalleled
opportunities to show their wares. As in the other examples,
sponsorship of conferences has been shown to lead to bias in favour
of a company's drugs, with increases in prescriptions being seen
for at least six months after an event.Drug company sponsorship of research and publications is of particular
concern. There are many ways in which research findings can be
directed towards producing a desired result, ranging from careful
design of a trial and selection of drug doses to selective reporting
of results or actual suppression of unfavourable outcomes. Delays
in the publication of unfavourable results are common, and it is
speculated that the results of many clinical trials are never
published at all.These facts have been known and have caused concern within the
medical profession for many years. However, the importance of
maintaining a balanced perspective has also been recognised.While it is true that, as in other industries, drug companies will
do whatever they can to maximise profits, it should not be forgotten
that they also do much that is good, such as providing medications
that save lives and alleviate suffering, and contributing massively
to medical research. Constructive co-operation between the two sides
can produce clear benefits for the community, including the stimulation
of research, development of new treatments and broad dissemination
of new knowledge and techniques.To make possible a critical, healthy dialogue with the pharmaceutical
industry and to manage conflicts of interests emerging from this
relationship, several medical professional bodies have engaged in
extensive discussion and public consultation over the past few
years, leading to guidelines for the conduct of doctors that are
increasingly influencing both clinical practice and research.Those of the Royal Australasian College of Physicians provide a
notable example. These emphasise four central principles: that
arrangements between physicians and pharmaceutical companies should
be open and transparent; that potential conflicts should be clarified
and clearly declared; that whether conflicts actually exist should
be decided not by the individuals concerned but by the communities
potentially affected; and that where conflicts are likely special
steps should to be taken to avoid unacceptable outcomes.Specific measures are recommended to ensure that interactions between
doctors and drug companies are consistent with the public interest.
Gifts should be accepted only if decision-making is left manifestly
unimpaired. Support for travel to conferences organised by professional
societies should be restricted to people making formal contributions.
Entertainment expenses should not be lavish. Access of representatives
to students and health services should be limited. Sponsorship of
meetings should be provided only through independently organised
scientific committees and speakers should indicate dualities of
interest at the time of presentation. Sources of commercial funding
should not influence the scientific, educational or public policy
decisions of professional bodies, which should not associate
themselves directly or indirectly with promotion of products of
commercial sponsors.Additional steps should be taken to minimise biases in research and
publication, which require action not only by individual practitioners
but also by the industry, government and academia.It is important that the community is able to have confidence in
the independence of medical practitioners and researchers. To
guarantee this, significant changes are needed, which will entail
a substantial cultural shift and no doubt take some time to realise
fully.The process will not be without pain. However, the outcome will,
it is hoped, offer the best of both possible worlds: a rigorous,
independent and critical profession in partnership with a productive,
creative industry serving the needs of the community.Paul Komesaroff is director of the Monash Centre for the Study of
Ethics in Medicine and Society, and ethics convener of the Royal
Australasian College of Physicians. [email hidden]This story was found at:
http://www.theage.com.au/articles/2003/12/17/1071337024455.html