PLATFORM * TRIBUNE
Snake oil and Caesar salad: the ethics of physician and pharmaceutical relationships Robert F. Woollard, MD Arthur Penn's movie Little Big Man the title character moves back and forth between Indian and white culture on the US frontier in the time of General George Custer. Several times he encounters snake oil salesman Dr. Merriweather, who on each occasion has had one more piece of his anatomy removed by a dissatisfied customer. Caught too often serving his own interests rather than those of his "patients" Dr. Merriweather saw his reputation reduced with his anatomy, so much so that in their last meeting Little Big Man makes the sardonic observation, "They're whittlin' away at you, Dr. Merriweather." We have come a long way in the last 125 years. We like to think that an MD degree conveys something of meaning about adequate training and dedication to patient welfare. We also like to think that our nostrums unlike snake oil have been effective against the many maladies that the unswerving eye of science has more clearly defined. All this may be true, but let us harbour no illusions that this view of a dedicated, valid profession is universally held and cannot be threatened if we are seen to be self-serving or unduly influenced by those whose remedies we recommend. We should not delude ourselves, either, that the skeletons of our snake-oilselling ancestors are forever hidden in the family closet. The runaway success, commercial and political, of books that purport to show the minor and expensive role modem medicine plays in overall health should disabuse us of any notion that our undeniable achievements immunize us against uninformed criticism. Indeed, tolerance of seemingly minor deviations from our stated commitment in the CMA Code of Ethics to always "consider first the In
-
well-being of the patient" will be taken as evidence of the profession's unworthiness. And so, like Caesar's wife, we must be very careful about those with whom we consort. What is the proper relationship between physicians and the pharmaceutical and health supply industries? Although we all like to think our personal actions are beyond reproach we should pause in our acceptance of gifts from industry and look to the greater gift alluded to by Robbie Bums: Oh wad some power the giftie gie us To see oursels as ithers see us! It wad frae monie a blunder free us An' foolish notion
To achieve this we could think of ourselves as entering the office of an "independent" insurance agent and hoping to have an objective discussion of our needs and the various companies and policies that might meet them. Does the sight of a company's corporate logo on such office items as letter openers, paper products, posters and pens reassure us of the agent's objective approach? Does the fact that he or she had been wined, dined and "educated" the previous evening by a particular insurance company or that the latest changes in insurance products have been made known at meetings sponsored and paid for by the companies whose products might be recommended leave us confident that the agent will assess our needs impartially? These are provocative questions even if we knew what our true needs were. Consider the patient who comes into our medical office and makes similar observations but who is made even more
Dr. Woollard is assistant professor in the Department ofFamily Practice, University of British Columbia, Vancouver, BC.
Reprint requests to: Dr. Robert F. Woollard, James E. Mather Building, University of British Columbia, 5804 Fairview Ave., Vancouver, BC V6T IZ3 OCTOBER 15, 1991
CAN MED ASSOC J 1991; 145 (8)
931
vulnerable by knowing little and having to trust the advice of the physician so encumbered with the trappings of pharmaceutical influence. The relationship between physicians and the health supply industry is changing rapidly under the influence of such factors as legislation (the Patent Act2), technology (information management), politics (decreased public funding for research) and the economy (decreased relative physician incomes). Thus, the issue is not whether the previous relationship was ethical but, rather, what forms we see for future relationships. The CMA has completed a 2-year process of consideration and consultation on this complex relationship. In August 1991 General Council gave final approval to the Guidelines for an Ethical Relationship Between Physicians and the Pharmaceutical Industry. These guidelines refer not only to pharmaceutical manufacturers but also to manufacturers of medical devices and infant formula. By thus stating clearly the principles and expectations of our collective medical peers the CMA has assumed international leadership in this area. However, the profession will only be honoured in the observance - not in the simple statement - of the guidelines. In this, each physician has an important role to play and should familiarize himself or herself with these guidelines. The relationships between our profession and industry are many and varied and involve activities such as research, publications, continuing medical education (CME), promotion and investment. The issues in each area are so numerous that even a brief listing is beyond the scope of this article, but salient examples will underscore the need for the profession to take a stand in defining acceptable behaviour. There has been a trend toward reducing public funding for basic research in Canada as part of a stated plan to encourage research and development in the private sector. The drug patent legislation is supposed to reflect this. Unfortunately, the regulations in this legislation rely on an income tax definition that limits the conditions under which money spent on general, primary research is allowed as a tax deduction; thus, research on product-related activities is encouraged. This results in an obvious skew to research priorities and, when coupled with a blurring of the distinction between legitimate research and product promotion (free computers for prescribing a particular medication), an expanding potential for ethical conflict. The explosion in the number of unrefereed, "throwaway" journals with reasonably well-paid contributors must be discouraging to the journal editors and authors who take seriously their responsibilities to colleagues by writing and publishing peer-reviewed and valid information. Given the 932
CAN MED ASSOC J 1991; 145 (8)
commercial interests of the publishers and their pharmaceutical advertisers, bias toward pharmaceutical-related topics is obvious. This is true not only for the articles themselves (often excellent) but also for the CME event that forms the basis of many such articles. Attempts have been made to encourage an arm's length relationship between CME organizers and sponsors. These arms, like Dr. Merriweather's, are looking pretty short these days as travelling speakers (and travelling audiences) are offered up free of charge to compete with needs-determined customdesigned CME for the time and money of the busy practitioner. When a fine meal at a delightful restaurant is thrown in, the competition is even more one-sided and unlikely to be affected by calls for an evaluation of the effectiveness of the CME. Indeed, there is a real danger that a more critical eye will be cast on the quality of the Caesar salad than on the educational experience. A study published in Canadian Family Physician3 revealed the striking number of items in family physicians' offices (on average 750 per office) that are supplied by pharmaceutical companies. It is possible that Canadian physicians walk delicately through this increasingly complex ethical minefield, but some healthy scepticism is in order. All physicians should review how they deal with pharmaceutical companies, discuss it with their peers and acquaint themselves with the guidelines suggested by their colleagues through the CMA. Having spent much of the last 2 years discussing these issues from coast to coast I have been struck by physicians' defensiveness. We sometimes seem to take ourselves too seriously and feel that our high calling is so onerous that we deserve the perks offered by industry. Therefore, if someone questions the propriety of accepting such largess we feel that our very worth is being challenged. We then tend to give a convoluted justification that is based on a comparison with common industrial practice and that focuses little attention on who is paying the price. By taking ourselves too seriously we court the danger of taking our principles too lightly. If we can avoid these twin dangers we will be well served; if we fail to do so the matter will be dealt with by forces outside the profession. The reality of the present situation cannot be summed up better than it was several years ago in the Lancet:4 Few doctors accept that they themselves have been corrupted. Most doctors believe that they are quite untouched by the seductive ways of the industry's marketing men; that they are uninfluenced by the promotional propaganda they receive; that they can enjoy a company's "generosity" in the form of gifts and hospitality without prescribing its LE 15 OCTOBRE 1991
products. The degree to which the profession, mainly composed of honourable and decent people, can practise such self-deceit is quite extraordinary. No drug company gives away its shareholders' money in an act of disinterested generosity.
must do better. In observing the growing possibility that physicians' self-interest will compromise the reputation of the profession I am tempted to borrow from Little Big Man: "They're whittlin' away at you, Mother Medicine."
Building on this concern Thompsons wrote in CMAJ several years later:
References
Physicians and pharmaceutical houses must act and be seen to act in the public interest. Otherwise, we risk censure that we are a medical-industrial- complex with ulterior motives.
Matters are not getting any easier to define in the complex relationships between our profession and the industries that supply our tools. We can and
Conferences
continuedfrom page 930 Nov. 7-9, 1991: Learning Disabilities Association of Canada 8th National Conference - Peak to Potential Banff Springs Hotel, Banff, Alta. Learning Disabilities Association of Alberta, Calgary Chapter, 745B 37th St. NW, Calgary, AB T2N 4T1; (403) 283-6606
Nov. 8, 1991: Annual Social Work Clinic Day Joseph E. and Minnie Wagman Centre, North York, Ont. Sybil Gilinsky, Education Department, Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, ON M6A 2E1; (416) 789-5131, ext. 2365, fax (416) 785-2378 Nov. 8, 1991: Diabetes Update: Current Controversies and future Directions (sponsored in part by the Metro Toronto branch of the Canadian Diabetes Association) Metro Toronto Convention Centre Norah Rankin, Banting and Best Diabetes Centre, 3 CCRW-836, Toronto Hospital (General Division), 200 Elizabeth St., Toronto, ON M5G 2C4; (416) 978-4656 Nov. 8, 1991: 2nd Annual Update in Child and Adolescent Psychiatry - Children and Divorce Metro Toronto Convention Centre Thomas Yoannidis, Child and Family Studies Centre, Clarke Institute of Psychiatry, 250 College St., Toronto, ON M5T 1R8; (416) 979-2221, ext. 2260
Nov. 12, 1991: Medical Literature Analysis and Retrieval System (MEDLARS) Course - Advanced Toronto Health Sciences Resource Centre, Canada Institute for Scientific and Technical Information, National Research Council of Canada, Ottawa, ON K 1 A 0S2; (613) 993-1604, fax (613) 952-8244 OCTOBER 15, 1991
1. Burns R: To a louse. In Poems, Burgess and Bowes, London, England 2. Patent Act, RS 1985, c P-4; RS, c 33 (3rd Supp) 3. Fogel ML: Survey of pharmaceutical promotion in a family medicine training program. Can Fam Physician 1989; 35: 1603- 1605 4. Rawlins MD: Doctors and the drug-makers. Lancet 1984; 2: 276-278 5. Thompson WG: The ethics of physician-pharmaceutical company relationships. Can Med Assoc J 1988; 139: 835836
Nov. 13, 1991: Medical Literature Analysis and Retrieval System (MEDLARS) Course - GRATEFUL MED Toronto Health Sciences Resource Centre, Canada Institute for Scientific and Technical Information, National Research Council of Canada, Ottawa, ON Ki A 0S2; (613) 993-1604, fax (613) 952-8244
Nov. 14-15, 1991: Ontario Workers' Compensation Board 1 st Biennial Information Conference Metro Toronto Convention Centre Ann Garland, special events coordinator, Communications Branch, Workers' Compensation Board, 2 Bloor St. E, Toronto, ON M4W 3C3; (416) 927-3505 Nov. 14-16, 1991: 1991 International Consensus Conference on Doctor-Patient Communication Toronto Marriott Eaton Centre Hotel GEMS Conference and Consulting Services Inc., 100-4260 Girouard, Montreal, PQ H4A 3C9, (514) 485-0855, fax (514) 487-6725; or Dr. Robert Buckman, Toronto-Bayview Regional Cancer Centre, 2075 Bayview Ave., North York, ON M4N 3M5, (416) 480-4928, fax (416) 480-4639 Nov. 14-17, 1991: Quebec Association of Urologists 16th Annual Meeting Hilton Hotel, Quebec Jacqueline Deschenes, Quebec Association of Urologists, 2 Complexe Desjardins, East Tower, Rm. 3000, Montreal, PQ H5B 1G8; (514) 844-9523 Nov. 15, 1991: Brief Solution-Oriented Therapy Nursing Residence Auditorium, Toronto Hospital
(General Division) Department of Social Work, Toronto Hospital (General Division), 8th Floor, Bell Wing, Rm. 669, 200 Elizabeth St., Toronto, ON M5G 2C4; (416) 340-5077 or (416) 340-3616
continued on page 952 CAN MED ASSOC J 1991; 145 (8)
933
Snake oil and Caesar salad: the ethics of physician and pharmaceutical relationships Robert F. Woollard, MD Arthur Penn's movie Little Big Man the title character moves back and forth between Indian and white culture on the US frontier in the time of General George Custer. Several times he encounters snake oil salesman Dr. Merriweather, who on each occasion has had one more piece of his anatomy removed by a dissatisfied customer. Caught too often serving his own interests rather than those of his "patients" Dr. Merriweather saw his reputation reduced with his anatomy, so much so that in their last meeting Little Big Man makes the sardonic observation, "They're whittlin' away at you, Dr. Merriweather." We have come a long way in the last 125 years. We like to think that an MD degree conveys something of meaning about adequate training and dedication to patient welfare. We also like to think that our nostrums unlike snake oil have been effective against the many maladies that the unswerving eye of science has more clearly defined. All this may be true, but let us harbour no illusions that this view of a dedicated, valid profession is universally held and cannot be threatened if we are seen to be self-serving or unduly influenced by those whose remedies we recommend. We should not delude ourselves, either, that the skeletons of our snake-oilselling ancestors are forever hidden in the family closet. The runaway success, commercial and political, of books that purport to show the minor and expensive role modem medicine plays in overall health should disabuse us of any notion that our undeniable achievements immunize us against uninformed criticism. Indeed, tolerance of seemingly minor deviations from our stated commitment in the CMA Code of Ethics to always "consider first the In
-
well-being of the patient" will be taken as evidence of the profession's unworthiness. And so, like Caesar's wife, we must be very careful about those with whom we consort. What is the proper relationship between physicians and the pharmaceutical and health supply industries? Although we all like to think our personal actions are beyond reproach we should pause in our acceptance of gifts from industry and look to the greater gift alluded to by Robbie Bums: Oh wad some power the giftie gie us To see oursels as ithers see us! It wad frae monie a blunder free us An' foolish notion
To achieve this we could think of ourselves as entering the office of an "independent" insurance agent and hoping to have an objective discussion of our needs and the various companies and policies that might meet them. Does the sight of a company's corporate logo on such office items as letter openers, paper products, posters and pens reassure us of the agent's objective approach? Does the fact that he or she had been wined, dined and "educated" the previous evening by a particular insurance company or that the latest changes in insurance products have been made known at meetings sponsored and paid for by the companies whose products might be recommended leave us confident that the agent will assess our needs impartially? These are provocative questions even if we knew what our true needs were. Consider the patient who comes into our medical office and makes similar observations but who is made even more
Dr. Woollard is assistant professor in the Department ofFamily Practice, University of British Columbia, Vancouver, BC.
Reprint requests to: Dr. Robert F. Woollard, James E. Mather Building, University of British Columbia, 5804 Fairview Ave., Vancouver, BC V6T IZ3 OCTOBER 15, 1991
CAN MED ASSOC J 1991; 145 (8)
931
vulnerable by knowing little and having to trust the advice of the physician so encumbered with the trappings of pharmaceutical influence. The relationship between physicians and the health supply industry is changing rapidly under the influence of such factors as legislation (the Patent Act2), technology (information management), politics (decreased public funding for research) and the economy (decreased relative physician incomes). Thus, the issue is not whether the previous relationship was ethical but, rather, what forms we see for future relationships. The CMA has completed a 2-year process of consideration and consultation on this complex relationship. In August 1991 General Council gave final approval to the Guidelines for an Ethical Relationship Between Physicians and the Pharmaceutical Industry. These guidelines refer not only to pharmaceutical manufacturers but also to manufacturers of medical devices and infant formula. By thus stating clearly the principles and expectations of our collective medical peers the CMA has assumed international leadership in this area. However, the profession will only be honoured in the observance - not in the simple statement - of the guidelines. In this, each physician has an important role to play and should familiarize himself or herself with these guidelines. The relationships between our profession and industry are many and varied and involve activities such as research, publications, continuing medical education (CME), promotion and investment. The issues in each area are so numerous that even a brief listing is beyond the scope of this article, but salient examples will underscore the need for the profession to take a stand in defining acceptable behaviour. There has been a trend toward reducing public funding for basic research in Canada as part of a stated plan to encourage research and development in the private sector. The drug patent legislation is supposed to reflect this. Unfortunately, the regulations in this legislation rely on an income tax definition that limits the conditions under which money spent on general, primary research is allowed as a tax deduction; thus, research on product-related activities is encouraged. This results in an obvious skew to research priorities and, when coupled with a blurring of the distinction between legitimate research and product promotion (free computers for prescribing a particular medication), an expanding potential for ethical conflict. The explosion in the number of unrefereed, "throwaway" journals with reasonably well-paid contributors must be discouraging to the journal editors and authors who take seriously their responsibilities to colleagues by writing and publishing peer-reviewed and valid information. Given the 932
CAN MED ASSOC J 1991; 145 (8)
commercial interests of the publishers and their pharmaceutical advertisers, bias toward pharmaceutical-related topics is obvious. This is true not only for the articles themselves (often excellent) but also for the CME event that forms the basis of many such articles. Attempts have been made to encourage an arm's length relationship between CME organizers and sponsors. These arms, like Dr. Merriweather's, are looking pretty short these days as travelling speakers (and travelling audiences) are offered up free of charge to compete with needs-determined customdesigned CME for the time and money of the busy practitioner. When a fine meal at a delightful restaurant is thrown in, the competition is even more one-sided and unlikely to be affected by calls for an evaluation of the effectiveness of the CME. Indeed, there is a real danger that a more critical eye will be cast on the quality of the Caesar salad than on the educational experience. A study published in Canadian Family Physician3 revealed the striking number of items in family physicians' offices (on average 750 per office) that are supplied by pharmaceutical companies. It is possible that Canadian physicians walk delicately through this increasingly complex ethical minefield, but some healthy scepticism is in order. All physicians should review how they deal with pharmaceutical companies, discuss it with their peers and acquaint themselves with the guidelines suggested by their colleagues through the CMA. Having spent much of the last 2 years discussing these issues from coast to coast I have been struck by physicians' defensiveness. We sometimes seem to take ourselves too seriously and feel that our high calling is so onerous that we deserve the perks offered by industry. Therefore, if someone questions the propriety of accepting such largess we feel that our very worth is being challenged. We then tend to give a convoluted justification that is based on a comparison with common industrial practice and that focuses little attention on who is paying the price. By taking ourselves too seriously we court the danger of taking our principles too lightly. If we can avoid these twin dangers we will be well served; if we fail to do so the matter will be dealt with by forces outside the profession. The reality of the present situation cannot be summed up better than it was several years ago in the Lancet:4 Few doctors accept that they themselves have been corrupted. Most doctors believe that they are quite untouched by the seductive ways of the industry's marketing men; that they are uninfluenced by the promotional propaganda they receive; that they can enjoy a company's "generosity" in the form of gifts and hospitality without prescribing its LE 15 OCTOBRE 1991
products. The degree to which the profession, mainly composed of honourable and decent people, can practise such self-deceit is quite extraordinary. No drug company gives away its shareholders' money in an act of disinterested generosity.
must do better. In observing the growing possibility that physicians' self-interest will compromise the reputation of the profession I am tempted to borrow from Little Big Man: "They're whittlin' away at you, Mother Medicine."
Building on this concern Thompsons wrote in CMAJ several years later:
References
Physicians and pharmaceutical houses must act and be seen to act in the public interest. Otherwise, we risk censure that we are a medical-industrial- complex with ulterior motives.
Matters are not getting any easier to define in the complex relationships between our profession and the industries that supply our tools. We can and
Conferences
continuedfrom page 930 Nov. 7-9, 1991: Learning Disabilities Association of Canada 8th National Conference - Peak to Potential Banff Springs Hotel, Banff, Alta. Learning Disabilities Association of Alberta, Calgary Chapter, 745B 37th St. NW, Calgary, AB T2N 4T1; (403) 283-6606
Nov. 8, 1991: Annual Social Work Clinic Day Joseph E. and Minnie Wagman Centre, North York, Ont. Sybil Gilinsky, Education Department, Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, ON M6A 2E1; (416) 789-5131, ext. 2365, fax (416) 785-2378 Nov. 8, 1991: Diabetes Update: Current Controversies and future Directions (sponsored in part by the Metro Toronto branch of the Canadian Diabetes Association) Metro Toronto Convention Centre Norah Rankin, Banting and Best Diabetes Centre, 3 CCRW-836, Toronto Hospital (General Division), 200 Elizabeth St., Toronto, ON M5G 2C4; (416) 978-4656 Nov. 8, 1991: 2nd Annual Update in Child and Adolescent Psychiatry - Children and Divorce Metro Toronto Convention Centre Thomas Yoannidis, Child and Family Studies Centre, Clarke Institute of Psychiatry, 250 College St., Toronto, ON M5T 1R8; (416) 979-2221, ext. 2260
Nov. 12, 1991: Medical Literature Analysis and Retrieval System (MEDLARS) Course - Advanced Toronto Health Sciences Resource Centre, Canada Institute for Scientific and Technical Information, National Research Council of Canada, Ottawa, ON K 1 A 0S2; (613) 993-1604, fax (613) 952-8244 OCTOBER 15, 1991
1. Burns R: To a louse. In Poems, Burgess and Bowes, London, England 2. Patent Act, RS 1985, c P-4; RS, c 33 (3rd Supp) 3. Fogel ML: Survey of pharmaceutical promotion in a family medicine training program. Can Fam Physician 1989; 35: 1603- 1605 4. Rawlins MD: Doctors and the drug-makers. Lancet 1984; 2: 276-278 5. Thompson WG: The ethics of physician-pharmaceutical company relationships. Can Med Assoc J 1988; 139: 835836
Nov. 13, 1991: Medical Literature Analysis and Retrieval System (MEDLARS) Course - GRATEFUL MED Toronto Health Sciences Resource Centre, Canada Institute for Scientific and Technical Information, National Research Council of Canada, Ottawa, ON Ki A 0S2; (613) 993-1604, fax (613) 952-8244
Nov. 14-15, 1991: Ontario Workers' Compensation Board 1 st Biennial Information Conference Metro Toronto Convention Centre Ann Garland, special events coordinator, Communications Branch, Workers' Compensation Board, 2 Bloor St. E, Toronto, ON M4W 3C3; (416) 927-3505 Nov. 14-16, 1991: 1991 International Consensus Conference on Doctor-Patient Communication Toronto Marriott Eaton Centre Hotel GEMS Conference and Consulting Services Inc., 100-4260 Girouard, Montreal, PQ H4A 3C9, (514) 485-0855, fax (514) 487-6725; or Dr. Robert Buckman, Toronto-Bayview Regional Cancer Centre, 2075 Bayview Ave., North York, ON M4N 3M5, (416) 480-4928, fax (416) 480-4639 Nov. 14-17, 1991: Quebec Association of Urologists 16th Annual Meeting Hilton Hotel, Quebec Jacqueline Deschenes, Quebec Association of Urologists, 2 Complexe Desjardins, East Tower, Rm. 3000, Montreal, PQ H5B 1G8; (514) 844-9523 Nov. 15, 1991: Brief Solution-Oriented Therapy Nursing Residence Auditorium, Toronto Hospital
(General Division) Department of Social Work, Toronto Hospital (General Division), 8th Floor, Bell Wing, Rm. 669, 200 Elizabeth St., Toronto, ON M5G 2C4; (416) 340-5077 or (416) 340-3616
continued on page 952 CAN MED ASSOC J 1991; 145 (8)
933
