COMMENTARY

Response to AMA's Council on Ethical and Judicial Affairs Draft Report on "Ethical Guidance for Physicians and the Profession With Respect to Industry Support for Professional Education in Medicine"

Thomas P. Stossel, MD

Disclosures

June 12, 2008

Risks Imputed to Commerce in Medicine and Medical Education

The Brennan paper begins with the following statement:

The current influence of market incentives in the USA is posing extraordinary challenges to medical professionalism. Physicians commitment to altruism, putting the interests of patients first, scientific integrity and an absence of bias in medical decision making now regularly come up against financial conflicts of interest.[2]

This paragraph merits close inspection because of its severe claims. What supporting evidence do Brennan and colleagues bring to bear on these strong statements?

Citing both sides of controversial issues is a requirement of serious scholarship. Violating this mandate, Brennan and colleagues not only ignored the benefits of commercial contributions to medicine, but exercised confirmation bias by referring only to publications critical of industry influences on medicine, although others rebutting these criticisms existed when the Brennan paper appeared.[19,20,21,22,23] All of the references that Brennan and colleagues cited were to books, medical journal articles, and newspaper reports supportive of the authors' claims. These references were compilations of anecdotes, purportedly exemplifying industrial corruption of medical research. Not only has follow-up due diligence challenged the interpretation of some of these stories (eg, Shuchman[24]), but, more importantly, considering the enormous expansion of corporate interactions with medicine, the paucity of examples is striking and their frequent repetition is not legitimate evidence. Like the Brennan paper, The Report only cited literature supportive of its conclusions and treated the benefits of commercialism in medicine cursorily.

Brennan and colleagues quoted a review article that summarized studies analyzing effects of corporate marketing on healthcare professionals to justify a claim that "the systematic review of the medical literature on (industry) gifting by Wazana found that an overwhelming number of interactions had negative results on patient care.[25]"

Ashley Wazana, the author of the paper referred to, however, explicitly stated that no patient care data exist concerning this topic. According to Wazana's literature survey, product marketing enables the "improved ability to identify the treatment for complicated illnesses" -- a clearly desirable effect. The "negative" consequences alleged are "inability to identify wrong claims," which would increase with cutbacks in CME funding; "formulary requests for new medications with no advantages over old ones," which begs the question of what requests to censor; "rapid prescribing of new products," which could be appropriate; and "a positive attitude toward company representatives,"which has no clear relation to medical practice.[25]" The favorable effects of promotion are arguably clear and the unfavorable ones ambiguous or trivial. Hence, the net effect of industry interaction with medicine as compiled by Wazana is, on balance, strongly positive, although the author did not come to that conclusion.

Unable to marshal evidence that corporate promotion adversely affects patient outcomes, The Report resorted to indirect arguments intended to convey that industry influence adversely biases physicians' judgment. In one, it mentions 2 notorious cases in which drug companies accused of promoting off-label drug use paid settlement fines to prosecutorial authorities. The obvious intention of mentioning such anecdotes is to imply that all corporations are fundamentally unethical. Considering the vast scope of corporate-sponsored medical education compiled by The Report, such extrapolation from isolated incidents -- meant to insinuate that such conduct is typical -- is grossly extravagant, bordering on slander.

In another indirect argument, Brennan and colleagues and The Report embraced the conclusion, derived from psychological experiments and embellished by neuroimaging studies, that physicians lack discriminatory powers to resist subtle persuasion tactics skillfully imbedded in educational activities by commercial marketers. A corollary of this viewpoint is that disclosure ("mitigation") is inadequate to control conflicts of interest, because in the face of the predetermined outcomes of the brainwashing sales pitch, disclosure is useless or even enabling because it imparts a false sense of security. The research behind these ideas is limited in extent and of questionable relevance. The behavior of college students engaged in experimental games may not apply to that of well-trained physicians in clinical practice. Even if the brain scans of a judge offered a large bribe and of a physician given a company pen look the same, neither scan predicts how the subjects will respond. To make such "evidence" the basis of policy is irresponsible.

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