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

Commerce in Medical Education and the Definitions of Professionalism

According to Brennan and colleagues,"altruism, putting the interests of patients first, scientific integrity and an absence of bias" define "professionalism," and therefore physicians receiving any fee or gift from a private concern for any reason are potentially unprofessional. As a result, the imposition of bright lines preventing such transactions guarantee "professionalism." The Report parroted the mantra often offered up to justify such segregation, namely: "Commercial entities have a responsibility to their shareholders and other vested stakeholders to thrive as businesses and maximize returns on investment. Medicine has a responsibility to put the needs of patients first.[1]"

This definition of professionalism, echoed by The Report, represents force feeding of one ethical framework for medicine when other, equally or more valid reference points exist.[28] The definition resonates with the contempt for trade embedded in primitive cognition, religious traditions, and feudal aristocracies and most recently promoted by socialism and interventionism.[29,30] When for millennia physicians had nothing substantive to offer patients, a high-minded aura of religious and learned authority was necessary for their social status. As "the youngest science," this requirement persisted until relatively recently.[31] However, this need to declare medicine a secular religion is no longer relevant and potentially damaging, and the mantra quoted above reflects muddled thinking about both commerce and medicine. First, companies maximize profitability by coming up with products that benefit patients, and to conclude that industry has no interest in social responsibility is an enormous leap. Second, if corporate support of educational activities enables physicians to sustain their patient care activities, it is in the interests of patients. At a time when public support of biomedical research is not meeting research opportunities, when medical students are laden with debts and when organized medicine must desperately fight to sustain physician reimbursement rates, the wisdom -- indeed the ethics -- of arbitrarily discarding a major source of revenue for medical education is questionable. Third, scholars have explicitly articulated that medicine and commerce are not residents of parallel universes; practicing doctors are commercial. They are not government; they are not judges; and they are not news reporters, all of which are held to standards of apparent freedom from conflict of interest.[32,33,34] The Report's assertion that private companies' support of education corrupts educational quality is oddly selective because it neglects the obvious fact that academic health centers and medical journals are also "commercial," engaged in vigorous competition with rivals, and they exhibit the same promotional behavior deemed unattractive when exhibited by private companies.

As discussed above, "absence of bias," is impossible and therefore inappropriate as a criterion for professionalism. Although frequently invoked, the meaning of "putting interests of patients first" is totally vague and never specifically defined. Defensive medicine, fee-for-service reimbursement, and prepaid care -- all highly prevalent phenomena -- work at cross-purposes against "putting the patient first." Abundant historical evidence that stated good intentions disguise self-dealing and tyranny and do not guarantee good outcomes or prosperity mandate that we not mindlessly accept "altruism" as a central tenet of medical professionalism. The moral life of a practicing physician is a balancing act between multiple competing values and incentives -- not the abstract worship of absolute altruism.[35,36,37]

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