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Academy News: July 2005 Relationships between healthcare providers, pharmaceutical industry Are all interactions between medical care providers and the pharmaceutical industry unseemly? In the thought-provoking book, On The Take: H ow Medicine's Complicity with Big business Can Endanger Your Health , by Jerome Kassirer, MD, one of the author's arguments is that nearly all interactions between industry and the medical community are dubious, if not outright inappropriate. He explains how our healthcare system has developed to the point where many physicians, because of these interactions, are extremely conflicted when treating their patients. Basing his argument on examples of egregious behavior by some physicians and medical organizations, Kassirer outlines how these interactions undermine the trust that the public must have in its healthcare system. Therefore, he proposes severing all of these relationships as the most effective way to guarantee patients' interests are always kept as the primary guiding principle. While it may be true that the best way to evade inappropriate behavior, or seemingly inappropriate behavior, is avoidance of any situation that may lead to a conflict of interest, it is not always such a simple task. In the ideal world, the pharmaceutical industry would make medicines that would be studied by disinterested, third-party funded physicians and scientists. The results of these studies would provide the needed data for appropriate evidence-based medicine. Practicing physicians would always remain current with the literature, so that they were always providing their patients with the most accurate evidence-based clinical medicine. There would be no need for industry to market medicines, as all practicing physicians would be aware of the appropriate literature, obtained from the disinterested researchers. Were this situation to occur, the request for no interaction between industry and medical providers might be achievable. However, since we do not live in the ideal world (at least most of us don't), is it still reasonable to argue for the absolute prohibition on industry–medical practitioner interactions? Perhaps not, especially since the pharmaceutical industry provides many useful services that directly and indirectly benefit patients. Some of the examples that more readily come to mind include support for continuing medical education (CME) programs, and national and international academic meetings. Kassirer would likely counter that these programs may be biased in terms of speakers, content and such. While this certainly does occur, the vast majority of these programs attempt to maintain appropriate balance. Further, since many physicians fail to have the time and resources to remain current with the ever more rapidly evolving medical literature, these CME programs and meetings may represent their best opportunity to brush up on the new advances. This clearly benefits the patient, which is the ultimate goal. So, should the activities of a few “bad apples” negate the benefits derived from industry–medical practitioner interactions? In my view, the answer is clearly no, however, while we want to keep the positive aspects of industry interactions with medical professionals, we must work to limit those activities that are more questionable. Perhaps Kassirer would not feel compelled to take such an absolute approach to this issue if industry grants for CME and other such meetings always were unrestricted, and there were absolutely no influences on programming by industry. He might also be apt to approve of these events if physicians were more wary of biased programming and avoided events that were or appeared biased—even when it might be to their financial disadvantage. Of course, in order to sense bias, except in cases of extreme bias, the physician would have to have a working knowledge of the literature. While I may not agree with all of his conclusions, Kassirer does an excellent job of outlining many of the conflicts that have arisen between practitioners and industry. He goes further to discuss the history on how we have gotten to this point. Forming the appropriate response to these conflicts is a case of determining with what level of conflict each individual person is comfortable. The ethical issues raised do not have a clear-cut right answer, just multiple shades of grey. Through his book, Kassirer challenges the reader to rethink his or her own ethical views. This provides a wonderful opportunity to re-examine our own ethical compass and re-align it as necessary. Sometimes when a writer takes the absolute view on an issue it provides a breath of fresh air. The AAAAI Ethics/Conflict of Interest Committee provides these discussions as a way to open a dialogue on the various ethical issues that confront our specialty on a daily basis. These issues are often quite complex and do not have simple “right” or “wrong” solutions. The articles are meant as a way to highlight the various issues that are involved in these ethical dilemmas, they should not be viewed as the AAAAI Ethics/Conflict of Interest Committee or the AAAAI's particular stance on an issue.
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