April 29, 2009

Medical Moral Hazards

A new report by the Institute of Medicine (IOM) calls for doctors to stop taking gifts from pharmaceutical companies. This could create all sorts of conflicts of interest. Here's an excerpt from the NYT:
"Drug companies spend billions of dollars wooing doctors — more than they spend on research or consumer advertising. Much of this money is spent on giving doctors free drug samples, free food, free medical refresher courses and payments for marketing lectures. The institute’s report recommends that nearly all of these efforts end.
The largest drug makers agreed last year to stop giving doctors pens, pads and other gifts of small value, but company executives have defended other marketing tactics as valuable to both doctors and patients. Medical device and biotechnology companies have yet to swear off free trips or even pens.
A 2007 survey found that more than three-quarters of doctors accepted free drug samples and free food, more than a third got financial help for medical refresher courses and more than a quarter were paid for giving marketing lectures and enrolling patients in clinical trials."
I don't see how samples and pens and paper would create a conflict of interest, i.e., for doctors to go against their professional judgment. But perhaps much larger payments (and trips) would. There's also the issue of physicians consulting for--and investing in--drug and biotechnology companies that benefit from their own prescriptions. Strangely, this is not addressed in the report. But it is in this recent assessment from the American Medical Student Association, claiming it's become a real problem, particularly at Harvard. Excerpts from the article:
"In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.
Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatment.

Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.
The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.
Harvard Medical School’s peers received much higher grades, ranging from the A for the University of Pennsylvania, to B’s received by Stanford, Columbia and New York University, to the C for Yale."
The question of course is where to draw the line. One might argue, as the IOM seems to, that any payment or gifting is inappropriate, as it creates a habit--a slippery slope--that may gradually grow into a serious moral hazard as physicians begin taking more liberties down the line. In any case, if state legislatures and medical associations establish clear guidelines on what is and is not appropriate, then doctors and medical schools might draw the lines somewhere that make sense to most everyone. It's a hard job, but it's one ethicists can surely step up to.

Update (Dec. 7, 2010): Harvard Medical School strengthened its conflict of interest (COI) policy a few months ago:
"Among many provisions, the new policy includes a streamlined central system for reporting faculty financial interests with industry; requires the public disclosure of certain faculty financial interests; bans faculty from accepting corporate gifts, including travel and meals; and ends faculty participation in industry speakers bureaus, making it one of the most stringent of any medical college in the country. In addition, faculty disclosures will be made available to the public on the Harvard Catalyst website. "
 As of this posting, I could not find faculty disclosures at the link above.

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