Debate Forum, 3/19

Debate Forum, 3/19

Debate Forum Center: Medicine or marketing?

 By Alex Culpepper

Doctors and pharmaceutical companies in the United States have worked together for a long time. After all, both are in the business of helping patients prevent, manage and even cure health problems. For the past several years, both have teamed up in another way to spread the word to other doctors about new treatments available. Pharmaceutical companies have been paying doctors to speak at conferences at which they describe medical breakthroughs developed by those companies, from new drugs to current research to the latest procedures. This practice, however, has raised an issue about ethics.

Until recently, there has been little disclosure about which doctors gave presentations at these conferences or for which companies. One tracking system is in place and another is coming soon. A website created by ProPublica, a nonprofit outfit specializing in investigative journalism, features a database called “Dollars for Docs.” This database tracks which doctors have received money from which companies and for what services. Soon, the federal government will be tracking this as well because beginning in 2014, every pharmaceutical company must report money given to doctors per the Affordable Care Act.

Opponents of doctors as paid speakers for pharmaceutical companies say doctors are basically marketing pharmaceutical company products rather than educating the doctors in the audience. Opponents’ concerns are mainly whether a doctor might be basing his or her treatment decision on where the money is coming from, rather than on what the patient needs. Opponents also argue part of the problem is that some doctors use company-produced materials in their presentations when they should be using their own information and research. Another problem for opponents is their concern whether speaking engagements reveal a potential lack of commitment on the doctor’s part because they believe he or she should be practicing medicine rather than speaking.

Proponents of the paid speaking engagements by doctors see no problems. Pharmaceutical companies contend doctors are experts in medicine and are a natural choice to present medical information. Proponents further say doctors are using their expertise to educate their colleagues by explaining the benefits of a drug or treatment that may be safer and more effective than drugs or treatments currently in use. According to reports, doctors who frequent the speaking circuit reject the idea of public speaking compromising their medical judgment. One doctor said he favors no product over another and works with companies he believes to be ethically motivated. Another says he’s in it for the teaching and presents the same information to everyone, no matter who pays him.

Debate about this issue has been ongoing for several years and each side raises valid points. One side says the promise of money from speaking engagements might be too much distraction for someone whose job is to provide medical treatment. The other side says it is business as usual and speaking engagements are simply a way to educate doctors and ensure the best treatments are available to patients, regardless of who writes the check.

Debate Forum Question of the Week:

 As medical professionals, doctors prescribe medicine and perform treatments based on science that shows that they work, regardless of which company developed them. Does it constitute a breach of ethics to have a doctor receive payment for speaking publicly on behalf of a pharmaceutical company?

Debate Forum Left: And you know better how?

 By Ben Tomkins

When I first read this topic my gut reaction was that there had to be something unethical about doctors getting paid for promoting a company’s pharmaceuticals. I kept thinking about it and thinking about it and I was sure the answer was hovering just on the periphery of my brain like one of those sliding number puzzles where one tile refuses to cooperate.

Unfortunately for my overdeveloped love of being right, I could not find a single way around the following points:

1. It’s not unethical to advocate a drug that works.

2. If a doctor prescribed a drug for which a case can’t be made for its use, it’s malpractice regardless.

3. Doctors don’t control drug dispensing: the pharmacy does. According to the head pharmacist at Swedish Hospital in Denver, a pharmacy always defaults to a generic drug regardless of what’s written on the prescription unless you choose to waste your money on a brand name.

4. Doctors who are prescribing new proprietary drugs that don’t have any long-term track record for success or failure barely know more than you or I what the long-term effects will be, so in reality the most important clinical trials occur over several years of public experimentation. Remember thalidomide? That’s pharmaceutical reality.

Of course, the major questions regarding pharmaceutical ethics are not about generic-versus-prescription drugs, but proprietary drugs that are new to the market and largely untested on a public scale. Now we’re dealing with a system where companies are invested in a drug’s success far too personally to allow objectivity.

After speaking with my wife, we both came to the conclusion that the most pure classification of drugs for which a doctor could be swayed to unethically advocate is birth control.  Nobody’s life is on the line and using one brand of birth control over another doesn’t result in cancerous growths or heart attacks unless it doesn’t work properly and you get pregnant. It’s not oncology. Oncologists make a living on the principle that ultimately it doesn’t matter “how,” it only matters “if.” No marketing campaign trumps a cure.

Today we’ve got the Nuva Ring, the pill, the shot, Yasmin – whatever the hell that is, the vaginal suppository thing that rattles around in your uterus and scrapes off anything inside – and a ton more. It’s about 90 percent what a woman wants to deal with and 10 percent “some things work a little better for some women than others.”

Now, let’s assume a doctor is receiving a billion dollars a year by Nuva Ring to push their product. This doctor puts the Nuva Ring front and center on the magazine rack of possible options for his patients, he extolls its virtues and perhaps even denigrates its competitors. Obviously, he is writing quite a few more prescriptions for Nuva Ring.

Here’s the big question: although this guy is pushing Nuva Ring in a non-objective, opportunistic, unethical way, has he actually caused any harm?  No, really, think about it. How does any woman decide to go on one birth control method or another? The same way I pick out a $7 bottle of wine at the liquor store; it’s whatever someone told me to get that one time and I stick with it until I have a good reason not to.

Isn’t that how pretty much everything works in medicine? Someone tells you what to do and you try it until it doesn’t work any more. No doctor on Earth – except homeopaths – will give you a proven failure, but until then everything is negotiable. The reality of medicine is, and I hate to have to say it, trial and error on the human animal.

Of course, I understand that our health is the most precious thing we have. However, not even doctors know what’s going to manifest down the road. In the meantime, it doesn’t change the fact that they have to pick something for some reason. Does it feel gross that some of them are cheerleading drugs for profit? Yes, but it doesn’t substantively affect the unknowable outcome.

 Ben Tomkins is a violinist, teacher, journalist and critically acclaimed composer currently living in Denver, Colo. He hates stupidity and generally believes that the volume of one’s voice is inversely proportional to one’s knowledge of the issue.  Reach Ben Tompkins at BenTomkins@DaytonCityPaper.com.

Debate Forum Right: Health system conflict of interest – Ethical lapse or free speech denial?

 By Dave Westbrock

The question of today’s debate is whether a physician in practice is in violation of professional ethics if he or she speaks on behalf of a particular pharmaceutical company or health equipment purveyor. I will first give a disclaimer and state without hesitation that I have given more than 50 presentations concerning disorders, diagnoses and treatments relevant to my specialty, endocrinology. Some of those presentations have been reimbursed by pharmaceutical companies and have involved drugs that I have used in my practice and which I fully support. For instance, a large Veterans Administration study was done several years ago showing that a particular hypertension drug significantly lowered the mortality risk, the death rate from heart attack and kidney failure. I studied the research extensively and found that other drugs in this category had either not been studied or did not show the same efficacy. I gave several talks based on these results and I still use this drug – now a generic – both personally and for my patients who have diabetes. I have done both because I believe the research!

My speaking engagements have been for one reason and that is to educate my colleagues. If I am able to have my time and expertise reimbursed for it, I see no conflict of interest. My purpose is to educate, not indoctrinate. I may prefer a particular drug in the course of a talk, but it is in the context of a new treatment or way of treating a particular disease. I have no interest in shilling for a company or a drug and, as in the most recent instance, I spoke about a disease state for the Medical School voluntarily – for no fee – as was my choice. The fact that the university was a government school did not make it more pure. College faculty and researchers draw a salary and give talks on behalf of the school’s research involving a new drug routinely. Is this a conflict of interest? Does the research they do and speak on behalf of mean they are being unethical, since they are speaking on behalf of research done at their particular institution, and does that constitute an ethical breach? If a university accepts grant money to do research and then allows their faculty to give testimony, is that illegitimate?  Anyone who answers “no” to the latter and “yes” to the former betrays the typical progressive mantra that government is good and private industry is bad.

Typically, professional medical education conferences may be – in part – reimbursed by medical device and pharmaceutical companies. The rules compel all speakers to state by whom they are now or formerly paid. This allows the audience members to judge potential bias, but does not constitute bias per se. Doctors are not idiots. We can be expected to determine for ourselves whether or not the speaker is expressing bias. The question and answer periods following talks often reflect this. Now, all pharmaceutical presentations must pass Food and Drug Administration guidelines about what can and cannot be stated about a particular drug. In many instances, to ensure this, slides are provided by the company to the speaker. Many of my colleagues and I will no longer give such presentations because the slides may not reflect individual experience and personal belief and indeed ensure bias toward the presented drug. Regulatory excess in this case is both counterproductive and poorly educates the audience.

In regard to the conflict of interest in medical affairs, Harvard Professor Dr. Thomas Stossel stated, “There is no evidence at all about the effect of physician-industry relations on patient outcomes, yet 76 percent of these papers claim patient harm.” And further, “evidence that relationships compromise scientific integrity is weak or false, but legal administration and legal strangulation is harming innovation and education and bodes ill for better patient care.”

As one might expect, ProPublica, a nonprofit news gathering organization, highly supported by George Soros and left-wing philanthropist Herb Sandler, is an important mover promoting conflict of interest in physician-industry relations. It might just be well to know that.

Dr. Westbrock has been in private medical practice for 35 years. He was the Republican candidate for the U.S House of Representatives in 1994 and 1996. He has written and lectured extensively on the subject of health care reform and health care policy. He can be reached at Dave.Westbrock@daytoncitypaper.com


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