Medical Tribune July 2008 P12-13
David Brill
Feeling their integrity questioned, some doctors are beginning to reject money
from the pharmaceutical industry. David Brill reports.
Professor Kelly Brownell
was once offered US$50,000
to join the advisory board
of a pharmaceutical company. He
turned it down and “feels good
about the decision.”
Brownell, director of the Rudd
Center for Food Policy and Obesity
at Yale, is one of several highprofile
US academics who have decided
to stop taking any payments
from the industry. He gradually
settled on the decision around 10
years ago, having begun to question
the influence that financial
reimbursement was having on his
professional judgment.
“Scientists pride themselves
on objectivity as their
cardinal virtue,
but it’s remarkable how nonobjective
scientists can be when
conflicts of interest are involved,”
he said, citing the literature published
around the subject as the
main factor in his decision.
“The studies suggest that
when industry pays for research
or pays people as consultants they
get something in return. And in
addition, the studies show that
industry-funded science typically
finds results favorable to the industry,”
said Brownell. In his own
experience, he added, he felt “a
natural tendency to want to help
the companies.”
“The money really comes in a
lot of different forms but the two
main ones are funding for one’s research,
and then the other is money
that you get as an individual,” he
explained.
“People become reliant on
these things. For some the money
can be considerable, and it pushes
them up the social and economic
ladder. And for a lot of people
they don’t want to go down a rung
or two.”
Brownell’s move has recently
been followed by two doctors at
Harvard – Peter Libby, the chief of
cardiovascular medicine, and Eric
Winer, the director of the Breast
Oncology Center at the Dana-Farber
Cancer Institute. How many
more doctors in the US will follow
their lead remains to be seen.
Conflicts of interest are presently
a hot topic in the US. A recent
high-profile editorial in the
New England Journal of Medicine
called for greater transparency in
the declaration of funding sources,
concluding that: “The public’s
trust in biomedical research depends
on it.” [N Engl J Med 2008
Apr 24;358(17):1850-1] The murky
nature of the relationships between
doctors and pharmaceutical
companies has also prompted
two senators – Chuck Grassley of
Iowa and Herb Kohl of Wisconsin – to propose new legislation
that would make it mandatory
for pharmaceutical companies to
publicly declare how much money
is given to doctors. The proposal,
known as the Physician Payments
Sunshine Act, has received the
public backing of the Association
of American Medical Colleges,
and was also recently endorsed by
Eli Lily.
In Southeast Asia, doctors are
largely governed by guidelines
and codes of ethics issued by the
various medical associations, and
these issues have yet to reach the
mainstream legal agenda. Dr. Ravindran
Jegasothy, former chairman
of the ethics committee at the
Malaysian Medical Association,
believes nonetheless that it remains
very important to educate
medical professionals about how
to handle their relationships with
the industry. He called the decision
by Brownell, Libby and Winer to
distance themselves financially a
“commendable move” in drawing
attention to some of the issues at
hand.
“It sets people thinking: ‘where
is it that we should draw the line?’”
he said. “My personal view is that
if possible, doctors should not be
sponsored by drug companies. I
feel there is always an ethical dilemma
when a pharmaceutical
company sponsors you.
“Senior people should be role
models in how they conduct their
relationships,” explained Jegasothy,
who is also head of the department
of obstetrics and gynecology
at Hospital Kuala Lumpur.
“I feel that an individual who’s
in a leadership position should as
far as possible diverge himself
from the pharmaceutical industry
… In some cases, in our country
we have had bad examples being
set by senior people taking part in
private excursions or golf tournaments
and so on, which you hear
about being sponsored by pharmaceutical
companies. I think that
does not set a good example for
the juniors.”
Jegasothy would encourage
more doctors take a similar stance
to Brownell. Not everyone, however,
is quite so supportive of the
move.
“I think the action in this case
is a bit extreme, quite frankly,” said
Professor Brian Tomlinson, who is
head of clinical pharmacology at
the Chinese University of Hong
Kong. “I think it’s a sort of noble
idea but in practice it’s not easy for
everyone to do that. If everyone
did it the whole progress of clinical
and medical research would grind
to a halt.
“It just isn’t viable for the majority
of doctors doing clinical
research, especially within Asia.
There isn’t that much funding
readily available and if you want
to do any substantial research it’s
necessary to collaborate with the
industry.”
As both a clinician and an academic
researcher, Tomlinson is
used to dealing with patients while
also liaising with pharmaceutical
companies over the development
of clinical trials. He feels that doctors
should keep a balanced view
and avoid aligning themselves with
any one company more than the
others, but should not be encouraged
to renounce pharmaceutical
money entirely. And if they have
to give up their time to advise, he
says, it is reasonable to expect payment
for it.
In Singapore, the academic
research community is not in the
same sort of quandary as Brownell
and his colleagues, according to
Dr. Thiru Thirumoorthy, a former
director of the Singapore Medical
Association’s Centre for Medical
Ethics and Professionalism. Fewer
phase I and II trials are conducted
in Asia than in the US and Europe
so it’s less of a problem at present,
he said.
Thirumoorthy warned, however,
that conflicts of interest will
inevitably arise as more research
is done in the region. He believes
that ethics committees should be
given greater financial support
and resources in order to monitor
research closely and avoid the situation
where doctors feel the need
to distance themselves from the industry,
as their counterparts in the
US have done.
“The lesson to learn is for us
not to reach this point. If you don’t
moderate, beginning early, and if
we don’t have the infrastructure
then we will end up like this,” he
said.
Brownell has his own suggestions
for limiting the potential for
future conflicts of interest involving
doctors and pharmaceutical
companies.
“The problem is pretty obvious.
If an industry does research
on their own products they have
a strong interest in positive outcomes.
One solution would be for
the industry to take some of the
money they’re spending on these
studies, pool it, and let some objective
outside group commission the
study,” he said.
Acknowledging that it could
be harder for more junior doctors
to say no to pharmaceutical sponsorship,
he added that: “The fact
that young people are vulnerable
to the money because they need it
speaks to the sad state of government
funding for research.”
Brownell agreed with Jegasothy’s
point that senior academics
should act as role models for
younger doctors but, not wishing
to sound as though he was
preaching, was reluctant to directly
encourage others to follow his
example.
“I did it because of my own
principles but if it serves as a model
for others then so be it.”
