Relations between drug companies and doctors need clearer boundaries

It is easy to understand why relationships between doctors and the pharmaceutical industry arouse alarm (see The Age investigation published last Saturday). The primary role of doctors is to care for sick and vulnerable members of the community, in return for which they receive significant social and material privileges. Pharmaceutical companies are among the largest and most powerful organisations in the world and their primary interest is to reap profits for their shareholders, which they do on a huge scale.

There are concerns that liaisons between doctors and drug companies will corrupt the primary purpose of medicine and squander the resources of the community, advancing the commercial objectives of industry and the acquisitive interests of clinicians in preference to legitimate care, education and research goals.

These concerns are well founded. The practice of medicine in the community is critically susceptible to influence by some of the core activities of drug companies.

For example, promotion and marketing, which make up a large part of these activities - totalling more than $A15 billion each year - have a profound impact on medical decision-making. While doctors generally deny that they are influenced by pharmaceutical advertising, there is overwhelming evidence from published studies that contact with drug company representatives leads to increased prescribing of drugs, acceptance of commercial rather than scientific views and a propensity to engage in non-rational prescribing behaviour.

Gift-giving is another widely used and pernicious device, with gifts ranging from trivial promotional items to business-class air tickets. As with advertising, the evidence that gift giving influences behaviour is clear: for example, an American study showed that doctors who meet pharmaceutical representatives are 13 times more likely, and those who accept money to speak at symposiums 21 times more likely, to recommend use of their products.

It is important that the community is able to have confidence in the independence of medical practitioners and researchers.

Sponsorship of meetings, on which many professional societies have come to depend, provides the pharmaceutical industry with unparalleled opportunities to show their wares. As in the other examples, sponsorship of conferences has been shown to lead to bias in favour of a company's drugs, with increases in prescriptions being seen for at least six months after an event.

Drug company sponsorship of research and publications is of particular concern. There are many ways in which research findings can be directed towards producing a desired result, ranging from careful design of a trial and selection of drug doses to selective reporting of results or actual suppression of unfavourable outcomes. Delays in the publication of unfavourable results are common, and it is speculated that the results of many clinical trials are never published at all.

These facts have been known and have caused concern within the medical profession for many years. However, the importance of maintaining a balanced perspective has also been recognised.

While it is true that, as in other industries, drug companies will do whatever they can to maximise profits, it should not be forgotten that they also do much that is good, such as providing medications that save lives and alleviate suffering, and contributing massively to medical research. Constructive co-operation between the two sides can produce clear benefits for the community, including the stimulation of research, development of new treatments and broad dissemination of new knowledge and techniques.

To make possible a critical, healthy dialogue with the pharmaceutical industry and to manage conflicts of interests emerging from this relationship, several medical professional bodies have engaged in extensive discussion and public consultation over the past few years, leading to guidelines for the conduct of doctors that are increasingly influencing both clinical practice and research.

Those of the Royal Australasian College of Physicians provide a notable example. These emphasise four central principles: that arrangements between physicians and pharmaceutical companies should be open and transparent; that potential conflicts should be clarified and clearly declared; that whether conflicts actually exist should be decided not by the individuals concerned but by the communities potentially affected; and that where conflicts are likely special steps should be taken to avoid unacceptable outcomes.

Specific measures are recommended to ensure that interactions between doctors and drug companies are consistent with the public interest. Gifts should be accepted only if decision-making is left manifestly unimpaired. Support for travel to conferences organised by professional societies should be restricted to people making formal contributions. Entertainment expenses should not be lavish. Access of representatives to students and health services should be limited. Sponsorship of meetings should be provided only through independently organised scientific committees and speakers should indicate dualities of interest at the time of presentation. Sources of commercial funding should not influence the scientific, educational or public policy decisions of professional bodies, which should not associate themselves directly or indirectly with promotion of products of commercial sponsors.

Additional steps should be taken to minimise biases in research and publication, which require action not only by individual practitioners but also by the industry, government and academia.

It is important that the community is able to have confidence in the independence of medical practitioners and researchers. To guarantee this, significant changes are needed, which will entail a substantial cultural shift and no doubt take some time to realise fully.

The process will not be without pain. However, the outcome will, it is hoped, offer the best of both possible worlds: a rigorous, independent and critical profession in partnership with a productive, creative industry serving the needs of the community.