JUST HOW TAINTED HAS MEDICINE BECOME?
Chief executives of multinational pharmaceutical companies have much to
celebrate this week. They saw spending on prescription
drugs in the USA soar by a remarkable 17% in 2001, according to figures
recently released by the National Institute for Health
Care Management Foundation. As bonuses for corporate leaders ratchet
upwards, so does the unalleviated financial
pressure on the elderly, the largest users of these drugs.
Direct-to-consumer advertising campaigns for cholesterol-lowering
agents, anti-ulcer medications, anti-arthritics, and
antidepressants have been strikingly successful. Total retail spending
on prescription drugs was US$155 billion in 2001, almost
double what it was in 1997.
The escalating influence of big pharma in medicine persuaded editors of
medical journals to come together last year and agree
strict rules on reporting sponsorship and conflicts of interest (see
Lancet 2001; 358:854-56).
While this consensus sets the highest
standards yet for disclosing
commercial influences in medical research, there are signs that it does
not go far enough--or, at the very least, that this guidance is
not being fully heeded.
A study of the interactions between authors of clinical practice
guidelines and the pharmaceutical industry, published in JAMA in
February, found serious omissions in declarations of conflicts of
Almost 90% of authors received research funding from or
acted as consultants for a drug
company. Over half had connections with companies whose drugs were being
reviewed in the guideline, and the same proportion
indicated that there was no formal procedure for reporting these
interactions. The guidelines studied covered all fields where
prescription drug use has seen the greatest increases.
An especially corrosive example of such a commercial influence,
involving one of the most respected US specialist societies--the
American Heart Association--was described in the BMJ last month.
AHA sensible to accept US$11 million in donations
from Genentech while at the same time producing guidelines about
thrombolytics in stroke? Genentech is the US
producer of one such thrombolytic, which was recommended for use in the
AHA 2000 guidance on stroke management.
Prestigious institutions are also not averse from mixing research with
commercial gain from industry partnerships. The Seattle
Times has conducted one of the most thorough investigations of how such
relations threaten to poison patient care.
In a series of
articles published last year, staff reporters Duff Wilson and David
Heath claimed to reveal how investigators at the Fred
Hutchinson Cancer Research Center completed experiments with
biotechnology products in which they had a direct financial
The journalists allege that doctors did not tell patients that
others had died using these products and that there were safer
alternatives available. The
Center denies these allegations but admits that it "could have handled
better" perceptions of conflict of interest.
These concerns extend to journal editors, especially those who edit
part-time while continuing to work in clinical practice and
research. The rules issued by the International Committee of Medical
Journal Editors state that, "Editors who make final decisions
about manuscripts must have no personal, professional, or financial
involvement in any of the issues they might judge".
However, the editor of the British Journal of Psychiatry was recently
questioned about his membership of a drug-company
sponsored "educational organisation", for which he received £2000
annually, together with his decision to publish a paper favouring
a drug manufactured by the same company. Only after receiving the letter
questioning his behaviour did the editor change his
journal's procedure, excluding himself from decisions about work
sponsored by that same company.
He avoided the issue about
whether he should have any commercial liaisons while acting as editor of
a supposedly independent medical journal.
The Lancet's policy is that editors should divest themselves of all such
links upon assuming their new duties.
To return to our first question: how tainted by commercial conflicts has
Heavily, and damagingly so, is the
answer. A more important question arises: do those doctors who support
this culture for the best of intentions—e.g., to undertake
important research that would otherwise remain unfunded--have the
courage to oppose practices that bring the whole of
medicine into disrepute?
Volume 359, Number 9313 06 April 2002
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