The Australian Medical Council draft code of professional conduct: good practice or creeping authoritarianism? In reply

IN REPLY: The debate about the proposed national code of conduct (“the Code”) has raised a number of important issues, including those highlighted by Myers. The original draft aroused serious concern in the community about the potential role of a centralised bureaucracy with the power to enforce a set of precepts derived from a narrow, largely discredited, philosophical perspective. Although the revised draft now circulated for public comment is admittedly less objectionable than its predecessor, significant concerns remain relating to both its form and its conten

Ebola, Ethics, and the Question of Culture (Editorial)

The Ebola virus disease (EVD) epidemic in Western Africa has, in recent months, aroused growing alarm in Western countries. Attention has been drawn to the threat posed to the inhabitants of the region by what has undoubtedly become a major health emergency. As the death toll has mounted, increasingly strident calls for action have been voiced by nongovernmental organizations (NGOs) and international agencies active in the area, such as Médecins Sans Frontières and the World Health Organization and, more recently, even by the U.S. president

It is time to move beyond a culture of unexamined assumptions, recrimination, and blame to one of systematic analysis and ethical dialogue

Conflicts of interest are a big topic in medicine today. There is a proliferation of articles, guidelines, and rules providing advice about how to address what is widely regarded as a rampant problem (Zinner et al. 2010; Rockey et al. 2010; Licurse et al. 2010). Despite the large quantity of materials, however, the quality of thinking and analysis is generally very poor. In part, this is because the whole field is dominated by a few basic assumptions that are simply incorrect. The article by Brody (2011) exemplifies this literature and these errors. In this commentary we draw attention to these mistaken assumptions and present a more rigorous and, we believe, more effective approach to the identification and management of conflicts of interests. What are the mistaken assumptions? Starting from the rather perplexing assertion that “medicine is a social role,” Brody asserts that a conflict of interest entails a physician “unnecessarily” entering into “a set of social arrangements” that are “morally blameworthy,” in that they carry the risk of “tempting” him or her away from “patient-centred duties,” or “patient advocacy,” in favour of a personal (or third party’s) interest, and thereby threatening public trust (Brody 2011). Each of these assumptions is wrong: The circumstances under which conflicts of interests occur may or may not be avoidable; they need not be blameworthy; they may have nothing to do with “patient-centeredness,” advocacy, or any other specific value; they need not assume any particular moral hierarchy; and they may have nothing to do with public trust

Ebola, Ethics, and the Question of Culture (Editorial)

editorialThe Ebola virus disease (EVD) epidemic in Western Africa has, in recent months, aroused growing alarm in Western countries. Attention has been drawn to the threat posed to the inhabitants of the region by what has undoubtedly become a major health emergency. As the death toll has mounted, increasingly strident calls for action have been voiced by nongovernmental organizations (NGOs) and international agencies active in the area, such as Médecins Sans Frontières and the World Health Organization and, more recently, even by the U.S. president

The Australian Medical Council draft code of professional conduct: good practice or creeping authoritarianism? In reply

IN REPLY: The debate about the proposed national code of conduct (“the Code”) has raised a number of important issues, including those highlighted by Myers. The original draft aroused serious concern in the community about the potential role of a centralised bureaucracy with the power to enforce a set of precepts derived from a narrow, largely discredited, philosophical perspective. Although the revised draft now circulated for public comment is admittedly less objectionable than its predecessor, significant concerns remain relating to both its form and its conten

Have we reached the limit of effectiveness of self-regulation and codes of ethics?

Over the past decade, both the health-care professions and the pharmaceutical industry have revised the codes governing their interaction. These adjustments were responses to changing public standards and to data demonstrating the adverse impact of such interactions on prescribing behaviour and on health spending. Now the relationships between health professions and industry are more tightly regulated than ever before. They’re characterised by a commitment to transparency and to processes that avoid conflicts of interest – more than at any time in the past. Perhaps the two most significant sets of guidelines governing interaction between doctors and the pharmaceutical industry - the Royal Australasian College of Physician’s “Guidelines for relationships between physicians and industry” and the “Code of Conduct” of Medicines Australia (the peak industry group for the pharmaceutical industry) – are currently under review. It’s clear that each body will likely introduce incremental changes to the way relationships are managed in the health sector. Sadly, incremental variations achieve little and what we need is fundamental change to the ways in which medicine and medical professionals interact with industry. And despite the progress to date, promotional activities continue, often under the guise of education. Marketing data remain generally aggregated, obscuring the identities of the beneficiaries of industry support.NHMR

Don't show me the money: the dangers of non-financial conflicts

The popular media frequently feature stories about surgeons profiting from installation of devices made by companies they hold shares in; professional bodies receiving sponsorship from industry; conference speakers whose travel has been paid for by the makers of products they’re commenting on; and GPs using software displaying drug company logos. This concern about conflicts of interest (a situation that exists where two or more interests are contradictory and compel incompatible outcomes) is undoubtedly well founded, as a large volume of research shows that financial links between individuals and industry do, in fact, influence decision-making. And now virtually every institution in the country has a process for addressing the issue and governments, peak bodies and professional bodies all, to a greater or lesser extent, require disclosure of financial interests in settings where a conflict of interest (CoI) may arise. But for all the attention the subject has attracted, the response has been curiously limited and partial. This reveals a major blind spot in the understanding of both interests and the conflicts they produce. The discussion has focused almost exclusively on pecuniary, or financial, interests. But these may play a relatively minor role in medicine. Most doctors or researchers don’t do what they do primarily to increase their material wealth. If making money was their primary goal, they could choose more effective ways of doing so

The Walking Wounded calls for a rethink of what we most value

Starting with Karl Marx, many thinkers have pointed out that the creative potential of the capitalist economic system comes at a cost – the lack of inherent ethical scruples to limit the inexorable logic of profit and growth. ABC TV’s Four Corners' exposé of the scandal about a defective medical hip replacement device known as “ASR” is a case in point. The Walking Wounded examines the case of a surgical treatment widely used to treat painful arthritic conditions, mainly in elderly people. Designed, manufactured and marketed by DePuy (a subsidiary of Johnson & Johnson, the world’s largest medical device company), nearly 100,000 people received the implants over a six-year period. More than 5,000 of them were from Australia. Originally launched in 2003, defects were soon apparent to many of the surgeons using the device. Some called for its withdrawal. But sales continued until 2009, and it was not until a year later that the company announced a worldwide recall. Legal actions In Australia, a class action has been launched on behalf of hundreds of patients whose implants failed. It follows a US case fought and won by Bill Kransky, who was awarded $US8 million from the company for damages he suffered as a result of the defective device..

The epistemology and ethics of journal reviewing: a second look.

The concept of “peer review” is widely regarded as fundamental to ensuring quality, integrity and rigour in all facets of academic and professional life, including career advancement, academic publication and the award of research grants, scholarships and fellowships. However, there is often little reflection on just what peer review is, what it is really meant to achieve and what its limitations may be. The issue of reviewing is an important one for any academic journal not just because it is central to the production process but also because it raises deep epistemological and ethical concerns. Reviewers and editors have the power both to influence the academic progression of authors [1] and to give status to selected information, thus, determining the direction of the research endeavour and the course, quality and reputation of scientific and intellectual practices [2]. An ethics journal such as the JBI should be especially sensitive to the ethical aspects of its own operations and policies. Following a long process of reflection on the issues raised by reviewing practices, the JBI has established comprehensive editorial policies regarding the review of manuscripts submitted to the journal [3]. In the course of our analysis, we sought to clarify: the goals and purposes of reviews and the possible ways in which they may be undermined or compromised; the available evidence regarding the quality and reliability of reviewing for academic journals; the evidence regarding the misuse of the reviewing process; and strategies for preventing abuses of power, such as declarations of dualities of interests and un-blinding of articles and reviews