It is in doctors’ and the drug industry’s best interests that their interactions be openly declared. There is no such thing as a free lunch. Pharmaceutical companies lavish meals, five-star travel, cash and gifts on doctors for one reason: to encourage them to prescribe their drugs. The standard retort from the medical profession is that doctors have sufficient clinical objectivity — and personal integrity — not to be so crudely swayed. Perhaps s

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EDITORIALSDoctors behaving badly?Martin H N Tattersall and Ian H KerridgeThe Medical Journal of Aus-tralia ISSN: 0025-729X 18 Sep-tember 2006 185 6 299-300©The Medical Journal of Australia 2006www.mja.com.auEditorialshe interaction between doctors and the pindustry was recently catapulted into the puba piece of inv stigative journalism published iian, detailing the wining and dining of doctors by thtical giant, Roche, at an educational meeting in Ssurprised many observers was not the revelations TIt is in doctors’ and the drug industry’s best interests that their interactions be openly declaredThere is no such thing as a free lunch. Pharmaceutical compa-nies lavish meals, five-star travel, cash and gifts on doctors forone reason: to encourage them to prescribe their drugs. Thestandard retort from the medical profession is that doctors havesufficient clinical objectivity — and personal integrity — not tobe so crudely swayed. Perhaps so.1harmaceuticallic domain byn The Austral-e pharmaceu-ydney.2 Whatregarding theextent of hospitality provided by pharmaceutical companies todoctors, but the response of the Australian Medical Association(AMA). The AMA’s public stance was that pharmaceutical industrysponsorship of accommodation and restaurant meals is perfectlyacceptable, that drug company sponsorship serves to “oil thewheels” of medical education, and that industry-sponsored eventsprovide valuable opportunities for doctors “to critically questionthe companies’ products” and that “no patient harm comes fromthis practice”.2 A review of the literature, however, suggests thatthis is not true.3,4The Australian Competition and Consumer Commission(ACCC) had a differing view. Following the recent release of theACCC’s revised guidelines for disclosure of industry support, theChairman of the ACCC noted that “Consumers should be able tohave confidence that decisions made by their doctors are madesolely having regard to their best interest without any potential forinfluence by benefits or perks”.5 Stated in these terms, the issue isnot so much the pharmaceutical industry itself, but the preven-tion, assessment and management of conflict of interest and, morefundamentally, the importance of public trust in doctors.The moral core of medicine and the therapeutic relationship hasalways been expressed in terms of the possession and expression ofvalues such as honesty, integrity, benevolence, respect, compassion,courage and trustworthiness. Trust, which in relation to health caremay denote faith, commitment, respect, belief and confidence, hasbeen the focus of extensive academic exploration by a broad rangeof writers.6-10 All have pointed to the centrality of trust intherapeutic relationships, the “non-legal” expression of trust, thespecific and contextual nature of trust and the manner in whichtrust can be threatened, diminished or destroyed by actions orbehaviour including professional incompetence, abuses of power,boundary violations, experience of harm or the lack of care orrespect, deception and manifest conflicts of interest.11 Of those thingsthat may damage trust in doctors, much of the attention in recentyears has been on recognising and managing conflict of interest.What then constitutes a conflict of interest and how may weavoid it occurring?Although medical codes of ethics and statements of medicalprofessionalism often give the impression that doctors have asingle higher duty to care for the sick, in reality, the relationshipsthat doctors have with their patients are determined by multipleinterests, many of which may influence care or decision making.Doctors may hold patient care as their highest professional ideal,but they may also be concerned with community welfare, partici-pation in research, career advancement, student teaching, contin-ued employment, public or professional recognition, and theobligations they have to their care for themselves and theirfamilies. While it is inevitable that doctors will have multipleinterests, true conflicts of interest (a set of conditions in whichprofessional judgement concerning a primary interest, such as apatient’s welfare, is unduly influenced by a secondary interest,such as financial gain) are neither inevitable nor common.12 Butdistinguishing where there are no conflicts between these interestsfrom where there is a genuine conflict of interest is sometimesdifficult, as any assessment of behaviour must take into accountthe ethical standards of the profession, the nature of the relation-ship in question, and the values of the community within which itoccurs. What makes this assessment even more difficult is thatstandards of doctors’ behaviour may change as a consequence ofdeeper sociocultural changes, and according to changes in profes-sional interests, and changes in public or patient needs andexpectations. This means that the only way to establish that aconflict of interest exists is to have all the relevant facts availablefor scrutiny by the participants in the relationship, and by thecommunity or an independent third party. This is only possible ifthere is a genuine commitment to disclosure and transparency inall areas of medical practice.Unfortunately, a review of the history of medicine suggests thatthe medical profession has, until recently, generally been reluctantto be exposed to public scrutiny, either out of fear of legal or socialrepercussions that may result from such disclosure, or on thegrounds that that there is no need for it or no public desire for it.Although such concerns may be understandable, for the most partthey are unfounded. Transparency and honest disclosure mayactually reduce loss of trust, formal and informal complaints andlitigation, and it is the culture of secrecy and sense of moralsuperiority that sometimes runs through the health professions,rather than “unnecessary” exposure to a disinterested public, thatthreatens public trust and undermines the doctor–patient orresearcher–patient relationship. In this regard, it is of note that arecent randomised trial in the United States of disclosing doctors’financial incentives to patients found that patients’ trust in theirdoctors was unharmed, and their loyalty to their doctor’s practicewas strengthened.13Therefore, it is hard to disagree with the ACCC that there is meritin increasing the degree to which the relationships between doctorsand the pharmaceutical industry are transparent. It may, as hasbeen claimed, ultimately prove to be the case that these relation-ships do not give rise to conflicts of interest and that the ACCC’snew reporting requirements are excessive or unreasonable, but atthis stage we do not know that this is true, and we have ampleevidence that interaction with industry can create complex andMJA • Volume 185 Number 6 • 18 September 2006 299EDITORIALSdependent relationships and influence decision making, prescrib-ing, formulary requests, attitudes and knowledge regarding phar-maceuticals and therapeutics, and the design and interpretation ofresearch.14 In light of this, it is in doctors’ and the industry’s bestinterests that their interactions be openly declared in the relevantcontext. This will enable informed public and professional consid-eration of the legitimacy of each group’s interest and determinationof whether a conflict of interest exists and what measures should betaken to deal with it.There are many means for encouraging transparency, respon-sibility and accountability in health care, including the incorp-oration of ethics in medical education; support for inquiries intoprofessionalism and trust; introduction of templates for disclo-sure of secondary interests in the research and clinical setting;15development and compliance with codes of ethics by the majormedical colleges and industry groups; incorporation of patients’representatives and conflict of interest committees into hospi-tals; and establishment of health care complaints commissionsby government. All are deserving of support, even thoughcurrently there are insufficient data to evaluate the effect of mostsuch interventions.Given what we know about the fragility of trust in medicineand the interaction between doctors and the pharmaceuticalindustry, the profession should support moves to increase disclo-sure. Even though disclosure may not, in itself, reduce thefrequency of unethical behaviour or relationships, and may haveno effect on public awareness, it is impossible to adequatelyidentify, manage or prevent conflicts of interest if doctors, thepeak bodies that represent them, and the industry groups withwhich they deal are not completely open about their interactions.Claims that the medical profession is not subject to influence,that the possibility of conflicts of interest arising in relationshipsbetween doctors and the pharmaceutical industry does not exist,and that disclosure requirements will lead to the collapse ofcontinuing medical education are naïve, unfounded, inappropri-ate, and counterproductive.Doctors occupy a unique position of trust in society. Theyshould act solely in the best interests of the patient — as manydo. But drug companies spend billions of dollars on promotionsbecause they work. The medical profession cannot have it bothways. If doctors want to be seen to be beyond influence, theremedy is simple. Be willing to say thanks, but no.1Competing interestsNone identified.Author detailsMartin H N Tattersall, FRCP, FRACP, MB BChir, Professor1Ian H Kerridge, FRACP, FRCPA, MPhil, Associate Professor of Bioethics and Director21 Department of Cancer Medicine, University of Sydney, Sydney, NSW.2 Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, NSW.Correspondence: kerridge@med.usyd.edu.auReferences1 Stop the gravy train [editorial]. Sydney Morning Herald 2006; 7 Aug: 8.2 Moynihan R. The sugar-coated pill. The Australian 2006; 25 July: 10.3 Wanzana A. Physicians and the pharmaceutical industry: is a gift ever justa gift? JAMA 2000; 283: 373-380.4 Kassirer JP. On the take. How medicine’s complicity with big business canendanger your health. Oxford: Oxford University Press, 2005.5 Moynihan R. Doctor treats to be disclosed. The Australian 2006; 26 Jul.6 Rogers C. The necessary and sufficient conditions of therapeutic person-ality change. J Consult Psychol 1957; 21: 95-103.7 Giddens A. The consequences of modernity. Cambridge: Polity Press,1990.8 Baier A. Trust and antitrust. In: Moral prejudices: essays on ethics.Cambridge, Mass: Harvard University Press, 1955.9 O’Neill O. Autonomy and trust in bioethics. Cambridge: CambridgeUniversity Press, 2002.10 Little JM. Community, security and human flourishing: an exploratoryessay. Sydney: Centre for Values, Ethics and the Law in Medicine, 2004.11 Gilson L. Trust and the development of health care as a social institution.Soc Sci Med 2003; 56: 1453-1468.12 Thompson D. Understanding financial conflicts of interest. N Engl J Med1993; 329: 573-576.13 Pearson SD, Kleinman K, Rusinak D, Levinson W. A trial of disclosingphysicians’ financial incentives to patients. Arch Intern Med 2006; 166:623-628.14 Breen KJ. The medical profession and the pharmaceutical industry: whenwill we open our eyes? Med J Aust 2004; 180: 409-410. 15 Tattersall M, Kerridge I. The drug industry and medical professionalism.Lancet 2006; 367: 28. ❏300 MJA • Volume 185 Number 6 • 18 September 2006

Doctors behaving badly?

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