This is the fifth in a six-part series on general practice ethics. Cases from practice are used to trigger reflection on common ethical issues where the best course of action may not be immediately apparent. The case presented in the article is an illustrative compilation and not based on specific individuals.
Dr Jana is a general practitioner (GP) in a practice where pharmaceutical company representatives are generally welcomed. However, Dr Jana has decided to have no contact with the representatives, receive no drug samples, and nor does she attend lunches offered by the companies. One of the partners at the practice, Dr Smith, is retiring. A dinner has been arranged at an expensive restaurant, where staff will celebrate Dr Smith’s retirement and listen to a lecture on a new drug to manage type 2 diabetes. The event will be fully funded by the pharmaceutical company that produces the new diabetes drug. What should Dr Jana do?
What ethical issues are at stake?
Unlike previous cases in this series, the issue here may seem to be one of etiquette rather than ethics: should Dr Jana risk offending her retiring partner and other staff by refusing to attend the dinner because it is sponsored by a pharmaceutical company? However, relations between doctors and the pharmaceutical industry can create conflicts of interest, potentially leading to commercial influences on patient care.
What is a conflict of interest?
Conflicts of interest in general practice occur when a GP’s primary interest (in this case, to provide high-quality patient care) is potentially affected by a secondary interest. GPs have many role-related and personal interests, including teaching students, undertaking research, financial gain, personal prestige, public recognition, maintaining professional and friendship bonds, and family responsibilities. All of these interests may influence a GP’s capacity and judgement in carrying out their primary role-related duty of providing care that is in patients’ best interests. Many of these interests are legitimate and unavoidable in general practice, requiring skills on the part of GPs to juggle competing demands. It is not so clear, however, that GPs have a legitimate interest in receiving gifts or hospitality from the pharmaceutical industry, especially as these interactions have the potential to bias clinical judgement.
Impact of pharmaceutical industry relationships
The practice of receiving gifts, including hospitality, from pharmaceutical companies is common.1 These actions may be considered innocuous by many GPs. Indeed, doctors are often offended by the suggestion that their practice is influenced by gifts, and fail to see the conflict created by receiving hospitality or apparently trivial items from the pharmaceutical industry. There is a strong view that scientific training and medical professionalism protect against any bias towards companies providing these items,2 and that succumbing to bias or influence is due to lack of personal integrity. However, evidence suggests that this view is wrong. Pharmaceutical industry interactions, such as providing gifts and meals, create a conflict of interest that influences practice,3 while psychological research has shown that bias caused by conflicts of interest is both unconscious and unintentional.2,4
Patients have a strong interest in receiving unbiased care that is evidence-based and tailored to their individual circumstances. Just how much patients know and understand about pharmaceutical industry-related conflicts of interest is unclear. One study found that patients have a spectrum of attitudes towards information given to physicians by pharmaceutical companies.5
Irrespective of patients’ attitudes, most interactions between physicians and pharmaceutical representatives are not transparent. Patients usually do not know which pharmaceutical company representatives their doctor is meeting, which drugs are discussed, the content of sponsored lectures, or what other ties their doctor may have with the pharmaceutical industry. This lack of transparency limits patients’ capacities to make autonomous decisions, because to be well informed, patients require information about factors that may bias their doctors’ decisions. If Dr Jana attends a meal tied to a lecture about a particular drug that will influence her prescribing, then this is relevant information for her patients who are subsequently offered treatment with that drug.
GPs’ obligations and interests
Dr Jana’s primary interest arises from her obligation to act in the best interests of her patients. Meeting this interest requires Dr Jana to stay up to date with new, potentially beneficial treatments. What is the best way for her to do this? Enjoying a good meal while receiving information about new drugs may seem to be a win–win situation, but there is considerable concern about the pharmaceutical industry’s funding of continuing medical education.6 For example:
- pharmaceutical industry representatives often omit relevant information about safety and adverse effects when they present drugs to physicians7
- pharmaceutical companies have been charged with using continuing medical education to promote off-label use of medications8
- key opinion leaders may be used to promote company products at events badged as educational.9
In addition to direct influences on Dr Jana’s decision-making, information provided by pharmaceutical companies can influence the care she provides in more subtle ways. The commercial focus on new drugs leads to a relative neglect of education about relevant but unprofitable areas of practice such as older drugs, diagnostic issues, non-drug treatments, overtreatment and overdiagnosis. New drugs are usually more expensive, and this has implications for public spending on healthcare and may increase costs to individual patients. Attending information sessions provided by pharmaceutical companies use up GPs’ time and cognitive resources that could otherwise be used for unbiased educational activities.
Dr Jana’s position on receiving gifts from the pharmaceutical industry is clear, but her retiring colleague does not share it. Dr Smith has an uncritical attitude towards pharmaceutical companies. He feels that a dinner is a respectful and enjoyable way to say goodbye to the practice and values the sponsorship that will make it possible for all his colleagues to attend.
Possible actions and their consequences
If Dr Jana decides not to attend the dinner, she may try to explain her position to Dr Smith. However, despite her explanation, Dr Smith may interpret her behaviour as disrespectful. Alternatively, Dr Jana may decide to arrive after the lecture, but this seems disingenuous. If Dr Jana attends the dinner, there are some options for her to minimise the impact of the lecture on her practice. She could pay for the dinner herself, thus avoiding any gift from and sense of obligation to the pharmaceutical company. Any materials she receives should be balanced by independent information. Dr Jana may consider noting the claims made in the sponsored presentation and performing her own independent research to assess the strength and validity of these.
In the longer term, Dr Jana may wish to engage with the growing research on the effects of conflicts of interest created by pharmaceutical industry relationships in medicine, and raise these issues at practice meetings. If she is in a teaching practice, she may consider investigating the medical school’s policy on relationships with the pharmaceutical industry.
It can be very hard for a single GP to avoid all pharmaceutical industry interactions when they are surrounded by other GPs, managers and healthcare organisations that have ties with pharmaceutical companies. However, the duty to act in the patients’ best interests requires GPs to understand:
- that accepting gifts and hospitality creates a conflict of interest
- the kinds of bias that conflicts of interest create
- the detrimental impact of unconscious bias on the cost and quality of patient care.
GPs’ educational activities should be driven by patients’ needs rather than a commercial agenda. If a pharmaceutical company provides information to GPs, a skeptical stance along with independent research may help to reduce biases and ensure that actions are made in the best interests of patients. The wider challenge of managing relationships between the pharmaceutical industry and medicine requires action at multiple levels, including regulatory, but individual GPs are also well placed to address these issues.10,11 At the very least, they have a duty to educate themselves in ways that will best help their patients.
Yishai Mintzker MD, Clinical Instructor, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Annette Braunack-Mayer BMedSci (Hons), PhD, Head, School of Public Health, University of Adelaide, Adelaide, SA
Wendy Rogers BMBS, BA (Hons), PhD, MRCGP, FRACGP, Professor of Clinical Ethics, and ARC Future Fellow, Department of Philosophy and Department of Clinical Medicine, Macquarie University, Sydney, NSW. firstname.lastname@example.org
Competing interests: None
Provenance and peer review: Commissioned, externally peer reviewed.
- Campbell EG, Gruen RL, Mountford J, Miller LG, Cleary PD, Blumenthal D. A national survey of physician–industry relationships. N Engl J Med 2007;356:1742–50.
- Cain DM, Detsky AS. Everyone’s a little bit biased (even physicians). JAMA 2008;299:2893–95.
- Spurling GK, Mansfield PR, Montgomery BD, et al. Information from pharmaceutical companies and the quality, quantity, and cost of physicians’ prescribing: A systematic review. PLoS Med 2010;7:e1000352.
- Thagard P. The moral psychology of conflicts of interest: Insights from affective neuroscience. J Appl Philos 2007;24:367–80.
- Holbrook A, Lexchin J, Pullenayegum E, et al. What do Canadians think about physician–pharmaceutical industry interactions? Health Policy 2013;112:255–63.
- Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: IoM, 2009. Available at http://iom.nationalacademies.org/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx [Accessed 15 July 2015].
- Othman N, Vitry AI, Roughead EE, Ismail SB, Omar K. Medicines information provided by pharmaceutical representatives: A comparative study in Australia and Malaysia. BMC Public Health 2010;10:743.
- O’Connell C. Pressure mounts to strip industry funding from continuing medical education programs. CMAJ 2010;182:E775–76.
- Moynihan R. Key opinion leaders: Independent experts or drug representatives in disguise? BMJ 2008;336:1402–03.
- Coopes A. Australian campaign aims to stop visits from drug representatives. BMJ 2014;349:g6183.
- No Advertising Please. Melbourne: No Advertising Please, 2014. Available at http://noadvertisingplease.org/evidence [Accessed 22 July 2015].