Over the past several years, the medical industry and physicians have come under fire. The charge is that industry “buys” the opinions and actions of physicians with their gifts and dollars in order to fatten their bottom lines and their shareholders’ pockets. Indeed, there have been many egregious activities, such as ghostwriting, undisclosed financial relationships, research that is inappropriate or that has been altered or belatedly reported, and unsupported claims of product efficacy. Clearly such behavior deserves shame and blame, but should we be considering other aspects as well?
What would happen if we eliminated all relations between industry and practicing clinicians? There would be no one to give practical advice to industry about clinical needs and no way for clinicians to learn about new developments. I believe we all realize that most of the advances in diagnosis and therapy of disease have occurred with the assistance of the medical industry. Without their commitment to innovation, we would still be treating pneumonia with compresses and examining internal organs with stethoscopes and percussion. Surely we don’t want that, so now we are talking about the boundaries governing a desirable relationship. That has created and will continue to create debate for years to come. Where should the line be drawn? Can it be drawn precisely for every situation? Can we codify the proper form of all industry-physician relationships? I suspect not.
Ultimately, in my view, we will have to depend on integrity. There is an interesting discussion of integrity at Wikipedia en.wikipedia.org/wiki/Integrity that is useful to review. There it is defined as “the basing of one’s actions on an internally consistent framework of principles.” Honesty is mentioned frequently.
Integrity is a bit like pornography; we know it when we see it. But unlike pornography, impaired integrity can be disguised more easily and, of course, that is the danger and the reason that some rules are necessary. But ultimately, we recognize integrity because it is practiced over time. As a result, the practitioner of integrity becomes trusted. Trust is hard to gain and easy to lose, but having integrity and living with it provides a shield that protects trust.
How does integrity relate to physician-industry relationships, which are perceived by some as undermining the trust that is the mainstay of the doctor-patient relationship? They argue that any financial relationship is, per se, a conflict of interest and a potential source of bias. That would suggest that they feel such a relationship cannot be handled with integrity. Can the physician who is a consultant to industry not treat his patients fairly and honestly? Is an unrestricted grant to a medical school or society automatically tainted? Is every teacher who investigates a new drug automatically dishonest? Can no one be trusted to do their best to deliver education with integrity?
We know that medical advances can’t happen without effective interaction between physicians and industry, and we know that money will change hands in the process. Thus the current debate about commercial bias is important. And hopefully it will lead to a renewed belief in and understanding of integrity.
As we continue the debate, I hope we will do so in a cooperative spirit—with integrity—and recognize that dollars alone do not destroy it.