Our prime focus as physicians is our patients’ health and welfare. It is most important that physicians avoid putting their personal interests—or the interests of pharmaceutical companies—before those of patients. Physicians can achieve this goal by establishing good principles with the help of ethics guidelines. Physicians should lead an ethical relationship with the pharmaceutical industry and accept responsibility to delineate standards of our ethical behavior. When doubts exist, the Ethics Committee of the Canadian Medical Association can provide advice and help address controversial issues.
By using our patients' best interests as our guiding beacon, we can avoid many of the ethical dangers inherent in the physician-pharmaceutical company relationship. Here are a number of guidelines to help you remain on solid ground.
The relationship between physicians and the pharmaceutical industry is a difficult one. There is ambiguity from both the point of the physician and the industry, and interpretation of the guidelines in the CMA’s Code of Ethics is sometimes controversial. While physicians have responsibilities to both their patients and their profession, the primary duty is to ensure the health of patients and society. The pharmaceutical industry exists to help us achieve that goal.
It is of paramount importance that physicians avoid putting their personal interests, or the interests of a pharmaceutical company, before the interests of their patients by, for example, prescribing a particular drug to a patient and receiving some benefit—financial or otherwise—from the pharmaceutical company that manufactures it. It is unacceptable to receive material or financial gain for prescribing a specific drug.
Physicians would be wise to consult with colleagues, licensing authorities, ethicists, or various ethical committees who have expertise in this field to obtain the necessary advice before making decisions on difficult issues.
At a conference or meeting, physicians should always disclose the nature of their relationship with the industry to both the organizers and the audience attending the event.
In continuing medical education events, the organizing physicians should ensure that the curriculum reflects the educational needs of the audience, not the profit of the pharmaceutical company or the presenting physicians. This potential conflict of interest—both of presenters and sponsors—must be disclosed and printed on the program. Preferably the physicians organizing the event should be encouraged to form an educational grant payable to the institution or the organization sponsoring the CME activity so that these funds can be directed toward the educational needs of physicians attending the event. Scientific activities should be distinct from any promotional events for the industry. Whenever possible, generic names should be used rather than trade names.
There should be no “peer selling” when the pharmaceutical manufacturer is sponsoring a seminar. For example, a physician conducting a seminar organized by a drug company must not encourage his or her colleagues to use or purchase only the product or device being exhibited or presented. Preferably, educational events should be in the hands of a CME organizer so that the presentations do not constitute an endorsement of a product.
Physicians attending CME activities sponsored by a pharmaceutical company should not accept payment for travel, accommodation, or social events. However, it is not a conflict of interest for physicians making presentations at an event to accept a reasonable honorarium and reimbursement for travel, lodging, and meals.
In universities and institutions where research is conducted, an ethics board is usually involved in remuneration issues. Physicians are justified in accepting remuneration for participation in approved pharmaceutical trials because they are putting in more hours than their normal practice pattern. The patients involved in these trials should be fully informed and participate in the project voluntarily and with consent. Physicians participating in drug trials should not invest in the pharmaceutical company if there is knowledge that the company’s success depends on the prescribing behavior of the physician.
Physicians involved in drug trials should not accept a fee for participating in a presentation or a promotional event arranged by a pharmaceutical company. It is permissible to accept teaching aids, some products, samples of drugs, baby formula, and so on, for trials.
Newer technologies, such as the use of endoscopes in minimally invasive surgery, have become marketing tools for advertising by physicians and the industry. The use of e-mail and web sites on the Internet have brought extensive medical marketing to the public. Some are simply confusing, on some the information is misrepresented, and some contain false claims. In the past 4 years, there has been an approximately 200% increase in aesthetic surgery, which has stimulated physicians toward competition to attract the consumer.
Given the increasingly complex ethical environment in which we practise, physicians should accept a leadership role with regard to:
• Patients, by sieving through this information, providing appropriate and timely advice, and being patient advocates. The medical organizations of family practice and various specialties should provide clear scientific information to medical consumers through a large database of meaningful information for the public to educate themselves about medical supplies, technologies, and devices.
• Colleagues, who might be enticed or have concerns about their involvement with the pharmaceutical industry.
• The pharmaceutical industry, for keeping the health and welfare of our patients as the primary goal.
The Canadian Medical Association has accepted the responsibility of delineating standards of ethical physician behavior by creating a Code of Ethics, published in October 1996. The Code of Ethics can be reviewed at www.cma.ca/inside/policybase/1996/10-15.htm. When in doubt, any member of the CMA Ethics Committee can be contacted for advice. The committee meets twice a year to discuss policy issues and ethical issues related to the medical profession.
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Dr Kimit Rai, MD, FRCSC
Dr Rai, a plastic surgeon practising in New Westminster, has been a member of the ethics committees of the Canadian Society of Plastic Surgeons, the Canadian Society of Aesthetic (Cosmetic) Plastic Surgery, and the American Society of Plastic Surgeons. He currently represents British Columbia on the Ethics Committee of the Canadian Medical Association.