So after reading ethicist Carl Elliott's incisive and disturbing new book, "White Coat Black Hat: Adventures on the Dark Side of Medicine," I asked him to inject some light into the darkness: What would he suggest to counteract the many pernicious ways that money influences the practice of medicine? He replied:
The Guinea Pigs
Well, the problem with paying research subjects is that you wind up exploiting poor people, who are often desperate enough to endure all kinds of risks and discomfort as long as they get a paycheck. I can see two options. One, you could just ban payment to research subjects, which might work, but you’d have to be vigilant about making sure that the pharmaceutical industry doesn’t simply find another exploitable population – for instance, in the developing world. Two, you could treat guinea-pigging like a job, and make sure that these subjects have all the protections of a decent job, like a fair wage, health insurance, compensation when they are injured, workplace inspections, the right to unionize, and so on – all the things that they are usually denied to them right now.
If we treated ghostwriting the way we treat scientific fraud, it’s hard to imagine it surviving for very long. The problem now is that even after half a dozen scandals in which ghosted articles were used to promote dangerous drugs, ghostwriting is still not seen as a serious problem. Universities, medical journals and professional groups need to sniff it out, identify it, and punish the offenders. (And if that doesn’t work: sue.)
The Detail Men
The main reason doctors agree to see reps is to get drug samples and all the other free giveaways, like lunches, concert tickets, invitations to dinner meetings, and so on. If every rep had to turn up at a doctor’s office empty-handed, they’d never get through the door. (Except maybe the women reps, who often look like NFL cheerleaders or supermodels. In some offices, those reps will always be welcome).
The Thought Leaders
Thought leadership is like prostitution. It will never go away; you just need to figure out a way to control it. If universities banned or capped the amount of money that faculty members could take from the drug industry for consulting or giving marketing talks — rather than just requiring them to disclose it, as they do now – it would help a lot. And of course, when trial lawyers are suing the drug industry for illegally promoting drugs, they could include the thought leaders too. Just a thought.
This is the toughest one. As long as there is a media industry, there will be PR experts trying to spin and manipulate it to their advantage. The only solution I can see is constant vigilance combined with relentless counter-attack. For example, VNRs, or “video news releases,” — fake news segments manufactured by paid PR experts and broadcast as legitimate news – used to be everywhere, but thanks to the Center for Media and Democracy, which has doggedly used its own PR expertise to expose them, they’ve mostly been banished to YouTube along with the piano-playing cats.
Do research subjects actually know that the ethics boards that are supposed to be protecting them might well be for-profit companies that are paid by the pharmaceutical companies whose research studies they are approving? As a means of regulating a multi-billion-dollar, global medical research industry, our for-profit ethics system is insane, and we should just get rid of it, like virtually every other country in the world.
This program aired on September 21, 2010. The audio for this program is not available.