The present study of the ethicality of relationships with the drug industry, by the Ethics Group of the Catalonian Society of Family and Community Medicine (SCMFiC), provides results that are both relevant and revealing. The data are relevant because of the scarcity of reliable information on the state of opinion among Spanish physicians regarding drug industry relations. In addition, the results are revealing because they show that among physicians, awareness of the need to face changes and debate these
issues openly is growing. This is evidence that things are finally moving in the right direction in this sensitive issue.
In 1998 I helped to organize a roundtable discussion to debate ethical issues surrounding the drug industry-physician relationship. At that time this was clearly a pioneering initiative, and organizing the event was an experience that deserves study because of the reactions it elicited from different participants. There was reticence, fear, mistrust and skepticism regarding the usefulness of the event. "Too many particulars will escape adequate attention," it was said. Of all the attitudes expressed, the one I found most disquieting was the call for "sensibleness" by many physicians who advised against meddling in the issue: "We´ll be better off if we don't pull the tiger's tail." It was clear who the tiger was, and in fact the tiger ended up taking a seat at the roundtable and discussing the issue openly without too many problems.
The authors note the limitations of their study unequivocally with regard to drawing conclusions representative of the entire collective of SCMFiC members. Nevertheless, the value of the knowledge they provide is considerable in view of the need for debate.
A majority of those surveyed were of the opinion that there are no objections to receiving publicity materials. This is consistent with the social acceptance of the concept of publicity in all ambits of consumption. In other words, there are no objections to receiving information that has been embellished to a certain degree, supplied directly by the seller of medications in honest competition with other drug suppliers. Medications have joined consumer culture, and it is perhaps for this reason why we should examine what it means for a drug to be financed by the public system. It is clear that freedom of prescribing is one thing, whereas financing prescriptions is quite another, but physicians should not be subjected to inappropriate pressures in such a sensitive issue. It is startling that the health administration discourages prescribing certain drugs of low therapeutic usefulness rather than ceasing to underwrite their cost to the public health system. This makes the physician-patient relationship vulnerable to pressures that politicians do not wish to face squarely and responsibly.
The drug industry has a legitimate desire to continue making money, and this sharpens the senses of sight, smell and opportunity. The idea that physicians maintain relationships with the drug industry that are not always entirely transparent is beginning to take root in public opinion. For whatever motive, the drug industry in Spain has taken firm steps in the right direction, as exemplified by the recent creation by Farmaindustria, the industry´s trade group, of an oversight office intended to ensure compliance with the new Code of Good Practice in the Promotion of Drugs. This is good news, and it is hoped that the code of good practice does not go the way of the recommendations set down in the 1990 Drug Law, which have been ignored in practice by the health administration.
The health administrations, for their part, have also been reluctant to grab the big cat by the tail, at least first-hand, and have opted lately for low-profile tactics such as directives approved by some regional governments to regulate contacts between drug sales representatives and physicians. These regulations, based as they are on guidelines handed down from above, are unrealistic and will never be effective within the medical community.
Most of the physicians surveyed by the SCMFiC Ethics Group are convinced that it is ethically appropriate to accept gifts and other arrangements from the drug industry that enhance professionalism. An analysis of this issue would be an interesting topic for ethics research aimed at defining clearly where the boundary lies between conditions under which it is and is not morally appropriate to accept certain types of gifts, even though they may be accepted with the best of intentions. Most participants were of the opinion that accepting these gifts does not influence their prescribing practices, a perception that can be considered odd (to say the least) despite the fact that it is apparently universal.
The pithy comments provided by participating physicians in response to the open-ended question are significant, and probably reflect opinions held by large sectors of the community of family physicians. However, the respondents seem to be drawn from among those who are most sensitive to the problem and most critical of the status quo. The authors warn us that the respondents are somewhat older than the mean age of SCMFiC members, which may make their responses less representative of the entire membership. Nevertheless, the fact that the group of members with an active e-mail address is likely to comprise the most dynamic participants as well as those with leadership qualities makes this study especially valuable with a view to future developments in this field.
Although this is not the place for extensive commentary, it is worth noting that remarks by some physicians reflect the feeling (tinged, in some cases, with resentment) that the health administration has been hesitant to involve itself in continuing eduction, and has left this in the hands of the drug industry. Among the rather dramatic comments was this one: "There are things I don't consider ethical but do anyway. It's hard to maintain ethical behavior within this health service firm, with the managers we have."
In any case, the issue comprises opinions from all angles within all three of the sectors originally involved, i.e., physicians, the drug industry and health administrations. Generalizations are obviously unfair, but the need is patently clear for structural reform based on a pact between these three sectors, and ideally involving a fourth party, i.e., citizens. At the top levels of administration there is full agreement regarding the need for reforms to be negotiated between all sectors; however, it is discouraging to watch the years go by without any one sector making the first move.
The time may have arrived to consider innovative proposals for reducing--in a way that does not lead to a significant decline in profitability--part of the 30%-40% proportion of sales profits the drug industry spends on advertising. But first, there are two issues that will need to be dealt with:
a) Financial support for continuing medical education and the attendant business interests that surround training events, keeping in mind that the salaries of Spanish physicians are among the lowest in Europe.
b) The drug industry's extensive sales network, which requires reform in a way that preserves as many jobs as possible.
It is up to economic and political science to investigate the viability, repercussions and side effects of reforms of this nature, but the gains in terms of social benefits, in my opinion, would be great.
These ideas may sound like economics-fiction within the current context of globalization, but the art of politics is presumably intended to meet such challenges. While we mull over these issues, we might at least aim in the short term to adopt measures that ensure maximum transparency in our relations with the drug industry.
Professional awareness among physicians is a many-faceted issue in which things are clearly beginning to move. The SCMFiC is to be congratulated for setting an example of how to face the issue squarely, both in this study and in its earlier initiatives, which include guidelines, advice on declaring conflicts of interest, and organization of the National Congress of Family and Community Medicine in Barcelona. These are achievements the Society's members have reason to be proud of.
Key Points
* There is a need for structural reform based on a pact between physicians, the pharmaceutical industry and the health administration. A fourth party--citizens--should also be involved.
* The time may have arrived to consider innovative proposals for reducing--in a way that does not lead to a significant decline in profitability--part of the 30%-40% proportion of sales profits the drug industry spends on advertising.
* It is clear that professional awareness of this many-faceted issue is increasing among physicians. The SCMFiC should be congratulated for setting an example of how to face this issue squarely.
