Sam Uretsky

The Price of Ethics

Years ago, a very distinguished pharmacist of my casual acquaintance received a box in the mail. Inside the box was a manuscript that he hadn’t written, a letter to the editor of a journal stating that he had written the piece, and a check which neatly maneuvered between the Scylla of tawdry insufficiency and the Charybdis of wretched excess. In case it wasn’t clear enough, a polite letter encouraged him to sign the letter first, and the check second.

What seemed remarkable is the absence of foreplay. No Deputy Regional Vice-President had taken the very distinguished pharmacist to lunch and dropped hints that for a small deviation of his ethical standards there might be a quid pro quo. The package was completely unsolicited. Apparently the senders of the box had concluded that this type of exploratory luncheon wasn’t required, that the moral compass of a health professional could be thrown off-course so predictably that no further research was required.

Very likely the people in the business of buying souls had already developed a price list, factoring in profession, distinction and market impact. Pharmacists are at the low end—they have some influence on formulary decisions in hospitals, but they can’t make the final decision on drug choices. Infectious disease specialists are almost as useless. The real choices on antibiotic use are made by bacteria, and bacteria are completely objective in their decision making. That’s as it should be. For a bacillus, the choice of antibiotic is a matter of life and death, and a dead bug is an excellent indicator of the proper choice. You get pretty much the same thing with other medical specialties; modern diagnostics has made medicine far more scientific than it was in the past. That’s also why today, the big money is in psychiatry. While the 2008 AMGA Medical Group Compensation and Financial Survey lists a mean income of about $206,000 for a psychiatrist, with some making far less based on regional variation, compared to an orthopedic surgeons doing joint replacements averaging $520,000, psychiatrists can make money on endorsements.

Psychiatry is about the last specialty area where there’s a high level of subjectivity in both diagnosis and evaluation of treatment. Since it’s also an area where treatment can go on for years, decades, drug manufacturers have a special affection for psychopharmaceuticals. Of the top 20 best-selling drugs in the United States, none are for infections, but 5 are for psychiatric conditions.

And that may be why there have been a number of reports of psychiatrists showing serious conflicts of interest in their dealings with drug manufacturers. Most recently, a prominent psychiatrist was reported to have earned $2.8 million in consulting fees with drug manufacturers over a 7-year period, while neglecting to report over $1 million of that to the university which employed him. In other cases, physicians have seriously under-reported their income from association with pharmaceutical manufacturers, often by hundreds of thousands of dollars.

While conflict of interest cases are by no means limited to the field of psychiatry, this area is the most recent to show problems, largely due to investigative reporting by the New York Times, which have been followed up by Sen. Charles Grassley, R-Iowa. The psychiatrists involved have been associated with highly respected universities including Stanford, Harvard and Emory. One thing that has come out of the investigations is that simple trust when it comes to reporting of potential conflicts of interest isn’t reliable.

Once again, psychiatry is more vulnerable than other specialties when it comes to conflicts of interest simply because there’s an element of subjectivity that is less prominent in other areas. Sometimes, in other specialties, there are legitimate debates on whether a case should be treated or simply observed, or whether the correct treatment is medical management or surgical intervention, but generally there are objective markers of disease and its progression. The result is not only the courting and coopting of prominent psychiatrists, but a focus on psychiatric agents as potential blockbuster drugs often to the exclusion of other areas of research. Pfizer, the maker of the anti-epileptic agent Neurontin (generic name “gabapentin”) has been accused of manipulating studies to encourage the use of the drug for other conditions including bipolar disorder and attention deficit disorder. These are conditions which can’t be diagnosed by an impartial machine, and clinical progress is subject to subjectivity.

Sen. Grassley has proposed legislation requiring drug companies to report all payments to physicians equal to or greater than $500, and two major pharmaceutical manufacturers have said that they’ll issue these reports on a voluntary basis. It’s a start.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.

From The Progressive Populist, November 15, 2008

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