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From the Editor

The current influence of market incentives in the United States is posing extraordinary challenges to the principles of medical professionalism. Physicians' commitment to altruism, putting the interests of the patients first, scientific integrity, and an absence of bias in medical decision making now regularly come up against financial conflicts of interest. Arguably, the most challenging and extensive of these conflicts emanate from relationships between physicians and pharmaceutical companies and medical device manufacturers.

Health Industry Practices that Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers, JAMA, 9-12-06

This week's symposium focuses on the emerging movement to restrict contact and communications between physicians, industry representatives, and physicians who work or consult for the health care industry, with the apparent goal of quarantining medical practice from the supposedly baleful influence of market incentives.

Our panel this week takes a respectful, but skeptical, view of the argument advanced by many critics that the profit motive of private firms conflicts with the desire of patients for the best health care or of physicians to maintain professional standards.

The fiduciary standards companies owe their shareholders are surely compatible with producing the highest quality products and research possible given existing technologies. Companies that made products that routinely harmed patients or produced deceptive marketing materials for physicians would find themselves punished by investors, physicians, courts and regulators in very short order. The drug and device industries are among the most heavily regulated in the world, with rigorous pre-market safety and efficacy testing at every stage of the product development process.

As one of our author's notes, potential conflicts of interest are rife in many human activities-particularly those where, as in medicine, there may be steep informational asymmetries between participants. With this in mind, there is broad agreement that disclosure of relevant conflicts of interest in published research and medical communications is necessary to help assure the integrity of research. Advisors with direct financial stakes in matters before regulatory agencies (FDA, NIH) should recuse themselves for the same reasons. Those who violate these policies, or otherwise deliberately distort or manipulate research should be punished harshly.

In the meantime, the solution is not less information, but more. Health insurers have powerful database tools at their disposal to help educate physicians on best practices and improve standards of care. The addition of more pricing and quality information across the health care sector (including for physicians' services) will help make consumers more active and more effective participants in their own treatment. The growing promise of personalized medicine and pharmacogenomics will slowly but surely reduce the enormous uncertainty accompanying drug therapy.

Using ever more restrictive conflict of interest regulations to police the marketplace for medical information is not only short-sighted, but counterproductive. Each one of the health care stakeholders-physicians, insurers, industry, government-has a bias (or perspective, if you will) that affects how they process and present information to the public. The challenge is not to purify the public square of provincial interests (an impossible task), but to structure our deliberations so that each of the participants carefully monitors the activities of the other in a fashion aligned with the ultimate goal of health policy: improving patient care.

By limiting doctors' access to new treatment and prevention alternatives, the conflict of interest movement ultimately reduces patients' access to care. The key to improving health outcomes is not restricting doctors' ability to interact with market providers but rather aligning patients' financial interests with their care decisions. When consumers have more financial control over their own health care decisions, they will demand transparency and quality improvements from all stakeholders.

Building a Chinese wall between industry and medical practitioners will only slow the dissemination and development of new technologies.

Before we enact widespread prohibitions on private-public interactions and communications, we need to first establish which problems we are trying to address and whether the regulations offered to address those problems are narrowly tailored to achieve those ends.

We hope that you find the following original submissions and linked materials (from diverse viewpoints) provide cause for further discussion and debate of this important issue.

Thursday, October 5: Michael Weber, MD
Friday, October 6: Richard Epstein, JD
Tuesday, October 10: Thomas Stossel, MD
Wednesday, October 11: John Calfee, Ph.D.

Required Reading

Health Industry Practices That Create Conflicts of Interest, Troyen A. Brennan et al., Journal of the American Medical Association, 1-25-06

Conflicts of interest in clinical research: opprobrium or obsession?, Richard Horton, The Lancet,
4-19-97 [Free Registration Required]

Financial Conflicts of Interest in Physicians’ Relationships with the Pharmaceutical Industry: Self-Regulation in the Shadow of Federal Prosecution, David M. Studdert, et al., The New England Journal of Medicine, 1-28-04

Regulating Academic–Industrial Research Relationships — Solving Problems or Stifling Progress?, Thomas P. Stossel, The New England Journal of Medicine, 1-8-05

Conflict of Interest in the Professions (Book Review), The New England Journal of Medicine,

Reporting Conflicts of Interest, Financial Aspects of Research, and Role of Sponsors in Funded Studies, Journal of the American Medical Association, 7-6-05

Consult for Wall Street?, Marcy Tolkoff, Medical Economics, 4-6-06

What's Wrong With Money in Science?, Thomas Stossel and David Shaywitz, Washington Post, 7-2-06

Public Policy Issues in Direct to Consumer Advertising, John Calfee, American Enterprise Institute,

Pharmaceutical Promotion: Don't Throw the Baby Out with the Bath Water, Robert DuBois, Health Affairs, 2-26-03

High Prices: How to Think About Prescription Drugs, Malcolm Gladwell, New Yorker, 10-25-04

Of Pills and Profits: In Defense of Big Pharma, Peter Huber, Commentary, July-August 2006

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