Bioethics Discussion Blog: “Here are Tickets to Disneyland”:Gifts to Physicians from Medical Industry

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Friday, April 15, 2005

“Here are Tickets to Disneyland”:Gifts to Physicians from Medical Industry

Gifts to physicians from patients represent one issue, only rarely occurs and usually is trivial. Gifts to physicians from medical industry is quite another issue and in one form or another is an ongoing practice. This practice, if unchecked, could easily bias the physicians prescribing patterns toward the contributing pharmaceutical company or instrument buying patterns or recommendations for patient use medical equipment. The American Medical Association has challenged this practice with a series of ethical guidelines to avoid what is felt to be actions which potentially could lead to conflict of interest. The guidelines are presented below:


Opinion 8.061, "Gifts to Physicians from Industry"
Many gifts given to physicians by companies in the pharmaceutical, device, and medical equipment industries serve an important and socially beneficial function. For example, companies have long provided funds for educational seminars and conferences. However, there has been growing concern about certain gifts from industry to physicians. Some gifts that reflect customary practices of industry may not be consistent with the Principles of Medical Ethics. To avoid the acceptance of inappropriate gifts, physicians should observe the following guidelines:

(1) Any gifts accepted by physicians individually should primarily entail a benefit to patients and should not be of substantial value. Accordingly, textbooks, modest meals, and other gifts are appropriate if they serve a genuine educational function. Cash payments should not be accepted. _The use of drug samples for personal or family use is permissible as long as these practices do not interfere with patient access to drug samples. It would not be acceptable for non-retired physicians to request free pharmaceuticals for personal use or use by family members.

(2) Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g., pens and notepads).

(3) The Council on Ethical and Judicial Affairs defines a legitimate “conference” or “meeting” as any activity, held at an appropriate location, where (a) the gathering is primarily dedicated, in both time and effort, to promoting objective scientific and educational activities and discourse (one or more educational presentation(s) should be the highlight of the gathering), and (b) the main incentive for bringing attendees together is to further their knowledge on the topic(s) being presented. An appropriate disclosure of financial support or conflict of interest should be made.

(4) Subsidies to underwrite the costs of continuing medical education conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. Since the giving of a subsidy directly to a physician by a company’s representative may create a relationship that could influence the use of the company’s products, any subsidy should be accepted by the conference’s sponsor who in turn can use the money to reduce the conference’s registration fee. Payments to defray the costs of a conference should not be accepted directly from the company by the physicians attending the conference.

(5) Subsidies from industry should not be accepted directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings, nor should subsidies be accepted to compensate for the physicians’ time. Subsidies for hospitality should not be accepted outside of modest meals or social events held as a part of a conference or meeting. It is appropriate for faculty at conferences or meetings to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging, and meal expenses. It is also appropriate for consultants who provide genuine services to receive reasonable compensation and to accept reimbursement for reasonable travel, lodging, and meal expenses. Token consulting or advisory arrangements cannot be used to justify the compensation of physicians for their time or their travel, lodging, and other out-of-pocket expenses.

(6) Scholarship or other special funds to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible as long as the selection of students, residents, or fellows who will receive the funds is made by the academic or training institution. Carefully selected educational conferences are generally defined as the major educational, scientific or policy-making meetings of national, regional or specialty medical associations.

(7) No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the physician’s prescribing practices. In addition, when companies underwrite medical conferences or lectures other than their own, responsibility for and control over the selection of content, faculty, educational methods, and materials should belong to the organizers of the conferences or lectures. (II) Issued June 1992 based on the report "Gifts to Physicians from Industry," adopted December 1990 (JAMA. 1991; 265: 501 and Food and Drug Law Journal. 2001; 56: 27-40); Updated June 1996 and June 1998.


..Maurice.

7 Comments:

At Wednesday, April 20, 2005 6:24:00 AM, Blogger Bioethics Dude said...

I agree with the AMA's ethical dicta as well as your take on it...but wonder if this is as good as it's going to get until something big/catastrophic happens. By this, I mean that there exists a statement of ethics that some may be aware of as a means of attempting to balance the bias introduced by pharma companies product handouts and gifts. Is there a policing body to oversee this? I don’t think so…but I’m not sure if one needs to be enacted yet. I know this is not what you were saying, I intend to emphasize that this may be as good as it gets. Maybe another approach outside of policing would be to reiterate this via some dialogue at meetings, or make the patients aware of the potential for this bias (as you may be doing with your blog) –but the downside with making the patients aware is that it may instill an unreasonable amount of skepticism…

 
At Wednesday, April 20, 2005 8:16:00 AM, Anonymous Anonymous said...

If you are the patient, what amount of skepticism is unreasonable? I'm bothered by the paternalism in your statement-the implication that maybe patients don't have the intelligence to make the right decision when given all the information.
5in9years

 
At Wednesday, April 20, 2005 2:53:00 PM, Blogger Maurice Bernstein, M.D. said...

Bioethics Dude, I would tend to agree with the comments of 5in9years. I think up to the present, patients have not been given full information about drugs and in fact most of the information provided by drug companies to the public is incomplete and misleading. Because of time limitations and perhaps because of biased "educational" feed by the drug companies to the doctors, physicians may also provide incomplete and misleading information to their patients.
I would encourage programs to objectively and without conflicts of interest provide full medication information to the public in terms that the public would understand. I would then wait and observe how the patients interpret this information before giving up on the patient's intelligence. ..Maurice.

 
At Thursday, April 21, 2005 11:47:00 AM, Blogger Bioethics Dude said...

perhaphs I was unclear; what I meant by downside with making the patients aware is that it may instill an unreasonable amount of skepticism… is that if the patients are aware of the biasing nature of gifts/handouts from pharma then their view of the medical system may further became jaded. I know quite a few intelligent people (don't we all though:-) who have a not so positive take on health care and those who provide it. Some may be because of an inherent distrust that such biases feed; while of course, some may be the expectation that medicine is perfect or more perfect in their own heads than in those of who understand the bigger scope of it. As a second point, 5in9years also pointed out in a more recent comment that patients do tend to go with the advice of the doctor...without being indignant, I don't see how the system is not intrinsically paternalistic. It's a matter of expertise, and acting on that knowledge. I know that it's a balance of paternalism and liberty, but I don't think we can just provide the patients with all the info and have them decide. They don't have the training to interpret that.

 
At Thursday, April 21, 2005 2:29:00 PM, Blogger Maurice Bernstein, M.D. said...

Bioethics Dude: Two points. I agree with you that patients aware of pharma gifts to doctors would and realistically should make the them skeptical about the physicians and medical practice.

On the other point, there is no doubt in my mind regarding the intrinsic paternalistic nature of medicine and its practitioners. By its very nature, the practitioners have the knowledge and experience of diagnosing and treating disease and not the patients. On the otherhand, the patient has the principle of autonomy and the title of "consumer" on their side (also don't forget the title of "patient" who knows things about themselves that the doctor does not know!) This balance.. and there really is a kind of balance..on the two sides is what makes "working together in a partnership" an essential feature of the good and productive doctor-patient relationship. ..Maurice.

 
At Thursday, April 21, 2005 7:19:00 PM, Anonymous Anonymous said...

But that's exactly what should happen. The doctor has the knowledge, but he/she doesn't have to live with the consequences of the decision. The only ethical thing to do is give the information to the patient, help interpret it as needed, and respect his/her decision. A prime example is the use of cytotec to induce labor. If women have all the information, many of them might refuse to be induced with cytotec. The information is often withheld by doctors who have evaluated the risks and decided they aren't serious enough to avoid using the drug. The problem? It isn't their body or their baby, so it isn't their decision. Another example-the patient in labor (sorry, I'm a L&D nurse-stick with what you know) is told that an epidural has "no direct effect" on the baby. Immediately after her epidural she suffers a hypotensive crisis and requires an emergency c/s (while hypotensive) for fetal bradycardia. The doctor chose to skim over that potential issue in order not to scare her. I say she had a right to be scared.
I am well aware that there are many-maybe even a majority-of patients who place complete faith in their physicians. The appropriate response to this is not to make decisions for them, but to gently push them toward self determination. I also think this course has the potential benefit of reducing medmal complaints. If patients bear some responsibility for their care, and understand that their hcps are human, that can only do good things for the relationship.
5in9years

 
At Thursday, April 21, 2005 7:20:00 PM, Anonymous Anonymous said...

Have to add-any sane person should perhaps be just a little cynical about modern medicine.
5in9years

 

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