The doctor’s dilemma
In his shortlisted essay for the 2017 John Henahan Writing Prize, Dr Conor Lyons says an important covenant exists between the physician and the patient
Dr Conor Lyons
George Bernard Shaw in The Doctor’s Dilemma stated: “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.”
The dilemma here is that of a doctor who has developed a revolutionary cure for tuberculosis, but due to limited resources and financial interests, must choose which patients are worthiest of the cure and which must continue to suffer. Commercial interest and influence over medicine are not new causes for unease. Long before Shaw first explored this concept, the idea of a conflict between the demands of medicine as a business and as a vocation existed.
While this age-old concern persists in medicine, fresh ethical dilemmas have come to the fore. Since the birth of the pharmaceutical industry there has been an underlying disquiet at the thought of drug companies and doctors as bedfellows. This is not an unfounded worry; the pharmaceutical industry in the USA spends approximately $24 billion annually on marketing to physicians. (1) Sponsorship from drug companies has been shown to affect prescribing habits. (2)
Among the general public there can be suspicion regarding the advice doctors provide, and at times justifiably so. When looking at recent controversies in the pharmaceutical industry ophthalmology unfortunately makes an appearance, and all ophthalmologists are aware of the bevacizumab versus ranibizumab debate. In the United Kingdom, it is alleged that Novartis representatives actively discouraged doctors from carrying out comparative trials, with the suspicion that some doctors were being offered research grants if they avoided this head-on evaluation. This episode highlights the dangers of becoming too friendly with drug companies.
Ophthalmology faces many of the same problems as other specialties, with drug representatives promoting their pharmaceuticals. Practitioner-business relations are varied, ranging from a free branded pen to a million-euro research endowment. In Ireland, there are sponsored teaching sessions throughout the year at which drug company employees distribute their promotional material, pay for lunch and speak at the start of the session. It would be naive to think that this doesn’t have an effect on prescribing habits.
Taking a superficial view, it could be concluded that doctors and drug companies should be kept apart. Many would argue that drug companies should not fund research into their own medication; however, without this funding medical advancement may stagnate. Similarly, teaching sessions and research meetings are essential, especially for trainee doctors like me. Many of my colleagues are carrying out research with funding from pharmaceutical companies, vital work that could not be carried out without funding. The question is how best to manage conflicts of interest while preserving the collaborations on which medical advances depend?
In recent times, editors of medical journals have made it more difficult to publish journal articles funded by industry, a response to concerns that such documents may be biased. Is this divide between clinicians and industry in patients’ best interests? I believe not — and I am not alone. Several independent organisations have championed greater interaction between doctors and industry: Institutes of Health, the World Economic Forum, the Gates Foundation, the Wellcome Trust, and the Food and Drug Administration. (3) These organisations realise that for advancements to occur in medicine collaboration rather that division is essential.
I am a first-year resident who has had very little interaction with drug companies; in my own career, so far, I cannot say that the role of industry has directly affected how I treat patients. At present, none of my research has been sponsored by industry and I have a pathological inability to keep any biro (branded or otherwise) long enough to develop loyalty to its manufacturer. However, as I progress in my career it is likely that I will have increased interactions with drug companies and, like all doctors before me, I will be placed in positions where commercial interest will influence my practice. For trainees and consultant ophthalmologists there are opportunities where patients’ best interests may be overlooked. An important covenant exists between the physician and the patient that must remain at the heart of medicine, unfettered by outside forces.
Forty years after a George Bernard Shaw character developed a fictional cure for tuberculosis, the microbiologist and future Nobel laureate Selman Waksman was working on the first (non-fictional) cure: streptomycin. Waksman understood that if his finding was to be of use to humankind, he required a partner able to manufacture sufficient quantities of the substance. For this reason, he struck a deal with Merck to produce streptomycin for clinical use. The partnership went on to assuage great levels of human suffering. In an ideal world, this is how all partnership should work, where patients’ best interests remain at the centre of the relationship. As with many aspects of life, and medicine, there are no black and white answers. Doctors and drug companies are like early explorers moving through uncharted waters, hoping to find the next medical advancement, in which doctors must use their own moral compass and expert judgement.
1. Data CS. US Pharmaceutical Company Promotion Spending (2013).
2. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift?. Jama. 2000 Jan 19;283(3):373-80.
3. Drazen JM. Revisiting the commercial–academic interface.
Dr Conor Lyons is a first-year resident (ophthalmol) at the Royal Victorian Eye and Ear Hospital, Dublin, Ireland