Date:   2/19/2004 8:53:38 PM ( 20 y ago)
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I was raised in a house filled with drug-industry trinkets. My father has been a family doctor for more than 40 years, and drug representatives bearing gifts have visited him throughout his career. My brothers and I grew up tossing Abbott Frisbees and Upjohn Nerf balls. We took down messages on Inderal notepads, wrote with Erythromycin pens, carried Progestin umbrellas. We constructed weird Halloween costumes from models of the human hand and brain supplied by Parke-Davis and Merck. My father was no great fan of "detail men," as drug reps were called then. (These days, if you're a male physician, your detail man is likely to be an attractive young woman.) Nor did he take part in the drug industry's more outrageous marketing efforts, such as frequent-flier miles in exchange for drug prescriptions. But he saw no great harm in accepting drug samples for his patients or toys for his children. Like virtually all doctors, he did not think that the gifts influenced him in any way.

Why pharmaceutical companies want the goodwill of doctors is no great mystery. The surprise is why they want the goodwill of someone like me. I am a philosophy professor, and I work at a bioethics center. While I do happen to have a degree in medicine, that degree is largely decorative: The only prescriptions I write these days are moral ones. Despite this difference (or maybe because of it), the pharmaceutical and biotechnological industries are funneling more and more cash into the pockets of academics who teach and study ethics. Some of it goes straight to individuals, in the form of consulting fees, contracts, honoraria, and salaries. Some of it--such as gifts to bioethics centers--is less direct. Many corporations are putting bioethicists on their scientific advisory boards or setting up special bioethics panels to provide in-house advice. While I have not yet been offered Frisbees or Nerf balls, I suspect that it is only a matter of time.

The issue of corporate money has become something of an embarrassment within the bioethics community. Bioethicists have written for years about conflicts of interest in scientific research or patient care yet have paid little attention to the ones that might compromise bioethics itself. Arthur Caplan, the director of the University of Pennsylvania Center for Bioethics, counsels doctors against accepting gifts from the drug industry. "The more you yield to economics," Caplan said last January, "the more you're falling to a business model that undercuts arguments for professionalism." Yet Caplan himself consults for the drug and biotech industries, recently coauthored an article with scientists for Advanced Cell Technology, and heads a bioethics center supported by Monsanto, de Code Genetics, Millennium Pharmaceuticals, Geron Corporation, Pfizer, AstraZeneca Pharmaceuticals, E.I. du Pont de Nemours and Company, Human Genome Sciences, and the Schering-Plough Corporation.

By no means does Caplan's center stand alone in its coziness with industry. The University of Toronto houses the Sun Life Chair in Bioethics; the Stanford University Center for Biomedical Ethics has a program in genetics funded by a $1-million gift from SmithKline Beecham Corporation; the Merck Company Foundation has financed a string of international ethics centers in cities from Ankara, Turkey, to Pretoria, South Africa. Last year the Midwest Bioethics Center announced a new $587,870 initiative funded by the Aventis Pharmaceuticals Foundation. That endeavor is titled, apparently without irony, the Research Integrity Project.

Bioethics appears set to borrow a funding model popular in the realm of business ethics. This model embraces partnership and collaboration with corporate sponsors as long as outright conflicts of interest can be managed. It is the model that allows the nonprofit Ethics Resource Center in Washington, D.C., to sponsor ethics and leadership programs funded by such weapons manufacturers as General Dynamics, United Technologies Corporation, and Raytheon. It also permits the former president of Princeton University, Harold Shapiro, to draw an annual director's salary from Dow Chemical Company while serving as chair of the National Bioethics Advisory Commission. Dow, of course, has been the defendant in a highly publicized lawsuit over the Dow Corning silicone breast implants as well as in numerous legal actions involving disposal of hazardous waste.

Part of the problem is aesthetic. It is unseemly for ethicists to share in the profits of arms dealers, industrial polluters, or multinationals that exploit the developing world. But credibility also is an issue. How can bioethicists continue to be taken seriously if they are on the payroll of the very corporations whose practices they are expected to assess?

Listening to Eli Lilly
Last year some colleagues and I helped put together "Prozac, Alienation, and the Self," a special issue of The Hastings Center Report, a bioethics journal. Some of the papers that we published, including one by me, expressed worries about the extent to which antidepressants are being prescribed, especially for patients who are not clinically depressed. One paper in particular - "Good Science or Good Business?" - was especially critical of the drug industry. Its author, David Healy, is a psychopharmacologist and a historian of psychiatry at the University of Wales.

Shortly after these Prozac essays were published, Eli Lilly and Company, which manufactures Prozac, withdrew its annual gift to the Hastings Center, citing the special issue as its reason. Lilly's yearly check for $25,000 was not especially large by industry standards, but it was the Hastings Center's largest annual corporate donation. Lilly's letter to the organization was especially critical of Healy's article. Healy had previously published research indicating that some patients, particularly those who are not clinically depressed, may be more likely to commit suicide while taking antidepressants. He has also testified as an expert witness against Lilly and other drug manufacturers in lawsuits brought by family members of patients who killed themselves or others after taking antidepressants. In "Good Science or Good Business?" Healy argued that manufacturers of antidepressants have gone into the business of selling psychiatric illnesses in order to sell psychiatric drugs. Apparently, this was not the kind of bioethics scholarship that Lilly had in mind when it donated money to the Hastings Center.

The reaction of bioethicists to all of this is emblematic of the difficulties raised by corporate money. Some were encouraged by the response of the Hastings Center staff -particularly by the Report's editors, who published the special issue without regard to Lilly's reaction. We are never hostage to corporate money, these scholars say. We can always turn it down, resign our posts, and do the right thing despite enticements to the contrary. For others, however, the fact that the Report's editors faced such incentives is precisely the problem. Given enough cases where bioethicists must choose between scholarship and their corporate funders, the funders will eventually win out. In the long run, money conquers all.

But the Hastings Center episode was only the first chapter of the Healy affair. In November 2000, Healy gave a talk on the history of psychopharmacology at the University of Toronto's Center for Addiction and Mental Health (CAMH), where he was scheduled to take up a new position as director of the Mood Disorders Program. In that lecture, Healy mentioned his worries about Prozac and suicide. Shortly thereafter, the center rescinded his appointment. He was given no reason but merely informed by e-mail that CAMH did not feel that his "approach was compatible with the goals for development of the academic and clinical resource" of the clinic. CAMH officials insist that the Eli Lilly Corporation had nothing to do with the decision; yet the center is the recipient of a $1.5-million gift from Lilly. The Mood Disorders Program, which Healy was to direct, gets 52 percent of its funding from corporate sources.

Whether Lilly or any other corporate funder had anything to do with Healy's dismissal is impossible to know. Even so, the trouble CAMH has had in convincing the public that industry sources were not involved points to the difficulty of discerning financial influence. Would CAMH have dismissed Healy if it had no ties to Lilly whatsoever? Does fear of being unable to attract future corporate money count as influence? Does fear of angering powerful industry-tied psychiatrists?

"Doctors fear drug companies like bookies fear the mob," says Harold Elliott, a psychiatrist at Wake Forest University. Corporate money is so crucial to the way that university medical centers are funded today that no threats or offers need actually be made in order for a company to exert its influence. The mere presence of corporate money is enough.

And researchers are probably right to be afraid. The University of Toronto itself has seen two other public scandals erupt over pharmaceutical-company funding in recent years. The most visible one involved Nancy Olivieri, a researcher at the university's Hospital for Sick Children,
"How can bioethicists continue to be taken seriously if they are on the payroll of the very corporations whose practices they are expected to assess?" who was conducting clinical trials of deferiprone, a thalassemia drug, for the generic-drug manufacturer Apotex. When Olivieri became concerned about possible side effects of deferiprone, she broke her confidentiality agreement with Apotex and went public with her concerns. In response, Apotex threatened her with legal action. Rather than backing Olivieri against Apotex, the Hospital for Sick Children attempted to dismiss her. News headlines had hardly faded when Apotex promised the University of Toronto $20 million (about $13 million in U.S. dollars) in funding for molecular biology, then threatened to withdraw it if the school's then-president, Robert Prichard, did not lobby the federal government to change its drug-patent regulations. Apotex wanted rules that would be more favorable to generic-drug manufacturers. The president did as he was asked and was later forced to apologize publicly when the story broke.

Industry-sponsored bioethics programs face problems that parallel those encountered by industry-sponsored medical researchers. What do you do when your scholarly work conflicts with the goals of your industry sponsor? No one is forcing industry money on bioethics programs, but many of them are located in academic health centers, where faculty members are expected to generate money to fund their research either by seeing patients or by obtaining grants. If bioethics is seen as an activity that can attract industry sponsorship, university administrators strapped for cash will inevitably look to industry as a financial solution. All that remains is for bioethicists themselves to dispense with the ethical roadblocks...

Still, we can all take heart: Help may be on the way. The American Medical Association's Council on Ethical and Judicial Affairs is planning a $590,000 initiative to educate doctors about the ethical problems involved in accepting gifts from the drug industry. That initiative is funded by gifts from Eli Lilly and Company, GlaxoSmithKline, Inc., Pfizer, U.S. Pharmaceutical Group, AstraZeneca Pharmaceuticals, Bayer Corporation, Procter and Gamble Company, and Wyeth-Ayerst Pharmaceutical.

http://www.phen.ab.ca/materials/intouch/vol4/intouch4-09.html

 

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