The Guardian have made available a podcast of the Making Sense of Series 2010 lecture by Dr Fiona Godlee, who is a editor-in-chief at the British Medical Journal. Godlee tackles the relationship between medical research and conflicts of interest directly during her talk. As an editor-in-chief at the BMJ, she speaks with great authority in this area and is able to comment from her experience of the commercial relationships of the BMJ noting that great care is taken to note these relationships when creating the publication. The listener will gain a good deal of insight into a number of controversies around conflict of interest in research and examples range from the sacking of editors of one journal for articles which resulted in removal of commercial sponsorship through to the effects of the recent change in libel law on the everyday practices of an influential medical journal. The talk also references Senator Charles Grassley’s investigation of pharmaceutical relationships with clinicians and academics over in the United States. However Godlee also notes that journals in many cases are businesses. This point I think is quite profound as it relates to a wider issue – that of capitalism. For a journal to be a business venture, this means that it must be considered in a wider social context.
In order for the journal to succeed, it must operate within the limitations imposed by business legislation and ultimately is accountable to the commercial reality of profit and loss. If in the marketplace, the journal is commercially successful it will prevail and if not then it will fail. As a result of these limitations, journals must necessarily move away from a consideration of the medical issues of maximum interest that would exist in an idealised utopia and instead consider the range of medical issues that are now presented after these additional limitations are imposed. This in turn means that to solve issues of conflict of interest satisfactorily, doctors must begin to turn their focus to a component of the underlying fabric of society – capitalism – and examine how ethics can be incorporated into the mechanics of the business itself.
If a business is ultimately governed by profit and loss – and of course operating within the relevant national laws – as well as the interests of shareholders but not by additional and ethically laden laws peculiar to the relevant marketplace, then this function is instead passed to external groups. In examples given during the talk, for medication, the external group consists of the doctors that examined the publication or non-publication of certain papers for specific drugs by the manufacturing companies and concluded that this influenced the ‘objective’ appraisal of the drug based solely on consideration of the ‘published’ literature. Indeed the results of this analysis challenged the implicit assumption that the ‘published literature’ presents us with the ‘scientific’ answers to the questions we pose when examining the literature. Intead Godlee is able to persuade us that this literature is riddled with conflicts of interests sufficient to realistically view the ‘literature’ as a anything but an objective scientific truth. This is the basis for incorporating critical appraisal skills into medical training. However, it is not just critical appraisal skills that are needed but instead an organised collective approach to the more significant ethical challenge posed by unconstrained capitalism which governs the behaviour of an organisation. Essentially capitalism is a model which simulates the principles of natural selection to produce ‘fit’ companies which are able to survive in the marketplace. The ‘trained’ organisational behaviours that result can come into conflict with the consumers expectations of the service or product that is being developed. This has the potential to go very wrong as countless examples given during the talk demonstrate.
So how might the medical profession act collectively to address these issues. On one level, this is a philosophical question that requires careful consideration and exploration of the issues. One practical possibility however might be for the an authorised medical body to be created with an assigned responsibility of constructing a set of rules for a pharmaceutical company to adhere to in certain parts of its ‘behaviour’. Indeed it might be argued that this body should consist of a wider group of professionals but the main point is that they would be in a position to directly influence regulation of pharmaceutical companies. Although this might influence the outcome in the market place, it would apply equally to all pharmaceutical companies and so the nature of the ‘environment’ that they must adapt to has been changed and nothing more. As before, the fittest will ‘survive’ and the less fit will just muddle along.
However an even more interesting question is why businesses must be responsible for leading innovation and production of medicines for the population. Another possibility is that this function could additionally be carried out by charitable bodies. If medications are generic then it should be possible for the production to occur with low overheads and for the revenue to be ploughed back into research on the relevant drug. Such bodies might not be responsible for innovative drugs but surely they will provide a path to a better understanding of the established drugs and to improved practice in their use if they are able to fund research (literature or clinical).
While I write, another issue of the same nature has surfaced – this time in the blogosphere. Science blogs have created a blog with the help of Pepsi Cola which has been roundly criticised for presenting readers with an infomercial. The same themes emerge – about the relationship between science and conflicts of interest. Science is a search for the ‘objective truth’ whereas in the commercial marketplace the presented information serves additional functions. However the same reflection about capitalism is necessary. In this case, it is the bloggers who may depend on their blogging income to live in society where the machinery is oiled by money. The employing organisation in turn must get its money from somewhere and there is a necessary trade-off between the content and interests of sponsors. Here again the argument is the same. An external group, in this case the blogging community, is responsible for the ethical policing of an area which is unregulated. If for instance, the blogs and the sponsors were to follow an ethical code specifically constructed for such relationships then it might be easier on all parties. Unlike some of the issues discussed in Godlee’s talk, here the cards are on the table and the reader knows that Pepsi Cola are behind the blog. That knowledge will enable them to make an informed decision although an ethical code would be useful in creating disclaimers for their readers to further support their informed reading.
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