At a time when leaders of the medical profession in Europe and North America are calling for a critical re-evaluation of how the medical profession “dances with the porcupine”1 of the pharmaceutical industry2-6 it is disappointing that leaders of the profession in Australia appear in denial about the influence of the industry on such things as the prescribing patterns of doctors, the clinical research agenda, and bias in the publication of pharmaceutical research findings.7-9 The most striking denial is that of the effect of pharmaceutical promotion of various kinds on the prescribing practices of doctors. 8,9 Here I wish to:

• acknowledge that the issues surrounding the relations between the medical profession and industry are not unidimensional;

• draw attention to the overwhelming evidence that our prescribing habits are open to industry influence;

• remind doctors of the key ethical issues which are at stake; and

• offer pragmatic suggestions for finding ways of reducing the dependence of the medical profession on support from the industry.

As remarked by an industry executive 40 years ago,10 the medical profession must look at its own conduct and not place responsibility on the pharmaceutical industry.

Within the pharmaceutical industry, at least two independent sections interact with doctors and the healthcare system: the drug development/research section, and the drug promotion/advertising section. The former has made major contributions to health improvements in the developed world, and its role is more comfortably acknowledged by doctors than is the drug promotion section. More than half the biomedical research being done in the United States is now privately funded, with sponsors able to set the research agenda.4 The pharmaceutical industry has learnt to influence our prescribing behaviour indirectly, and uses “opinion leaders” from within the profession to promote its products and to help identify its research agenda. 11,12 There is also clear evidence of publication bias, selective publication and selective reporting of sponsored clinical trials. 3,13 However, I do not want to explore these and other important research-related issues here.

Rather, I will focus on the very strong evidence regarding the effectiveness of industry activities on prescribing practices (Box). In identifying this compelling evidence, I accept that the pharmaceutical industry mostly consists of public companies with legally mandated responsibilities to shareholders and legitimate rights to promote their products. My criticism is of the naïveté of doctors and/or their unwillingness to accept overwhelming evidence that the techniques used by the industry to increase prescribing of their products actually work.

Doctors interact with the pharmaceutical industry in various ways. Most common are direct face-to-face visits from company representatives (referred to as “drug reps” rather than “sales reps”). Also common are indirect interactions via a wide range of marketing techniques, including direct mailing, advertising in medical journals and medical newspapers, and sponsorship of medical conferences and medical products (such as computer software).

For a smaller proportion of the profession, the interactions may be through involvement in clinical trials or in industry advisory groups, speakers’ panels and the like. Although only a select few play these latter roles, they are greatly valued by the pharmaceutical industry as “opinion leaders” in shaping the views of the rest of the profession, especially for new medications. 11,12

In addition to drug promotion, the industry seeks to alter our prescribing patterns by other means. These include “illness promotion” (using public awareness campaigns in the general media to encourage more people to seek new treatments) and support for patient-help organisations (again indirectly encouraging more patients to present to doctors identifying either their ailment or its desired drug treatment). 2,17-19

There is nothing inherently improper about any of these interactions, provided that the medical profession, collectively and individually, is fully and openly aware of the effect of the interactions, that all such interactions are transparent to the community, and that doctors are capable of negating any undesirable effects on their prescribing habits. At present, none of these provisions are being met.

The ethical issues at stake here for most practising clinicians are simple to identify but complex to resolve. To be a medical “professional” implies that patients can rely upon the independence and trustworthiness of any advice or treatment proffered.20 It is a significant ethical failing to aspire to such independence and to the respect and trust that underpin an effective doctor–patient relationship while wilfully or ignorantly denying the evidence that the pharmaceutical industry does affect our prescribing behaviour. The impropriety of this stance is compounded by information asymmetry (where the patient is almost always dependent upon the doctor for information and guidance about medications) and by the fact that the prescribed drugs are usually subsidised by public funds.16

Most doctors seem to genuinely perceive they are immune to such influences, seeing themselves as acting only on the best available evidence in the interests of their patients.14 To change this perception, a new and systematic approach to these ethical issues is warranted. These issues are not new, but their significance has increased in parallel with the growth of the size, power and influence of the pharmaceutical industry. The medical profession needs to confront these issues before a concerned public forces us to do so. The pharmaceutical industry has had sufficient awareness of public opinion to see the need to strengthen its code;21 surely the medical profession might also have the initiative to re-examine its performance in this area?

If we agree that these are significant ethical issues, what practical steps can the profession, and the institutions and healthcare structures in which we work, take to maintain community trust? Several writers have proposed a range of suggestions. 5,6,14,16,22 Ideas of special relevance include the Australian website that critically monitors drug advertising (www.healthyskepticism.org/adwatch.asp)10 and the American Medical Student Association’s campaign “PharmFree”, which is based on another US initiative, “No Free Lunch”.5 Apart from doctors choosing not to see pharmaceutical company representatives (a very simple step which I took a decade ago), readily achievable steps include adoption of policies by hospitals, colleges and professional associations to make those organisations and their staff or members more independent of the industry. Such policies might include:

• funding directly (from hospital budgets and doctors’ contributions) the catering and other facilities needed to promote continuing education of staff, more especially, but not solely, the education programs provided for junior doctors;

• taking formal, publicly announced decisions to reduce financial reliance on the pharmaceutical industry in all areas; and

• developing and policing procedures for identifying and dealing with conflicts of interest for staff and the organisation in regard to the use of pharmaceutical industry support.

In addition, our medical school faculties and medical colleges must ensure that the ethical issues surrounding relationships with the pharmaceutical industry are included in medical student and postgraduate training programs, and that knowledge and attitudes of students and trainees to the industry are included in formal assessment. As the World Medical Association has reviewed its code of conduct about relationships with the industry,23 so too our responsible bodies (medical boards, medical colleges and professional associations) should critically review their codes and take whatever steps are available to them to enforce these codes. It is surely time for leaders of the profession to truly open their eyes to these issues.