Ethics

To the Editor: Since 1 October 2016, under changes in the Medicines Australia code of conduct,1 the names of all doctors receiving payments from pharmaceutical companies are being published online, together with the dollar amount received; the data will remain available for 3 years. Up until now, this information could only be published with the doctor’s consent. This change — part of the latest edition of the code of conduct — is the industry’s response to attempt to legislate for greater transparency. It represents a significant step forward in the transparency of the relationships between doctors and pharmaceutical companies. In 2015, pharmaceutical company-funded educational expenses for doctors included a $70 000 trip to Sweden for six oncologists and a $176 000 trip to Vancouver for nine dermatologists.2 With the new changes, it is likely that doctors will think twice before accepting large pharmaceutical company funding for educational events, given this information will be available to the public. Despite a considerable body of evidence showing that receipt of meals and sponsorship is associated with altered prescribing patterns,3,4 many doctors continue to incorrectly believe that they can effectively manage the influence of pharmaceutical company promotion on their decision making.4 The challenge for the profession is to foster doctor–pharmaceutical company relationships that benefit patients, while maintaining freedom from undue influence on prescribing habits. This requires system and individual change. Medicines Australia should be commended for its efforts to improve transparency; its measures are a lesson for other companies with financial interests relating to the practice and preferences of doctors, including medical devices companies. However, to fully realise the benefit of the code of conduct changes, all information on doctor payments must be accessible via a centralised repository that allows patients and third parties to search for an individual doctor. Regarding individual change, doctors must take heed of the evidence above and eschew gifts and education funding provided by pharmaceutical companies. Moreover, up to date and freely accessible evidence-based information is available via independent organisations such as NPS MedicineWise. Greater transparency in the relationships between doctors and pharmaceutical companies is a positive step to maintaining high levels of accountability and public trust in the medical profession.

Jessica Dean · Malcolm P Forbes · Richard Di Natale

To the Editor:In her MJA article, Murphy poses the question “who are we talking about when we discuss voluntary euthanasia laws?” and presents two hypothetical scenarios.1 The South Australian Voluntary Euthanasia Bill 2016 defines an eligible person as a competent adult, subject to unbearable and hopeless suffering, with no impaired decision-making capacity, and who has lived in the state for no less than 6 months.2 The degree to which the suffering is unbearable is determined subjectively. A person’s suffering is considered hopeless if medical treatment cannot reduce or relieve the suffering to a level that is bearable to the person. The nature, availability and potential effectiveness of such treatment are determined objectively under the provisions of the Bill. As Murphy observes: “Every person’s story is different and we must be careful not to lump them together”.1 It is also true that aged care and mental health systems need much greater government investment. However, this alone will be unable to deal with the highly particularised needs of people whose lives have become unbearable despite the best medical or palliative care. The 2016 Victorian inquiry into end of life choices stated: “Under the existing legal framework, Victorians with serious and incurable conditions and irremediable suffering are exposed to the possibility of a traumatic death. Some are driven to suicide.”3 The inquiry recommended a legal framework to allow assisted dying for the small number of people who seek help to end their suffering. Such legal reform would surely provide great reassurance by ending the fear of enforced protracted suffering, which leads to pre-emptive and often violent suicides. Examples of the tragic circumstances triggering these actions were compellingly recounted by Coroner John Olle before the Victorian inquiry4 and alluded to in Murphy’s own account of reading “emotionally draining” case files of suicides in nursing homes. The legal status quo is an indictment of a civilised society.

Julia M Anaf

In reply

Briony J Murphy

To the Editor:The retrospective observational study by Juergens and colleagues1 raises some concerning questions. They chose the variable of English either as first language (EFL) or second language (ESL) and measured significant inferiority of care and outcome for people with ESL. This variable has the advantage of being reasonably easy to collect in a standardised way, but the effect that is being measured is likely to be a proxy for limited English proficiency. We do not need a large trial to know that a patient who is unable to communicate with his or her doctor will have inferior care and outcomes. To be able to provide clinical care, we need to know the language proficiency of the patient. To assess the outcome of the clinical care using an EFL or ESL variable, we need to know whether an interpreter was used and if the interpreter was professional or ad hoc. The authors acknowledge this omission, but they make the contentious statement that “using non-professional interpreters can be expedient”. I would argue that in the setting of an admission for acute coronary syndrome, where vital issues of informed consent and patient understanding of the condition are involved, the use of non-professional interpreters is unethical.2 This is particularly true in Australia where, as Phillips notes, “the Translating and Interpreting Service offers the most extensive telephone interpreting system in the world, providing doctors and pharmacists with rapid, 24-hour access to interpreters”.3 Although, as the authors point out, we cannot know how much of this adverse outcome in correlation with ESL is related to poor communication and how much is related to a higher prevalence of cardiovascular risk factors, it is inconceivable that poor communication is not part of the explanation. A professional interpreter should be used routinely in the setting of an admission for acute coronary syndrome because this will almost certainly improve outcomes4 and is likely to decrease costs,5 and it is a basic right for a patient to be able to communicate fully with clinicians when suffering from a potentially fatal illness.

Ben Gray