Friday, January 25, 2008

Do I Hate Capitalism? Wild and Crazy Accusations

Robert Goldberg of the Center for Medicine in the Public Interest was so kind as to include my name in a minor place in his diatribe:

He offers a psychological assessment of what really motivates those of us who "pile on" the drug industry and its supporters over issues of conflicts of interest--we really, at bottom, hate drugs and hate capitalism and hate profits.

Now, there is nothing original in his posting. Previously published commentaries by Richard Epstein and Thomas Stossel cover much the same territory. I have written a long and rather boring paper in rebuttal to what they say and have submitted it to an academic journal. (What can I say? It is what us academics do for a living.) I will try to provide here a much shorter, and hopefully much less boring summary.

First, this is good news. If I can further insult Mr. Goldberg by referring to him as a drug industry apologist, it is notable that he and his kin now think people like me worth powder and shot, in order to attack us. A few years ago they simply ignored us, because everything was going their way. So these attacks signal a bit of a turning point in the battle for public opinion.

Next, what are the specific charges lodged against me and others? They seem to be the following:

  1. We ignore the many other conflicts of interest that afflict academics and focus on the one conflict of interest, drug company money.
  2. We hate capitalism and really want to see government take over the drug industry and all technology-generating industries. (Stossel is kind enough to add that we are jealous of the pro-drug industry folks because they make more money than we do.)
The main point about #1 is that all conflicts of interest ought to concern us. Why do we pick on the drug industry specifically? First, because of overwhelming evidence of its deleterious effect on medicine and the public health--more on that later. Second, because as I argue in HOOKED, the conflict of interest is mostly unnecessary for medicine and science to proceed about their business. It is vitally important that medical scientists exchange information with the pharmaceutical industry and that physicians learn about new drugs; it is not at all important or necessary that either line their pockets with drug industry largesse. If we are going to do something about conflicts of interest, it seems to make good sense to start out by eliminating the unnecessary ones; then we can talk about how to manage the ones we cannot get rid of--such as the fact that somebody has to pay for the research and there is always the danger that scientists will be unduly deferential to the funders.

On to #2. I ask anyone to read HOOKED and then explain how it opposes capitalism and calls for a government takeover of the drug industry. Rather the book is written specifically to deny and avoid those unnecessarily extreme positions. (Goldberg mentions in passing that maybe I favor single-payer health insurance, and in fact I do, and say so frankly in HOOKED; but I fail to see how that equates with a nationalization of Pharma.)

To point out what's wrong with the relationship between medicine and Pharma today is one thing. To call for an end to capitalism and the government takeover of the pharmaceutical industry is quite another. To reply to your critics who are doing the first, by accusing them of doing the second, is simply to change the subject and to fail to recognize or respond to their real criticisms. It's as much of a straw man argument as the claim, "You critics must want all patients today to stop taking all pharmaceuticals and to die of easily treatable diseases just like patients did in the 19th century and before."

Also, I feel a need to repeat a point that I would think by now would be crystal clear. I would again defy anyone to read HOOKED and to say in the end that it is Pharma-bashing. My main target is not Pharma; it is my fellow physicians who act in ways I argue are unprofessional. (To be fair, Goldberg grasps this point; but he thinks that the "unprofessional" behavior I accuse my fellow physicians of is in fact exemplary entrepreneurialism.)

I'll end this perhaps overlong comment by using my own career as an example. I entered the field of medical ethics in 1972. In 1980, I made the personal decision not to meet with or accept most gifts/bribes from drug reps. At the time, I viewed that solely as a personal choice; I did not go around and tell my colleagues, who were seeing reps, that I thought them unethical. It never occurred to me to combine these two disparate parts of my life--my academic interest in medical ethics, and the personal choice I had made to avoid industry influence--until 1997, when I read Drummond Rennie's JAMA editorial, "Thyroid Storm." That editorial started me down the pathway that ended up in writing HOOKED and in starting this blog.

My point in recounting this story is that for all those years between 1980 and 1997, I agreed basically with Robert Goldberg. I did not see any need to "pile on" in criticizing the drug industry, or in criticizing my colleagues who accepted its favors. What changed me was simply the overwhelming evidence that we could no longer ignore the poisonous impact of layers and layers of conflict of interest on medicine's trustworthiness as a patient and public advocate. I defy anyone to read HOOKED, or the similar books by the likes of Marcia Angell, Jerome Kassirer, Jerry Avorn, John Abramson, et al. and deny that the evidence has piled up to the level I describe.

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