Tuesday, April 20, 2010

Encounters with Dr. Tom Stossel

I spent some of last week at Davidson College in North Carolina, in the company of Dr. Thomas P. Stossel, driving force behind ACRE (Association of Clinical Researchers and Educators). Both Dr. Stossel and ACRE have come in for considerable criticism on this blog, so I thought a brief report was appropriate. I am first happy to be able to say that Danny Carlat, over at his psychiatry blog, was correct--I found Dr. Stossel to be personally very congenial and affable regardless what one thinks of his opinions on medicine-Pharma issues. I discovered that he and I have equally compelling reasons for psychopathology, having each of us been raised in our tender years as Chicago Cubs fans.

He and I each spoke at the Speas Colloquium, an annual medical ethics program at Davidson (where our host was Lance Stell, philosopher and another ACRE stalwart). I spoke in defense of the meaningfulness and relevance of the notion of conflict of interest. Dr. Stossel gave an overview of the ACRE position that defends financial ties between medicine and Pharma as the engine that drives innovation, and that sees all recent attempts to limit those ties as both unnecessary and harmful. My limited attempt to hold out an olive branch was to note that ACRE contains a lot of expertise on how medicine can collaborate with Pharma around biotech and pharmaceutical research, so that they could be leading the way to develop an ethically sounder relationship between medicine and the pharmaceutical industry--if only they would admit, for starters, that we currently have a problem. Dr. Stossel obviously was having none of that. He continues the trend in his previously published work of minimizing all bad stuff that happens at the med/Pharma interface--the stuff I have to find time weekly or even more often to post here--as disconnected, rare anecdotes, not as any sort of recurring or worrisome pattern.

In most respects I thought that the talk he gave at Davidson was more or less what we would expect, based on his previous publications. The exception was one slide that he presented on professionalism. The primary source he cited was the recent book by David Wootton, Bad Medicine. The point seemed to be that when folks like me who are concerned about undue influence of commercial interests on medical practice cite "professionalism" as our concern, this ought to be questioned if not dismissed--that much more harm than good has been done over the centuries by invoking "professionalism" in medicine, that "professionalism" has often stood in the way of accepting new scientific evidence, and that it is simply wrong to characterize medicine as something over and above a business. (In short, the sorts of arguments that result when one ignores the more recent, ethical sense of 'professionalism' and invokes only the descriptive, sociological sense of the term.)

My comment here would be that it is perhaps indicative of the strength of the arguments raised by the ACRE folks, to see how wide a swath of ethical countryside they have to lay waste to, in order to defend their chosen position. They want to defend docs taking bundles of cash from Pharma; we invoke conflict of interest as an ethical concern with that approach; so they decide they have to throw out conflict of interest. (Not limit or refine the scope of conflict of interest, mind you, but completely dispense with it.) So now we continue to worry about their heels with some quaint ideas of medical professionalism; and they now find it necessary to dispense completely and totally with medical professionalism. It is not merely a matter of throwing out the baby with the bathwater. It appears to be the baby, the rest of the family, the dog, and the hearth, and still they are not done.


Bernard Carroll said...

Thanks for this update, Howard. I have had my say about Thomas Stossel and ACRE across on Health Care Renewal. Dr. Stossel has a bad case of selective attention. Would he put up a Charles Nemeroff or an Alan Schatzberg to defend their actions?

Barney Carroll.

Joseph Arpaia, MD said...

I find the mention of Dr. Stossel's affability quite irrelevant. Some of the most cruel, anti-social and destructive people on the planet have been described as affable.

I'm not saying that Dr. Stossel falls in the former category, just that affability is irrelevant in determining someone's morality.

TSH73 said...

Dr Stossel's publications, at least, do not reflect quite the complete rejection of coi as a concern that it appears you felt from him; I read his 05 NEJM piece to suggest that coi involving industry often needs to be managed but not necessarily removed--a slightly more nuanced position.

perhaps he went a bit further than he might have otherwise in the heat of debate?
Tom Huddle

Howard Brody said...

Dr. Huddle-- thanks for your comments. You are correct in that Stossel's 2005 paper (NEJM 353:1060-64)appears to accept the basic idea of COI and to recommend disclosure as the preferred remedy. It's my impression that since then, Dr. S's position has hardened up, and one sees in later writings (and certainly in the slides he presented at Davidson) a more uncompromising defense of his stance with fewer concessions to his critics. He wrote for instance in Mayo Clinic Proceedings, 82:1013, 2007, "concern about conflicts of interest has little empiric justification and rests on shaky logic," and attributes other's devotion to the idea of COI to "a fuzzy and antiquated set of platitudes concerning medical 'ethics and professionalism,'" which seems to me to be a fairly blanket dismissal. In Perspect Biol Med 50:54-71, 2007, he accused the "conflict of interest movement" of subjecting the COI concept to an inappropriate "definition creep." It is true, so far as I can tell, that Lance Stell has been more forthright than Dr. S in specifically denying that COI has any coherent meaning, so it may still be the case that I am attributing to Stossel views that are properly Stell's. I think it fair to say, as a purely descriptive matter and not as any attempt at criticism, that Dr. Stossel writes as a polemicist and not as an ethicist; he is not fastidious about detailing the precise logic of his arguments and the definition of his terms.

Sam Van Hallgren said...

Hi Dr. Brody,

Just came across this blog post about your visit to Davidson College and your "encounters" with Dr. Stossel.

I'm Sam Van Hallgren, the producer of The Recovery Room - the radio show that you and Dr. Stossel appeared on together while at Davidson.

Just wanted to pass along a link to the show, in case you were curious to hear it or wanted to pass it along to anyone.

Here's the link:

Thanks again for your time,

Sam Van Hallgren

Anonymous said...

Dr. Thomas Stossel has been analyzed recently