Adventures in Ethics and Science

There is a story posted at ProPublica (and co-published with the Chicago Tribune) that examines a particular psychiatrist who was paid by a pharmaceutical company to travel around the U.S. to promote one of that company’s antipsychotic drugs. Meanwhile, the psychiatrist was writing thousands of prescriptions for that same antipsychotic drug for his patients on Medicaid.

You might think that there would be at least the appearance of a conflict of interest here. However, the psychiatrist in question seems certain that there is not:

In an interview and in response to written questions, [Chicago psychiatrist Dr. Michael] Reinstein said industry payments he has received for speeches and other engagements have had no bearing on his research results or patient care. He said he does not “accept any money from corporations to study their medications. This eliminates any possible conflicts of interest.”

(Bold emphasis added.)

So, dear readers, does Dr. Reinstein’s plan for eliminating conflicts of interest (COIs) strike you as plausible?

If not, are there further steps you think someone in a similar career situation ought to be taking to disclose and manage such potential COIs?

Do you think this might be the kind of COI that cannot plausibly be managed? (If so, what features do you think distinguish manageable COIs from impossible ones?)

Finally, are we to the point where we need a serious body of social scientific research that follows psychiatrists (among other scientists who draw their financial support from private and public sources) to get some hard data on what kind of influence various financial arrangements actually exert on their prescribing behavior and research results?

Comments

  1. #1 Pat Cahalan
    November 12, 2009

    Some thoughts here that will have to wait, but the short answer is that your last question’s response is, “sure, why don’t we encourage that already?”

  2. #2 Janet D. Stemwedel
    November 12, 2009

    But Pat, surely physicians and scientists have crystal-clear awareness of what is driving them, since they are a bazillion times more objective than everyone else! Why waste the time and money getting the empirical data to confirm what we already know?

  3. #3 chezjake
    November 12, 2009

    IMHO, any physician who receives any kind of money from a drug company has enough of a potential COI that full disclosure is warranted. The industry as a whole has such a bad ethical reputation that one can almost presume that there is a conflict.

  4. #4 Rev Matt
    November 12, 2009

    “I have investigated myself and found that not only have I done nothing wrong, but I’m an incredibly cool guy as well.”

    Always a convincing argument.

  5. #5 Jeff
    November 12, 2009

    Dr. Reinstein was paid to promote the drug, not to research it, so there’s no conflict of interest?!

    Unfortunately, as Byron Richards tells it, conflict of interest and a certain amount of fraud are built into the system.

  6. #6 Nick
    November 12, 2009

    It’s really kind of appalling how transparently self-serving these justifications are, and they serve as a beautiful example of the corruption that comes from self-regulation (see also: legislative bodies).

    My temptation would be to say that the AMA cannot ethically allow practicing medical professionals to receive any gifts of money, food, or travel (over some tiny nominal amount, like the $20 or whatever for civil servants) from medically-related companies or to be retained for any employment by them. There may be some valid ethical argument for allowing gifts or employment in certain circumstances, although the attempts to make such arguments that I have heard qualify as “woeful,” but the corruption in the current system fails the laugh test of anyone not benefitting from it.

  7. #7 8
    November 12, 2009

    Dear Dr Free Ride:

    Is a ride really Free? Like Motel Sixx, near SF Airport. Experience a grounding in materialist ontology, if you will.

    Grazi,

    Eight

  8. #8 Pascale
    November 12, 2009

    Receiving any freebie, even a pen, can influence prescribing (Pharma isn’t stupid; they wouldn’t hand them out if they didn’t work). So receiving thousands to be a paid speaker doesn’t influence you?
    The only way to avoid COI is not to take Pharma money. Maybe it’s because no drug company wants to pay me millions to whore for them (pediatric nephrology is not exactly a big-bucks drug market), but I just don’t see how you could justify not disclosing this relationship to everyone.
    And if it really isn’t COI, then no one will object to the realtionship, so why not disclose???

  9. #9 DrugMonkey
    November 12, 2009

    Pascale, while I endorse your conclusion, the conflation of a cheap pen with $500K in various payments is a problem. I say start with the most salient conflicts ($$$$) and work down. Policies designed to make sure each $20 lunch is reported distract from the real problem. I.e. Those who are pulling major money via the usual consulting fees, speaker honoraria, etc..

  10. #10 ComplianceOfficer
    November 13, 2009

    There are several volumes of research on the influence of “gifts” on human behavior. This really isn’t hard, it’s just that no one, except Sen Grassley, wants to tackle it. We need to make a brightline rule: if you get more than $X from the company you cannot have any other interaction with them (research, prescribing their treatment, etc.).

  11. #11 anon
    November 14, 2009

    Note that all my experience with psychiatry is patient-side.

    It’s a bit misleading to simply label quetiapine an antipsychotic: that description suggests patients in a state of psychosis, who often cannot make drug choices for themselves. In my limited experience, the drug was prescribed for pretty much any and all patients in a general psychiatry setting, including unipolar depression without psychotic symptoms.

    It might be best just to refer to it by (nonproprietary) name, rather than getting into the game of having to choose how scary to make the drug sound: compare promethazine, which can be labelled (scarily) an antipsychotic, or (harmlessly) an anti-allergy drug that’s available over-the-counter in the UK.

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