Notes for Health Action International seminar (Paris, 11 December 1998) on
Weighing the benefits and risks of pharmaceutical industry sponsorship
Equilibrium between self and others defines what a people make of themselves - but where does self-expression end, and common cause begin? A wealth of options exists, everything that fills the gulf between the best and worst of the human spirit. The challenge is to strike a good balance between individual and collective achievement - but there is never a stable, enduring equilibrium between them, only a wealth of ideas about how things should really be.
Sponsorship arrangements are part of this tangle. Ideally, they express coincidence of motive and purpose, but conflicts of interest and commitment are never far away. Sponsorship plays an important part in defining the values of medicine and the very meaning of health - but whose values predominate, and what meanings matter most? Beyond the obvious benefits of sponsorship, many problems arise because of concentration of wealth in the business sector - and as health systems, government and consumer interests increasingly depend upon it. Sponsorship by the pharmaceutical industry is yet another play about the relationship between power and dependence, and the balance between 'self' and 'non-self'.
I was asked to speak about "the nature of the problem", but the main point is already clear. Its nature is hugely complicated, partly constructive and partly destructive. Here I outline reasons for thinking that sponsorship has become so invasive in some areas as to present real hazards to health. These notes were intended for distribution to HAI seminar participants, also as something of an index to information about conflict of interest on this website.
1. Weighing the benefits and risks of pharmaceutical industry sponsorship is not easy. What weight is attached to the needs and priorities of the different interests? How do you assess impact when it is made through complicated networks of influence and routes/roots of understanding? How much evidence is hidden because issues are too sensitive to disclose, and/or because industry sponsorship is extensive and increasingly relied on? How do you take stock of a phenomenon that has such extensive manifestations and such diffuse impacts? Measurement in this area can feel like trying to observe individual snowflakes in a snowstorm.
2. Weighing the benefits and risks of pharmaceutical industry sponsorship is no easier. It may be safe to assume that the immediate and primary beneficiaries are the sponsor and recipient, but the nature and extent of benefit would very much depend on who was being sponsored to do what, and how. Sponsorship underpins a great deal of research, a good part of medical education, and much clinical practice. It promotes understanding, experience and collaboration, career development and job satisfaction, as well as being of fundamental importance in marketing. Sponsorship is an integral and indispensable part of modern medicine
3. Weighing the benefits and risks of pharmaceutical industry sponsorship is no laughing matter either. It means taking account of large-scale corruption of information and understanding, substantial bias towards drug treatment, the suppression of independent thought and honest dissent, the medicalisation of life and the obsessional pursuit of health. Sponsorship is also an integral part of the promotion of new drugs, and of belief in the greater worth of new products over old. As such, it inhibits rational and economic drug use, and restricts access to essential medicine.
4. Weighing the benefits and risks of pharmaceutical industry sponsorship isn't only a task for the main beneficiaries. In individual cases, they will have to make decisions about what is acceptable and what not, but society has to take a broad view about the desirability of sponsorship overall - and the compatibility of all these private arrangements with public purpose, and standards in public life. At present there appears to be no systematic assessment of the risks.
5. Weighing the benefits and risks of pharmaceutical industry sponsorship means taking stock of all kinds of arrangements, in every area of medicine, from the very top down - including some which already presents some quite unacceptable risks. Examples will be discussed of some exceptionally sensitive areas, drawing mainly from The Antidepressant Web. These include: funding of consensus and similar statements; formulation of guidelines for diagnosis of treatment; conduct of clinical trials; funding of press and media, including professional journals; donations to patient & consumer and professional organisations; and contracting with individuals who work within the drug regulatory framework.
6. What options exist for containing the conflicts of interest and commitment that arise through sponsorship? They relate to formal (contract) and implied terms in sponsorship arrangements; setting standards and guidelines governing personal conduct; disclosure requirements relating to possible conflicts of interest; dilution of influence of vested interests on panels, committees and boards etc; quality of leadership and example; audit and legal remedies; and public intolerance.
This seminar marks the start of a process of enquiry into problems arising from sponsorship, and the need for appropriate remedies. To start with, we need to make an inventory of all the areas, and all the ways, in which there is some danger of the commercial tail wagging the professional dog.
CM, 10 December 1998