Earlier this week, pharmaceutical giant Glaxo-Smith-Klein (GSK) paid $3 billion to settle charges that it improperly marketed drugs. For those of you not familiar with how drug companies go about the uglier side of their business, it can work like this: consultants, marketers, representatives, and paid “experts” are paid to deliver specific messages about medications. These messages are delivered to doctors, consumers, and anyone else whose behavior can be influenced to improve drug sales. This is neither immoral nor illegal—normally. But drug companies have for years skirted the edges of legality, sometimes falling onto the wrong side of ethics and the law.
As part of the Government’s complaint against GSK, they allege that celebrity doctor Drew Pinsky was part of a scheme to “promote the use of Wellbutrin SR for unapproved uses.” Forbes’ Matthew Herper summarizes the allegations quite well. I’m not entirely surprised that a celebrity doctor should be accused of improper behavior, or that an expert may have been payed to engage in marketing. What caught my interest was a question from journalist Kevin O’Reilly posed during a twitter discussion with me and writer David Dobbs (that I get to converse with folks like this is one of the wonderful things about twitter). He asked a relatively simple question: “What should, or could Dr. Drew do to set things right.”
Setting aside legalities, and positing that the allegations are true, it is a breach of trust. We can divide that breach into two categories: breach against the public, and breach against the patient. The duty to the individual patient should be obvious. A physician also has a duty to society. Physicians hold a position of power and respect and should not abuse this for their own benefit.
The clearest ethical breach here is that of informed consent. When a patient is prescribed a drug, they should be informed of the possible risks and benefits but also any other motivations the physician may have to prescribe the drug. This can be as “big” as accepting large fees to promote the drug or as small as getting a box of donuts from a drug rep. There are limits, of course. I may run into a drug rep with whom I am also friends. Maybe we run into each other on the way to work and he buys my coffee–as a friend. Even though we might not report every little occurrence to our patients, we have to be honest with ourselves and recognize that even small gestures influence our prescribing behaviors.
If a donut or a cup of coffee can influence my behavior (and it can), what might a few hundred thousand bucks do to my judgement?
To “set things right” in this sort of situation, an ethical thing to do would be to publicly state that, while he might not have consciously intended to breach his ethical responsibilities, the very nature of his relationship to GSK was likely to affect his statements and advice, and that his patients and the public should take this information into account in evaluating his advice*. If it were me and I wanted to rebuild trust with my patients and with the public, I would commit to make no further agreements that could create a conflict of interest, since my primary interest should be to my patients.
*That being said, from what I’ve read, his claims about Wellbutrin seem to be well within accepted practice. While a drug company can only make claims that it has proved to the FDA, doctors may choose to use drugs in any way they see fit.