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HEAD TO HEAD: Thomas P Stossel Has the hunt for conflicts of interest gone too far? Yes BMJ 2008; 336: 476 [Full text]

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who to trust?

Michael Tremblay   (1 March 2008)

We need to agree on the conflicts and train to manage them

Peter Aitken   (1 March 2008)

Money motivation is a two way street

david egilman   (2 March 2008)

Questions for Dr.Stossel

Robert Matz   (4 March 2008)

who to trust? 1 March 2008
Michael Tremblay, health policy advisor Tremblay Consulting, TN25 5RJ United Kingdom Send response to journal: Re: who to trust?	I doubt either author is opposed to disclosure; for as jurist Sir John Chadwick said in 1990, "secrecy is the badge of fraud". So how do we make sense of these two views? Much of the art we take for granted, many historical buildings and much science and technology we enjoy were produced by people who had patrons, wealthy or powerful individuals that sponsored their work. Perhaps disclaimers are required in case we think that that our enjoyment of a particular art work for instance would be compromised by knowing this. No, instead we commend the far-sightedness of the sponsor, and are grateful that they saw the talent in the individual whose work we today enjoy. The bloodlessness of the world that would have otherwise come to pass would be without merit or humanity. To some extent, that is the point I take from Stossel. From Lee, however, I see a neo-McCarthyism, of officious approval and retribution, indeed authoritarianism thinly veiled by the aura of public interest claims. For who is without conflict, who is without a sponsor, who is immune from the pressures to publish, to perform on committees, donate time to charities and who does not reciprocate, often with kindness and often out of duty? Are we to stop sharing our experience for fear of opporbrium from colleagues who have little of interest to say as they sit in their tiny conflict-free worlds? Let those without sin cast the first stone. The interesting people are all conflicted -- they are engaged in the real world, with all its faults. The world is not neat and tidy, it is messy and complex, and better we learn to understand the conflicts, than naively believe we can avoid them. I believe the public interest has far more to fear from the Lees of the world than the Stossels; the latter drives us closer to honesty while the former toward fear and concealment. Competing interests: I advise companies and governments on health policy.
We need to agree on the conflicts and train to manage them 1 March 2008
Peter Aitken, Medical Director www.arborvitae.org.uk Centre for Education Research & Development, Wonford House, Dryden Road, Exeter EX2 5AF Send response to journal: Re: We need to agree on the conflicts and train to manage them	Stossel & Lee provide arguments for professional freedoms and differ in their acceptance of a need for regulatory constraint on these freedoms. Lee makes two compelling points. There is a wide variation and a poor understanding in regard to what constitutes a conflict of interest. Secondly current regulatory frameworks appear ineffective in restoring public confidence in the relationship between physicians and the pharmaceutical industry. This is unsurprising. There is a paucity of undergraduate & post graduate education & training to support the implementation of what little guidance exists. (1) Where there is guidance it is often high level and open to interpretation. It is of concern that given the high level of investment from the pharmaceutical industry in medical education so little of it has been devoted to training the professional side of the partnership in compliance with industry's own promotional codes of practice. Of further concern is the apparent failure of the medical professions to grasp the need to behave as professionally with this work as they would with other aspects of medical practice. We should train for this work, conduct transparent discussion with our peers regarding the nature of the work, and the standard of practice should reflect the majority body of medical opinion. The work should be amenable to audit.(2) I would like to see an educational levy taken from industries sponsoring medical meetings toward the creation of relevant post graduate training in best practice in partnership working. Companies working in this way would come to preferentially value the opinion of thought leaders and researchers with their reputations protected by this training. The availability of training has the potential to increase the medical talent pool confident to work with the pharmaceutical, bio-tech and devices industries. I am left trying to decide whether my directorship with one such training organisation, www.arborvitae.org.uk, (3)consitutes a conflict of interest or not. We provide free on-line educational tools and discussion forum. We charge fees for our courses. Debate is welcome. 1. Mintze B. Educational initiatives for medical and pharmacy students about drug promotion: an international cross sectional survey.Geneva: World Health Organization, 2005.www.who.int/medicines/areas/rational_use/haipromosurvey.pdf 2.Hewitt P. Trust, assurance and safety – the regulation of health professionals in the 21st century. London: Stationery Office, 2007. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution License. 3. www.arborvitae.org.uk Competing interests: Peter Aitken is a director of www.arborvitae.org.uk a training organisation that stands to gain if more health professionals train in their workiing relationship with industry
Money motivation is a two way street 2 March 2008
david egilman, clinical associate prof Brown University 8 north main st attleboro ma 02703 Send response to journal: Re: Money motivation is a two way street	Dr. Stossel argues that the prospect of profits motivates big pharma to do only great things. But financial incentives encourage folks to do whatever it takes to make money good or bad. Capitalist externalities (polluting the environment, making workers or customers sick) are not incorporated into the cost of the product. The current regulatory and tort climate does not account for these costs either. Greed produces good or bad results. Doctors are not immune. Fianlly Dr. Stossel does not mention his ideologic bias. He is a libertarian and views life through the Lens of Rand. Competing interests: I have srved as an expert witness att he request of injured patients in Vioxx and other litigation and was a co-author of one of the papers the author critiques
Questions for Dr.Stossel 4 March 2008
Robert Matz, Medical; Director of Quality Assurance Mount Sinai Hospital, 1 Gustave Levy Place,New York,NY 10029 Send response to journal: Re: Questions for Dr.Stossel	Does Dr.Stossel think that the pharmaceutical companies are altruistic when they expend a significant amount of money on taking physicians to restaurants to hear a lecture or supporting CME programs at hospitals,medical schools and the like? Does Dr.Stossel believe that the cow which provides the major portion of milk for most professional organizations annual meetings,their speakers,their incidental expenses,hotel rooms,airline flights,etc. will be thought of as a friend of the family or be kept at arms length in their stall? Contrary to Dr Stossel much of the research which underlies new drugs and treatments comes from basic research supported in large measure by public funds[for the NIH they are called "taxes";for pharmaceutical companies "tax breaks"]. Why not advocate a blanket contribution from drug companies to medical education and CME with a list of contributors ? Why not similarly support annual meetings and instead of advertising their products thru slick merchandising campaigns. Why not support publication of the major presentations at such meetings? Does Dr.Stossel really believe in the Easter Bunny and that the companies have not studied the effectiveness of their current programs? Does he really believe that being nice to physicians doesn't rub off alittle in the warm-fuzzy neiborhood when it comes to choosing one drug over another? To surrender our medical education,meetings,reviews of scientific papers,journals[Oh yes! Which journal would continue without drug company advertising and don't you think the editors know that.]to dependence on drug company support does raise a wiff of trouble in the air don't you think? Competing interests: I have recieved no stipends,payments,meals nor trips from any medical nor pharmaceutical organization for over 20 years,but I rely on them for ball-point pens and note pads.