The age of entitlement

BMJ 2005; 331 doi: (Published 24 November 2005) Cite this as: BMJ 2005;331:1279
  1. Des Spence, general practitioner (destwo{at}
  1. Glasgow

    If I fulfil this oath and do not violate it, may it be granted to me to enjoy life… if I transgress it and swear falsely, may the opposite of all this be my lot.” My thumping hangover didn't help on my graduation day. I flushed, sweated, and suppressed wave on wave of nausea. I was a cloaked polyester angel alongside 200 other gowned students in a large university hall. We stood, electricity crackling, and recited an oath before we were ushered through for graduation—I can't remember what we said or even if it was in English—but we glibly took that oath. A friend turned and said, “It's all Greek to me,” and we both laughed. Now in these faithless days the notion of an oath or even of vocation have little relevance. We are a detached and fractionated profession; conversations focus on “time limited contracts,” no payment, no work, study leave, and so on, and a sense of entitlement pervades everywhere.

    We have tarnished our profession, and it is little wonder that our status has fallen

    I spent 10 years in inner city medicine. I commuted from my five bedroom suburban home in my Golf GTi. I enjoyed the hospitality of the drug industry—meals, freebies, flattery, and money. It was comfortable and complacent. My own hospitality paled in comparison with the stories that circulated in medical circles, but my sense of entitlement rationalised this greed and excess as harmless and acceptable. However, that “Greek” kept nagging in my subconscious. Finally my wife gave voice to what I knew to be true: that we were lost. For my penance I decided to bear witness to what I had seen.

    Blame is in the nature of humanity. It was the drug companies' fault, I reasoned—avaricious, secretive, manipulative, capitalist, spinning research, abusing charities, and disease mongering. The industry was an evil empire whose public standing had reduced to that of tobacco companies, its roots in innovation and research long forgotten. Beyond salvation?

    In response to this image the Association of the British Pharmaceutical Industry (ABPI) has launched a new code of practice. Its core features include promotion of adverse drug reporting by patients, a commitment to openness between the industry and charities, and naming and shaming companies that breach the code. Also, doctors will now have to slum it in economy class, and “lavish venues” are out—a tacit admission of the excess of the past. The code is still not actively enforced and has no financial censor. A strong argument remains that ABPI is not capable of regulating this multibillion pound business and that responsibility should pass to an independent body. Only time will tell if the hospitality culture is really over or if this is mere expedient window dressing. The ABPI, however, should be given the benefit of the doubt for now; moreover, as its director, Richard Barker, ruefully remarked, “It takes two to tango.” He is right. For too long we have hidden behind our professionalism and projected ourselves as naive victims in all this. We are not victims, but we have been at best thoughtless and at worst utterly selfish, lapping up the hospitality even though we knew it was inappropriate. We have tarnished our profession, and it is little wonder that our status has fallen.

    Commitment, duty, service, and caring are our lineage. We were mostly trained by the state, and many of us received maintenance grants to allow us to study. We earn good salaries, enjoy full employment, and have generous holidays, sickness protection, and an enviable index linked pension. We are privileged public servants and should be grateful. Forget the puff, the feigned wounded indignation, and the idea that somehow because we are the academic elite we are different—we are not. Professionalism is neither passive nor a right but must be actively shown.

    The industry has moved and accepted responsibility. It is now time for the General Medical Council to act and issue specific guidance on acceptable levels of contact with the industry, hospitality, and transparency in all financial dealings. It is only what the public deserves and expects of all public servants. The statement “You must act in your patients' best interests… you must not ask for or accept any inducement, gift, or hospitality which may affect or be seen to affect your judgement” is simply not enough.

    If we want to be more than just bystanders in the march towards medicalisation and inappropriate polypharmacy then we need a new, mature, and equal relationship with the drug industry. A time bomb of resentment is ticking among children and adults who are subjected to this medicalisation and who may well in time view doctors as nothing more than weak collaborators.

    The party's over and now it's time to deal with our collective hangover. We may be flushed, sweating, and suppressing wave on wave of nausea at the thought. The new ABPI code is now on general release in a health centre and hospital near you, and in the words of a modern day icon, Albus Dumbledore of Harry Potter fame, “You have to make a choice between what is right and what is easy.”


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