Introduction
When the editor asked me to write an essay on the subject of company sponsorships for medical specialists, I realised that I had to pay a price to bell the cat. My immediate provocation for a debate on this subject had come from a news item inThe Times of India of 7 May, 1997, about a government order banning doctors sponsored by medical companies from attending conferences abroad. It is one matter to hold an opinion about a certain subject and a totally different proposition to write a comprehensive essay on it.

I propose to deal with the subject by highlighting the basic duties and privileges of physicians to the professional organisations to which they belong and then take their relationships with commercial establishments.

The objectives of any scientific society or association are commonly based on the following principles:

There are minor variations between the objectives of different associations and societies of different disciplines depending upon the special needs of the specific speciality.

What are the ethical and moral obligations of the members of professional organisations?
In order to remain in good standing, all members must abide by the rules and regulations of the society. Most societies have rigorous rules for enrolment of its members. Amongst the rights and duties of its members, it shall be the duty of each active member to attend regularly the meetings of the Society, to participate in the scientific programmes, to uphold the ideals and objectives of the society, and to pay the dues and assessments of the society.

Similarly every association or society has a number of committees to ensure that the goals and objectives set by the founding members are achieved and the standards maintained. In professionally mature associations and societies, amongst many such committees are also the committee on Continuing Education and the Committee on Standards and Ethics. These committees as well as the Medical Councils are suitably empowered to take disciplinary action against erring members.

What is the need for medical professionals to attend national and international conferences, seminars and updates etc.?
Practising physicians need to keep abreast of the rapid and continuous advances being made in their respective specialities. Medical technology is changing at a very fast pace and is contributing to major changes in the management of various ailments. In fact, Continuing Medical Education (CME) is an important requirement for doctors in order to keep up with changes in diagnostic and therapeutic medicine. A certain number of hours of CME are mandatory for most physicians practising in the USA and several updates, symposia and conferences have the accreditation for certain hours for CME.

As is evident from the foregoing discussion, attending these meetings, updates, seminars and conferences is not only the primary duty of the physicians laid down by their association or society but also a mandatory requirement and a legal obligation as per the prevalent laws of the particular state for license to practice.

Apart from such programmes and conferences, other avenues to keep up with the latest knowledge are journals and other publications related to the subject. Many of these publications are significantly supported by medical and pharmaceutical companies. The current revolution in information technology (most advanced societies are on the Internet), including satellite conferences, have enabled physicians to access the latest happenings in their fields from the comfort of their offices or homes. And yet, the charm and bonhomie of personal interactions is possible only by attending conferences and updates. These are also occasions for mixing pleasure with work for many physicians, otherwise busy and overworked, as they attend these meetings with the spouse and family.

Who should fund these conferences, updates and seminars?
Organising a conference or an update has become a highly professional job. The big meetings and conferences are held in five- star hotels or convention centres with excellent facilities for lectures, audio- visuals and banquets. These conferences, therefore, need big money to pay for all the facilities. Medical and pharmaceutical companies give significant financial support in organising these meetings and in turn have the privilege of participating in a trade exhibition to promote their products to professionals in the field. Besides, all such meetings have a registration fee paid by physician and non- physician members attending these conferences. The registration fees have risen over the years keeping up with the increased costs and inflation. Surely it should be possible for the organisers to meet the expenses through money collected by the registration fees. The actual scene is different as most lunches, dinners and social events, becoming increasingly extravagant by the day, are fully sponsored by various commercial organisations flush with money and eager to influence the doctors.

While the commercial aspects of holding the conferences are beyond the scope of this essay, I cannot but refer to huge profits made by the organisers of the conferences. This achievement of the organising committee is enviously applauded by the main professional body who accept the share of the profits gratefully while the organisers keep a handsome share, albeit for educational and research activities. This in turn sets a standard for the organisers of the subsequent conferences who once again depend heavily upon bigger support from commercial organisations. And thus a vicious cycle has been set in motion with no one in particular to blame. One may argue that it is not possible to hold such big meetings without commercial support and yet some time back, a meeting of the Indian Academy of Pediatrics was organised without accepting any commercial support and was by all accounts a successful one!

While one may argue in favour or otherwise of commercial support for organising conferences, the issue under discussion relates to individual doctors getting sponsored by these companies. It should be difficult to defend such sponsorships for doing something which should be their normal duty. As mentioned by Dean Ornish in his best selling book, "Drug companies make millions of dollars educating physicians. Drug companies are the major advertisers in all medical journals. They fund clinical trials and pay the researchers to speak at hospitals and medical schools... Drug companies provide sandwiches and doughnuts at hospital conferences... They provide free samples.. . also sponsor scientific meetings . . . sometimes held in resorts, and doctors who attend may even be given free transportation and expenses. There is nothing wrong with any of this, and it is all very comfortable and familiar. But a subtle and sometimes overt message to doctors gets through that drug companies are friends."

 

It is common for doctors to get influenced thus.

Why do medical and pharmaceutical companies support these meetings and/ or physicians attending these meetings?
Medical and pharmaceutical companies are basically business enterprises making huge profits. They have a substantial budget for promotion of their products which they achieve by advertising in medical and non- medical media as well as by sponsoring medical events as stated earlier. Some of the big companies have a separate budget for educational and research activities which they use for sponsoring clinical trials, updates, seminars and conferences. They are also keen to sponsor willing doctors to attend these meetings and are ready to pay airfare, five- star lodging and other perks. Spouses may be included at times!

The argument that they do so because of their genuine commitment to education and dedication to research for the benefit of mankind should be taken with a generous pinch of salt. After all, Enron is on record as having paid for the ‘education of politicians’ though one may never know the nature and other details of such education. To a common person it should mean, in plain words, an attempt to gain favour, and that is what it is. It should also be understood that the cost of all such education, research and other promotional activities is passed on to the consumers -- in the present context, patients.

From the foregoing, several points become clear. First, doctors belong to a noble profession and their professional organisations have lofty goals and objectives. Second, attending conferences and updates is absolutely essential for doctors to keep up with the desired professional standards. Third, modern medicine is controlled by high- tech sophistication, which is expensive and therefore, generates fierce competition between companies and consequently, generates marketing pulls and pressures. Fourth, doctors become unwitting collaborators of these companies and are at a significant risk of getting influenced while making treatment choices for their patients. Finally, the increased costs are directly passed on to patients. In government and public hospitals, this would mean that the administration has to spend large amounts in getting high-tech equipment. It is not surprising that several such purchases involve middle- men and fraudulent practices. It is not uncommon even in public sector hospitals with limited resources to charge patients for expensive investigations and procedures and in spite of that, find it difficult to maintain such equipment. In private sector hospitals, once the technology is procured at an exorbitant cost, there is increasing pressure on attending doctors to refer patients in order to recover the cost of the equipment. This is one explanation for the unnecessary investigations, procedures and even operations.

Doctors - a part of society
The medical profession is a part of society and suffers from the same maladies of erosion of values as do the other segments of society. Is it fair to expect medical professionals alone to hold moral and ethical values when many others have forgotten even the definitions of these terms?

I find it extremely difficult to refute such arguments from my friends. At the same time there are conflicts and blurring of views regarding legal, moral, social and ethical values in any society. What may be socially sanctioned in one society or culture may be taboo in another society. Similarly, a legal sanction may not be moral or ethically correct and what is ethical may not have legal sanction. Also there are likely to be as many individual variations about what should be considered moral and ethical. However it is in order to say that general ethical principles should have general acceptance and should determine what ought to be done.

 

The present erosion of values seems to stem from the materialistic growth of society. Upwardly mobile trends brought in by economic liberalisation have focused sharply on the haves and have- nots. I find it paradoxical that reforms in the economic sector, long perceived to be necessary and overdue, should be accompanied by such mayhem and chaos in moral and ethical values. It is a reflection on the times that each subsequent scam is bigger than the preceding one; so much so that the scandal involving purchase of the Bofors guns appears to be woefully small and boring in contrast to scams worth thousands of crores unearthed in recent times. Desensitisation is complete. What is then wrong in doctors doing something totally legitimate and innocent like enjoying the hospitality of rich companies who after all cannot force them to use their products? In any case, the companies are going to sponsor so many others attending the same conference and an individual not accepting the generous .hospitality cannot make any difference, or can s/ he?

Depriving doctors working in the public sector
The reason that a government order was necessary to ban such practice itself means that something was more than just wrong. I, however, have several problems in understanding this order though I must admit that my impressions are based only on the newspaper report and I have not been able to get a copy of the said order. Was it legal, before the above order was brought in, for government doctors to attend conferences sponsored by medical companies? Is it all right for doctors to attend such conferences within the country as the order refers to conferences organised abroad? If the government order is applicable only to doctors working in government hospitals, would it imply that the law makers thought it to be legal and moral for doctors in private hospitals to accept such sponsorships? If at all one has to justify commercial support, it should be for doctors working in government and other public sector institutions rather than for super rich doctors in private practice charging illogically high fees from their patients and who, in any case, can not only afford these expensive conferences but also get attractive tax benefits!

Several big private and corporate hospitals usually sponsor their staff periodically to attend national and international conferences. Conference funds at government and public hospitals, on the other hand, have remained limited and unrealistically low. There is no doubt in my mind that research funding and funds for continuing medical education in teaching institutes must increase substantially to promote the professional skills and standing of their staff.

Measures to prevent corruption
Since there are real risks in doctors accepting direct sponsorships from commercial companies, several options need to be experimented with. These options should aim at increasing the available funds of public institutions and at the same time maintaining a healthy relationship between doctors and commercial organisations. These arrangements should be such as to allay the present fears ofquid pro quoand also have legal, moral and ethical sanctions.

I have a few suggestions to make in this regard:

 

 

Summing up
I have made a sincere attempt to initiate discussion on what is currently wrong in the relationship between physicians and commercial companies. I am aware of the limitations of generalisations on a topic like this. I hope that this essay will be followed by other useful and valuable contributions on this subject, both from the readers of this journal as well as from others including commercial organisations. It will be eminently rewarding for me if suitable guidelines emerge after a thorough discussion on the subject. This, in turn, will encourage a healthy and ethical relationship of mutual respect and dignity between the medical profession and commercial organisations which are dependent upon each other for meeting their commitment to the patients.

Ratna Magotra,Professor and Head, Department of Cardiovascular and Thoracic Surgery, Seth G. S..Medical College and K. E. M. Hospital, Parel, Mumbai 4000 12